biopharmaceutical characteristics of autologous red blood cells ghosts containing cytokines and antibiotics new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. biopharmaceutical characteristics of autologous red blood cells ghosts containing cytokines and antibiotics zhaxybay zhumadilov1, kulzhan berikkhanova1, zarina shulgau1, alexander gulyayev1, zanybek bokebayev2, nadiyar mussin2, talgat nurgozhin1 1center for life sciences, nazarbayev university, astana, kazakhstan; 2astana medical university, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.103 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ zhumadilov this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.103 | http://cajgh.pitt.edu abstract introduction: transport systems based on autologous red blood cells for targeted drug delivery can be considered as a promising approach in the treatment of surgical infections. experimental studies have revealed the feasibility of targeted drug delivery by encapsulation of cytokines and antibiotics into autologous erythrocyte ghosts. purpose: to study biopharmaceutical characteristics of autologous erythrocyte ghosts containing cytokines and antibiotics (pharmacocytes). material and methods: the erythrocyte pharmacocytes were prepared by the hypotonic hemolysis method, or the use of human red blood cells. the association and dissociation indicators of rifampicin and cytokine substances with the erythrocyte ghosts were conducted using standard methods. results: we have defined the following extracellular concentrations to be optimal for deposition of drug substances into pharmacocytes: for rifampicin – 10 000 μ/ml, erythropoietin 1000 iu / ml, tnf-a 5000 iu / ml, il-1-β 5000 u / ml, ifn-γ 10 000me / ml, il-2 50 000 iu / ml, angiogenin 0.04 mg / ml. two types of correlations of cytokines and pharmacocytes were identified. in this study, we found that 40-60 % of the erythropoietin, ifnγ and angiogenin were bound to red blood cells ghosts, more than 10% of which were bound irreversibly. for tnf-a, il-1-β and il-2, the red blood cells ghosts were capable of binding and depositing within 10-20 % of the input extracellular concentration, and these bindings were almost completely reversible. the rifampicin was bound by red blood cells ghosts with 5 % efficiency and also completely reversibly. conclusion: the study has shown the effectiveness of inclusion of the studied components, such as erythropoietin, ifn-γ and angiogenin into the red blood cells ghosts, with significant efficiency (40-60 %). it presents the potential of using this system in targeted delivery of cytokines and antibiotics for treatment of surgical infections, thus facilitating the reduction in toxicity and adverse systemic effects of drugs and improving the treatment results. keywords: autologous red blood cells, cytokines, antibiotics http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx the state of cardiovascular disease in the kyrgyz republic the state of cardiovascular disease in the kyrgyz republic ryskul b. kydyralieva the national center of cardiology and internal medicine named after academician m.mirrahimov at ministry of health of the kyrgyz republic, bishkek short report according to the republican medical informational centre1 of the kyrgyz republic, cardiovascular disease (cvd) was the leading cause of death in 2011, representing half (50.1 %) of all deaths. figure 1: the structure of the reasons of death rate of the kyrgyz republic population (according to republican medical and informational centre, 2011) in 1991, the death rate from cvd was 261.9 (per 100,000 population), while in 2011 this reached 326.3, a 24.5% increase. more than eighteen thousand people in kyrgyzstan die from cvd each year, over 50 every day.1,2 the primary cause of death as related to cvd is coronary heart disease (80% of all cvd mortality, including acute myocardial infarction), followed by cerebrovascular diseases. figure 2: death rate of the kyrgyz republic population from different cardiovascular diseases kyrgyzstan has the sixth highest cvd mortality in eurasia following russia, byelorussia, ukraine, kazakhstan and moldova. it is first in the eurasian region on the standardized parameter of mortality from stroke at 88.5 cases per 100,000. 2,3,4 figure 3: standardized death rate from cerebrovascular diseases (per 100,000 population, who, 2004) figure 4: standardized death rate from coronary heart diseases (per 100,000 population, who, 2004) it is especially alarming that cvd death rates are increasing among young and able-bodied people.1,2 from 1991 to 2010, cvd mortality increased by 40.5% and 18.1 % in age categories 30-39 and 40-59, respectively. figure 5: death rate from cardiovascular diseases in kyrgyzstan, ages 30-39. figure 6: the death rate from cardiovascular diseases in kyrgyzstan, ages 40-59. cvd is not only the leading cause of death in kyrgyz population; it causes a large percentage of premature disability. cvd accounts for 19.6% of all disability cases, exceeding similar disability parameters for other diseases.1,2 figure 7: structure of premature disability of the kyrgyz republic population (according to republican medical and informational centre, 1998-2011) using estimation methods of economic efficiency, we calculated economic losses connected to cardiovascular diseases in kyrgyzstan. analysis revealed that economic damage from premature death and physical disability from cvd in kyrgyzstan totaled more than 14 billions soms (around 360 million us dollars) in 2007.5 as reflected, the healthcare system must be reorganized to combat cardiovascular diseases and stop the deterioration of kyrgyz health. in doing so, we may prevent serious economic and social consequences of these diseases. taking into account the data outlined above, combating cvd in the kyrgyz republic is one of the key directions and priorities of national programs to reform public health. these programs, entitled "manas taalimi" (2006-2011)6 and “densooluk” (2012 – 2016) are supported by the government of the kyrgyz republic. these program implementations are performed in four key directions, including: integrating republic-level cardiology service systems, program monitoring, and evaluation.7 increasing the preventive work within the general population and providing training to identify key cvd prevention principles as well as cvd treatment and complications. empowering communities to join the fight against cvd, including institutions of local self-government, non-governmental organizations, etc.8 improving awareness and knowledge among family doctors, nurses, and medical assistants regarding methods to combat cvd9 introducing modern technologies of diagnostics, treatment, and prevention of cvd into public health practice. organizing public health programs to combat cvd at the republic level will provide opportunities to lower the death rate from cardiovascular diseases,10,11,12,13 promote significant improvement of health state of kyrgyz people, and prolong their longevity and productivity. references 1. the public healthcare and activities of healthcare institutions of republic of kyrgyz. the reports of 1999-2011. republican medical information center of ministry of healthcare of rk. bishkek. 2. kyrgyzstan in numbers. national statistical committee of republic of kyrgyzstan. statistical reports of 2000-2011. bishkek. 3. national report on human development. kyrgyzstan. undp. bishkek. 1997-2011. 4. the world health report, 2002. reducing risks, promoting healthy life 5. kydyralieva r. scientific organizational methods of development and introduction of modern preventive and diagnostic techniques in cardiology. d.sc. abstract. 2010. 6. national program for healthcare reform of republic of kyrgyzstan «manas-taalimi» for 2006-2010. bishkek. 2006: p56. 7. the world health report, 2008. primary health care (now more than ever). 8. the world health report, 2003. shaping the future. 9. the world health report, 2006. working together for health. 10. e.i. chazov. cardiology in ussr. ams of ussr. medicine. 1982: p288. 11. health care in central asia. who information center. bishkek. 2000 12. suhrcke m., rosso l., mckee m. healthcare investment: key condition for successful development of western europe and central asia. european observatory on health systems and policies. 2008: p274. 13. adeyi o., smith o., robles. c. public policy and the challenge of chronic noncommunicable diseases. world bank. moscow. 2008: p187. study of genetic markers of cardiac arrhythmias in kazakhstan new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. study of genetic markers of cardiac arrhythmias in kazakhstan makhabbat bekbossynova1, ainur akilzhanova2, zhannur abilova2, ayan abdrahmanov1, omirbek nuralinov1 1national research center for cardiac surgery, astana, kazakhstan; 2department for organization and development of genomic and personalized medicine, center for life sciences, nazarbayev university, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.85 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ bekbossynova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.85 | http://cajgh.pitt.edu abstract introduction: cardiac arrhythmias are the most common cause of mortality and sudden cardiac death worldwide. in the past decade, genetic factors underlying arrhythmogenic diseases have been revealed and given novel insights in to the understanding and treatment of arrhythmias predisposing one to sudden cardiac death. material and methods: we conducted a pilot genetic screening of two patients with catecholaminergic polymorphic ventricular tachycardia (cpvt) and 14 patients with ventricular tachycardia (vt) for genetic variants in the human ryanodine receptor gene 2 (hryr2). the most relevant 45 hot-spot exons of hryr2 were amplified by polymerase chain reaction (pcr) and directly sequenced. results: one novel mutation in a cpvt patient (c.a13892t; p.d4631v) and a novel mutation in a vt patient (c.g5428c; p.v1810l) were identified. both variants are located at phylogenetically conserved positions and predicted pathogenesis. three known synonymous snps (rs3765097, rs2253273, and tmp esp1 237664067) were detected in the study group. no further variants within the target regions were detected in the study group. conclusion: the results of study can be applied to risk asssessment for life-threatening arrhythmias and assist in development of appropriate strategies for prevention of sudden cardiac death. the implementation of these strategies would assist in the management of patients with genetically determined arrhythmias in kazakhstan. keywords: cardiac arrhythmia, genetic screening, genetic markers, kazakhstan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx individuality and temporal stability of the human gut microbiome new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. individuality and temporal stability of the human gut microbiome shinichi sunagawa, siegfried schloissnig, manimozhiyan arumugam, kristoffer forslund, makedonka mitreva, julien tap, ana zhu, alison waller, daniel r. mende, jens roat kultima, john martin, karthik kota, shamil r. sunyaev, athanasios typas, george m. weinstock, peer bork european molecular biology laboratory, heidelberg, germany vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.120 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ sunagawa this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.120 | http://cajgh.pitt.edu abstract introduction: the breakthrough of next generation sequencing-technologies has enabled large-scale studies of natural microbial communities and the 16s rrna genes have been widely used as a phylogenetic marker to study community structure. however, major limitations of this approach are that neither strain-level resolution nor genomic context of microorganisms can be provided. this information, however, is crucial to answer fundamental questions about the temporal stability and distinctiveness of natural microbial communities. material and methods: we developed a methodological framework for metagenomic single nucleotide polymorphism (snp) variation analysis and applied it to publicly available data from 252 human fecal samples from 207 european and north american individuals. we further analyzed samples from 43 healthy subjects that were sampled at least twice over time intervals of up to one year and measured population similarities of dominant gut species. results: we detected 10.3 million snps in 101 species, which nearly amounts to the number identified in more than 1,000 humans. conclusion: the most striking result was that host-specific strains appear to be retained over long time periods. this indicates that individual-specific strains are not easily exchanged with the environment and furthermore, that an individuals appear to have a unique metagenomic genotype. this, in turn, is linked to implications for human gut physiology, such as the stability of antibiotic resistance potential. keywords: gut microbiome, genotype, antibiotic resistance http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx the impact of global institutions on national health hiv/aids policy making in developing countries the impact of global institutions on national health hiv/aids policy making in developing countries zhanat mokushev, msc london school of economics and political sciences review keywords: hiv/aids policy making, wto, imf, world bank abstract this article explores the relationship of global institutions such as the international monetary fund, world trade organization, world bank, and individual developing countries in social health policy making in terms of hiv and aids. we examine the role of igos and ngos in regarding to hiv/aids issues then analyse the trips agreement as a tool for developing countries to negotiate with international organisations in global health policy decisions. introduction one of the most significant, current discussions around the world is the impact of various forms of globalisation. it is obvious that globalisation affects migration patterns, national economies, and cultural and political developments.1 in recent years, there has been an increasing interest in the role of the international monetary fund (imf), world bank, and world trade organization (wto).2 however, these rapid changes are having serious positive and negative effects on national health policymaking. for example, questions have been raised about the social policy of individual countries under the global health policy in terms of hiv and aids treatment.3 many authors contend that global health policy dictates their rules and conditions to individual countries,4 but there has been little discussion about the role of states in the process of social health policy priority decision-making in relation to global institutions. as a result, while some claim that individual countries still decide their own trade-related intellectual property (trips) social health policy priorities, others regard it as the domination of global social policy making, particularly in hiv/aids.5 the aim of this article is to examine the possibilities of individual developing countries in making decisions about their own social policy priorities in terms of hiv and aids treatment. we first give a brief overview of the impact of globalisation, then examine the role of different global institutions such as the imf, wto and world bank regarding to hiv/aids issues. next, we analysed the capabilities of individual developing countries in decision making of their own social policies in terms of trips agreement. finally, we assess the place of developing countries in global health policy decisions. global institutions: understanding their divergent impact on policy making the role of global institutions “as important policy actors is widely recognized in relation to the social policy processes for developing countries”.6multilateral organisations like the imf, world bank, and wto became more powerful in global policy making than other bilateral or individual countries.7 it is important to focus on understanding their divergent impact on domestic policy making. in the past three decades, “imf intervention in domestic policy making has increased commensurately”.7 on the one hand, the imf can support national economies through the prolonged use of resources by recipient countries. on the other hand, “the views expressed regarding the impact of prolonged use on the policy formulation process were generally negative”.7 according to rowden, many poor “countries are under pressure to stay ‘on track’ with their imf programs”. for example, most developing countries cannot increase funding to fight against hiv/aids because they are “under current imf policy choices and spending constraints”.8 furthermore, other global institutions like the wto have intruded into national policy, and “have extended its authority into areas of domestic regulation, legislation, governance and policy making central to the development process”.7 other contend that in spite of the strong restrictions and rules of the wto, in some cases the wto uses the principle “one country, one vote”.4 as a result, it gives some developing countries opportunity to use this principle in its national policy making. nevertheless, though there are many compromises and negotiations between global institutions and individual countries, the former “still remain embedded in local decision making”.7 many authors maintain that the main objective of the wto “is to regulate and facilitate world trade [and] it is not a welfare-oriented organization”.9 in the era of globalisation, the role of global institutions is obvious. however over the past two decades, non-governmental organisations and institutions have started to play significant roles in policy decision making, particularly in health policy.8 for example, the world health organisation (who) proclaims that every human have rights to the highest healthcare standard.9 there were many programmes providing health policy in the past by who such as the declaration of alma ata (1978), primary health care (1979) and others, which were a main agenda to the strategy of “health for all”.9 it is also established as the central objective of international and national health activities by the nation states throughout the world.9 in spite of the fact that the main objective of who is providing healthcare for humanity, many scholars maintain that “the world bank is the greatest single donor in health and one of the greatest single donors in the fight against hiv/aids”.9 owing to the structural adjustment policy, the world bank could influence domestic health policy making.10 in 1993, the world bank published the world development report (wdr), which focused on health issues.11 it is clear that the main document of the world bank “had an important conceptual influence on health system reforms in the 1990s”; however, many researchers argue “the bank tried to link an expansion of social services to neoliberal economic concepts”.9 as a result, international organizations and institutions started to provide the global social policy in terms of health. developed countries recognize diseases like hiv/aids in developing countries on a global scale. consequently, “health is increasingly perceived as a global public good that requires strengthened global efforts”.9 nevertheless, these issues lead to look more deeply to health problems by developed countries and significantly increased their interest to the hiv/aids diseases. it has been argued that “the self-interest of rich countries may be one of the most important driving forces behind” global health governance.9 for example, in 2002 the global fund was established, which mainly targeted the fight against hiv/aids in developing countries.9 the global fund included a great number of different global institutions and developed countries (like the world bank and g8 countries) as well as recipient countries (like india and brazil). besides, the developing states “create a country coordinating mechanism with the participation of all stakeholders (including civil society and private sector) that is authorized to apply for funds to conduct programmes”.9 as a result, in this case, individual countries still can protect their own social policy priorities through efforts such as the global fund. while there was a growing role of new policy making actors, it was inevitable to escape “conflicts around the trips agreement and the access to treatment for millions of hiv/aids patients”.9 the role of individual countries in social policy priorities: the issue of trips agreement an increasing number of scholars suggest that global social policy national countries cannot totally decide their own social policy priorities.12 however, despite the fact that many countries integrated into the global social policy, many authors assert that individual countries still can decide their own social policy priorities partially, particularly in the case of trips.13 contrary to this belief, many researchers contend that new actors’ participation in global health policy making led to barriers and conflicts like “the access to medicines under the conditions of the internationalization of intellectual property rights through trips” in the south.9 according to correa,14 “under the trips agreement, all wto member countries became bound to grant patents for pharmaceutical products”, particularly for hiv/aids drugs. this secures investment into innovation and protects against free riders but introducing a patent system in some countries imposes a social cost.15 while some claim that these hiv/aids treatments were available, others argue that it did not satisfy the needs of poor countries.9 thus, the concern was that trips serves the interests of major producers of pharmaceutical products and restricts access to essential medicine for the poor. as correa notes: “developing countries were coerced to accept the new standards set forth by the agreement in exchange for the benefits they would supposedly obtain in other areas, such as agriculture and textiles”.14 nevertheless, some developing countries might provide compulsory licensing provisions in respect to trips' rights to produce drugs, especially for treating hiv/aids. generic drug manufacturers in india, china, and brazil are challenging the monopoly of the drug transnationals.7 such patent regime allowed the indian pharmaceutical industry to thrive. it makes india one of the most efficient manufacturers of generic medicine, giving this country's substantial expertise in reverse engineering and a new method of producing pharmaceutical goods. the same pattern can be seen in other developing countries like brazil.16 overall, the opportunity to design the patent regime that meets the particular needs of each country increased the world supply of low-cost, generic medicines; poor, developing countries benefited from this. however, most drugs manufacturers argued that compulsory licenses did not permit trade in generic medicine in accordance trips.13 correa asserts that in the 1990s, thailand's government tried to produce specific hiv/aids drugs like ddi, invented by pharmaceutical manufacturer “bristol-myers squibb” in the usa; in turn, the us government imposed trade sanctions on exports to thailand.14 as a result, the massive production of drugs in thailand decreased dramatically. developing countries tried to find compromise with developed countries to use compulsory licensesthey promised not to produce medicines in case wealthy countries decreased the price of drugs, particularly for poor people.5 stiglitz suggests that rich countries cannot play “one-size-fits-all” policies. the granting of a compulsory license may be an important tool to introduce competition and thereby lower the prices and affordability drugs”, but developing countries were right to demand a trips's revision.5 in order to cope with hiv/aids problems, in 2001 brazil forced the us pharmaceutical companies to decrease the prices of medications for the treatment of hiv/aids by threatening them with compulsory licences and parallel importation.15 as a result, it was estimated that a generic medicine would become available for more than 600,000 hiv-positive patients in the country.5 therefore, to some extent the limitation to patent right in trips could be effective to pursue public interests. another problem was that some developing countries (like in sub-sahara africa) could not afford to set up production of essential medicine under the trips compulsory licensing arrangements and therefore failed to secure their domestic health situation.16 they also could not import cheap medicine from other countries because export and import of patented goods under compulsory licensing initially was not permitted by trips.5 many critics accuse the trips agreement of limiting the poor’s access to essential generic medicine, worsening the aids crisis.9 in order to address such a failure, the wto ministerial conference adopted the “doha declaration” on the trips agreement in 2001 and waiver decision in 2003.5,15,16 stiglitz, for example, suggests that we “‘waive‘ the tax allowing [poor countries] to use the intellectual property for their own citizens”. some developing countries were satisfied; they expressed concerns about the complexity of its arrangements.14 the usa proposed that the system must be applied to limited lists of diseases agreed by wto members.16 even so, the usa proposal was denied and is now under the discretion of the individual member to decide whether the public health situation needs to be addressed through granting mandatory licences to the exporters of pharmaceutical products.16critics have also argued “the developing countries are simply free-riding on the advanced industrial countries”.5 it is clear that individual countries can decide their own social policy priorities. trips illustrates that through cooperation among developing countries, negotiation and mitigation with global institutions and organizations can be successful. on the contrary, many authors argue that the waiver decision does not establish a straightforward and expeditious system (abbott et al, 2007). the procedure of granting compulsory licences for exports contains many bureaucratic formalities that discourage the wide use of this system.16 thus, according to evidence, it seems reasonable to conclude that individual countries can still partially decide their own social policy priorities. conclusions: the place of individual countries in global health policy making over the past three decades, the role of global institutions (imf, wto and the world bank) has increased rapidly. also, in the 1990s “due to the domination of economic globalization concepts, there was slow progress in implementation of human rights to making decision in health by developing countries” (kohlmorgen, 2008:99). secondly, there is an increasing role of health diseases like hiv/aids on a global scale, allowing developing countries (like india and brazil) to use their power in domestic making decision. nevertheless, patents for producing hiv/aids drugs have two sides that are affecting developed and developing countries. they foster the development of new drugs that contribute to health care and wealth creation in developed countries; however, patents impede broad access to such drugs in developing countries, while they fail to promote the development of drugs needed by the poor”.14 finally, implicated is the possibility that in the era of globalization, individual countries can provide their own social health policy due to the trips agreement (like compulsory licenses, parallel imports), though in some cases the developed countries try to create barriers. references 1. meyer jw. globalization: theory and trends. international journal of comparative sociology. 2007;48(4):261-273. 2. o'brien r. organizational politics, multilateral economic organizations and social policy. global social policy. 2002;2(2):141-161 3. seckinelgin h. introduction in international politics of hiv/aids: global disease-local pain. london: routledge; 2008. 4. chang h. globalization, economic development and the role of the state. london: zed press; 2003. 5. stiglitz j. making globalization work. new york: norton & company, inc.; 2006. 6. seckinelgin h. global social policy and international organizations: linking social exclusion to durable inequality. global social policy. 2009;9(2):205-227. 7. mehrotra s. global institutions in local decision making: the trojan horses of the new millenium? global social policy. 2004;4(3):283-287. 8. rowden r. blocking progress: the imf and hiv/aids. global social policy. 2008;8(1):19-24. 9. hein w, kohlmorgen, l. global health governance: conflicts on global social rights. global social policy. 2008;8(1):80-108. 10. oestreich je. the human rights responsibilities of the world bank: a business paradigm. global social policy. 2004;4(1):55-76. 11. noël a. the new global politics of poverty. global social policy. 2006;6(3):304-333. 12. yeates n. globalization and social policy: from global neoliberal hegemony to global political pluralism. global social policy. 2002;2(1):69-91. 13. shadlen k. the political economy of aids treatment: intellectual property and the transformation of generic supply. international studies quarterly. 2007;51:559-581. 14. correa c. public health and intellectual property rights. global social policy. 2002;2(3):261-278. 15. abbott f, cottier t, gurry f. international intellectual property in an integrated world economy. new york: aspen publishers; 2007. 16. duncan m. when farming meets law; using human rights as a practical instrument to facilitate access to medicines in developing countries. the wipo journal. 2011;3(1):113-127. erythrocytes as carriers for drugs and contrast agents new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. erythrocytes as carriers for drugs and contrast agents mauro magnani department of biomolecular sciences, university of urbino, urbino, italy vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.89 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ magnani this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.89 | http://cajgh.pitt.edu abstract erythrocytes, also known as red blood cells (rbc), are typically used in transfusion medicine to replace lost blood in patients who underwent different kinds of medical treatments as well as those involved in accidents resulting in blood loss. in addition to these common uses, rbc are being used for a variety of new applications either as therapeutics or as diagnostics. most of these novel approaches are made possible due to the peculiar properties of these cells. we have invented a technology that allows cells to be opened and resealed without affecting their main physiological characteristics with a minimal amount of patient blood. uses of processed rbcs in biomedical engineering include work with drugs, biomedical compounds and/or nanomaterials. these constructs are a new armamentarium available to the physicians for the release of drugs in circulation, for targeting drugs to selected sites in the body, or for in vivo diagnostic procedures based on magnetic and/or optical methods. autologous human rbc loaded with dexamethasone (erydex), a common corticosteroid, have been used in the treatment of cystic fibrosis, crohn’s disease, and other severe inflammatory conditions. benefits and safety of this technology have been documented in over 2,500 treatments. erydel spa is a company focused on developing and commercializing innovative therapies and diagnostics based on the use of autologous rbcs as agent carriers. more recently, erydel spa completed a phase ii proof of concept study in patients with ataxia telangiectasia (at), a rare progressive neurological autosomal recessive disorder that leads to mortality in most patients at an early age, with significant benefit seen on primary and secondary end-points. erydex treatment has received orphan drug designation by ema for the treatment of cystic fibrosis and both by ema and fda for the treatment of at. the encapsulation of superparamagnetic nanoparticles within rbc has lead to the generation of new biomimetic constructs that now permits the use of these nanomaterials in vivo avoiding their rapid sequestration and their accumulation in unwanted districts (pct wo 2008/003524 a3). similarly, the encapsulation of infrared fluorescent agents into rbc gives opportunity to the measurement of vasomotion in the human retinal vasculature suggesting a possible correlation with retinal edema. in summary, the newly developed rbc-based drug delivery system is an innovative technology platform that could be used in a wide range of applications opening to unlimited new therapeutic approaches. furthermore, the same system has been adapted to deliver contrasting agents within the body enabling the improvement of current fluorangiographic procedures and the imaging by magnetic resonance (mri) and magnetic particle (mpi). erydel s.p.a. has recently completed trials to bring erydex treatment to the market and to implement the clinical applications of the rbc technology. keywords: erythrocytes, biomedical engineering, red blood cell technology http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx modernization and growth in kazakhstan modernization and growth in kazakhstan almaz sharman deputy ceo for medicine, nazarbayev university, astana, republic of kazakhstan editorial kazakhstan has experienced tremendous growth and rapid economic expansion in recent years. with oil wealth and a vibrant financial sector and investment climate, the country is in a position to leverage its economic prosperity by first of all fostering economic growth in key industries and fields. as a next step, the government of kazakhstan wants to diversify the economy and develop high-value added goods and services. as part of its modernization program, kazakhstan has singled out institutional reforms in higher education and science as a priority to foster a new generation of world-class researchers, engineers, and social scientists. a crucial element in this process is a new research university. nazarbayev university, which was established in astana only two years ago, aims to become a globally recognized teaching and research institution. its primary goal is to equip the country's students to compete globally by integrating teaching, research and the industrial application of science. we recognize that the fruits of scientific discovery have already been taken from the bottom of the tree of knowledge. to get to the top of the tree of knowledge more efforts and more resources are needed. therefore, research is the crucial component in our development strategy. until recently, policy on research funding in kazakhstan was focused on sustaining the existing institutions rather than the development of research and innovative mechanisms. because of that, there was insufficient funding for high quality research, and few opportunities existed for research jobs in-country. intellectual property was not managed in a structured fashion while long-term venture-like funds have not been established to help develop an industry. recently kazakhstan adopted a new law on science that is expected to radically change the research environment in kazakhstan. the new law prioritizes the following areas: energy research innovative technologies in processing of raw materials innovation and telecommunication technologies life sciences basic research in humanities and other fields the new law establishes national research councils in the relevant priority areas and three streams of research funding: basic funding to support scientific infrastructure, property, and salaries grant funding to support research programs program-target funding to resolve strategic challenges in addition, the new law establishes a system for peer review of research grant applications. in 2012, the government funding for research and development is expected to reach us$331 million, which is 40 percent higher than in 2011. the plan is to exceed 1 percent gdp in research funding. in the light of these new developments and funding opportunities, researchers in kazakhstan aspired to prove their capabilities to the world’s scientific arena. we recognize that the best way to be internationally recognized is through publishing scientific results in international peer reviewed journals with high impact factor. indeed, this is one of the critical and well recognized measures of scientific merit. unfortunately, kazakhstan and the other countries of central asia are far behind in publication rate and impact compared to such nations as the us, japan, korea, russia, etc. only 439 articles have been published so far in peer reviewed journals by kazakhstani researchers, while the rate of publications in the other central asian countries is even lower. despite the fact that the publication rate has grown over the past decade, it is still insufficient to demonstrate the regions significance in the area of research and development. in this regard, we are pleased to announce the inaugural issue of the central asian journal of global health (cajgh.pitt.edu), which is a peer-reviewed scientific journal developed as a result of a partnership of nazarbayev university with the university of pittsburgh’s supercourse program (www.pitt.edu/~super1). the program was developed within the framework of the world health organization’s collaborating centre for disease monitoring and telecommunications at the university of pittsburgh. this is a newly launched journal aimed at publishing research data, reviews, and other important issues relevant to various fields of public health and biomedicine. specifically, it focuses on quality publishing and is aimed at increasing the number of peer reviewed publication coming from researchers from kazakhstan and central asia. our best hope is that scientists, doctors, epidemiologists and other researchers will use this opportunity to present their results and observations to the worldwide scientific community. we believe that this new initiative will help us to achieve our strategic goals of transforming medicine and healthcare in kazakhstan from a curative to a preemptive paradigm, accelerating translation of research findings from the bench to the bedside to the community. it will also help in in our efforts to provide the evidence and knowledge base to allow for a rational transformation of kazakhstan’s healthcare system. almaz sharman, md, phd, professor of medicine deputy ceo for medicine, nazarbayev university, astana, republic of kazakhstan http://zdrav.kz/almazsharman/en dr.sharman@gmail.com www.twitter.com/almazsharman use of public health promotion items to improve health in saudi arabia new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this site is published by the university library system of the university of pittsburgh as part of its dscribe digital publishing program and is cosponsored by the university of pittsburgh press. use of public health promotion items to improve health in saudi arabia khalid al aboud, waleed jameel, zaheer al asmari, hamdan al osaimy, awateef al sobiani, samiah abdul salam, yasser al zahrani department of public health, king faisal hospital, makkah, saudi arabia vol. 2, no. 2 (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.77 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ al aboud this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.77 | http://cajgh.pitt.edu keywords: promotional gifts, saudi arabia, public health, e-health, disease prevention use of public health promotion items to improve health in saudi arabia khalid al aboud, waleed jameel, zaheer al asmari, hamdan al osaimy, awateef al sobiani, samiah abdul salam, yasser al zahrani department of public health, king faisal hospital, makkah, saudi arabia short report in recent decades, the saudi arabian government has prioritized the development of health care services at all levels of care: primary, secondary, and tertiary. this has caused an improvement in health among the saudi population. 1,2 despite these improvements, there remains a large problem of language barriers between healthcare providers and their patients. 3,4 many saudi health care providers come from other countries and do not speak arabic. bridging the gap between providers and their patients is crucial for improving the understanding of disease prevention. in the past, healthcare providers have tried multiple techniques to connect with their patients, including: utilization of the internet and social media, promotional items like posters and leaflets, and information distributed through text-messaging services. 5,6 because addressing the language barrier has proven very difficult, experts have sought alternative methods for connecting health care providers to their patients. one potential method is to increase awareness about health care using gifts and promotional items. the use of gifts with printed public health messages has been suggested as an alternative because it helps to deliver important health care messages to the community. 5,7-9 by definition, promotional or advertising gifts are merchandise that promote a company, corporate image, or brand. some examples of gifts include calendars, mugs, bags, watches, or toys. the messages of these items can be used to promote any area related to public health awareness, such as: dengue fever control, early detection of breast cancer, and immunizations for childhood diseases. these messages must be concise, understandable, and targeted to the proper audience. for example, mugs with information about the importance of blood sugar control may be placed in diabetic clinics. the use of promotion items has proven successful when used appropriately, as shown among tb patients. 10 a recent study by the center for global development shows that people were more compliant and enthusiastic when given promotional gifts. through use of promotional gifts, health care providers in saudi arabia may help change the public perception of health care and medicine, create awareness regarding specific public health messages, as well as improve health care providers’ relationships with their patients, despite language barriers. references 1. almalki m, fitzgerald g, clark m. health care system in saudi arabia: an overview. eastern mediterranean health journal = la revue de sante de la mediterranee orientale = alhttp://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.77 | http://cajgh.pitt.edu majallah al-sihhiyah li-sharq al-mutawassit. 2011;17(10):78493. 2. al-ahmadi h, roland m. quality of primary health care in saudi arabia: a comprehensive review. international journal for quality in health care : journal of the international society for quality in health care / isqua. 2005;17(4):331-46. 3. mansour a, al-osimy m. a study of satisfaction among primary health care patients in saudi arabia. j community health. 1993;18(3):163-73. 4. shabrawy ali m, ali mahmoud me. a study of patient satisfaction with primary health care services in saudi arabia. j community health. 1993;18(1):49-54. 5. vyas a, landry m, schnider m, rojas a, wood s. public health interventions: reaching latino adolescents via short message service and social media. jmir. 2012. 6. ybarra ml, holtrop js, prescott tl, rahbar mh, strong d. pilot rct results of stop my smoking usa: a text messaging-based smoking cessation program for young adults. nicotine & tobacco research : official journal of the society for research on nicotine and tobacco. 2013;15(8):1388-99. 7. kickbusch i, payne l. twenty-first century health promotion: the public health revolution meets the wellness revolution. health promotion international. 2003;18(4):275-8. 8. the proven, often unconscious, influence of small gifts. prescrire international. 2011;20(122):303-5. 9. sandberg ws, carlos r, sandberg eh, roizen mf. the effect of educational gifts from pharmaceutical firms on medical students' recall of company names or products. academic medicine. 1997;72(10):916-8. 10. beith a, eichler r, weil d. worldwide: incentives for tuberculosis diagnosis and treatment. in: development cfg, editor. 2009. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx herbal extracts in the treatment of diabetic foot syndrome new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. herbal extracts in the treatment of diabetic foot syndrome tatyana kustova1, tatyana karpenyuk1, alla goncharova1, leonid mamonov2, samir ross3 1department of biology and biotechnology, al-farabi kazakh national university, almaty, kazakhstan; 2institute of plant biology and biotechnology; 3school of pharmacy, university of missisippi, oxford, mississippi vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.86 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kustova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.86 | http://cajgh.pitt.edu abstract introduction: one of the most serious complications of diabetes is the formation of diabetic foot syndrome. herbal extracts that combine high antioxidant and antimicrobial properties can be used to treat the resulting neuropathy. the aim of this study was to determine antimicrobial and antioxidant activities of crude extracts isolated from plants growing in kazakhstan, which could be used to develop products for treatment of diabetic foot syndrome. method: different solvents, including dichloromethane and ethanol, were used to prepare plant extracts. the crude extracts from the plants were tested for antimicrobial activity using a modified version of the clsi/nccls methods. all organisms were obtained from american type culture collection. these included the fungi candida glabrata attc 90030, the bacteria staphylococcus aureus atcc 29213, and methicillin-resistant s. aureus atcc 43300. the 2,2-diphеnyl-1-picrylhydrazyl (dpph) assay, 2,2-azinobis (3-ethylbenzothiazoline-6-sulfonic acid) diammonium salt (abts) radical scavenging assay were used to analyzed the antioxidant capacity. results: the results clearly indicate that antibacterial and antifungal activities vary with plant species. dichloromethane extracts produced favorable results in all assays. epilobium hirsutum, rhodiola quadrifida, rumex confertus showed antifungal activity against candida glabrata in all extracts where ic50 less than 3 μg/ml. rumex confertus, glycyrrhiza uralensis and vexibia alopecuroides showed anti-fungal activity against staphylococcus aureus (ic50 =10.80 μg/ml), (ic50 =11.10 μg/ml), (ic50 =3.05 μg/ml) and methicillin-resistant s. aureus (ic50 =16.20 μg/ml), (ic50 =11.00 μg/ml), (ic50 =2.90 μg/ml) respectively. in spite of this, vexibia alopecuroides extract showed no antioxidant activity. the other extracts showed a dose dependent abts scavenging activity. ic50 values were for the following: 6.6 μg/ml epilobium hirsutum; 4.5 μg/ml rumex confertus; 3.8 μg/ml rhodiola quadrifida, 5.7 μg/ml glycyrrhiza uralensis. extracts of epilobium hirsutum and rumex confertus had high antioxidant activity greater than 85% inhibition of dpph (p ≤ 0.05). conclusion: the demonstrated antimicrobial and antioxidant activities showed evidence supporting the use of herbal extracts to treat diabetic foot syndrome. keywords: diabetes, diabetic food syndrome, herbal extracts, kazakhstan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx reversibility of cellular aging by reprogramming through an embryonic-like state: a new paradigm for human cell rejuvenation new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. reversibility of cellular aging by reprogramming through an embryonic-like state: a new paradigm for human cell rejuvenation jean-marc lemaitre director of inserm laboratory, genome plasticity and aging, institute of functional genomics, montpellier, france vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.88 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ lemaitre this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.88 | http://cajgh.pitt.edu abstract direct reprogramming of somatic cells into induced pluripotent stem cells (ipscs) provides a unique opportunity to derive patient-specific stem cells with potential application in autologous tissue replacement therapies and without the ethical concerns of embryonic stem cells (hesc). however, this strategy still suffers from several hurdles that need to be overcome before clinical applications. among them, cellular senescence, which contributes to aging and restricted longevity, has been described as a barrier to the derivation of ipscs. this suggests that aging might be an important limitation for therapeutic purposes for elderly individuals. senescence is characterized by an irreversible cell cycle arrest in response to various forms of stress, including activation of oncogenes, shortened telomeres, dna damage, oxidative stress, and mitochondrial dysfunction. to overcome this barrier, we developed an optimized 6-factor-based reprogramming protocol that is able to cause efficient reversing of cellular senescence and reprogramming into ipscs. we demonstrated that ipscs derived from senescent and centenarian fibroblasts have reset telomere size, gene expression profiles, oxidative stress, and mitochondrial metabolism, and are indistinguishable from hesc. finally, we demonstrate that re-differentiation led to rejuvenated cells with a reset cellular physiology, defining a new paradigm for human cell rejuvenation. we discuss the molecular mechanisms involved in cell reprogramming of senescent cells. keywords: embryonic stem cells, aging, longevity, cell rejuvination http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx deprivation of human natural killer cells and antitumor immune response new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. deprivation of human natural killer cells and antitumor immune response vyacheslav ogay1, aliya sekenova1, inpyo choi2 1laboratory of stem cells, national center for biotechnology, almaty, kazakhstan; 2immunotherapy research center, korea research institute of bioscience and biotechnology, daejeon, republic of korea vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.98 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ ogay this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.98 | http://cajgh.pitt.edu abstract introduction: cell-based immunotherapy has been given increased attention as a treatment for cancer. human natural killer (nk) cells are resident lymphocyte populations. they exhibit potent antitumor activity without human leukocyte antigen matching and without prior antigen exposure. they also are a promising tool for immunotherapy of solid and hematologic cancers. however, most cancer patients do not have enough nk cells to induce an effective antitumor immune response. this demonstrates a need for a source of nk cells that can supplement the endogenous cell population. material and methods: in this study, we derived induced pluripotent stem cells (ipscs) from peripheral blood t-lymphocytes using sendai virus vectors. results: generated ipscs exhibited monoclonal t cell receptors (tcr) rearrangement in their genome, a hallmark of mature terminally differentiated t cells. these ipscs were differentiated into nk cells using a two-stage coculture system: ipscs into hematopoietic cd34+ cells with feeder cells m210-b4 (atcc, usa) and cd34+ cells into mature nk cells with aft024 cells (atcc, usa). our results showed that ipsc-derived nk cells expressed cd56, cd16, nkp 44 and nkp 46, possessed high cytotoxic activity and produced high level of interferon-γ. conclusion: based on our data, derivation of nk cells from induced pluripotent stem cells should be considered in the treatment of oncologic diseases.this would allow for the development of cell therapy for cancer using immunologically compatible nk cells derived from ipscs. this may contribute to a more efficient treatment of oncologic diseases in addition to traditional cancer treatment. keywords: human natural killer cells, antitumor immune response, oncologic diseases http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx pharmacogenetic research in kazakhstan new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. pharmacogenetic research in kazakhstan elena zholdybayeva1, aisha iskakova1, aliya romanova1, erlan ramanculov2, kuvat momynaliev1 1national center for biotechnology, astana, kazakhstan; 2nazarbayev university, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.87 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ zholdybayeva this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.87 | http://cajgh.pitt.edu abstract introduction: pharmacogenomics is an emerging field of medicine that combines genetics and pharmacology. pharmacogenomic research is relatively new in kazahkstan, but, in recent years, significant progress has been made in this field. the national scientific laboratory for biotechnology has launched several government-funded research projects focused on finding genetic markers that determine susceptibility to various drugs. another goal of pharmacogenetic research in the laboratory is to find the pharmacogenomic markers that target cardiovascular diseases, accounting for allelic frequencies in selected genes in the kazakh population. in addition, pharmacogenomic testing kits allow patients to choose the drug dosage. for example, the drug warfarin has been developed within the framework of the "technology commercialization project,” funded jointly by the ministry of education and science of the republic of kazakhstan and the world bank. material and methods: the pharmacogenomic studies were conducted using the real-time pcr and direct dna sequencing. dna was isolated from venous blood or buccal cells, collected from patients. results: to date, we have identified the most promising areas of research in the field of pharmacogenomics in kazakhstan. the allelic frequencies of a number of polymorphisms in the kazakh population have been calculated (cyp2c9, cyp2c19, cyp3a4, vkorc1, cyp4f2, ggcx, cyp2d6, cyp1a2, nat2, gstp1, slc47a1). a unique repository of dna samples was established and is being replenished during the implementation of aforementioned projects. development of the testing kit for individual selection of warfarin dosage is nearing completion. a patent, named "method of selection based dose warfarin genotyping for the kazakh population" has been recently obtained. an application for another patent, titled "express method of correction of warfarin dosing, based on real-time pcr" has received positive evaluation. the results of domestic pharmacogenomic studies will allow a more rational selection of drugs and their dosage regimens specific to the kazakh population. keywords: pharmogenomic research, genotyping, allelic frequencies, kazakhstan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx keeping up with the time keeping up with the times valentina burambayeva head of the department of organizational and analytical work; quality manager of the center for sanitary and epidemiological expertise, mangistau region news the republic of kazakhstan is in transition to the world trade organization (wto) accession. accessing to wto has always been and remains a foreign policy priority for kazakhstan. as a part of this transition, kazakhstan is identifying new directions for developing and reforming healthcare disciplines. the goal of this overview is to provide information about the work of centers of sanitary and epidemiological expertise to medical and public health professionals in various fields. additionally, the goal of this paper is to provide information about international accreditation and quality control activities of the centers. there are 16 centers of sanitary and epidemiological expertise in the republic, 15 of which have been locally accredited. implementation of innovation policy at the centers for sanitary and epidemiological expertise fueled the process of international accreditation. it is important to point out that the only center which has an international accreditation as of september of 2012 is the astana city center. the center for sanitary and epidemiological expertise of mangistau region was accredited in 2010 and gained the status as a test center. the mangistau test center applies previously developed criteria and procedures to estimate technical competence. one of the main standard documents used to estimate competence is iso/iec 17025 from the international organization for standardization/international electrotechnical commission, which assesses the following factors: personnel technical competence validation of testing methods efficiency, calibrating test and service of testing equipment testing environment selection, processing and transportation of testing samples quality provision of testing and calibration data the introduction of a quality management system was a success. in order to increase the technical competence level, 29 specialists from the center have been trained and have received certificates of compliance. in september 2011 and april 2012, the ministry of healthcare of the republic of kazakhstan within the framework of the world bank project, component f (“food safety program and world trade organization accession”), arranged international workshops aimed to train quality managers to meet international requirements and standards. training seminars for international accreditation provided hands on and methodological sessions combined with the dissemination of the comprehensive tutorial materials. regional trip seminars were organized by the center specialists. laboratories of the republic were accredited by the national center for accreditation (nca). on october 27, 2010, nca signed the international laboratory accreditation cooperation mutual recognition arrangement (ilac mra) agreement on mutual international acceptance of ilac standards. all accredited testing centers for sanitary and epidemiological expertise have an agreement with the national accreditation centers regarding the application of the laboratory combined mra mark. it allows for laboratories to apply this quality brand where applicable on internationally accepted test procedures and measurements. laboratory test records are issued with the nca logo and ilac mra marking. all these procedures are directed to achieve mutual cooperation with international organizations as a part of the world trade organization accession. the international acknowledgement of the national accreditation system will serve as the basis for bilateral arrangements between kazakhstan and its trade partners, which will create favorable conditions for entering wto. genomic research perspectives in kazakhstan new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. genomic research perspectives in kazakhstan ainur akilzhanova center for life sciences, nazarbayev university, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.101 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ akilzhanova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.101 | http://cajgh.pitt.edu abstract introduction: technological advancements rapidly propel the field of genome research. advances in genetics and genomics such as the sequence of the human genome, the human haplotype map, open access databases, cheaper genotyping and chemical genomics, have transformed basic and translational biomedical research. several projects in the field of genomic and personalized medicine have been conducted at the center for life sciences in nazarbayev university. the prioritized areas of research include: genomics of multifactorial diseases, cancer genomics, bioinformatics, genetics of infectious diseases and population genomics. at present, dna-based risk assessment for common complex diseases, application of molecular signatures for cancer diagnosis and prognosis, genome-guided therapy, and dose selection of therapeutic drugs are the important issues in personalized medicine. results: to further develop genomic and biomedical projects at center for life sciences, the development of bioinformatics research and infrastructure and the establishment of new collaborations in the field are essential. widespread use of genetic tools will allow the identification of diseases before the onset of clinical symptoms, the individualization of drug treatment, and could induce individual behavioral changes on the basis of calculated disease risk. however, many challenges remain for the successful translation of genomic knowledge and technologies into health advances, such as medicines and diagnostics. it is important to integrate research and education in the fields of genomics, personalized medicine, and bioinformatics, which will be possible with opening of the new medical faculty at nazarbayev university. people in practice and training need to be educated about the key concepts of genomics and engaged so they can effectively apply their knowledge in a matter that will bring the era of genomic medicine to patient care. this requires the development of well-equipped laboratories, bioinformatics, as well as qualified trained physicians and laboratory staff. keywords: genomic research, biomedical science, kazakhstan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx emerging infectious diseases, antimicrobial resistance and millennium development goals: resolving the challenges through one health g. v. asokan1, r. k. kasimanickam2 1public health program, college of health sciences, university of bahrain, manama, bahrain; 2department of veterinary clinical sciences, college of veterinary medicine, washington state university, pullman, wa abstract most emerging infectious diseases are zoonoses, which could severely hamper reaching the targets of millennium development goals (mdg). five out of the total eight mdg’s are strongly associated with the emerging infectious diseases (eids). recent emergence and dissemination of drug-resistant pathogens has accelerated and prevent reaching the targets of mdg, with shrinking of therapeutic arsenal, mostly due to antimicrobial resistance (amr). world health organization (who has identified amr as 1 of the 3 greatest threats to global health. until now, methicillin-resistant staphylococcus aureus (mrsa) and vancomycin-resistant enterococci (vre) have been observed in hospital-acquired infections. in india, within a span of three years, new delhi metallo-β-lactamase prevalence has risen from three percent in hospitals to twentyfifty percent and is found to be colistin resistant as well. routine use of antimicrobials in animal husbandry accounts for more than 50% in tonnage of all antimicrobial production to promote growth and prophylaxis. this has consequences to human health and environmental contamination with a profound impact on the environmental microbiome, resulting in resistance. antibiotic development is now considered a global health crisis. the average time required to receive regulatory approval is 7.2 years. moreover, the clinical approval success is only 16%. to overcome resistance in antimicrobials, intersectoral partnerships among medical, veterinary, and environmental disciplines, with specific epidemiological, diagnostic, and therapeutic approaches are needed. joint efforts under “one health”, beyond individual professional boundaries are required to stop antimicrobial resistance against zoonoses (eid) and reach the mdg. keywords: emerging infectious diseases, zoonoses, antimicrobial resistance, millennium development goals, one health research emerging infectious diseases (eid), mostly zoonoses, pose enormous threats, which could severely hamper reaching the targets of the health-related united nations millennium development goals (mdg) set for 2015.1 the following five out of the total eight mdg’s are strongly associated with the eids: 1. reducing child mortality rates; 2. improving maternal health; 3. combating hiv/aids, malaria, and other diseases; 4. ensuring environmental sustainability; and 5. developing a global partnership for development. of all known infectious diseases, zoonoses constitute about 60%. within emerging infectious diseases, approximately 75% are of zoonotic origin. by classification, 40% of fungi, 50% of bacteria, 70% of protozoa, 80% of viruses, and 95% of helminths that infect human beings are zoonotic. it has been recognized that more than 50% of human pathogens can infect other vertebrate hosts.2 only 100 of the approximately 400 known emerging pathogens occur as human pathogens.3 among the marine mammal pathogens at least 49% are zoonotic, and 28% are emerging zoonoses.4 emerging zoonoses, such as hendra, nipha, avian influenza, and severe acquired respiratory syndrome (sars) are a growing threat to global health and have caused huge economic loss in the past 20 years. there is poor understanding of how zoonotic pathogens evolve from natural ecology and cause disease, and how various circumstances, such as animal production, extraction of natural resources, and antimicrobial application alter the dynamics of disease exposure to human beings.5 to counter the shared risks between animals and humans, the concept of “one health” was developed during the early 21st century and is based on a systems approach.6 one health has been defined as "the collaborative effort of multiple disciplines working locally, nationally, and globally to attain optimal health for people, animals, and the environment."7 the purpose of this review is to look at the challenges faced due to antimicrobial resistance in eid particularly zoonoses and find solutions under a “one health” approach to reach the targets of the mdg. antimicrobial resistance microorganisms have evolved over the ages and have an innate ability to survive by developing resistance to antimicrobial compounds administered. antimicrobial resistance (amr), sometimes known as drug resistance, occurs when microorganisms such as bacteria, viruses, fungi and parasites change ways to render the existing standard medications such as antibacterials (antibiotics -mrsa), antifungals (candida resistance to fluconazole), antivirals (h1n1 resistance to oseltamivir), and antiparasitics (chloroquine resistance to malarial parasite) ineffective. in recent times, the emergence and dissemination of drug-resistant pathogens has accelerated, proving to be global, extremely dangerous, and preventing reach of the set targets of mdg. with no borders between ecosystems, the spread of drug resistance is linked to the following: human life activity and travel, animals and the food trade, wild animals, migration, transportation, as well as water and wind flow. further, eid are becoming untreatable and uncontrollable due to shrinking of the existing therapeutic arsenal, mostly due to amr. sensing the public health threat and having identified amr as one of the three greatest threats to global health, the world health organization (who) announced the theme for world health day 2011 as “antimicrobial resistance: no action today, no cure tomorrow.”8 moreover, the emergence of “superbugs” occurs when microorganisms become resistant to most antimicrobials currently available. these resistant superbug infections are of great concern, since this may spread and cause death, placing burden on health care expenditures. amr in humans in humans, antimicrobials are commonly used for the treatment and control of infectious diseases that address three of the eight mdg, namely: reducing child mortality rates, improving maternal health and combating hiv/aids, malaria, and other diseases. besides, antimicrobials are used for treatment and prophylaxis of complex surgeries, intensive care, organ transplants, care of premature babies and the elderly, and survival of the immunosuppressed. severe problems of amr are associated with multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis. rarely, mycobacterial infections of livestock are treated with antimicrobials, which could therefore add to the pool of tuberculosis. falciparum malaria parasites resistant to artemisinins are emerging. new resistance mechanisms, such as the beta-lactamase (new delhi metallo-β-lactamasendm-1) have emerged among several gram-negative bacilli. the beta-lactamase resistant strains of escherichia coli from india have spread to other countries.9 until recently, such completely resistant bacteria have only been found in hospitals, such as methicillin-resistant staphylococcus aureus (mrsa) and vancomycin-resistant enterococci (vre) in hospital-acquired infections. in india, within a span of three years, ndm-1 prevalence has gone up from three percent in hospitals to 20 to 50 percent, and patients were found to be resistant to colistin which is used against multi resistant gram negative bacteria.10 other causes of amr in humans include: over-the-counter selling of antimicrobials without a licensed physicians prescriptions has been rampant mostly in the developing world and pharmaceutical incentives to the physicians for prescriptions. amr in animals and environment manifestation of antimicrobial resistance in veterinary medicine is intricate because of the number of animal species, the diversity of environmental conditions in which the animals are reared, the differences in the microbes involved and pathogenicity mechanisms, and the complex epidemiology.11 in most parts of the world, routine use of antimicrobials in animal husbandry account for more than 50% of the tonnage of all antimicrobial production to promote growth and for prophylaxis in food-producing animals of cattle, poultry, swine, fish, and honeybee. in the united states alone, 80% of all antibiotics sold are administered to food producing animals for growth promotion and prophylaxis.12 it has been estimated that antibiotic use in animals and fish is far greater than the usage in humans (as much as 1,000-fold higher).13 risk quantification by the use of antimicrobials in animal husbandry is not possible due to the vast dispersal area from run-off and other sources of environmental contamination.14 further, use of antimicrobial agents in food-producing animals has also contributed to the development of resistant pathogens with resistance genes. the direct effect was observed more than 35 years ago, with high rates of amr in the intestinal flora of farm animals and farmers.15 molecular detection tools have shown that resistant bacteria in food producing animals reach consumers through meat products.16 usually, resistant microbes in animals are transferred to people, not only through consumption of food but also through direct contact with food-producing animals or through environmental spread. as an indirect impact, it has been observed that up to 90% of antimicrobials given to animals are excreted in urine and stool and then widely dispersed through fertilizer, surface runoff, and groundwater, with a profound impact on the environmental microbiome. this has implications on two mdg’s namely: ensuring environmental sustainability, and developing a global partnership for development. various environmental samples of different geological age have proved that resistance genes in the environment are higher than those found in pathogens, and have existed for thousands of years. the word ‘resistome’ refers to the population of resistant genes in nature.16,17 this has resulted in human infections with resistant microbes to antimicrobial agents and is difficult or impossible to cure. extensive use of invasive procedures, and high rates of antimicrobial use, results in a nosocomial “environmental resistome.” of special concern is resistance to antimicrobial agents classified by the world health organization (who) as critically important for human medicine, such as fluoroquinolones, thirdand fourth-generation cephalosporins, and macrolides.18 research and development of new antimicrobial agents the discovery of antibiotics in the 1930s and 1940s transformed medicine from a diagnostic to a therapeutic discipline.19 sulphonamides and penicillin came into use in the 1940s. selman waksman discovered streptomycin in 1943 which propelled important findings related to the ‘secondary metabolites’ produced by actinomycetes,20 and the next 40 years was considered as the golden era of antimicrobials. new classes of antibiotics were discovered, existing antibiotics were modified, and synthetic components were constantly tailored to combat emerging amr by improving the clinical qualities. until the late 1980s, the problem was not considered significant as many new substances were developed and marketed when resistance rendered existing drugs inefficient. however, views changed, as few new antibiotics have been introduced since the 1990s. in addition, financial challenges for antibiotic development showed a poor investment return, as they are taken as a short course to cure the targeted disease. in contrast, drugs that treat non communicable diseases, such as high blood pressure, are continuously taken for the patient’s life. this can be illustrated in terms of net present value (npv): at discovery, an antibiotic has a npv of –$50 million and are generally priced at a peak charge of $1,000–$3,000 per course, whereas, npv for a new musculoskeletal drug is estimated to a +$1 billion and a chemotherapy for cancer sometimes costs >$80, 000.21 antibiotic development is now considered a global health crisis. the average time required to take a product from the start of clinical testing to regulatory approval is 7.2 years, this excludes phases of discovery, research, preclinical and animal testing.22 moreover, the clinical approval success rate (the likelihood that a compound entering clinical testing will eventually reach the marketplace) is only 16%.23 a report published in 2004 showed that, of 506 drugs in development by 15 large pharmaceutical companies and seven major biotechnology companies, only six were antibiotics. this has declined further; by 2008, eight of the 15 major pharmaceutical companies had abandoned antibiotic discovery programs and two others had reduced them.24 approval of new antibacterial agents by the united states food and drug administration has shown a decrease of 56% between 1998 and 2002, and a 75% decrease in systemic antibacterials approved from 1983 through 2007;25 evidence of continued decrease in approvals was noticed between 2003 and 2007.26 yet another discouraging report mentions that no new class of antibiotics for gram negative bacilli has been found in the last four decades; only 2 drugs with new microbial targets (linezolid and daptomycin) have been introduced since 1998.27 recently, a study on antibiotic development involving small firms as well as large pharmaceutical companies revealed that only 15 of 167 antibiotics under development had a new mechanism of action.28 subsequently, a review identified that eight out of nine synthetic compounds are derived from quinolones, a class of antibiotic that may only require minor chromosomal mutations to gain resistance.29 it is estimated that over the next 5–10 years, the number of approved antibacterials will plateau at a level similar to that of the past 5 years which may approximate 1 drug per year.30 the association between disease status and antimicrobials is illustrated in figure 1. while the drug development process diminishes the disease load in a population it is countered by an increased disease load in humans, animals including aquatic and the environment by amr. figure 1. association between disease status and antimicrobials. conclusion most of the emerging infectious diseases are zoonoses, which have a direct influence on the majority of mdg. the emergence and spreading of drug-resistant pathogens, particularly zoonoses, has accelerated due to overuse, not following the prescribed length of use, misuse, and abuse of antimicrobials. more essential medicines are failing. the speed with which these drugs fail and are being lost far outpaces the development of replacement drugs. amr challenges control of infectious diseases, hampers mdg, threatens a return to the pre-antibiotic era, increases the health care budget, jeopardizes health-care gains achieved, compromises health security, and damages trade and economies. in order to reach the mdg, antimicrobial conservation must be one of the essential strategies. with limited health care resources, achieving a balance between conserving the effectiveness of existing antibacterial drugs and developing new ones is attracting attention among policy circles that will best serve public health, such as in viral respiratory tract infections a “delayed prescription” (any prescription for an antimicrobial where the patient is advised to delay getting the antimicrobial agent). preventing use of these drugs in self-resolving disease with uncertain evidence of effectiveness would limit the spread of antimicrobial resistance. in addition, maximizing hospital infection-control practices, antimicrobial surveillance and restricting the use of antibiotics in humans and animal husbandry can achieve conservation of antimicrobials. finally, to overcome microbial evolution, issues in antibiotic pipeline, and resistance in antimicrobials, intersectoral partnerships in research among medical, veterinary medical, and environmental disciplines, with specific epidemiological, diagnostic and therapeutic approaches needed. the “10 x '20” initiative of the infectious disease society of america is one such initiative. diagnostic tests to identify resistant organisms with new approaches (i.e. procalcitonin levels) are markers to facilitate decisions for when to use or stop antibiotics as these levels reflect bacterial replication. evidence has come from a meta-analysis and has shown that decisions guided by procalcitonin levels reduced antibiotic use by 51% without altering outcome.31 joint efforts are required under the “one health” multidisciplinary/interdisciplinary collaborative approach, beyond individual professional boundaries, to stop antimicrobial resistance against zoonoses (eid) and reach the mdg. references 1. united nations. united nations millennium development goals. http://www.un.org/millenniumgoals/reports.shtml. accessed july 27, 2013. 2. taylor lh, latham sm, woolhouse mej. risk factors for human disease emergence. phil trans r soc lond b. 2001;356(1411):983-989. 3. woolhouse mej, taylor lh, haydon dt. population biology of multihost pathogens. science. 2001;292(5519):1109-1112. 4. venn-watson s, stamper a, rowles t. thinking outside the terrestrial box: how high-priority, emerging, and zoonotic marine mammal pathogens reflect those of human pathogens. eco health. 2011;7. 5. karesh wb, dobson a, lloyd-smith jo, et al. ecology of zoonoses: natural and unnatural histories. lancet. 2012;380(9857):1936-1945. 6. american veterinary medical association. one health. https://www.avma.org/kb/resources/reference/pages/one-health94.aspx. accessed may 23, 2013. 7. one health initiative. www.onehealthinitiative.com. accessed october 10, 2013. 8. world health organization. who world health day. http://www.who.int/world-health-day/2011/en/index.html. accessed august 11, 2013. 9. thoen co, steele jh, gilsdorf mj. mycobacterium bovis infection in animals and humans, 2nd edition. emerg infect dis. 2006;12(8):1306. 10. castanheira m, deshpande lm, farrell se, shetye s, shah n, jones rn. update on the prevalence and genetic characterization of ndm-1-producing enterobacteriaceae in indian hospitals during 2010. diagn microbiol infect dis. 2013;75(2):210-213. 11. acar jf, moulin g, page sw, pastoret pp. antimicrobial resistance in animal and public health: introduction and classification of antimicrobial agents. rev sci tech. 2012;31(1):15-21. 12. us food and drug administration. 2010 summary report on antimicrobials sold or distributed for use in food producing animals. 2011; http://www.fda.gov/downloads/forindustry/userfees/animaldruguserfeeactadufa/m277657.pdf. accessed august 15, 2013. 13. marshall bm, levy s. food animals and antibiotics: impacts on human health. clin microbiol rev. 2011;24(4):718-733. 14. aarestrup fm, jensen vf, emborg hd, jacobsen e, wegener hc. changes in the use of antimicrobials and the effects on productivity of swine farms in denmark. am j vet res. 2010;71(7):726-733. 15. ansari f, molana h, goossens h, davey p. esac ii hospital care study group. development of standardized methods for analysis of changes in antibacterial use in hospitals from 18 european countries: the european surveillance of antimicrobial consumption (esac) longitudinal survey. antimicrob chemother. 2010;65(12):2685-2691. 16. wright gd. antibiotic resistance in the environment: a link to the clinic. curr opin microbiol. 2010;13(5):589-594. 17. d'costa vm, king ce, kalan l, et al. antibiotic resistance is ancient. nature. 2011;477(7365):457-461. 18. aidara-kane a. containment of antimicrobial resistance due to use of antimicrobial agents in animals intended for food: who perspective. rev sci tech. 2012;31(1):277-287. 19. infective diseases society of america (idsa). combating antimicrobial resistance: policy recommendations to save lives. clin infect dis. 2011;52(5):s397-428. 20. aminov ri. a brief history of the antibiotic era: lessons learned and challenges for the future. front microbiol. 2010;1:134. 21. sharma p, towse a. new drugs to tackle antimicrobial resistance: analysis of eu policy options. http://www.ohe./org/publications/article/new-drugs-totackle-2012resistance-5.cfm. accessed july 9, 2013. 22. kaitin ki. deconstructing the drug development process: the new face of innovation. clin pharmacol ther. 2010;87(3):356-361. 23. the nih common fund. common fund initiative. http://nihroadmap.nih.gov/initiatives.asp. accessed may 16, 2013. 24. taubes g. the bacteria fight back. science. 2008;321(5887):356-361. 25. infectious diseases society of america. the 10×20 initiative: pursuing a global commitment to develop 10 new antibacterial drugs by 2020. clin infect dis. 2010;50(8):1081-1083. 26. spellberg b, guidos r, gilbert d, et al. the epidemic of antibiotic resistant infections: a call to action for the medical community from the infectious diseases society of america. clin infect dis. 2008;46(2):155-164. 27. spellberg b, powers jh, brass ep, miller lg, edwards je. trends in antimicrobial drug development: implications for the future. clin infect dis. 2004;38(9):1279-1286. 28. braine t. race against time to develop new antibiotics. bull world health organ. 2011;89(2):88-89. 29. butler ms, cooper ma. antbiotics in the clinical pipeline in 2011. j antibiot (tokyo). 2011;64(6):413-425. 30. boucher hw, talbot gh, bradley js, et al. bad bugs, no drugs: no eskape! an update from the infectious diseases society of america. clin infect dis. 2009;48(1):1-12. 31. tang h, huang t, jing j, shen h, cui w. effect of procalcitonin guided treatment in patients with infections: a systematic review and meta-analysis. infection. 2009;37(6):497-507. editorial: brca1 and brca2 gene mutations screening in sporadic breast cancer patients in kazakhstan editorial: brca1 and brca2 gene mutations screening in sporadic breast cancer patients in kazakhstan rachel c. jankowitz1, kelly z. knickelbein2 1university of pittsburgh cancer institute, upmc magee women's cancer program; 2upmc center for medical genetics editorial while the majority of breast cancer cases are sporadic, up to 30% have been described as familial. hereditary breast cancer, accounting for approximately 10% of breast cancer cases, has classically been associated with highly penetrant gene mutations that are highly likely to cause cancer, vertical transmission, autosomal dominant inheritance pattern, association with other cancers, and early age of onset.1-5 in contrast, these characteristics are often not exhibited in familial breast cancers. therefore, although familial breast cancers occur more in an individual family than in the general population, they are thought to be due to a complex interaction between lower penetrance genes and environmental factors and/or random intra-familial sporadic cancer cases.3-5 in 1994, inherited mutations in brca1 and brca2 genes that encode for tumor suppressor proteins were linked to hereditary breast and ovarian cancer.6,7 since this groundbreaking scientific discovery, much has been learned about genetic risk of breast cancer (such as newer detection techniques with improved sensitivity to detect brca1 and brca2 large genomic rearrangements);8 however, many brca-related questions remain unanswered. the prevalence of known deleterious brca1 and brca2 gene mutations is approximately 1 in 400 individuals.9 due to variable penetrance, the probability of cancer development varies amongst brca mutation carriers, (even amongst carriers in families with the same mutation),10 but in general, brca deleterious mutations confer a 45-84% lifetime risk for breast cancer.11 it is, therefore, not surprising that known deleterious brca mutations are variable across different ethnic and geographic populations. moreover, founder mutations have been identified within ashkenzi jewish, icelandic, and other populations. when discussing brca1 and brca2 sequence variants, the terminology can be difficult to discern. variations that confer increased cancer risk are termed “deleterious mutations,” but a number of other changes in brca1 and brca2 are rapidly emerging, the significance of which are less clear. it is important, therefore, to use consistent language when discussing such findings. mutations and polymorphisms are both sequence variants. the term “mutation” signifies any rare deviation in the dna sequence of a gene from the normal wild type. polymorphisms, on the other hand, are common variations in dna that are generally considered to occur with a frequency greater than 1%.12 if a polymorphism is known to be disease-causing, then it will typically be referred to as a deleterious mutation, although most, but not all, deleterious mutations are seen at a lower frequency in the population. polymorphisms include, but are not limited to: single nucleotide polymorphisms (snps), insertions, deletions, or repeated sequences. snps are the most common type of polymorphism accounting for approximately 90% of all human genetic variation.13 most snps are benign or neutral polymorphisms with no known clinical impact; however, it is thought that some may provide useful clinical information, such as likelihood of developing disease, response to disease, and perhaps implications for treatment.14 polymorphisms and mutations can be further classified as synonymous or non-synonymous based on their impact on the resulting amino acid. a synonymous substitution results in a codon that does not lead to a change in the coded amino acid, whereas non-synonymous substitutions, such as missense mutations, do result in an amino acid change. lastly, variants of uncertain significance (vus) are novel dna changes with unknown effects on protein function and disease risk. pending further investigation, an identified vus could be reclassified as a deleterious mutation or a polymorphism of no clinical significance in the future.15 in the current publication, akilzhanova and colleagues examine the role of brca1 and 2 mutations in kazakhstan women with sporadic breast cancer. they studied genomic dna from 156 sporadic breast cancer cases (defined as women without family history of affected firstor seconddegree relatives with breast and/or ovarian cancer) and 112 controls (matched on age and ethnicity) from two different areas in kazakhstan. ultimately, mutational screening of brca1 and brca2 coding regions for these patients and controls identified 22 distinct variants (16 missense mutations of unknown clinical significance and 6 polymorphisms). no deleterious brca1 or 2 mutations were identified. there were significantly more variants in the caucasians versus the asian breast cancer cases and more variants in the asian versus the caucasian controls. they also found a number of women (79 of 156, 71%) who carried 4-6 alterations. this makes these alterations in the brca sequence much less likely to be deleterious, particularly if they were the same sequence variants that they termed “likely neutral polymorphisms,” (those that were expressed at a high frequency in both cases and controls). models incorporating variables from cancer history of patients as well as multiple other factors into logistic regression analyses potentially have the ability to segregate uncertain brca1 and brca2 variants into deleterious and non-deleterious categories.16-22 these models work best when there are enough occurrences of a single variant amongst unrelated families to help aid in its classification. we are still limited in finding ways to classify variants that occur rarely in a specific region.23 several resources exist for obtaining information regarding previously identified vus and snps including: the snp consortium,24 the dbsnp database from the national center for biotechnology information (ncbi), the breast cancer information core (bic) (http://research.nhgri.nih.gov/bic/), and hgvbase (human genome variation database), which is a human gene-based polymorphism database. due to the difficulty in screening the literature in order to determine whether a specific variant of uncertain significance has been classified, reporting variants to such large comprehensive databases of brca1 and 2 genes is critically important. additionally, there is an enigma consortium that has been established to evaluate the significance of uncertain variants in high-risk breast cancer genes. the success of this group can only be achieved by collecting genetic and clinical information, functional assays, and mrna expression and splicing assays.23 via computational approaches, functional assay data has been shown to correlate well with pathogenicity of brca1 variants of uncertain significance.25 a guide for functional analysis of brca1 variants of uncertain significance has recently been published.26 additionally, a five-tiered classification scheme for dna sequence variants and correlation of clinical recommendation with probability that any given alteration is deleterious has been developed based on the posterior probability model, with class 1 and 2 being not likely pathogenic, class 3 remaining a true vus, and class 4 and 5 considered pathogenic/deleterious for clinical purposes.27,28 as an example, the authors of the current publication found a brca1 amino acid variant of pro871leu, which is listed as class 1, likely not pathogenic,28 which is consistent with the fact that it was found in about half of their total population, both in cases and controls. in conclusion, despite major advances in our brca testing, in many instances we are still in a very elementary stage in applying such information clinically toward the care of patients. it is only through collaboration that the rapidly developing field of molecular genetics will lead to advances in patient care. references 1. lynch ht, et al. clinical/genetic features in hereditary breast cancer. breast cancer res treat. 1990; 15(2):63-71. 2. pharoah pd, et al. family history and the risk of breast cancer: a systematic review and meta-analysis. int j cancer. 1997; 71(5):800-9. 3. genetic/familial high-risk assessment: breast and ovarian. nccn guidelines version 1.2012. 2012. 4. foulkes wd. inherited susceptibility to common cancers. n engl j med. 2008; 359(20):2143-53. 5. pharoah pd, et al. polygenic susceptibility to breast cancer and implications for prevention. nat genet. 2002; 31(1):33-6. 6. miki y, et al. a strong candidate for the breast and ovarian cancer susceptibility gene brca1. science. 1994; 266(5182):66-71. 7. wooster r, et al. localization of a breast cancer susceptibility gene, brca2, to chromosome 13q12-13. science. 1994; 265(5181):2088-90. 8. woodward am, et al. large genomic rearrangements of both brca2 and brca1 are a feature of the inherited breast/ovarian cancer phenotype in selected families. j med genet. 2005; 42(5):e31. 9. shannon km, chittenden a. genetic testing by cancer site: breast. cancer j. 18(4):310-9. 10. levy-lahad e, et al. founder brca1 and brca2 mutations in ashkenazi jews in israel: frequency and differential penetrance in ovarian cancer and in breast-ovarian cancer families. am j hum genet. 1997; 60(5):1059-67. 11. king mc, marks jh, mandell jb. breast and ovarian cancer risks due to inherited mutations in brca1 and brca2. science. 2003; 302(5645):643-6. 12. brookes aj. the essence of snps. gene. 1999; 234(2):177-86. 13. collins kj. physiological variation and adaptability in human populations. ann hum biol. 1999; 26(1):19-38. 14. bentley dr. the human genome project--an overview. med res rev. 2000; 20(3):189-96. 15. lindor nm, et al. a review of a multifactorial probability-based model for classification of brca1 and brca2 variants of uncertain significance (vus). hum mutat. 2012; 33(1):8-21. 16. chenevix-trench g, et al. genetic and histopathologic evaluation of brca1 and brca2 dna sequence variants of unknown clinical significance. cancer res. 2006; 66(4):2019-27. 17. easton df, et al. a systematic genetic assessment of 1,433 sequence variants of unknown clinical significance in the brca1 and brca2 breast cancer-predisposition genes. am j hum genet. 2007; 81(5):873-83. 18. goldgar de, et al. integrated evaluation of dna sequence variants of unknown clinical significance: application to brca1 and brca2. am j hum genet. 2004; 75(4):535-44. 19. gomez garcia eb, et al. a method to assess the clinical significance of unclassified variants in the brca1 and brca2 genes based on cancer family history. breast cancer res. 2009; 11(1):r8. 20. spurdle ab, et al. clinical classification of brca1 and brca2 dna sequence variants: the value of cytokeratin profiles and evolutionary analysis--a report from the kconfab investigators. j clin oncol. 2008; 26(10):1657-63. 21. whiley pj, et al. splicing and multifactorial analysis of intronic brca1 and brca2 sequence variants identifies clinically significant splicing aberrations up to 12 nucleotides from the intron/exon boundary. hum mutat. 32(6):678-87. 22. tavtigian sv, et al. classification of rare missense substitutions, using risk surfaces, with geneticand molecular-epidemiology applications. hum mutat. 2008; 29(11):1342-54. 23. spurdle ab, et al. enigma--evidence-based network for the interpretation of germline mutant alleles: an international initiative to evaluate risk and clinical significance associated with sequence variation in brca1 and brca2 genes. hum mutat. 33(1):2-7. 24. thorisson ga, stein ld. the snp consortium website: past, present and future. nucleic acids res. 2003; 31(1):124-7. 25. iversen jr es, et al. a computational method to classify variants of uncertain significance using functional assay data with application to brca1. cancer epidemiol biomarkers prev. 20(6):1078-88. 26. millot ga, et al. a guide for functional analysis of brca1 variants of uncertain significance. hum mutat. 27. plon se, et al. sequence variant classification and reporting: recommendations for improving the interpretation of cancer susceptibility genetic test results. hum mutat. 2008; 29(11):1282-91. 28. lindor nm, et al. a review of a multifactorial probability-based model for classification of brca1 and brca2 variants of uncertain significance (vus). hum mutat. 33(1):8-21. satisfaction with surgical correction of stress in urinary incontinence in women: a pilot study in almaty, kazakhstan satisfaction with surgical correction of stress in urinary incontinence in women: a pilot study in almaty, kazakhstan sayara m. mukhtarova, gulzhahan k. omarova, aynura i. yoldasheva kazakh national medical university, almaty, kazakhstan short reports introduction stress urinary incontinence (sui) is a very important problem in the fields of gynecology and geriatrics. while sui in not necessarily related to elevated mortality, it leads to significant loss of quality of life, psychological distress, and social isolation or avoidance of recreational activities.1 little has been published on sui in kazakhstan and the central asian region. according to the international continence society, urinary incontinence is the "involuntary loss of urine that is objectively demonstrable and a social or hygienic problem". sui is the most common form of incontinence. sui occurs when there is involuntary leakage of urine in the event of sudden extra pressure ('stress') on the bladder, often associated with physical activity. the key reason for incontinence development is weakened pelvic floor muscles, which support the bladder and urethra.2 according to international statistics, about 24% of women aged 30 to 60 years, and more than 40% of postmenopausal women reported symptoms of sui.2 according to the united states and european publications, 45% of women aged 40 60 years suffer stress incontinence, and in russia, 38%.3,4 sui affects women of all ages young mothers, women in preand perimenopausal age groups, and the elderly. it is important to note that sui is not an inevitable part of aging. there are multiple surgery types to correct sui that are currently being practiced in kazakhstan, including injectable bulking agents, retropubic colposuspension, sling procedure, and many others. little has been published about patient satisfaction with those procedures in central asian region. thus, the aim of this pilot investigation was to examine the risk factors for stress incontinence in women who were seeking surgical correction for stress incontinence. the secondary goal of our investigation was to evaluation satisfaction with surgical procedures to correct sui 3, 6, and 12 months after surgery. methods tthis study included 40 women with stress incontinence treated in almaty, kazakhstan. these women underwent traditional surgery (burch colposuspension) and combined methods using synthetic endoprostheses (tension-free slings (tvt) with the plastic of the perineum, vaginal hysterectomy + tvt). satisfaction with the surgical procedure was assessed 3, 6, and 12 months after surgery. data were obtained through medical record review, as well as by collecting self reported satisfaction after surgical treatment. patients were recruited from two medical facilities: city hospitals #1 and #7, almaty, kazakhstan. results the average age of the patients in this pilot study was 52.9 ± 1.6 years, with 20% peak and late reproductive stage, 30% perimenopausal, and 50% postmenopausal. reproductive age cut offs are based on the staging system outlined by harlow et al.5 evaluation of reproductive history of patients revealed that all women had a history of childbirth: 10 (25%) one birth, 24(60%) up to three births, and in 6 (15%) four or more. in this sample, 36 women (90%) delivered newborns of normal body weight, whereas four women (10%) had newborns with macrosomia. obstetric injuries were reported in 42.5% of cases. gynecological morbidity analysis showed that 35 (87.5%) had comorbid gynecologic pathologies including uterine fibroids (18 (45%)), cervical erosion (10 (25%), adenomyosis (3 (7.5%)), disease of the ovaries and fallopian tubes (3 (7.5%)), and bartholin’s gland cyst (1 (2.5%)). descriptive statistics demonstrated that the major risk factors for stress urinary incontinence in this sample of women, were a combination of 2 or more factors, including: hypoestrogenia in 20 women (50%), obstetrical trauma in 17 women (42.5%), increased abdominal pressure in 6 (15%), complicated labor in 6 (15%), and connective tissue dysplasia in 4 (10%). we found that 28 (70%) of patients in this group were overweight or obese. specifically, 10 (25%) were classified as class 1 obese (bmi 30 34.9 kg/m2), 18 (45%) were overweight (bmi 25 29.9 kg/m2), and 12 (30%) were of normal weight (bmi 18.5 24.9 kg/m2). gynecologic health assessment showed that 35 (87.5%) patients had comorbid gynecologic conditions including uterine fibroids, cervical erosion, and ademomyosis. overall, we found that women were satisfied with symptoms post surgery. significant improvement and/or absence of complaints after 3 months was found in 34 (85%) women, after 6 months in 35 (87.5%), and after 1 year in 37 (92.5%). conclusion our pilot study demonstrated that sui occurs most frequently in parous women, mainly in the postmenopausal period. our results are consistent with previously published evidence about the risk factors of sui. it should be noted that previous studies reported more frequent incidence of macrosomia than in our study.2,3 previous publications also suggest that risk factors for the development of sui include conditions such as hypoestrogenia, heavy physical work, varicose disease, and hernias of different locations, which were all more common in previous publicactions than in the current study.2,3 sui in women is a polyethiologic disease and is directly related to age, parity, and metabolic disorders. surgical correction appears to be effective procedure in our sample, with 92% women reporting satisfaction with procedure 1 year after the surgery. various treatment options for this condition, including innovative options such as global postural re-education, must be considered globally, especially in settings with limited resources.6 references hunskaar s, vinsnes a. the quality of life in women with urinary incontinence as measured by the sickness impact profile. j am geriatr soc. apr 1991;39(4):378-382. abrams p, cardozo l, fall m, et al. the standardisation of terminology of lower urinary tract function: report from the standardisation sub-committee of the international continence society. am j obstet gynecol. 2002;187(1):116-126. adedokun ao, wilson mm. urinary incontinence: historical, global, and epidemiologic perspectives. clin geriatr med. aug 2004; 20(3):399-407. krasnopolskiy vi, chechneva ma. modern methods of diagnosing the state of the bladder and urethra for stress urinary incontinence. bulletin of the russian association of obstetricians and gynecologists 2000. 2000; 3:54-61. harlow sd, gass m, hall je, et al. executive summary of the stages of reproductive aging workshop + 10: addressing the unfinished agenda of staging reproductive aging. j clin endocrinol metab. apr 2012; 97(4):1159-1168. fozzatti c, herrmann v, palma t, riccetto cl, palma pc. global postural re-education: an alternative approach for stress urinary incontinence? eur j obstet gynecol reprod biol. oct 2010; 152(2):218-224. randomized clinical trial: efficacy of a new synbiotic in adults with metabolic syndrome new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. randomized clinical trial: efficacy of a new synbiotic in adults with metabolic syndrome almagul kushugulova1, valerii benberin2, raushan karabayeva2, saule saduakhasova1, samat kozhakhmetov1, gulnara shakhabayeva1, indira tynybayeva1, talgat nurgozhin1, zhaxybay zhumadilov1 1center for life sciences, nazarbaev university, astana, kazakhstan 2medical center of president's affairs administration of republic of kazakhstan, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.111 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kushugulova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.111 | http://cajgh.pitt.edu abstract introduction: metabolic syndrome is a lifestyle disease and is a frequent problem among the adult population. human gut microbiota plays a key role in the development of metabolic syndrome. recently, the gut microbiota has emerged as an important contributor to the development of obesity and metabolic disorders through its interactions with environmental (e.g. diet) and genetic factors. the aim of this study was to research the effects of synbiotic on the gut microbiota and host metabolism. methods: we conducted a double-blind, randomized, placebo-controlled trial. our sample included 180 adults (ages 30-89) with symptoms of metabolic syndrome, who were allocated to either placebo or synbiotic group. the main inclusion criteria were: blood pressure of around 130/90 mmhg; raised fasting plasma glucose (fpg) >100 mg/dl (5.6 mmol/l), previous diagnosis of type 2 diabetes, dyslipidemia triglycerides (tg) of 1.70 mmol/l, a high-density lipoprotein cholesterol (hdl-c) of 0.90 mmol/l in males and 1.0 mmol/l in females, and central obesity with a waist/hip ratio > 0.90 in males or > 0.85 in females or a body mass index > 30 kg/m2. results: we enrolled 90 adults in the placebo group and 90 in the synbiotic group. the two groups had similar demographic and clinical characteristics. consent was signed by all patients. all patients underwent clinical and laboratory evaluation, including complete blood tests, glucose test, glycosylated hemoglobin, total cholesterol and triglycerides, cholesterol, ldl, hdl plasma, immunogram, and coprogram. all patients were interviewed with a questionnaire that included 200 questions related to diet, lifestyle, and health. synbiotic were used by patients in a dose of 200 grams twice a day. the duration of applying of the synbiotic was 90 days. to study the composition of the intestinal microbiota, stool samples were collected before and after applying the synbiotic. the microbial composition will be determined by analyzing the locus of 16s rdna. conclusion: this ongoing study is currently undergoing microbial composition analysis in order to establish the efficacy of the new synbiotic in adults with metabolic syndrome. keywords: synbiotics, efficacy, metabolic syndrome http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx the need for standardized biobanks in kazakhstan new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. the need for standardized biobanks in kazakhstan kuvat momynaliev, meruert imanbekova 1national center for biotechnology, almaty, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.99 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ momynaliev this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.99 | http://cajgh.pitt.edu abstract biobanks are an important tool for clinical and research studies conducted on biomarkers of genetic therapy, diagnostic tests and new drugs; however, most biobanks remain incomplete and are often used without uniform standards and criteria. there is also a a lack of high-quality biological samples and many bioethical problems are often overlooked. currently, kazakhstan has no standard requirements and protocols for biomedical organizations. however, .an analysis of published data shows that possibly hundreds of samples are analyzed. therefore, an establishment of biobank with standardized requirements could create better quality research. the national center for biotechnology has already started a biobank with more than 1,500 blood samples, with the ultimate goal of creating a biobank including around 10,000 blood samples of healthy volunteers, the same number of samples obtained from individuals with cardiovascular and endocrine diseases with samples stored under special conditions. the database contains demographic characteristics of donor’s medical history. informed consent for research received from all donors. this biobank can be considered as a national resource for scientific research. keywords: biobanks, biomedical organizations, scientific reseach, kazakhstan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx vitamin d receptor gene polymorphisms and breast cancer risk in kazakhstan new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. vitamin d receptor gene polymorphisms and breast cancer risk in kazakhstan ainur akilzhanova1, zhannur abilova1, nurgul sikhayeva2, ivan shtefanov3, abay makishev3, tasbolat adylkhanov4, tolebay rakhypbekov4, zhaxybay zhumadilov1, kuvat momynaliev2 1center for life sciences, nazarbayev university, astana, kazakhstan; 2national center for biotechnology, almaty, kazakhstan; 3astana medical university, astana, kazakhstan; 4semey state medical university, semey, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.95 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ akilzhanova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.95 | http://cajgh.pitt.edu abstract introduction: the steroid hormone 1,25-dihydroxyvitamin d3 is thought to protect against breast cancer. the activity of 1,25dihydroxyvitamin d3 is mediated via the vitamin d receptor (vdr), and a number of polymorphisms in the vdr gene have been identified. these result in distinct genotypes, some of which may alter susceptibility to breast cancer. two common single nucleotide polymorphisms (snp) in the vdr gene (vdr), rs1544410 (bsmi) and rs2228570 (foki), have been inconsistently associated with breast cancer risk. increased risk has been reported for the foki ff genotype, which encodes a less transcriptionally active isoform of vdr. a reduced risk has been reported for the bsmi bb genotype which may influence vdr mrna stability. aim: we have investigated whether specific vdr gene polymorphisms are associated with breast cancer risk in kazakhstan women. material and methods: in a case–control study, female breast cancer patients (315) and a female control group (n=604) were tested for two vdr polymorphisms. statistical analysis was conducted using spss19.0. results: the vdr rs2228570 (foki) polymorphism was associated with an increased occurence of bc [rs2228570 (folk) ff vs. ff genotype: or=1.71; 95% ci=1.21-2.43]. no association was noted between rs1544410 (bsmi) bb and breast cancer risk [or=0.68; 95% ci=0.49-0.95]. conclusion: although the factors that increase breast cancer susceptibility remain uncertain, future large studies should integrate genetic variation in vdr with biomarkers of vitamin d status. additional testing on the effect of varying genotypes on the functional mechanisms of the vdr could help to improve future testing and treatment of woman at risk for breast cancer. keywords: breast cancer, gene polymorphysm, vitamin d receptors, genetype suseptibility http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx peptidoglycan hydrolases of local lactic acid bacteria from kazakh traditional food new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. peptidoglycan hydrolases of local lactic acid bacteria from kazakh traditional food serik shaikhin, asel moldagulova, abzal kazhybayev, markhabat kairova, constantine lee, maira urazova, kairtai almagambetov republican collection of microorganisms, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.94 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ shaikhin this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.94 | http://cajgh.pitt.edu abstract introduction: peptidoglycan (pg) is a major component of the cell wall of gram-positive bacteria and is essential for maintaining the integrity of the bacterial cell and its shape. the bacteria synthesize pg hydrolases, which are capable of cleaving the covalent bonds of pg. they also play an important role in modeling pg, which is required for bacterial growth and division. in an era of increasing antibiotic-resistant pathogens, pg hydrolases that destroy these important structures of the cell wall act as a potential source of new antimicrobials. the aim of this study is to identify the main pg hydrolases of local lactic acid bacteria isolated from traditional foods that enhance probiotic activity of a biological preparation. methods. lactococcus lactis 17а and lactococcus garvieae 19а were isolated from the traditional sausage-like meat product called kazy. they were isolated according to standards methods of microbiology. genetic identification of the isolates were tested by determining the nucleotide sequences of 16s rdna. the republican collection of microorganisms took strains of lactobacillus casei subsp. rhamnosus 13-p, l. delbrueckii subsp. lactis cg-1 b-rkm 0044 from cheese, lactobacillus casei subsp. casei b-rkm 0202 from homemade butter. they used the standard technique of renaturating polyacrylamide gel electrophoresis to detect pg hydrolases activity. results. according to the profiles of pg hydrolase activity on zymograms, the enzymes of lactococci 17a and 19a in kazy are similar in electrophoretic mobility to major autolysin acma, while the lactobacilli of industrial and home-made dairy products have enzymes similar to extracellular proteins p40 and p75, which have probiotic activity. conclusions. use of peptidoglycan hydrolases seems to be an interesting approach in the fight against multi-drug resistant strains of bacteria and could be a valuable tool for the treatment of diseases caused by these microorganisms in kazakhstan. keywords: lactic acid, peptidoglycan hydrolases, multi-drug resistant strains, traditional food http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx intra-articular injection of synovium-derived mesenchymal stem cells and hyaluronic acid promote regeneration of massive cartilage defects in rabbits new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. intra-articular injection of synovium-derived mesenchymal stem cells and hyaluronic acid promote regeneration of massive cartilage defects in rabbits vyacheslav ogay1, miras karzhauov1, ainur mukhambetova1, eric raimagambetov1, nurlan batpenov2 1laboratory of stem cells, national center for biotechnology, almaty, kazakhstan; 2scientific and research institute of traumatology and orthopedics, almaty, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.97 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ ogay this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.97 | http://cajgh.pitt.edu abstract introduction: the purpose of this study was to investigate whether intra-articular injection of synovium-derived mesenchymal stem cells (sd mscs) with low molecular weight hyaluronic acid (ha) could promote regeneration of massive cartilage in rabbits. material and methods: the sd mscs were harvested from the knees of 10 flemish giant rabbits, expanded in culture, and characterized. a reproducible 4-mm cylindrical defect was created in the intercondylar groove area using a kit for the mosaic chondroplasty of femoral condyle cor (de puy, mitek). the defect was made within the cartilage layer without destruction of subchondral bone. two weeks after the cartilage defect, sd mscs (2 × 106 cell/0.15 ml) were suspended in 0.5% low molecular weight ha (0.15 ml) and injected into the left knee, and ha solution (0.30 ml) alone was placed into the right knee. cartilage regeneration in the experimental and control groups were evaluated by macroscopically and histologically at 10, 30, and 60 days. results: on day 10, after intra-articular injection of sd mscs, we observed an early process of cartilage regeneration in the defect area. histological studies revealed that cartilage defect was covered by a thin layer of spindle-shaped undifferentiated cells and proliferated chodroblasts. in contrast, an injection of ha did not induce reparation of cartilage in the defect area. at 30 days, macroscopic observation showed that the size of cartilage defect after sd msc injection was significantly smaller than after ha injection. histological score was also better in the msctreated intercondylar defect. at 60 days after msc treatment, cartilage defect was nearly nonexistent and looked similar to an intact cartilage. conclusion: thus, intra-articular injection of sd mscs can adhere to the defect in the intercondylar area, and promote cartilage regeneration in rabbits. keywords: synovium-derived mesenchymal stem cells, cartilage regeneration, hyalunoric acid http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx a 24-hour dietary recall for assessing the intake pattern of choline among bangladeshi pregnant women at their third trimester of pregnancy new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. a 24-hour dietary recall for assessing the intake pattern of choline among bangladeshi pregnant women at their third trimester of pregnancy shatabdi goon1, sima rani dey2 1dept. of nutrition and food engineering, daffodil international university, dhaka, bangladesh; 2dept. of applied statistics, east west university, dhaka, bangladesh vol. 3, no. 1 (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu abstract maternal choline intake during the third trimester of human pregnancy can modify systemic and local epigenetic marks in fetalderived tissues, promoting better pregnancy outcomes, increased immunity, as well as improved mental and physical work capacity with proper memory and cognitive development. 103 pregnant women presenting to the antenatal care of azimpur maternity hospital of dhaka, bangladesh in their third trimester of pregnancy were randomly selected for this cross sectional study exploring dietary intake patterns of choline. a dietary recall form was administered to estimate frequency and amount of food consumption of foods for the previous 24 hours. most women reported diets that delivered less than the recommended choline intake (mean ± sd; 189.5 ± 98.2) providing only 42.72% of total rda value. the results of this study may indicate that dietary choline among pregnant, bangladeshi women may not be adequate to meet the needs of both, the mother and fetus. further studies are warranted to determine clinical implications. keywords: choline, pregnancy, fetal development, cognition, pregnancy outcome a 24-hour dietary recall for assessing the intake pattern of choline among bangladeshi pregnant women at their third trimester of pregnancy shatabdi goon1, sima rani dey2 1dept. of nutrition and food engineering, daffodil international university, dhaka, bangladesh; 2dept. of applied statistics, east west university, dhaka, bangladesh research introduction choline, an essential 1-6 nutrient found in eggs, liver, milk, meat, nuts, legumes, and cruciferous vegetables, 7 plays a significant role during the third trimester of human pregnancy to reduce the negative effect of a mother’s stress 8 on child health 8 , promoting fetal growth, 6,9,10 proper brain 11-16 and memory function, 17-22 and learning capabilities, 23-27 while protecting the future health of the child. previous findings suggest that higher maternal choline intake may counter some adverse effects 25,28,29 of prenatal stress on behavioral, 29-32 neuroendocrine, and metabolic development 33,34 in offspring. higher choline intake contributed to a more stable hypothalamic-pituitaryadrenal (hpa) axis, 8 which translated to lower cortisol levels in the fetus. changes in fetal genetic expression likely continue into adulthood, where they play a role in stress-related disease prevention. 35 dietary choline intake by the pregnant mother and by the infant directly affects brain development and results in permanent changes in brain function. 36 variations in maternal choline intake influence memory performance in their offspring. 37 several animal model studies have reported on the effect of choline intake and fetal development. offspring born to pregnant rats given choline supplements were found to be faster learners with better memories. 12 more choline during days 11 to 18 of gestation resulted in increased cell proliferation and decreased apoptosis in rodent fetal hippocampal progenitor cells, promoting better memory and cognitive function. 12 choline deprivation (cd)-induced dysfunction in brain mitochondria may be responsible http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu for impairment in cognition and underlines that the brain needs an adequate choline supply for its normal functioning. memory can be permanently enhanced by exposure to choline during the latter part of gestation. 16 also, zeisel et al. showed that when rat pups received choline supplements, their brain function changed, resulting in lifelong memory enhancement. 27 mellot et al. showed that increased dietary intake of choline early in life improves performance of adult rats on memory tasks and prevents their age-related memory decline. 22 choline supplementation during gestation in rats leads to augmentation of spatial memory in adulthood. 38 maternal choline appears to decrease the risk of neural tube defect (ntd). 39,40 a retrospective case-control study of periconceptional dietary choline intake in california, usa women found that women in the lowest quartile for daily choline intake had a 4-fold greater risk of having a baby with an ntd than women in the highest quartile for intake. 40 another study showed that a deficiency of choline substantially impaired the body’s ability to regulate homocysteine levels. 41 excessive homocysteine is apparently linked with increased risks for birth defects, cardiovascular disease, 42 cancer, type-2 diabetes, hypertension, depression, and more. higher intakes of dietary choline are related to lower homocysteine concentrations. 43,44 foods rich in choline may help reduce the risk of inflammation associated with chronic diseases such as cardiovascular disease, bone loss, dementia, and alzheimer's disease. 43 a study funded by the national institutes of health concluded that dietary choline during pregnancy is associated with a 24% reduced risk of breast cancer in female offspring. 45,46 tumor growth rate was inversely related to choline content in the prenatal diet, resulting in 50% longer survival. choline deficiency during pregnancy may lead to increased risk of complications during delivery, including prolonged labour, preterm delivery, preeclampsia, prematurity, very low birth weight, 47 and maternal and neonatal death. it is recommended that pregnant women take 450mg of choline per day from common food sources or supplements. in bangladesh, knowledge of the impact of maternal food and micronutrient supplementation on infant micronutrient status is limited. most pregnant bangladeshi women do not meet recommended levels of micronutrients, including choline. the main objective of this study was to determine the present status of the choline intake pattern by bangladeshi pregnant women in their third trimester of pregnancy. methods this cross sectional study was carried out from the 4-may to 6-june, 2013 at azimpur maternity hospital, dhaka, bangladesh. a total of two hundred pregnant women were randomly selected from all pregnant women present the first day of the survey. of the initial 200, 103 women were in their third trimester of pregnancy and were included in this investigation. exclusion critieria included: women not in their third trimester of pregnancy, history of hypertension, gestational diabetes, or history of spontaneous abortions. all participants signed an informed consent form. a semi-structured pre-tested questionnaire (see appendix 1) was developed to gather participant characteristics including: age, occupation, stage of pregnancy, weight, height, and educational level. a dietary recall form was administrated to gather information regarding dietary intake for the previous 24 hours. choline content of foods was calculated using published data from the usda-nutrient database for standard reference then multiplying the frequency of consumption of each food item by its choline content and summing the nutrient contributions of all foods. all of the collected data were analyzed using spss v-15.0. descriptive statistics including mean, standard http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu deviation, and frequency were obtained. all variables were normally distributed. result subject profile in the maternity hospital in dhaka, bangladesh, 69.9% of participants aged 21-25 years. 27.2% and 2.9% of were aged 26-30 years and >31 years, respectively. approximately 6.8% of participants were illiterate; 10.7%, 56.3%, 11.7%, and 14.5% completed primary, secondary, undergraduate, and graduate levels of study, respectively. 87.4% of participants were housewives and 12.6% were service holders. in this study, 30.1% of participants were in the seventh month of pregnancy, 28.16% in the eighth month of pregnancy, and 41.74%, the ninth. based on calculated body mass index (bmi), 3.8% were underweight, 42.72% normal weight, 33.98% overweight, 13.59% moderately obese, 3.88% severely obese, and 1.95% were very severely obese. table 1 shows the overall subject profile attending the study. table 1: characteristics of pregnant women dietary choline consumption most participants reported low consumption of choline-rich foods selected from the bangladeshi diet. only one participant showed adequate or near adequate intake of choline (> 400mg). the mean dietary choline consumed was 189.5mg ± 98.2 (mean ± sd). 25.2%, 31.2%, 23.3%, and 19.4% of pregnant women took choline ranges from 0-100, 101-200, 201-300, and 301400 mg/day, respectively, through regular diet. table 2: distribution of pregnant women by daily intake of choline (mg) parallel improvements were observed in average choline intake with educational achievement. average intake level of choline was 147.7 ± 83.3, 157.8 ± 110.5, 185.9 ± 97.4, 208.2 ± 94.2, and 231.4 ± 94.9 mg/day for illiterate participants, those who completed primary, secondary, undergraduate, and graduate levels of study, respectively. table 3 illustrates dietary choline consumption. table 3: gradual improvement of average choline intake per day with educational status among the factors affecting choline level intake, education level and age of participant have substantial effect. both factors are positively correlated with choline level intake, though the correlation is weak. table 4: correlation analysis discussion improving choline intake through regular diet benefits all individuals through increasing immunity and lower morbidity from infectious diseases, improving physical work capacity, memory and cognitive development. pregnant women are less likely to have poor pregnancy outcomes (including perinatal mortality) and may deliver infants with larger birth weights and greater choline stores. in this study, an assessment of dietary choline intake was made using a dietary recall system to record food intake by pregnant women over the previous 24 hours. analysis revealed that the choline status of bangladeshi pregnant women is far below clinical suggestions, as defined by the institute of medicine of the national academy of sciences (450 mg/day). http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu data suggest that pregnant bangladeshi women are consuming less than adequate amounts of choline, with mean consumption of 189.5 ± 98.2 mg/day. for comparision, in a new zealand study, 49 daily intake of choline was 316 (± 66) mg/day; in another, mean intake was 304 mg/day in women; 50 in a third study, mean intake of choline by common food sources among a taiwanese female population 51 was estimated as 265 ± 9 mg/day. a study conducted in jamaica also showed poor choline status among pregnant women with 278.5 mg/day, which was higher than the bangladeshi scenario. 52 bangladeshi pregnant women took only 42.72% of the rda value of 450mg/day. poverty and lack of knowledge regarding the importance of choline among both pregnant women and health care professionals leads to less choline supplementation during pregnancy. therefore, the dietary intake pattern of choline during third trimester of pregnancy is important to estimate. maternal age is an important determinant of nutritional status for pregnant women. the ideal age of pregnancy is 19-30 years. in this population, the majority were 20-25 years of age. maternal education level has a significant effect on choline status during pregnancy. the present study showed a direct relationship between increase in consumption of choline in pregnancy and increase in maternal education level. this may due to generally better understanding of the mother regarding public health knowledge and nutritional status. weight status also reflects the nutritional status of women. about 43% of pregnant women were categorized as “healthy weight”. 13.59%, 3.88%, and 1.95% of participants were moderately, severely, and very severely obese, indicating an increase level of obesity during pregnancy. the overall survey result also shows that most women don’t consume the recommended level of choline. this is the first documented study evaluating dietary choline intake among the bangladeshi population and suggests a need to further assess whether the diets of this population ensure an adequate plasma choline levels during pregnancy. an extension of this study should also examine the implications of low plasma choline concentration including the significance it may have in ensuring healthy fetal brain development in humans. our study has a number of limitations. the data was self-reported and the study is cross-sectional which does not infer causal relationships. furthermore, we examined only one maternity hospital located in dhaka, bangladesh. caution should be taken to generalize the data for other maternity hospitals outside dhaka city. a 24-hour dietary recall was taken to calculate the daily choline intake. twenty-four hour recall is a retrospective method of diet assessment, where an individual is interviewed about their food and beverage consumption during the previous day or the preceding 24 hours. however, a single 24-hour recall is not considered to be representative of habitual diet at an individual level. while there may have been a small amount of recall bias, this methodology is adequate for surveying intake in a large group and estimating group mean intakes of diet. conclusion choline is a mostly neglected micronutrient by both pregnant women and health care professionals. these professions have poor knowledge regarding its importance and therefore are missing many potential causes of health complications due to choline deficiency. the results of this study may be an indication that the choline included in the diet of pregnant bangladeshi women may not be adequate to meet both the needs of the mother and fetus. the results presented here may be useful in understanding the present choline status among bangladeshi pregnant women aiming to improve using strategic nutritional http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu intervention by both government and public stakeholders. acknowledgement we would like to thank our honorable professors, colleagues, and friends for supporting us in initiating the study subject. we are also grateful to those pregnant women, the doctors, and the staff of the selected maternity hospital. conflict of interest the authors report no conflict of interest. references 1. zeisel sh, da costa ka. choline: an essential nutrient for public health. nutr rev. nov 2009;67(11):615-623. 2. corbin kd, zeisel sh. the nutrigenetics and nutrigenomics of the dietary requirement for choline. prog mol biol transl sci. 2012;108:159-177. 3. blusztajn jk, mellott tj. choline nutrition programs brain development via dna and histone methylation. cent nerv syst agents med chem. jun 2012;12(2):82-94. 4. sheard nf, zeisel sh. choline: an essential dietary nutrient? nutrition. jan-feb 1989;5(1):1-5. 5. buchman al. the addition of choline to parenteral nutrition. gastroenterology. nov 2009;137(5 suppl):s119-128. 6. zeisel sh. choline: critical role during fetal development and dietary requirements in adults. annual review of nutrition. 2006;26:229. 7. zeisel sh, mar mh, howe jc, holden jm. concentrations of choline-containing compounds and betaine in common foods. j nutr. may 2003;133(5):1302-1307. 8. jiang x, yan j, west aa, et al. maternal choline intake alters the epigenetic state of fetal cortisol-regulating genes in humans. faseb j. aug 2012;26(8):3563-3574. 9. zeisel sh. nutrition in pregnancy: the argument for including a source of choline. int j womens health. 2013;5:193-199. 10. mehedint mg, craciunescu cn, zeisel sh. maternal dietary choline deficiency alters angiogenesis in fetal mouse hippocampus. proc natl acad sci u s a. jul 20 2010;107(29):12834-12839. 11. albright cd, tsai ay, friedrich cb, mar mh, zeisel sh. choline availability alters embryonic development of the hippocampus and septum in the rat. brain res dev brain res. mar 12 1999;113(1-2):13-20. 12. craciunescu cn, albright cd, mar m-h, song j, zeisel sh. choline availability during embryonic development alters progenitor cell mitosis in developing mouse hippocampus. the journal of nutrition. 2003;133(11):3614-3618. 13. michel v, bakovic m. editorial: choline and brain function. cent nerv syst agents med chem. jun 2012;12(2):69. 14. zeisel sh. nutritional importance of choline for brain development. journal of the american college of nutrition. 2004;23(suppl 6):621s-626s. 15. zeisel sh. the supply of choline is important for fetal progenitor cells. semin cell dev biol. aug 2011;22(6):624-628. 16. zeisel sh, niculescu md. perinatal choline influences brain structure and function. nutrition reviews. 2006;64(4):197-203. 17. wong-goodrich sj, glenn mj, mellott tj, blusztajn jk, meck wh, williams cl. spatial memory and hippocampal plasticity are differentially sensitive to the availability of choline in adulthood as a function of choline supply in utero. brain res. oct 27 2008;1237:153-166. 18. niculescu md, craciunescu cn, zeisel sh. dietary choline deficiency alters global and gene-specific dna methylation in the developing hippocampus of mouse fetal brains. faseb j. jan 2006;20(1):43-49. 19. mehedint mg, niculescu md, craciunescu cn, zeisel sh. choline deficiency alters global histone methylation and epigenetic marking at the re1 site of the calbindin 1 gene. the faseb journal. 2010;24(1):184-195. 20. zeisel sh. importance of methyl donors during reproduction. the american journal of clinical nutrition. 2009;89(2):673s-677s. 21. kovacheva vp, mellott tj, davison jm, et al. gestational choline deficiency causes global and igf2 gene dna hypermethylation by up-regulation of dnmt1 expression. j biol chem. oct 26 2007;282(43):31777-31788. 22. mellott tj, follettie mt, diesl v, hill aa, lopez-coviella i, blusztajn jk. prenatal choline availability modulates hippocampal and cerebral cortical gene expression. faseb j. may 2007;21(7):1311-1323. 23. boeke ce, gillman mw, hughes md, rifas-shiman sl, villamor e, oken e. choline intake during pregnancy and child http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu cognition at age 7 years. am j epidemiol. jun 15 2013;177(12):1338-1347. 24. wu bt, dyer ra, king dj, richardson kj, innis sm. early second trimester maternal plasma choline and betaine are related to measures of early cognitive development in term infants. plos one. 2012;7(8):e43448. 25. beydoun h, saftlas af. physical and mental health outcomes of prenatal maternal stress in human and animal studies: a review of recent evidence. paediatr perinat epidemiol. sep 2008;22(5):438-466. 26. blusztajn jk, mellott tj. neuroprotective actions of perinatal choline nutrition. clin chem lab med. mar 1 2013;51(3):591599. 27. zeisel sh. choline: needed for normal development of memory. j am coll nutr. oct 2000;19(5 suppl):528s-531s. 28. marasco v, robinson j, herzyk p, spencer ka. preand post-natal stress in context: effects on the stress physiology in a precocial bird. j exp biol. nov 15 2012;215(pt 22):39553964. 29. catalani a, alema gs, cinque c, zuena ar, casolini p. maternal corticosterone effects on hypothalamus-pituitaryadrenal axis regulation and behavior of the offspring in rodents. neurosci biobehav rev. jun 2011;35(7):1502-1517. 30. macri s, zoratto f, laviola g. early-stress regulates resilience, vulnerability and experimental validity in laboratory rodents through mother-offspring hormonal transfer. neurosci biobehav rev. jun 2011;35(7):1534-1543. 31. mairesse j, lesage j, breton c, et al. maternal stress alters endocrine function of the feto-placental unit in rats. am j physiol endocrinol metab. jun 2007;292(6):e1526-1533. 32. rangon cm, fortes s, lelievre v, et al. chronic mild stress during gestation worsens neonatal brain lesions in mice. j neurosci. jul 11 2007;27(28):7532-7540. 33. hirst jj, walker dw, yawno t, palliser hk. stress in pregnancy: a role for neuroactive steroids in protecting the fetal and neonatal brain. dev neurosci. 2009;31(5):363-377. 34. son gh, geum d, chung s, et al. maternal stress produces learning deficits associated with impairment of nmda receptormediated synaptic plasticity. j neurosci. mar 22 2006;26(12):3309-3318. 35. wilkinson j. high maternal choline intake may prevent the development of stress-related disorders through epigenetic mechanisms. epigenomics. oct 2012;4(5):479-480. 36. zeisel sh. the fetal origins of memory: the role of dietary choline in optimal brain development. the journal of pediatrics. 2006;149(5):s131-s136. 37. zeisel sh. choline: essential for brain development and function. advances in pediatrics. 1997;44:263. 38. pyapali gk, turner da, williams cl, meck wh, swartzwelder hs. prenatal dietary choline supplementation decreases the threshold for induction of long-term potentiation in young adult rats. j neurophysiol. apr 1998;79(4):17901796. 39. rees wd, wilson fa, maloney ca. sulfur amino acid metabolism in pregnancy: the impact of methionine in the maternal diet. j nutr. jun 2006;136(6 suppl):1701s-1705s. 40. shaw gm, carmichael sl, yang w, selvin s, schaffer dm. periconceptional dietary intake of choline and betaine and neural tube defects in offspring. am j epidemiol. jul 15 2004;160(2):102-109. 41. molloy am, mills jl, cox c, et al. choline and homocysteine interrelations in umbilical cord and maternal plasma at delivery. am j clin nutr. oct 2005;82(4):836-842. 42. chan j, deng l, mikael lg, et al. low dietary choline and low dietary riboflavin during pregnancy influence reproductive outcomes and heart development in mice. am j clin nutr. apr 2010;91(4):1035-1043. 43. cho e, zeisel sh, jacques p, et al. dietary choline and betaine assessed by food-frequency questionnaire in relation to plasma total homocysteine concentration in the framingham offspring study. am j clin nutr. apr 2006;83(4):905-911. 44. detopoulou p, panagiotakos db, antonopoulou s, pitsavos c, stefanadis c. dietary choline and betaine intakes in relation to concentrations of inflammatory markers in healthy adults: the attica study. am j clin nutr. feb 2008;87(2):424-430. 45. kovacheva vp, davison jm, mellott tj, et al. raising gestational choline intake alters gene expression in dmbaevoked mammary tumors and prolongs survival. faseb j. apr 2009;23(4):1054-1063. 46. xu x, gammon md, zeisel sh, et al. choline metabolism and risk of breast cancer in a population-based study. faseb j. jun 2008;22(6):2045-2052. 47. vollset se, refsum h, irgens lm, et al. plasma total homocysteine, pregnancy complications, and adverse pregnancy outcomes: the hordaland homocysteine study. am j clin nutr. apr 2000;71(4):962-968. 48. allen mc. neurodevelopmental outcomes of preterm infants. curr opin neurol. apr 2008;21(2):123-128. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu 49. mygind vl, evans se, peddie mc, miller jc, houghton la. estimation of usual intake and food sources of choline and betaine in new zealand reproductive age women. asia pac j clin nutr. 2013;22(2):319-324. 50. yonemori km, lim u, koga kr, et al. dietary choline and betaine intakes vary in an adult multiethnic population. j nutr. jun 2013;143(6):894-899. 51. chu dm, wahlqvist ml, chang hy, yeh nh, lee ms. choline and betaine food sources and intakes in taiwanese. asia pac j clin nutr. 2012;21(4):547-557. 52. gossell-williams m, fletcher h, mcfarlane-anderson n, jacob a, patel j, zeisel s. dietary intake of choline and plasma choline concentrations in pregnant women in jamaica. west indian med j. dec 2005;54(6):355-359. 53. caudill ma. preand postnatal health: evidence of increased choline needs. j am diet assoc. aug 2010;110(8):1198-1206. 54. albright cd, friedrich cb, brown ec, mar mh, zeisel sh. maternal dietary choline availability alters mitosis, apoptosis and the localization of toad-64 protein in the developing fetal rat septum. brain res dev brain res. jun 2 1999;115(2):123129. 55. fisher mc, zeisel sh, mar mh, sadler tw. perturbations in choline metabolism cause neural tube defects in mouse embryos in vitro. faseb j. apr 2002;16(6):619-621. 56. meck wh, smith ra, williams cl. preand postnatal choline supplementation produces long-term facilitation of spatial memory. dev psychobiol. may 1988;21(4):339-353. 57. jensen hh, batres-marquez sp, carriquiry a, schalinske kl. choline in the diets of the us population: nhanes, 2003–2004. faseb j. 2007;21:lb219. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu table 1: characteristics of pregnant women variable n (%) age (years) 21-25 72 (69.9%) 26-30 28(27.2%) > 31 3(2.9%) years of education illiterate 7(6.8%) primary (level 1-5) 11(10.7%) secondary (level 6-10) 58(56.3%) undergraduate (level 11-12) 12(11.7%) graduate (more than 12 years of education) 15(14.5%) status of pregnant women housewife 90(87.4%) service holder 13(12.6%) stage of pregnancy 7 th month of pregnancy 31(30.1%) 8 th month of pregnancy 29(28.16%) 9 th month of pregnancy 43(41.74%) bmi status 15-16 0 16-18.5 4(3.9%) 18.5-25 44(42.72%) 25-30 35(33.98%) 30-35 14(14% 35-40 4(3.9%) over 40 2 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu table 2: distribution of pregnant women by daily intake of choline (mg) choline intake level (mg/day) n (%) 0-100 26 (25.2%) 101-200 32 (31.2%) 201-300 24 (23.3%) 301-400 20 (19.4%) ≥ 400 1 (0.9%) total 103 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu table 3: gradual improvement of average choline intake per day with educational status educational level average choline intake/day (mg) illiterate 147.7 ± 83.3 primary 157.8 ± 110.5 secondary 185.9 ± 97.4 undergraduate 208.2 ± 94.2 ≥ graduate 231.4 ± 94.9 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu table 4: correlation analysis correlations choline level education level age choline level 1 0.186 0.166 education level 0.186 1 -0.008 age 0.166 -0.008 1 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.72 | http://cajgh.pitt.edu appendix 1: questionnaire name: age: level of education: a. illiterate b. primary c. secondary d. undergraduate e. graduate height: …………… cm weight: ………………… kg bmi: month of pregnancy: http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx tb cases detection in tajikistan – analysis of existing obstacles new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. tb case detection in tajikistan analysis of existing obstacles alexei korobitsyn1, oktam bobokhojaev2, thomas mohr1, jamila ismoilova1, mavluda makhmudova1, alex trusov1 1project hope; 2national tb centre, dushanbe, tajikistan vol. 2, no. 2 (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.48 | http://cajgh.pitt.edu http://creativecommons.org/licenses/by/3.0/us/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx korobitsyn this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu abstract background: tajikistan national tb control program objective: (1) to identify the main obstacles to increasing tb detection in tajikistan. (2) to identify interventions that improve tb detection. methods: review of the available original research data, health normative base, health systems performance and national economic data, following who framework for detection of tb cases, which is based on three scenarios of why incident cases of tb may not be notified. results: data analysis revealed that some aspects of tb case detection are more problematic than others and that there are gaps in the knowledge of specific obstacles to tb case detection. the phenomenon of “initial default” in tajikistan has been documented; however, it needs to be studied further. the laboratory services detect infectious tb cases effectively; however, referrals of appropriate suspects for tb diagnosis may lag behind. the knowledge about tb in the general population has improved. yet, the problem of tb related stigma persists, thus being an obstacle for effective tb detection. high economic cost of health services driven by under-the-table payments was identified as another barrier for access to health services. conclusion: health system strengthening should become a primary intervention to improve case detection in tajikistan. more research on reasons contributing to the failure to register tb cases, as well as factors underlying stigma is needed. keywords: tuberculosis, detection, health services, access tb case detection in tajikistan analysis of existing obstacles alexei korobitsyn1, oktam bobokhojaev2, thomas mohr1, jamila ismoilova1, mavluda makhmudova1, alex trusov1 1project hope; 2national tb centre, dushanbe, tajikistan research tajikistan is a landlocked country in central asia, bordering china, afghanistan, uzbekistan and kyrgyzstan, formerly part of the soviet union, with a territory of 143.1 thousands sq. km and population size of 6,952,223. 1 the majority of its territory (93%) is mountainous. according to world bank data, tajikistan is the poorest country in former soviet union with a gross national income (gni) per capita usd 800. 2 the country gained independence in 1991. in 1992-1997, however, tajikistan plunged into civil war. as a result of this fratricidal conflict, various sources estimate that between 40,000 to 100,000 people died, thousands were handicapped, about a million became refugees and internally displaced, more than 50,000 households destroyed, and a damaged economy estimating at a us$7 billion. 3 the effect of the conflict on health care has not been studied; however, it is logical to assume that the health system infrastructure and human resources suffered along with other parts of a civil society. tuberculosis (tb) is among the most important public health problems in tajikistan. in 2010, the tb notification rate amounted to 92/100,000 for all cases. 3 world health organization (who) estimated a tb http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu mortality rate of 41/100,000 in 2010, which ranks tajikistan highest in the who euro region. 3 the who promoted directly observed therapy short (dots) course strategy implementation was started in 2 pilot districts in 2002 by project hope, international non-governmental organization (ngo), and the support of united states agency for international development (usaid). the massive scale-up of the new tb control strategy started in 2004, accelerated with support from the global fund to fight aids, tuberculosis and malaria, and by the end of 2007, the strategy was implemented in the whole country. the national tb control strategy adopted in 2010 in tajikistan is aligned with the global “stop tb” strategy and has among its objectives detection of 70% of all existing tb cases in the country and the successful treatment of 85% of cases. 1 tb detection is primarily taking place in primary health care (phc) facilities where individuals are evaluated by physicians and undergo sputum smear microscopy if tb diagnosis is suspected. tb reference diagnosis is made on a regional level in tertiary health facilities. the treatment success rate (tsr) in tajikistan reached who target level (85%) in 2006. 3 that, however, was attributed to the 40 pilot districts implementing the dots strategy (approximately 2/3 of the country population). in 2007, rapid expansion of the dots strategy was undertaken, and 100% coverage was achieved within 1 year. thereafter, there was an observed gradual negative trend in tsr (83% in 20072008, 81% in 2009). 3 there were efforts undertaken to verify quality of the data on treatment outcomes in 2009-2010. randomly selected primary documentation was verified, with a focus on whether it was complete and sufficient to support the fact of the sputum conversion. in approximately 90% of the cases, the existing primary documentation was judged sufficient to support the quality of the data. 5 the who estimated case detection rate (cdr) in tajikistan for 2009-2010 was 44% (36-54%) for all cases, which was the lowest in the who euro region. 3 the trend of low case detection has continued for the last 14 years. from 1995 to 2005 (after civil war ended), there was minimal positive dynamics in case detection rate, 1-2% per year. even though in 2005 to 2008 there was a period of rapid dots strategy scale up, there was no substantial increase in cdr in 2009 (all countries covered by dots) or 2010. according to the who global tb report in 2010, tajikistan case detection was substantially lower than average case detection of the central asian countries (67.2%, p < 0.0001), former soviet countries (75.0%, p < 0.0001), and european who region in general (87.2%, p < 0.0001), thus demonstrating one of the lowest cdr in the world. 3 objective this article analyzes the underlying reasons for the low tb case detection in tajikistan. it attempts to answer the following questions: what are the main obstacles for improving tb case detection in tajikistan? are those obstacles only within health sector? what interventions can increase case detection? according to the who framework for assessment of tb cases detection, there are three main reasons why incident cases of tb may not be notified: (a) cases are diagnosed but not reported. for patients in this category, strengthening surveillance systems, establishing links with the full range of heathcare providers for effective information exchange, and corrective measures for early patient default will help. stronger enforcement of legislation regarding notification of cases (where this is mandated by law) is important as well. (b) cases seek care but are not diagnosed. for patients in this category, better http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx korobitsyn this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu diagnostic capacity is needed. this means better laboratory capacity as well as knowledgeable and experienced staff, both laboratory technicians and clinicians, especially in peripheral-level healthcare facilities. normally, this is achieved through quality training, on-the-job mentoring linked to a monitoring system. (c) cases do not seek care. for people in this category, reasons include not recognizing any symptoms of tb and/or no access (financial or geographic) to healthcare services, or seeking care outside of “official” health services boundaries (i.e. either from traditional healers or privately from known health professionals). the latter option may occur either due to above-mentioned financial/geographical constraints or due to stigma. to reach cases in this category, health systems need to be strengthened so that basic healthcare services are available to more people, and financial barriers to diagnosis (and subsequently, treatment) need to be mitigated or removed. the general population needs to be aware of tb symptoms, prevention, and care principles following evidencebased approach. 6 in order to understand reasons underlying each of these scenarios, available data from related studies conducted in tajikistan were analyzed. the analysis was supported by the data from public domains (government strategies and reports, international development data sources). analysis of the problem (a) cases are diagnosed but not reported the first possible group of reasons “cases are diagnosed but not reported” may include two options – tb cases may be treated without reporting or not reported due to early default. there is anecdotal data in regard to the former option in tajikistan; however, no systematic studies were undertaken. the current analysis will focus on the latter option “initial default.” substantial attention was given to this phenomenon recently worldwide. in 2008, the “international journal of tuberculosis and lung diseases” published three original articles on the initial default. 7-9 an initial defaulter is a patient who was detected in a smear microscopy laboratory and consequently recorded in laboratory register as a sputum smear-positive, but was not registered in tb patient register and, hence, did not start treatment. 10 it is recognized that phenomenon of initial defaulters limits both detection (registration) and treatment outcomes of tb cases in society. 10 the referenced original studies documented frequency of initial defaulters from 5% (india) to 26% (south africa). 8,9 the problem of initial defaulters as a contributing factor to the low case detection rate was studied in tajikistan to a limited extent. as part of routine monitoring visits, the registration of new pulmonary ss+ tb cases was cross-checked in microscopy laboratory register (tb 04) and tb district register (tb 03) in selected districts in quarters 3 and 4 in 2008 and quarters 1 and 2 in 2009. during that period, 45 out of 254 (18%) sputum smear positive cases were revealed as unregistered. of those 45.6% (27) were inhabitants of other districts. the reasons the remaining 18 unregistered cases did not start treatment were: 2 deaths, 1 refused to start treatment, 1 moved out of the country, and 1 was imprisoned. 13 cases (29%) did not start treatment for unidentified reasons. 11 the analysis of initial defaulters in tajikistan revealed two important findings: firstly, that people are commonly referred to a different district than the one they reside in for a sputum microscopy test (10.6% of detected ss+ cases were residents of neighboring districts). secondly, among newly detected ss+ cases who are residents of same districts, initial defaulters have comprised on average 7.9% (18/227), being as high as 25% (13/52) in the least effective dots center. the major limitation of this study is that reasons for initial defaults for the large portion of patients were not investigated further. 11 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu (b) cases seek care but are not diagnosed this scenario includes tb cases visiting health services but not being diagnosed. there are two principal reasons for that – laboratory service fails to detect mycobacterium tuberculosis or primary health care service fails to refer appropriate suspects for tb laboratory test. we will analyze each of the abovementioned contributing factors in tajikistan. to successfully detect tb cases, better diagnostic capacity is needed. the latter assumes availability of equipment, disposable supplies, qualified laboratory and clinical staff, and effective referral patterns. 3 though recent advancements in tb laboratory technologies are promising, sputum smear microscopy is still the primary basis for tb diagnosis, being effective and efficient in detecting most epidemiologically dangerous tb cases (i.e. excreting large amounts of mycobacterium tuberculosis). even though more sensitive methods are important for increasing tb case finding, smear microscopy remains the cornerstone of tb detection, especially in less developed countries. for these reasons, the article will focus only on sputum smear microscopy. in march 2010, officially there were 97 designated microscopy laboratories in tajikistan, roughly 1 per 70,000/population. however in practice, only 92 microscopy laboratories were functioning. the laboratories are generally centralized at the district (nokhia) level; however, certain districts have more than one laboratory due to larger population (>100,000) and/or accessibility reasons, (remoteness and/or mountainous terrain). each tb suspect upon presenting at a microscopy laboratory is recorded in tb laboratory register (tb 04), where test results are recorded. diagnosis of tb cases by means of smear microscopy is a priority both for the ntp and international partners in tb control, attracting major financial resources and being a target for a technical support. between 2005 and 2010, smear microscopy increased both in number and in quality, suggesting these concerted efforts are successful (table 1). table 1. smear microscopy results in tajikistan 20082011. effective referral mechanism is another factor contributing to quality tb diagnosis, which consists of a well-performing health workforce and sound management practices. a well-performing health workforce is one that works in ways that are responsive, fair, and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient, competent, fairly distributed staff; they are responsive and productive). 12 improving the performance of the health workforce was one of the objectives for knowledge, attitude and practice (kap) surveys implemented in 2005 and 2008 jointly by the international ngo project hope, who office in tajikistan, sino project/swiss center for international health with funds from global fund to fight aids, tuberculosis and malaria (gf) and usaid. in 2008, 185 doctors and 357 nurses working in primary health care have participated in the survey. the health providers were questioned if they have passed formal training in principles of the dots strategy. there was an attempt to evaluate their competence as well. only 43% of doctors and 32% of nurses had attended dots courses during the last five years preceding the survey. regarding the quality of knowledge, 72.4% of physicians, compared to only 29% of nurses, working in primary health care correctly noted that the first step in tb diagnosis is a referral for microscopy examination (table 2). 13 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx korobitsyn this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu table 2.suggested actions of phc providers toward tb suspects. quality of sputum is a critical factor influencing tb diagnosis. the same survey showed nurses have insufficient knowledge about contributing factors to collecting quality sputum samples (table 3). 13 table 3.knowledge of factors influencing the reliability of sputum smear microscopy results. another critical factor for making correct tb diagnosis is following the tb diagnostic algorithm. when tb is suspected (prolonged cough, abnormalities on a chest x-ray) but the smear microscopy result is negative, the diagnostic algorithm indicates prescribing broad-spectrum antibiotic therapy. according to the study results, phc physicians followed this algorithm only in 38.9% of cases. 13 (c) cases do not seek care the third group of reasons for not detecting tb cases can be attributed to the situation when “cases are not seeking care.” the following reasons in this group, which are of utmost importance for tajikistan: (1) stigma, (2) high economic cost of the medical services, and (3) lack or insufficient knowledge of tb symptoms by the general population. the stigma attached to tuberculosis in many societies has been recognized as a major global cause of the limitations of the world health organization’s dots strategy for tb control. 14 in the 1960s, stigma was defined by goffman as “an attribute that is deeply discrediting” and the stigmatized as “individuals who are negatively regarded by the broader society and are devalued, shunned or otherwise lessened in their life chances.” 15 jones et al. proposed that people are stigmatized “when they are found to possess a mark that makes them deviate from a prototype or norm.” 16 it was broadly studied and proved that, for tb patients, stigma has a major impact on access to health care. it affects healthcare seeking behavior, as people are hesitant or choose not to disclose their symptoms to family members, friends or neighbors for fear of possible isolation and hostility towards them. 15-17 in tajikistan, stigma related to tb was studied in depth within kap surveys as well. in 2005, tb patients (n=350) were asked if they noticed a change in attitude among family members toward them once the diagnosis of tuberculosis was revealed. about 15% of the patient respondents noticed deterioration in attitude toward them. 18 the results of survey in 2008, as well as in 2005, showed that the majority of the respondents believe that tb patients should be isolated (2005-84%, 2008-94.4%). more than 52% of them noted that tb patients should be isolated for the entire period of treatment; 32% until their health improved and 15% for contagious period only. 13,18 the manifestation of stigma is more distinct on a personal level. even though the majority of respondents from the general population in 2008 believed that tb can be cured (84%), at the same time 45.3% of them indicated that they would not accept a former tb patient into their family. 13 reasons for refusal to accept people with tb into families were explained by respondents as following: fear to be infected with tb (48.9%), tb can be inherited (25.2%), and risk of re-infection (24.1%). these data correlate with self-reports from tb patients, when over 50% of respondents among tb patients of marital age, both men and women reported difficulties when creating a family and high level of tb related stigma among migrant workers. 13,19 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu illness often results in an economic burden for individuals as well as households, especially for socially disadvantaged and impoverished groups of the population. 20 the negative economic effect is further exacerbated in a situation when social support is missing. 21 in case of underfunded health services, the private out-of-pocket payments can become an important source of health system financing. 22,23 there is overwhelming anecdotal data of prevalent private outof-pocket payments for health services in tajikistan. these facts were confirmed at least by several systematic studies. 13,18,24-26 the “kap” surveys conducted in 2005 and in 2008 documented the problem of unofficial payments for health services in tajikistan along with their possible detrimental effect for tb care. 13,18 in 2008, 1/3 of respondents representing general population stated that tb treatment is provided on a pay basis. 13 over 68% stated that key reason of delayed care seeking is shortage or lack of money (in 2005, 67.5%) whereas only 7.3% of them mentioned lack of knowledge of tb symptoms as reason for delayed care-seeking (2005 26%). 13,18 the study on household costs of illness during different phases of tb treatment found that an illness episode cost averaged as high as $1,053 usd, with a peak in early stages of treatment ($145 per month before the start of treatment, $153 per month in an intensive, and $95 in a continuation phase, p < 0.0005). 24 these costs not only seriously compromise affordability, but also have a devastating effect on an household budgets in tajikistan. 24 finally, knowledge of tb symptoms by general population plays an important role whether patients are seeking care, should symptoms of tb occur. it has been proven in a number of countries that educational campaigns among population may increase both use of health services by general population and number of newly detected tb cases. 27 the comparison of 2008 and 2005 kap survey results indicate improvement in awareness of tb transmission among the population in the pilot districts. comparative analysis revealed that 63.7% of respondents in the 2005 survey mentioned cough as a basic tb symptom, versus 84.9% of respondents in 2008. there is also increase in respondents’ knowledge of other tb symptoms. in 2005, over a quarter of respondents could not define any of tb symptoms versus just 7% in 2008. according to 2008 survey results, the majority of respondents (61%) believe that the transmission through air (2005, 25.3%) and commonly used items (27.3%) are the main ways for tb transmission. taking into account that the latter (contact) mode is not epidemiologically significant, this rate (27.3%) indicates that further public education is needed. while 20% of respondents in 2005 were not aware of the means of tb transmission, in 2008 survey this decreased to 5.2%. 13, 18 discussion detection of tb cases is an essential component of tb control. its objective is to identify infectious tb sources in society and treat them, thus discontinuing chain of transmission of tb infection. 28 while it is considered critical to prioritize efforts to treat earlier detected cases of tuberculosis, 29 it is also important to look into detecting the highest possible proportion of them in order to achieve sustainable control of the tuberculosis epidemic. tajikistan has achieved tangible progress in treatment of tb cases, despite having the lowest tb detection rates in the who euro region (44% in 2010). therefore, tb detection needs to be strengthened, and new approaches applied in order to further improve the trend of tb case detection. the analysis reveals that some aspects of tb case detection are more problematic than others, whereas certain gaps in knowledge of specific obstacles http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx korobitsyn this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu to tb case detection exist. thus, the scenario “cases are diagnosed but not reported” is studied considerably less than others. the phenomenon of treatment without registration and reporting due to various reasons (stigma, deprived access to health services due to either distance or financial affordability, belief in traditional healers) was not studied. alternatively, there have been attempts undertaken to study and prove the phenomenon of “initial default” in tajikistan. the preliminary analysis has shown that majority (60%) of initial defaulters are residents of the districts different from those where they seek health care. it is not clear at this stage why this has happened, which may be due to stigma or family connections and needs to be studied. at the same time the system of information exchange between districts requires urgent improvement. for “cases that seek care but are not diagnosed,” it appeared that laboratory services detect infectious tb cases rather effectively, whereas referral of appropriate suspects for sputum smear microscopy possibly lags behind. the problem may be related to the qualification and performance of the health staff, which is possibly being impacted by training and monitoring or by the effectiveness of referral pattern of the existing tb suspects, integration and collaboration between tb and phc services. the scenario “cases do not seek care,” appeared to be explored extensively, with two kap surveys conducted in 2005 and 2008 as well as several other studies yielding mutually supportive results. starting from 2002, concerted efforts have been applied for public education in regard to general information on tb, which produced measurable results. yet, the problem of tb attached stigma persists, being one of obstacles for the effective tb detection in tajikistan. high economic cost of health services driven by under-the-table payments was identified as another barrier for access to health care. while a simplistic way of regarding this phenomenon would be to call it “corruption” leading to punitive measures only, deeper assessment, supported by a number of studies, is that viewing informal payments as a characteristic of health system frailty which necessitate health system strengthening rather than police measures. if average official salary of doctors in 2011 was usd $71 (tajik somony 337), 30 when health services are severely underfunded, under-the-table payments become a means of survival and are difficult to mitigate through punitive action. conclusion low case detection in tajikistan is a complex problem with barriers to its improvement lying on different stages of the tb diagnostic path within health system domain as well as beyond. based on results of this study, it may be plausible to suggest health system strengthening (hss) activities, broadly defined elsewhere as a logical primary approach to increase of tb detection in tajikistan. 31 the information collected and analyzed in this article suggests that suboptimal qualification of health cadres, ineffective management and supervision practices, and suboptimal health funding mechanisms are contributing to losing detected cases as “initial defaulters,” ineffectively referring of tb suspects, and, finally, prohibiting access to health services through high informal payments. more research on unofficial treatment for tb patients outside of tb services, reasons contributing to “initial default,” especially from the perspective of a patient, and factors underlying tb-related stigma is needed. references 1. national program for tuberculosis protection of the population of the republic of tajikistan, 2010-2015. dushanbe. 2010. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu 2. world bank, data and statistic for tajikistan. 2010. available from http://web.worldbank.org/wbsite/external/countries/eca ext/tajikistanextn/0,,menupk:287273~pagepk:141132~pi pk:141109~thesitepk:258744,00.html. accessed 2011 jun 15. 3. toshmuhammadov m. civil war in tajikistan and postconflict rehabilitation. hokkaido university center of slavic researches, sapporo. 2004. available from http://srch.slav.hokudai.ac.jp/pdf_seminar/040607tasmuhammadov_eng .pdf. accessed 2012 jul 12. 4. global tuberculosis control: who report2011.who/htm/tb/2011.16: 187-211. 5. project hope, 2009-2010. routine monitoring reports of the supervisory visits. 6. global tuberculosis control: who report 2010.who/htm/tb/2010.7: 14-5. 7. botha e, den boon s, verver s, et al. initial default from tuberculosis treatment: how often does it happen and what are the reasons? int j tuberc lung dis. 2008; 12:820–3. 8. botha e, den boon s, lawrence ka, et al. from suspect to patient: tuberculosis diagnosis and treatment initiation in health facilities in south africa. int j tuberc lung dis. 2008; 12:936–41. 9. saibabu b, satyanarayana vv, venkateshwaralu g, et al. initial default among diagnosed sputum smear-positive pulmonary tuberculosis patients in andhra pradesh, india. int j tuberc lung dis. 2008; 12:1055–8. 10. harries ad, rusen id, chiang cy, et al. registering initial defaulters and reporting on their treatment outcomes. int j tuberc lung dis. 2008; 13(7):801–3. 11. korobitsyn a, rajabov j, norov o, shekhov a. analysis of initial defaulters in selected districts in tajikistan. 41st iuatld conference; berlin. 2010. 12. world health organization. health systems topics. available from http://www.who.int/healthsystems/topics/en/. accessed 2012 april 25. 13. kosymova s, ismoilova j, korobitsyn a, saifitdinov s. tuberculosis knowledge, attitudes and practices survey among health care providers, tb patients and general population of tajikistan. technical report. dushanbe. 2009. 14. world health organization. treatment of tuberculosis. guidelines for national programmes, 3rd ed. geneva, switzerland. 2003. 15. goffman e. stigma: notes on the management of spoilt identity. london, uk: penguin; 1963. 16. jones ee, farina a, hastorf ah, markus h, miller dt, scott ra. social stigma: the psychology of marked relationships. new york, ny: freeman; 1984. 17. weiss mg, ramakrishna j. stigma interventions and research for international health. stigma and global health: developing a research agenda international conference 2001; bethesda, maryland, usa. available from http://www.stigmaconference.nih.gov/finalweisspaper.htm. accessed 2009 jan. 18. kosymova s, ismoilova j, purves m. tuberculosis knowledge, attitudes and practices survey among health care providers, tb patients and general population of tajikistan. technical report. dushanbe. 2006. 19. salikhov b, bobokhojaev o, sirojidinova u. stigma associated with tuberculosis among tajikistan labor migrants. 6th conference of the union europe region; imperial college, london. 20. russell s. the economic burden of illness for households in developing countries: a review of studies focusing on malaria, tuberculosis, and human immunodeficiency virus/acquired immunodeficiency syndrome. am j trop med hyg. 2004; 71(2):147-55. 21. mcintyre d, thiede m, dahlgren g, whitehead m. what are the economic consequences for households of illness and of paying for health care in lowand middle-income country contexts? socsci med. 2006; 62:858-65. 22. feeley fg, sheiman im, shiskin sv. 1999. health sector informal payments in russia. boston university, boston, massachusetts. 23. feeley fg, boikov ve, sheiman im. 1998. russian household expenditures on drugs and medical care. boston university, boston, massachusetts. 24. ayé r, wyss k, abdualimova h, saidaliev s. household costs of illness during different phases of tuberculosis treatment in central asia: a patient survey in tajikistan. bmc public health. 2010; 10:18. available from http://www.biomedcentral.com/1471-2458/10/18. 25. makhmudova m, rajabov j, chorgoliani d, hasker e. tb drug use study in tajikistan. 39th iuatld conference; paris. 2008. 26. makhmudova m, joseph j, ismoilova j, norov o, korobitsyn a. tb patients’ needs and costs study in tajikistan. 41st iuatld conference; berlin, 2010. 27. world health organization. advocacy, communication and social mobilization (acsm) for tuberculosis control: a handbook for country programmes. 2007. 4-5. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://web.worldbank.org/wbsite/external/countries/ecaext/tajikistanextn/0,,menupk:287273~pagepk:141132~pipk:141109~thesitepk:258744,00.html http://web.worldbank.org/wbsite/external/countries/ecaext/tajikistanextn/0,,menupk:287273~pagepk:141132~pipk:141109~thesitepk:258744,00.html http://web.worldbank.org/wbsite/external/countries/ecaext/tajikistanextn/0,,menupk:287273~pagepk:141132~pipk:141109~thesitepk:258744,00.html http://src-h.slav.hokudai.ac.jp/pdf_seminar/040607tasmuhammadov_eng.pdf http://src-h.slav.hokudai.ac.jp/pdf_seminar/040607tasmuhammadov_eng.pdf http://src-h.slav.hokudai.ac.jp/pdf_seminar/040607tasmuhammadov_eng.pdf http://www.who.int/healthsystems/topics/en/ http://www.stigmaconference.nih.gov/finalweisspaper.htm http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20ay%26%23x000e9%3b%2br%5bauth%5d http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20abdualimova%2bh%5bauth%5d http://www.biomedcentral.com/1471-2458/10/18 korobitsyn this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu 28. luelmo f. world health organization. what is the role of case detection in tuberculosis control? toman’s tuberculosis, 2nd ed, geneva, 2004. 29. who expert committee on tuberculosis, 9th report. geneva, world health organization, 1974. 30. statistical agency president of the republic of tajikistan database. available from http://www.stat.tj/ru/database/realsector/. accessed 2012 aug 26. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.stat.tj/ru/database/real-sector/ http://www.stat.tj/ru/database/real-sector/ central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu table 1. smear microscopy results in tajikistan 2008-2011. dm (phc+tb services) # positive pr (%) dm (phc) # positive pr (%) 2008 28619 2900 10 12077 538 4 2009 37175 3568 10 16708 712 4 2010 40712 3896 10 19555 925 5 2011 (9 months) 31705 2774 9 14648 1036 7 note: dm – diagnostic microscopy; phc – primary health care services; pr – positivity rate. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx korobitsyn this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu table 2.suggested actions of phc providers toward tb suspects. phc doctors phc nurses referral to sputum collection spot 72.4% 28.9% referral to dots center 11.4% 32.5% referral to tb center 3.2% 30.0% referral to x-ray room 13.0% 3.4% do not know 0.0% 0.8% other 0.0% 4.5% note: phc-primary health care services. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no.2 (2013) | issn 2166-7403 (online)| doi 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu table 3.knowledge of factors influencing the reliability of sputum smear microscopy results. phc nurses, providing correct answer controlled sputum collection 40.9% following sputum collection techniques 65.3% number of sputum samples examined 5.3% adequate instructions for patients 14.0% qualifications of laboratory technician 17.6% other 8.8% note: phc-primary health care services. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aringazina public health challenges kazakhstan public health challenges and priorities for kazakhstan altyn aringazina1, gabriel gulis2, john p. allegrante3 1department of population health and social sciences, kazakhstan school of public health, almaty, republic of kazakhstan; 2unit for health promotion research, university of southern denmark, esbjerg, denmark; 3department of health and behavior studies, teachers college, and department of sociomedical sciences, mailman school of public health, columbia university, new york, ny usa abstract the republic of kazakhstan is one of the largest and fastest growing post-soviet economies in central asia. despite recent improvements in health care in response to kazakhstan 2030 and other state-mandated policy reforms, kazakhstan still lags behind other members of the commonwealth of independent states of the european region on key indicators of health and economic development. although cardiovascular diseases are the leading cause of mortality among adults, hiv/aids, tuberculosis, and blood-borne infectious diseases are of increasing public health concern. recent data suggest that while kazakhstan has improved on some measures of population health status, many environmental and public health challenges remain. these include the need to improve public health infrastructure, address the social determinants of health, and implement better health impact assessments to inform health policies and public health practice. in addition, more than three decades after the declaration of alma-ata, which was adopted at the international conference on primary health care convened in kazakhstan in 1978, facilitating population-wide lifestyle and behavioral change to reduce risk factors for chronic and communicable diseases, as well as injuries, remains a high priority for emerging health care reforms and the new public health. this paper reviews the current public health challenges in kazakhstan and describes five priorities for building public health capacity that are now being developed and undertaken at the kazakhstan school of public health to strengthen population health in the country and the central asian region. keywords: central asia, kazakhstan, health care, health promotion, population health, public health introduction the republic of kazakhstan is one of the former soviet republics that are now part of the commonwealth of independent states (cis). it has one of the largest and fastest expanding economies in central asia, growing an estimated 9% between 2000 and 2007. in 2011, kazakhstan marked the 20th anniversary of post-soviet independence by introducing new social policies designed to strengthen its domestic socioeconomic standing and political position in the international community. in addition, the central government of kazakhstan has prioritized several goals aimed at diversifying the economy beyond its reliance on oil, natural gas, and other extractive industries, decreasing dependence on the government sector, and increasing competitiveness of the state as a whole. a key area of the central government’s interest is the improvement of population health. despite strong macroeconomic indicators and considerable progress in building civil society, efforts to democratize its system of higher education and related institutions and modernize infrastructure to support population health, numerous challenges remain in delivering public health services to a population of over 16 million people, 59% of whom now live in the two largest urban centers: almaty and the capital city of astana. although many health status measures show kazakhstan to be ahead of most nations of the region, kazakhstan continues to lag behind nations with the size of its economy on several important health and environmental indicators.1 this paper briefly reviews the current health status and features of health care in kazakhstan and describes the current public health challenges. we also present five priorities for public health capacity building that are now being developed at the kazakhstan school of public health to strengthen population health in the country and the central asian region. socio-demographic and health status profile the population of kazakhstan is currently estimated (as of 2011) to be 16.5 million, with a growth rate of 1.235%.2 the world bank3 has estimated the gross national product to be $149.06 billion in 2010, with a per capita gross national income of $6,280, which is below the average of other european region states. life expectancy the world health organization (who) health profile for kazakhstan, which is located within the who european region, estimates the average overall life expectancy at birth to be 64 years (59 years for males and 70 years for females), which lags behind the regional average of 75 for both genders.1 the trend in life expectancy in kazakhstan is similar to that observed in the other cis. similar to other nations, female life expectancy at birth exceeds that for males by 11 years. causes of mortality the who estimates that, with only a few exceptions, the rates of mortality due to the main diseases are above the averages for other regional states. according to who, noncommunicable chronic diseases (cardiovascular diseases, including diabetes, and cancer) accounted for about 85% of all deaths in kazakhstan, injuries about 11%, and communicable diseases about 2%.1 cardiovascular diseases accounted for 57% of all mortality.4 infant mortality in 2010 was 29 deaths per 1,000 live births and maternal mortality was estimated in 2008 to be 25 deaths per 100,000 births. infectious and sexually transmitted diseases blood-borne diseases such as hepatitis c and hiv, sexually transmitted infections, and tuberculosis still constitute a challenge for the public health system in kazakhstan. as of the end of 2010, kazakhstan reported to the who regional office for europe and the european centre for disease prevention and control a cumulative total of 15,754 hiv and 1,242 aids cases, including 881 deaths due hiv/aids.5 for the year 2010 alone, 1,988 hiv and 256 aids cases, with 165 deaths due to hiv/aids, were reported. the rate of newly diagnosed hiv infections in 2010 was 12.4 per 100,000 populations. although kazakhstan currently has a relatively low prevalence rate of hiv infection, there are a number of factors in place that create the potential for a dramatic increase, including those of migration, injection drug use, commercial sex work, and the marginalization of vulnerable groups.6 kazakhstan has a prevalence rate for tuberculosis (tb) of 198 per 100,000, which, when compared to 63 per 100,000 people for other nations in the who european region, is the highest in the region. while working on a region-wide initiative to improve the effectiveness of the health system in response to tb, project hope initiated an anti-tb strategy by implementing directly observed therapy-short course (dots) in 1994. since then, the tb program has expanded to become a region-wide disease management program. in 2009, project hope implemented a five-year, usaid-funded partnership with population services international (psi) to increase access to tb prevention and treatment among at-risk populations in kyrgyzstan, tajikistan, uzbekistan, and kazakhstan. the initiative provides direct outreach services and training to those populations most at-risk and focuses on increasing tb and hiv knowledge and prevention as well as training for providers on stigma reduction. immunizations kazakhstan has been officially considered a poliomyelitis free country by the who since 2002, with the national immunization coverage at 98 percent in 2010. concerning other vaccine-preventable diseases, coverage in 2010 for bcg was at 96%, measles-containing vaccine (mcv) at 98%, and dtp1 and dtp3 were at 99%. vaccination against 21 infectious diseases is conducted in kazakhstan. in accordance with the national calendar of prophylactic vaccination, children under two years old are given vaccine treatment against 11 infectious diseases. a national advisory committee on immunization was established in spring 2012 with the aim of being an advisory body to deal with the issues of vaccination and resolve the issues of introduction and application of new vaccines in kazakhstan. vaccines certified by the who are procured and, moreover, all vaccines undergo laboratory control, tests, hospital control to ensure safety and effectiveness. population risk factors although the adult risk factors of blood glucose, blood pressure, and the rate of female obesity are higher in kazakhstan than other countries in the region, male obesity and adult tobacco use is lower. in 2008, the rate of obesity among adult males aged 20+ was 20.2, while adult female obesity was 27.4. according to data collected by the national center for healthy lifestyle development, the average smoking rate in 1998 was 28%, which had declined to 27% by 2007 and where it has remained as of 2011. average alcohol consumption has declined from 55% in 1998, to 41.9 % in 2007, to 35.6 in 2011. adult participation in physical activity was 15.3% in 1998 and 18.6% in 2007; however, in 2011 levels of participation in physical activity declined slightly to 17.6%. major efforts are now being taken to improve the management and control of hypertension.7 health care since the post-soviet era and as the result of reforms, health care in kazakhstan has developed and evolved into a stable government function that is designed to provide high-quality medical and related pharmaceutical and rehabilitation services to the population. one of the main priorities of the central government of kazakhstan is the modernization of a high-quality health sector and development of an integrated health care system that utilizes high technology.8 the state health development program calls for an intersectoral approach to improving population health and includes benchmarking measures on a wide range of legislative, investment, structural, economic, and personnel indicators. additionally, one of the main goals of the program is to introduce incentives for people to engage in “self-keeping” behavior and lifestyle changes that can promote and protect health. thus, the overall goal of the program is to improve health for all citizens of kazakhstan in an effort to ensure sustainable social and economic development. the program is also intended to promote dynamic development of the health care system by creating conditions for economic reforms that can improve access to high-quality medical and social services and the provision of prevention programs. this has included development of a new system of social insurance as part of reforms that replaced the soviet system and are designed to improve access, especially among those in the rural areas where access to care has been problematic,9-11 and reduce the problem of informal payments to medical personnel that often has been a feature of reimbursement in the provision of medical care.12 in addition, the program aims to elevate the professional personnel qualifications of medical specialists and foster development of an equitable health care system that is capable of adapting to market conditions of society. recent developments along these lines include the creation of a health care legal base, significant increases in health care funding that have allowed for the construction of new, state-of-the-art clinics and hospital facilities, capital repairs and improvement of the technical infrastructure of health facilities, and the introduction of new medical technologies for diagnosis and treatment. as a result of improving the quality and accessibility of health care, some positive trends in the health status of the population related to infectious and other diseases have been achieved. however, the majority of public health parameters remain unsatisfactory. the state program’s specific goals for improvement of key indicators by 2015 include: increasing life expectancy at birth from 68.4 to 70 years; decreasing maternal mortality per 100,000 births from 28.1 to 24.5; and decreasing infant mortality per 1,000 births from 16.5 deaths to 12.3. as in other middle-income countries, the increase in life expectancy is expected to be accompanied by an increase in the number of people living with chronic disease and thus a significant increase in the demand for primary health care is likely to occur.13 even with key elements of the most recent state program reforms for health care now in place, the health care system continues to be in transition6 and significant barriers to implementation have remained.14 kazakhstan’s difficult economic context, lack of resources, the legacy of soviet-era policies, and the complex and often corrupt political arrangements between national and local authorities are among the challenges that remain to be overcome.15 however, there are some positive changes in the health status and health care system of kazakhstan. for example, health care indicators have continued to improve on most measures as the health care system has modernized. moreover, the birth rate has increased, together with years of life expectancy, and although the rates of some noncommunicable diseases have risen, the mortality due to cardiovascular diseases has decreased by 1.7%. public health challenges public health in kazakhstan is under the direction of the ministry of health. public health efforts are organized and undertaken through a coordinated system of central, regional, and local entities.16 there are several key elements of this system. the committee on sanitary-epidemiological surveillance of the ministry oversees the “sanepid” (sanitary-epidemiological) service, which has organized a network of subdivisions whose role is to conduct disease surveillance, prevent the transmission of communicable diseases, and enact quarantine and other control measures in the event of epidemic outbreaks. the national program of health reform and development for 2005-201017 outlined an ambitious set of goals for the reduction of infectious diseases through programs that are now being implemented at the national, regional, and local levels. an interministerial coordination committee on aids coordinates an inter-agency system of hiv/aids centers that are implementing a national strategic program on hiv/aids prevention to address the hiv/aids epidemic and related diseases. finally, a national centre for healthy lifestyles focuses on health promotion and disease prevention, including drug abuse and trafficking, alcohol and tobacco use, maternal and child health, nutrition, and environmental health. in addition, primary health care providers, nongovernmental organizations (ngos) and several international agencies, including usaid, the u.s. centers for disease control and prevention (cdc), the world bank, and who, provide a range of consultative, programmatic, and other public health services that support domestic public health efforts in kazakhstan and throughout the region.16 among the most significant public health challenges is the legacy of poor environmental management that has led to two catastrophic environmental health disasters, the effects of which continue to unfold. in the case of the first, a population of approximately 200,000 kazakhs living in the vicinity of the semipalatinsk test site, located in the steppe region of northeast kazakhstan, was exposed to large doses of radiation when, starting in the 1940s, the soviet union conducted over 400 nuclear weapons tests over the course of four decades. the health and environmental impacts of these tests and the subsequent radiation exposure have become evident in recent decades with the increase in the incidence of cancers and other related diseases.18 the second was the environmental disaster that resulted from the draining of the aral sea during the 1960s, when soviet irrigation projects destroyed what was then the fourth largest lake in the world. the destruction of the lake has left the lake bed and surrounding land polluted and the region economically depressed. perhaps the most pressing challenges for public health are of organizational, political, and philosophical nature. according to the who, the “biggest challenge of the country’s health sector in the domain of public health lies in clarifying, coordinating and streamlining the roles and responsibilities of different agencies responsible for public health and health promotion activities.”16 moreover, related to this is making the promotion of health a core responsibility for all of the government ministries.19 the new policy argues for “whole-of-government” and “whole-of-society” approaches that will consolidate the ideas encompassed in health in all policies. this concept emphasizes the need to improve the integration of government activities with health and to reach out beyond government to engage patients and citizens, developing a responsive and inclusive approach to governance for health.20 thus, policy integration across government functions and in intersectoral partnership with the agricultural, education, housing, and transportation sectors will be critical to achieving the goals of public health in kazakhstan. finally, despite recent reforms, young scholars in public health still face significant barriers to mounting successful programs of research that could contribute to improving population health in kazakhstan and the region. the relative lack of investment in research, the institutional infrastructure necessary to support grants and contracts, and a culture of competitive, peer-reviewed investigational public health science hampers kazakhstan from achieving breakthroughs in the improvement of population health in a region where the public health needs are critical to advancing the goals of civil society, further economic development, and regional security. the recent attention given to population health and evidence-based practice has catalyzed interest in the region to build the necessary research culture and institutional infrastructure that can support multidisciplinary research to inform policies and practice, not only in kazakhstan but also across institutions in the region. such a culture and infrastructure exists in western europe, north america, and the united kingdom, where the benefits of robust national mechanisms for funding research and institutional infrastructures to support competitive procurement of funds is evident in the history of research discoveries that have altered the course of the human condition for the better. priorities for building public health capacity against this backdrop and despite negative trends in many lifestyle indicators and the apparent lack of resources for public health, much has been achieved in the last decade to provide a foundation for the improvement of population health going forward. the establishment of various state programs and many organizations in the field of public health, such as the kazakhstan school of public health (ksph), has created the essential conditions for the development of a post-soviet, modern public health movement in the republic of kazakhstan. the central government of kazakhstan has created a national coordination council on health protection, the aim of which is the development and maintenance of interactions between central and local executive bodies and international and other organizations for conducting research and programmatic activities on health protection. the council is a consultative body governed by the minister of health, comprising 32 representatives from various ministries, departments, non-governmental scientific institutions, and other organizations that meet quarterly. the main objectives of the council include the preparation of recommendations and suggestions regarding: 1) performance and maintenance of actions assigned by the programs; 2) improvement of the state policy and normative legislative documents in the area of health protection; and 3) definition of guidelines for health protection of the citizens of kazakhstan. thus, the council is an example of one of the many innovations in public health capacity that is supporting integration of a state health care policy that promotes multi-level, intersectoral decision-making processes concerning the main determinants of health. the kazakhstan school of public health was established in 1997 in accordance with an agreement with the who european regional office and the kazakhstan ministry of health. the mission of ksph is to: 1) provide postgraduate education for health care managers, physicians, and other medical specialists; 2) conduct research in public health; and 3) provide expertise and consulting services. one of the objectives of the ksph academic program is to train public health specialists in a two-year master’s degree program. since 2005, 224 students have been prepared with the degree of master of science in public health; currently, 56 master of science students and 15 phd students are studying at ksph. ksph also conducts continuing education for public health specialists with shortand mid-term programs of fiveto ten-month durations. more than 12,000 professionals have received professional preparation in public health since 1998. ksph is an institutional member of the asian pacific academic consortium for public health (apacph), the association of schools of public health in the european region (aspher), and the international union for health promotion and health education (iuhpe). although in recent years new faculties and departments of public health have been established in the country, ksph remains the flagship professional preparation program in the field of public health in the central asian region. as the only well recognized school of public health in the central asian region, ksph is now pursuing the development of public health capacity in five key priority areas that are critical to advancing public health knowledge and practice in kazakhstan and the region. 1. implementing the new public health kazakhstan is implementing a new public health strategy that is guided by a set of core values and principles.21-22 health promotion is the cutting edge of this new public health strategy and its theoretical approach and methods are grounded in an ecologic model of health that takes into account cultural, economic, and social determinants and makes a commitment to equity, civil society, and social justice. in 1997, the president of kazakhstan set out a 30-year welfare strategy for the country in an address titled kazakhstan 2030.23 in the address, the president emphasized the importance of public health and health promotion as long-term national priories. the strategy includes the promotion of health and prevention of disease by reducing alcohol, drug, and tobacco use, and improving maternal and child health, nutrition, and the environment. nevertheless, the current public health model in kazakhstan is still largely grounded in a biomedical orientation. key players and decision makers continue to underestimate the importance of public health while they make investments in curative medicine. thus, there is an urgent need to support the development of public health programs at the local level and encourage an interdisciplinary and intersectoral approach to public health policy and program development. in addition, there is a need to facilitate the increase of knowledge and skills of health promotion specialists in the country and cultivate social responsibility for health.  2. addressing social determinants recent attention to the social determinants of health24 has stimulated a renewed interest in kazakhstan to improve the social circumstances that are necessary for improved health. consistent with the who’s expectation that member states in the european region focus on reducing health inequities that are socially determined, kazakhstan is currently making progress to improve education, employment, and housing conditions. efforts to prevent diseases related to poor nutrition, poor sanitation, and poor water supplies also continue to be a priority.25 however, more than three decades after the declaration of alma-ata, which was adopted at the international conference on primary health care convened in kazakhstan in 1978, improving social circumstances remains a priority that has not fully matured. the newly reconstituted department of population health and social sciences at ksph has been leading the development of work on health economics, health impact assessment, and social determinants of health. recent master classes sponsored with the support of the ministry of health have focused on basic principles of public health policy-making, the role of behavioral and social determinants in population health, and the use of economic methods and health impact assessment in evaluating national public health programs. such activity is designed to convene specialists with different backgrounds from different organizations in order to foster cooperation in finding common ways to solve public health problems that arise from or are related to social determinants. 3. conducting health impact assessment a third critical priority of ksph is improving the use of health impact assessment (hia) to inform policy and benchmark progress.26 the powerful hygiene and sanitary system established during the soviet era provided a good foundation for the introduction of practices like health impact assessment. yet, the lack of democracy has hindered the full-scale use of the method due to many of same reasons as in other countries of the former soviet bloc.27 hia is one of the main tools available to public health leaders to implement the heath in all policy approach and is especially relevant for the rapidly developing countries with a high level of economic activity, such as kazakhstan. concepts and methods of hia were first introduced in kazakhstan in 2005 when ksph organized and conducted the first summer workshop on the topic for medical and public health professionals. the workshop led to the introduction of a course on hia into the regular mph curriculum at ksph. a second workshop on hia was conducted in may 2012. an existing memorandum of understanding between ksph and the university of southern denmark, esbjerg, currently provides for ongoing teaching and consultative support in hia, including the use of hia in research and as a tool for benchmarking that can inform public health policy and practice. the national coordination council on health protection seems to be a promising infrastructure within which to situate capacity for hia, not only at the project level but also the policy level in kazakhstan. 4. strengthening scientific communication and exchange a fourth priority is improving public health through scientific communication and exchange. ksph is focusing on this priority by doing two things. the first involves emphasizing the importance of professional development and, specifically, the value of english as a second language for all of its faculty and students. fluency in english will be critical to the future development of the public health profession in kazakhstan. because the next generation of public health professionals will have to be proficient in conducting searches of the global evidence-base, exchanging knowledge and ideas with colleagues from different countries, and sharing the results of scientific findings and practice in international peer-reviewed journals, english as a second language must become a priority for all professional education in public health. the second involves revitalizing the central asian journal of health service (cajhs) as a key scientific journal of the region for public health research and practice. cajhs provides many medical professionals from the region a peer-reviewed outlet for publication in the health services. the journal has recently established an online presence and manuscripts are translated into and published in russian, kazakh, and english. expanding the range of published content to include more reports of public health research and commentary, and strengthening the editorial board and peer review capacity of the journal, are key priorities for ksph, the home of the journal editorial offices. 5. building public health workforce capacity in education and training the final critical priority is capacity-building in public health professional education and training. ksph is cooperating with international organizations such as the american international health alliance (aiha), the european union tacis project on strengthening environmental information and observation capacity in the commonwealth independent states, and other organizations, such as unicef, the usaid zdravplus project, and who, to achieve institutional reforms and training and education for improving teaching programs on public health and health promotion. in addition, it is working on collaborative research and education projects with the british council, council on health research for development (cohred), environmental resources management (erm), and the cdc central asia regional office. ksph also currently collaborates with several academic institutions, including the columbia university global research center of central asia and the columbia university schools of education, public health and social work; ohio university; semmelweiss university (hungary); the university at albany of the state university of new york; and the university of southern denmark. ksph is at the vanguard of efforts to strengthen public health professional education and training and bring its public health curriculum into line with current international standards, including the integration of european and global core competencies and quality assurance standards for health promotion and health education28-29 and other areas of public health. these efforts include, for example, participating in a program of curriculum reform that is being supported by the soros open society foundations (soros europe foundation) higher education support program’s academic fellowship program, and voluntarily undergoing accreditation with the associations of schools of public health (aspher) during 2012-2013. these and other efforts now underway should further the development of educational resources at ksph and deepen the capacity and professional skills of its academic faculty to conduct scientific research, training courses, and other vital public health functions and services. conclusion the republic of kazakhstan faces many public health challenges. these include the need to improve public health infrastructure, address the social determinants of health, and implement better health impact assessments to better inform health policies and public health practice. in addition, the threats to health created by the unfortunate legacy of soviet nuclear testing and poor environmental management of natural water resources have continued to endure. in the context of national policy reforms that have placed a high priority on improving the health of the population, the ministry of health, the kazakhstan school of public health, and other government and non-governmental entities are responding and making progress with new and fast-developing public health policies and programs to meet the challenges. however, improving public health capacity is critical and will require new incentives and new investments in the system of public health education and training and public health research, if further improvement of population health in kazakhstan is to be achieved. continued interest and support of the global public health community—particularly that of who—in developing and sustaining international collaborative research and training efforts will be critical and promises to accelerate the process of public health capacity building that is so critical to the future of kazakhstan and the region. acknowledgements the work on this paper was supported, in part, by the ministry of health of the republic of kazakhstan (allegrante, aringazina, and gulis) and the soros open society foundations (osf europe foundation) higher education support program, academic fellowship program (allegrante). we thank rector zhanna kalmatayeva and kalissa dosbayeva, assyl nurbayev, aigul shinbolatova, gainel ussatayeva, and others at the kazakhstan school of public health, whose assistance and participation in the may 2012 master classes conducted by professors allegrante and gulis generated ideas that helped inform the preparation of this manuscript. references 1. health profile. world health organization; 2012; available from: http://www.who.int/gho/countries/kaz.pdf 2. world fact book. central intelligence agency. 3. google public data 2012; available from: http://www.google.com/publicdata/explore?ds=d5bncppjof8f9_&met_y=ny_gdp_mktp_cd&idim=country:kaz&dl=en&hl=en&q=gross+domestic+product+of+kazakhstan. 4. highlights on health in kazakhstan who; 2005. 5. hiv/aids country profile 2011: kazakhstan. world health organization; 2011; available from: http://www.euro.who.int/__data/assets/pdf_file/0004/158467/kaz-hivaids-country-profile-2011-rev1.pdf 6. kulzhanov m, rechel b. kazakhstan: health system review. health systems in transition. 2007. 7. nugmanova a, pillai g, nugmanova d, kuter d. improving the management of hypertension in kazakhstan: implications for improving clinical practice, patient behaviours and health outcomes. global public health. 2008. 8. state health development program for the republic of kazakhstan for 2011-2015. 9. ensor t, rittmann j. reforming health care in the republic of kazakstan. int j health plann manage. 1997. 10. ensor t, thompson r. rationalizing rural hospital services in kazakstan. int j health plann manage. 1999. 11. thompson r, miller n, witter s. health-seeking behaviour and rural/urban variation in kazakhstan. health econ. 2003. 12. ensor t, savelyeva l. informal payments for health care in the former soviet union: some evidence from kazakstan. health policy. 1998. 13. deloitte u. primary care: today and tomorrow – improving general practice by working differently. centre for health solutions report, 2012. 14. mckee m, figueras j, chenet l. health sector reform in the former soviet republics of central asia. int j health plann manage. 1998. 15. rechel b, ahmedov m, akkazieva b, katsaga a, khodjamurodov g, mckee m. lessons from two decades of health reform in central asia. health policy plan. 2012. 16. facts and figures. kazakhstan. who; 2007; available from: http://www.euro.who.int/en/what-we-do/health-topics/health-systems/public-health-services/facts-and-figures/kazakhstan-2007 . 17. national programme of health reform and development for 2005–2010. in: health mo, editor. 2004. 18. kassenova t. the lasting toll of semipalatinsk's nuclear testing. bulletin of the atomic scientists. 2009; available from: http://www.thebulletin.org/web-edition/features/the-lasting-toll-of-semipalatinsks-nuclear-testing . 19. aringazina a. public health policy in the republic of kazakhsta. health promotion comes of age: research, policy and practice for the 21st century. 19th world conference on health promotion and education, international union for health promotion and education; vancouver, british columbia 2007. 20. figueras j, mckee m. health systems, health, wealth and societal-well-being: assessing the case for investing in health systems. open university press; 2012. 21. aringazina a, macdonald g. new horizons for public health in kazakhstan. promot educ. 2006. 22. aringazina a. the new public health in the republic of kazakhstan. the new public health in the republic of kazakhstan; ohio state university, columbus, ohio. 2011. 23. president of the republic of kazakhstan. kazakhstan 2030. prosperity, security and ever growing welfare of all the kazakhstanis. available from: http://www.akorda.kz/en/kazakhstan/kazakhstan2030/strategy_2030. 24. commission on the social determinants of health. closing the gap in a generation: health equity through action on the social determinants of health. 2008. 25. aringazina a. public health programs on improving environment. children’s environmental health in central asia international conference, almaty; the university at albany, usa. 2005. 26. aringazina a, yegeubayeva s. health impact assessment – concepts and role in public health. int prof j med. 2008. 27. gulis g. health impact assessment in cee region: case of the former czechoslovakia. environ impact assessment rev. 2004. 28. allegrante jp bm, airhihenbuwa co, auld me, collins jl, lamarre m-c, magnusson g, mcqueen dv, mittelmark m. on behalf of the galway consensus conference. domains of core competency, standards, and quality assurance for building global capacity in health promotion. 2009. 29. dempsey c, battel-kirk b, barry m. the comphp core competencies framework for health promotion handbook. international union of health promotion and education (iuhpe) paris. 2011. new directions in building a scientific social network: experiences in the supercourse project and application to central asia new directions in building a scientific social network: experiences in the supercourse project and application to central asia meredith hennon1, ronald e. laporte1, eugene shubnikov2, faina linkov3 1department of epidemiology, university of pittsburgh; 2institute of internal medicine, novosibirsk, russia; 3department of medicine, university of pittsburgh abstract introduction: networking leaders in the field of public health and medicine is very important for improving health locally and globally, especially in times of disaster. methods: fishing can best be defined as using an internet search engine to find the name and email address of the person or organization that is being sought. results: with over 500 hours of work, the group compiled a list of nearly 2,000 email addresses of ministers of health, deans of the 1,800 medical schools and schools of public health, and heads of medical and public health societies. keywords: social networking; public health; health societies introduction social networking is becoming more and more important in various areas of science (tuire, 2001). despite this fact, there is little known about the “science of social networking.” in this research project, we have begun to evaluate the science of social networking with approaches that heretofore have not been explored. the social networking evaluation has been established as part of the supercourse. laporte (2004) detailed both the high-tech and low-tech methods of building the supercourse faculty network from word of mouth (low-tech) to weekly updates alerting users of new additions (high-tech). the interconnectivity of users and knowledge in different arenas makes it possible for experts to quickly distribute information in a time of need or emergency. here we describe an approach to build networks in the area of global health. the supercourse is an online repository of public health resources designed to empower teachers, accessible by anyone with an internet connection and a desire to know more about a certain topic (http://www.pitt.edu/~super1). the resources are powerpoint lecture slides on topics ranging from basic methods of epidemiology to lectures on specific diseases, as well as lectures relating to disasters (e.g. earthquakes, tornadoes) that can be brought to global attention an instant after such an event occurs. nearly 5,200 lectures are being shared by over 48,000 faculty members in 174 countries around the world with thirty one languages represented in the supercourse (supercourse 2010). utilizing the “golden lecture of prevention” (supercourse 2009), faculty can introduce basic knowledge of the importance of prevention and what it means for the betterment of global health. this powerpoint lecture was initially developed in 2003 and has slides developed by many different collaborators. it has been translated into 18 different languages by volunteers associated with the supercourse. the lecture has been viewed thousands of times and accessed from 140 different countries. this is a good example of networking at the global level and how global competence in this area can increase as anyone with access to the internet or the supercourse on cd can view this lecture. as of june 2010, there are no complete listings of deans of medical schools and schools of public health worldwide, nor is there one for the ministers of health of each country readily available. the world health organization (who) is interested in working through the supercourse team and the library of alexandria to compile these lists so as to be able to reach the deans and ministers for collaboration in the fields of public health education. it is with the potential for building networked collaboration and exchange of ideas and knowledge that this “fishing” expedition began. one of the most difficult problems in global health is how best to disseminate global health knowledge, especially through global health leaders. we decided to create a network of deans and ministers of health to serve as a gateway for the sharing of information with the faculty in the schools and the staff in the ministries of health. in addition, we took it upon ourselves to network the national directors of medical and public health societies so that we can reach through them as gatekeepers to their members. in addition to developing a network of deans, ministers, and heads of medical and public health societies, this model for network building is especially applicable to the five countries of central asia. collaboration, scientific social networks, and scientific connectivity are low between researchers at different universities within each country as well as between the five individual countries. utilization of the networking building process described hereafter can open scientific and collaborative doors in the countries of central asia that have not been previously accessible. background the lack of relevant scientific literature on building social networks, scientific networks, or scientific collaborations indicates that novel ideas are needed to build a network of the most knowledgeable and influential people in the medical and public health world. we describe a novel approach used by our group to achieve an important public health goal of scientific networking and encouraging collaboration amongst deans of medical schools, ministers of health, and other influential people in the world of medicine and public health. moreover, the ultimate goal of building the network is to be able to better share information with who, other agencies, and ultimately all public health and medical faculty and students worldwide. newman (2001) found that a social network is a collection of people, each of whom is acquainted with some subset of the others. in the medical and scientific communities, not every member knows every other member – the large number of network members makes it impossible. however, according to newman, each member knows a subset of others within the group. thus, a scientific social network could be built by bringing together small groups so that it could be possible to interact, at least casually, with every other member of the network. by reaching leaders in the field of medicine and public health, such as deans, the chances of reaching multiple members of medical social networks are greatly increased, as these leaders are well connected in their respective areas. a search for literature indicates that manuscripts addressing the accessibility of email addresses and contact information for these “powerbrokers” in the fields of medicine and public health are not currently available, as it has not been a focus of previous research studies. lawrence and giles (1999) found in a now outdated article discussing accessibility of information on the web that only 9% of the information on the internet is related to science, education, or health. this indicates that fishing for contacts is more likely to be found on less than reputable (i.e. non-academic or organization) websites. today, most medical schools of the world have either websites or contact information for the school or its dean listed on the internet. who has a complete list of world’s medical schools at http://www.who.int/hrh/wdms/en/, however email information is missing from that list. availability of this information suggests that the first step in creating a social network of medical and public health leaders would be finding or “fishing” for their emails, so that in the future they could be contacted and networked for various projects. the process of fishing for e-mails is not complicated, but it is an important activity, as there are no lists of contacts for deans, ministers of health, or heads of medical societies. although there are articles on searching for information, we could find no information about how best to find high level medical personnel worldwide. without careful planning and teamwork, it can turn into quite a time-consuming task. with the appropriate planning and delegation of tasks, it yields great results – a further connected and more collaborative world. fishing for contacts and any subsequent networks that are built and contacted from these efforts hold the potential to expand the supercourse lectures exponentially. moreover, what we are developing is a model for other disciplines such as agriculture, business, or any area of science. recruitment of new members means more scientific and public health knowledge being shared which can lead to more and better information dissemination in emergencies (e.g. natural disasters or epidemics) as well as more specialized topics being shared amongst supercourse users. methods finding fishers the first step in fishing is deciding upon who or what one wishes to find. over the course of a year, our group, consisting of students and faculty members identified through the supercourse network, “fished” (searched) for email addresses of the deans of all the medical schools in the world, as well as the deans of schools of public health, all heads of medical and public health societies in the world, and ministers of health for all countries. these groups were selected for networking, as they have high relevance to the field of public health, and potentially have the power to make a difference in public health education. students, staff, and faculty involved in this project were all motivated by an interest in global health and teamwork. the group was comprised of individuals from a variety of countries including the united states, united arab emirates, egypt, and japan. effective distribution of work upon deciding who or what it is that one wishes to find by fishing, the work must be split evenly amongst those who are participating. a typical line of division is to split the world up by countries into ten groups. each group has approximately 20 countries for which information needs to be located. this method varies in dividing the work evenly depending on what information is being sought. if one is searching for deans, groups containing china, india, or the united states will have hundreds more contacts or addresses to be located than a group containing zambia, uruguay, and iceland which only have one medical school each. however, fishing for ministers of health or medical and public health societies is a limited burden. there is usually only one per country, so fishing for these contacts should be relatively easy. in our study, the task of fishing was split among approximately 10 volunteers, each assigned approximately 10 countries. development of a search it is important to take no more than 10 to 15 minutes per search, mostly focusing on “.edu” or similar educational or governmental web domains. the idea is that if the information cannot be located within this timeframe, it likely does not exist or, at the very least, it is not worth finding when one is searching for a large quantity of deans or ministers. also, as this is a large task, if one takes too much time searching for one name, the task will be impossible to complete. the time spent looking for upwards of 200 names or email addresses already guarantees, at the very least, a couple hours of work for each fisherman. it can also mean up to as much as 50 hours to search and find information for those 200 names. university pages that are not in the english language can be translated using the google translate feature. while this does not provide a flawless translation, the fisherman is able to get the general idea of what the page says. building the database the list of medical schools was obtained from the who website http://www.who.int/hrh/wdms/en/. information related to medical and public health societies, as well as ministries of health, was located by searching for the type of organization (society, ministry, etc.) and the name of the country. volunteers were instructed to locate the contact’s name and email address, as well as position, organization, and country, when available. physical address and telephone number play a larger role when attempting to send a package containing a supercourse cd/dvd to the contacts. for our initial purposes, that information was accepted, but not absolutely necessary. fishing methods utilized in this project are outlined in figure 1. results fishing for the deans or heads of all medical schools and schools of public health worldwide was the first collaborative fishing expedition. splitting the countries into 10 even groups would yield approximately 180 schools for each fisher to search. however, as indicated previously, not all countries have an equal number of schools. there is a higher concentration of medical schools and schools of public health in countries with larger populations – where the demand for these types of institutions would be higher. approximately 180 searches per individual can equate to upwards of 30-45 hours of work if the maximum “acceptable” time (10-15 minutes per single search) is spent searching for each school and head of school (dean or most senior faculty member). this is indicative of how large of an undertaking the identification of the head of each of these medical schools and schools of public health is – a potential 450 hours spent building a scientific social network of the most senior members of the worldwide scientific faculty. the 10 people working to locate this elite group of individuals found 1566 email addresses for medical school and school of public health deans; about 87% of them were identified (table 1). medical and public health societies are membership organizations that have been established with the goals of treatment and prevention of diseases. these societies have a variety of mission statements, priorities, and goals. they offer membership to individuals who meet their specific qualifications and wish to work towards achieving their goals and priorities. reaching the heads of these organizations would be very beneficial in spreading the supercourse message of prevention and preparedness. it is difficult to estimate the number of members in these 156 different societies worldwide. with the american medical association, its state affiliates, and the american public health association having approximately 250,000-300,000 members, it’s indicative that worldwide membership in these societies is well into the millions (apha 2010, peck, 2007). approximately 113 email addresses for heads of the various societies were identified which was almost three quarters of the leaders (table 1). the last of our group fishing projects was identifying the ministers of health for all countries of the world. these government officials are usually the top officials responsible for protecting the health of the citizens of their respective countries as well as promoting public health practices. through internet searches 137 ministries of health were identified (55 countries did not have ministries of health or information regarding them or were not found in the allotted amount of search time). a notable 125 email addresses for ministers of health were found (table 1). table 1: results of fishing total number identified total number located through "fishing" percentage located medical school & school of public health deans (worldwide) 1804 1566 86.8% medical & public health societies (worldwide) 156 113 72.4% ministers of health(worldwide) 137 125 91.2% discussion now that nearly 2,000 email addresses of top ranking medical and public health officials from around the world have been compiled, what is the next step? with most public health and medical professionals having regular access to email and internet, the first step of scientific network development would be to make sure that all these professionals are aware of the supercourse and its mission and goals. the supercourse is constantly seeking ways to initiate collaborative activities at the global level to promote the health of populations worldwide. the supercourse has many things to offer including up-to-date educational resources to empower educators and clinicians. evidence-based practice in prevention and health promotion means reaching out to stakeholders who can help in distributing these resources to key informants in their communities. many medical schools do not have much, if any, public health coursework included in the curriculum, so a cd/dvd with supercourse lectures presented at the time of matriculation – perhaps included with orientation materials – could be a student’s first introduction to public health and prevention. those who are in the high ranking medical and public health positions are likely to be passionate about treatment and prevention of different diseases and conditions. it is this passion for global health that indicates that building this scientific social network can be very successful even if there is only an initial response of 40-50% of deans, medical and public health society heads, and ministers of health. worldwide, there are already many collaborative teams or groups working on various projects. if only one member of such a collaboration responds to an inquiry and recruits his or her colleagues, this scientific social network can grow exponentially. by reaching the deans, ministers, and heads and getting them interested in the project, they can act as gatekeepers to additional faculty, staff, students, and others. with who providing bulletin information for the supercourse to feed to the schools, societies, and ministries of health, this will open the gatekeepers to being more receptive to the project. these lists of deans, ministers, and public health leaders have been developed with the agenda of creating awareness and networking with other medical and public health professionals. to our knowledge, very little standardized global health information is shared among those in the medical field, those involved in public health, and ministers of health. this would be the first attempt for an international global network of information sharing. privacy of these lists is very important for keeping the network intact, as global health leaders would not be happy about getting multiple poorly focused messages. no one is required to remain on the list and can request to be removed if they do not care to participate. a foreseeable problem with fishing for ministers of health is a term limit. many ministers, if not all, are only in their position for a fixed number of years, with rapid turnaround in politically unstable countries. these limits may not be the same for every country and the ministers likely did not enter their position at the same time. this means there will forever be turnover. this problem can also extend to medical and public health society heads, as well as deans of medical schools and schools of public health. no one is guaranteed a position forever. in order to keep current on who is in charge, additional fishing will need to be done on a regular basis (preferably once per year) to determine who is no longer a dean, head, or minister, and then remove those no longer in their leadership positions from the list and add the contact details for their replacements. we will also want to find a person within the ministries of health with a more stable position. it has been suggested by the head of training in afghanistan that the heads of training in the ministries of health may be ideal as they are in contact with all of the educators in countries, and they are in their position for years. another group to potentially target is the heads of non-communicable diseases at the universities as these people are being mobilized now through who; one of the major efforts of the supercourse is the prevention of non-communicable diseases. this model of information retrieval can be used to build networks of professionals in areas where little networking is available. fishermen at the library of alexandria had an intensive course on the ‘art’ of fishing in 2009 and have begun compiling a list of schools of agriculture, along with the listing of deans of these schools. this approach to building a network can be taken by anyone and can be built for any discipline of science (e.g. physics, engineering, psychology, nursing, etc.). fishing for deans and contact information is a relatively easy and straight forward first step of building a new, collaborative scientific social network made up of individuals from all over the world. a little planning, as well as facilitators to distribute countries, schools, or organizations evenly amongst fisherman, is needed to ensure that the end product is delivered in a timely manner and no one person is left with an unmanageable amount of work to do. many academic individuals involved with medicine and public health are interested in building collaborative relationships. with the introduction of this scientific social network, they will be able to view lectures on a variety of topics and contact the authors with new ideas or submit lectures on topics that may or may not already be available through the supercourse. there is likely much unshared knowledge in medicine and public health worldwide waiting to be introduced to an audience eager to learn more. the supercourse has the materials to share this information with those who wish to learn. while this article has only touched upon the first step of building a scientific social network – the creation of a database – it is important to note that there are further activities to follow this step. development of a newsletter, meeting other members face to face, collaborations, and sharing content are all subsequent steps in the successful building of a social network and execution of relevant activities. approaching the schools, societies, and ministries will be done through both the top down – contacting the deans and heads and asking them to act as gatekeepers to those that they represent – as well as bottom up from the supercourse network of 48,000 individuals who are associated with an estimated 60% of the schools. this process is still in its infancy and we are willing to share our expertise with others who have ideas about building scientific social networks or wish to collaborate on such a project in the future. application to central asia the use of the fishing techniques described in depth above can be directly applied to the creation of a scientific social network specific to the five countries of central asia (kazakhstan, kyrgyzstan, tajikistan, turkmenistan, and uzbekistan). the central asian countries currently have a low level of connectivity amongst scientists, public health professionals, doctors, dentists, nurses, and others in health related disciplines. creating this network of central asian individuals will be the first step in collaborations with others in central asia and around the world. the launch of the central asian research and educational network (caren) three years ago put researchers in a unique position to interact with others which had not previously existed due to the digital divide, the inequalities between groups in access to, use of, and knowledge of information communication technologies. “caren will help [in] decreasing the digital divide and will directly contribute to the development of the education and research sector in the region by enabling access to modern ict technologies and support distant collaboration through online applications such as telemedicine, distance education, applications in energy and water resources management, seismology and environmental studies” (european commission, 2012). collaborations amongst scientists from central asia provide the potential for increased publications from authors in these countries. currently, the five countries of central asia have low productivity with regards to publications. uzbekistan is the only country in central asia to publish above the median (laporte, 2011). increased publication can, in turn, create more of a demand for collaboration with scientists in central asia. with the development of a central asian scientific social network, the need for country and region specific public health lectures increases. developing these lectures and disseminating them to medical, nursing, dental, and public health graduate students each year will create an expansion of the network as these students go on to graduate and enter the professional workforce. references 1. tuire p, erno, l. exploring invisible scientific communities: studying networking relations within an educational research community. a finnish case. higher education. 2001;42(4):493-513. 2. supercourse – epidemiology, the internet and global health [internet]. 2010 [cited 2010 may 27]. available from: http://www.pitt.edu/~super1. 3. laporte re. recruiters and academia. nature. 2004;428,876. 4. supercourse. golden lecture of prevention [internet]. 2009 [cited 2010 jul 7]. available from: http://www.pitt.edu/~super1/lecture/lec10511/index.htm. 5. newman mej. the structure of scientific collaboration networks. proceedings of the national academy of sciences. 2001;98(2):404-409. 6. lawrence s, giles cl. accessibility of information on the web. nature. 1999;400:107-109. 7. american public health association. membership information [internet]. 2010 [cited 2010 apr 23]. available from website: http://www.apha.org/about/membership/. 8. peck p. ama: after one-year increase, ama membership declines again [internet]. 2007 jun 25 [cited 2010 apr 23]. available from: http://www.medpagetoday.com/meetingcoverage/ama/6006. 9. european commission. central asian research and education network (caren) [internet]. 2012 [cited 2012 may 2]. available from: http://ec.europa.eu/europeaid/where/asia/regional-cooperation-central-asia/education-and-research/caren_en.htm. 10. laporte re. strategic plan to build research capacity in central asian countries [internet]. 2011 [cited 2012 may 2]. available from: http://www.pitt.edu/~super1/lecture/lec42351/003.htm. precision of disability estimates for southeast asians in the american community survey 2008-2010 microdata precision of disability estimates for southeast asians in the american community survey 2008-2010 microdata carlos siordia, vi donna le preventive medicine and community health, university of texas medical branch abstract detailed social data about the united states (us) population were collected as part of the us decennial census until 2000. since then, the american community survey (acs) has replaced the long form previously administered in decennial years. the acs uses a sample rather than the entire us population, and therefore only estimates can be created from the data. this investigation computes disability estimates, standard error, margin of error, and a more comprehensive “range of uncertainty” measure for non-latino-whites (nlw) and four southeast asian groups. findings reveal that disability estimates for southeast asians have a much higher degree of imprecision than for nlw. within southeast asian groups, vietnamese have the highest level of certainty, followed by the hmong. cambodian and laotian disability estimates contain high levels of uncertainty. difficulties with self-care and vision contain the highest level of uncertainty relative to ambulatory, cognitive, independent living, and hearing difficulties. keywords: southeast asians; disability; acs; population estimates; usa introduction the american community survey (acs), collected by the census bureau, is a primary source of population-level disability information in the united states (us). the acs influences the distribution of millions of dollars, including funding that directly affects people with disabilities. for instance, in the 2008 fiscal year, 184 federal domestic assistance programs used acs datasets to guide the distribution of $416 billion federal funding.1 data derived from the acs are used to apportion money for handicapped facilities in mass transit systems and are used in state-level planning for future eligible medicare and medicaid recipients (federally funded healthcare insurance).2,3 the six questions (see appendix a) in the acs reflect how disability is conceptualized in the international classification of functioning, disability, and health.4 the questions use a functional perspective to measure “difficulties” with six different areas of daily living so as to assess the disabled and nondisabled population in the us.4 pre-constructed tabulations on the prevalence of disability amongst the different racial-ethnic groups in the us are available.5 from the cited source, about 6% of asians and 13% of nlws in the us are said to have reported having a disability (i.e., difficulty completing one or more of the six tasks). this data source appropriately warns non-technical readers that caution should be used when comparing population-level measures on specific groups when the statistics are based on small sample sizes and when the margin of error (moe) is large relative to the given estimate. moe is a measure of the accuracy in the estimate. when using sample survey-based estimates to determine population characteristics, the representativeness of the sample—as is the level of precision in the estimate—is of great importance for producing sufficiently meaningful measurements. in this sense, data are said to be unbiased only to the degree that survey-based estimates do not systematically deviate from the ‘true’ population value. the formation of probability samples assumes that all units in the universe have a known, nonzero probability of being selected in the sample—the basic assumption validating the use of inference to generalize from the sample to the target population. in the case of disability estimates for specific populations, the term “estimate” signals that a sophisticated approximation is being made based on a sample and statistical inference.6 this means that the estimate contains some uncertainty. because accurate information is the primary goal of the us census bureau, they produce statistically rigorous data products. the agency provides extensive documentation of their procedures, thereby making imprecision (a measure of sampling error) measurable. sampling error can be quantitatively estimated with acs products because replicate weights are provided to public microdata users. sampling error is the variation between samples drawn from target population where the same random procedure for selection is used. large variation between samples signals high sampling error and thus that the survey-based estimate may significantly deviate from the true population value. sampling error operates as a function of sample size, variability in the measure of interest, and the methodology employed in the production of the estimates. sampling error can be measured using the standard error (se) of the estimate—sometimes referred to as the moe. se measures represent how closely the survey-based estimate approximates the average result of all theoretically possible samples. this brief report fundamentally argues that before comparisons on disability prevalence between racial-ethnic groups can be made, researchers must evaluate if the “range of uncertainty” (i.e., level of imprecision in the estimate) allows for such comparisons. accordingly, this exploratory project compares the level of uncertainty in disability estimates between non-latino-white (standard reference group in the us) and the following southeast asian groups: vietnamese, cambodian, hmong, and laotians. these southeast asian groups are selected because they provide a significantly smaller sub-population than the nlws and may thus have larger variability between the systematically selected samples from the target population (i.e., larger sampling error and thus imprecision). methods this analysis uses microdata from the acs 2008-2010 public use microdata sample (pums) file.7 acs pums files allow researchers the flexibility to prepare customized variables and tabulations where moes and se around an estimate can also be computed using replicate weights in the microdata. a full discussion on the estimation of moes and ses is given elsewhere.8 confidence intervals on disability estimates, using the standard moe approach, are provided to show the reader the upper and lower bounds of the estimate—where a 90% confidence level is assured in the measure. to provide a more standardized metric for comparing the precision of disability estimates across the five groups, the following equation is used to calculate the range of uncertainty (ru): [(se*3) ÷ x]*100, where x is the estimate. as ru increases, the level of imprecision in the estimate tends to increase. in addition to these measures, the percent of allocated cases is measured. the acs pums files contain an allocation “flag”—a dichotomous variable of whether or not each response was observed or allocated. an allocation occurs when missing items or inconsistent data are replaced through assignment (fixed using within-person information) or allocation (fixed using outside-person information). for the sake of simplicity, both are referred to as allocations here. greater details on allocation procedures are available elsewhere.9 the percent allocated is determined using the following equation: (weighted allocated count ÷ total weighted population)*100. this measure is given to remind the reader that nonsampling error is not accounted for in the ru measure. nonsampling error is the practically unmeasurable error that may be created in each stage of the survey process—as when data collection is taking place. in this particular case, nonsampling error is created as a result of nonresponse (when no responses are given) and measurement (when illogical responses are given) errors. moes, ses, rus, and percent allocated are calculated for the following disability items: self care, hearing, vision, independent living, ambulatory, and cognitive. for a detailed list of disability related questions, please see appendix a. the variation of uncertainty in disability estimates in the southeast asian groups is examined since the detection of a “central asian” group is problematic with the data being used. for example, the dataset does not include any individuals residing in the us and who report being born in kyrgyzstan, tajikistan, or turkmenistan—nor are there any ancestry codes for these places. this may due to the ‘true’ absence of such individuals or to editing protocols that recode their reported place of birth and ancestry into different labels. please note that previous work has used the us census bureau’s definitions with acs data to create a “south central asia” group that includes: afghanistan; bangladesh; bhutan; india; iran; kazakhstan; kyrgyzstan; maldives; nepal; pakistan; sri lanka; tajikistan; turkmenistan; and uzbekistan.11 since sample size matters in both weighed counts (using person-weights) and unweighted counts (using actual number of observations). we provide their details. in our analytic sample, nlws have a weighted count of 148,734,362 and an unweighted count of 4,866,427; vietnamese have a weighted count of 1,235,633 and an unweighted count of 34,141; cambodians have a weighted count of 188,749 and an unweighted count of 4,714; hmong have a weighted count of 129,282 and an unweighted count of 2,779; and laotians have a weighted count of 164,432 and an unweighted count of 3,945. a rate of inflation (ri) is the average number of persons each individual represents and can be computed by dividing the weighted count by the unweighted number. we note that nlws have an ri of 30, followed by vietnamese (36), cambodians (40), and laotians (41). hmong have the highest ri—where, on average, each hmong survey respondent represent 47 other hmong. results since our specific aim is to evaluate the level of precision in the various disability items across the different groups, we focus our discussion on comparing rus across groups. nlws are a standard reference group when investigating the us population, therefore we begin by highlighting that their rus range from a low 1% to 2% (see table 1). by comparison, the vietnamese have rus ranging from 11% to 14%. from table 2, we note that cambodians have rus ranging from 22% to 44%, hmong from 30% to 46%, and laotians from 24% to 93%. as is clear from these numbers, relative to nlws, all southeast asian groups have larger degrees of uncertainty in their disability estimates. amongst the southeast asians, the vietnamese have the least level of uncertainty in their disability estimates. cambodians have the largest level of imprecision in the vision item and hmong in the self care item. the self care and vision disability items amongst laotians have a comparatively high level of imprecision. table 1: weighted number of non-latino-white and vietnamese with disabilities and corresponding estimate precision measures   disable se moe   lcl ucl ru   a non-latino-white ambulatory 14,439,768 26,505 43,600 14,396,168 14,483,368 1% 3% cognitive 8,361,648 20,346 33,468 8,328,180 8,395,116 1% 3% hearing 8,224,412 19,041 31,322 8,193,090 8,255,734 1% 3% independent 9,932,839 36,643 60,278 9,872,561 9,993,117 1% 3% self-care 5,585,330 19,082 31,389 5,553,941 5,616,719 1% 3% vision 4,162,395 22,080 36,321   4,126,074 4,198,716 2%   3% vietnamese ambulatory 58,565 2,508 4,126 54,439 62,691 13% 5% cognitive 59,223 2,088 3,435 55,788 62,658 11% 5% hearing 31,431 1,509 2,483 28,948 33,914 14% 4% independent 58,259 2,248 3,698 54,561 61,957 12% 5% self-care 29,384 1,489 2,450 26,934 31,834 15% 5% vision 24,377 1,111 1,827   22,550 26,204 14%   4% abbreviations: a, percent allocated= (total weighted population ÷ weighted allocated count)*100; disable, number of people reporting a “difficulty” with the disability related item; lcl, low limit of 90% confidence interval= (disability – moe); moe, margin of error; ru, range of uncertainty= [(se*3) ÷ disability]*100; se, standard error; ucl, upper limit of 90% confidence interval= (disability + moe). table 2: weighted number of cambodian, hmong, and laotians with disabilities and corresponding estimate precision measures   disable se moe   lcl ucl ru   a cambodian ambulatory 11,795 1,747 2,873 8,922 14,668 44%   5% cognitive 14,459 1,070 1,761 12,698 16,220 22% 5% hearing 4,743 530 872 3,871 5,615 34% 3% independent 12,589 1,266 2,082 10,507 14,671 30% 4% self-care 4,721 746 1,226 3,495 5,947 47% 5% vision 5,691 1,103 1,815   3,876 7,506 58%   4% hmong ambulatory 6,518 652 1,072 5,446 7,590 30%   6% cognitive 7,457 883 1,452 6,005 8,909 36% 6% hearing 4,267 425 700 3,567 4,967 30% 4% independent 7,147 808 1,329 5,818 8,476 34% 6% self-care 3,431 526 866 2,565 4,297 46% 6% vision 4,229 538 885   3,344 5,114 38%   4% laotian ambulatory 7,814 631 1,037 6,777 8,851 24%   4% cognitive 8,479 1,248 2,053 6,426 10,532 44% 4% hearing 4,333 830 1,365 2,968 5,698 57% 3% independent 9,718 1,244 2,047 7,671 11,765 38% 4% self-care 4,038 1,044 1,718 2,320 5,756 78% 4% vision 4,214 1,307 2,150   2,065 6,364 93%   3% abbreviations: a, percent allocated = (total weighted population ÷ weighted allocated count)*100; disable, number of people reporting a “difficulty” with the disability related item; lcl, low limit of 90% confidence interval = (disability – moe); moe, margin of error; ru, range of uncertainty = [(se*3) ÷ disability]*100; se, standard error; ucl, upper limit of 90% confidence interval= (disability + moe). although it was not the primary focus, we note that disability item allocations for nlws are at 3%, while allocations ranged from 4% to 5% for vietnamese, 3% to 5% for cambodians, 4% to 6% for hmong, and 3% to 4% for loatians. these numbers indicate that in general, allocations were more prevalent for all disability items in southeast asian groups than nlws. conclusions we find that precision levels on the estimates of disability for four southeast asian groups are much lower than for nlws. since the range of uncertainty qualitatively differs by disability item and asian group, comparisons of disability prevalence—where acs data is used—should be avoided or done with great caution. future work should explore if and how language, amongst southeast asian groups, may affect self-reporting of disabilities and how it may impact the rates of allocation with the survey since both introduce imprecision in the estimate.10 acs survey-based disability estimates could potentially affect the quality of services southeast asian groups receive, therefore, more research should be undertaken to understand how precision can be improved. this brief report adds to the literature by poignantly signaling the variability of imprecision on survey-based disability estimates. the level of precision matters and should be accounted for when comparing survey-based estimates between sub-populations. a high level of accuracy in disability estimates is important because they influence us federal funding aimed at aiding the already underserved disabled population. unfortunately, investigating small-size sub-populations limits the ability to produce large samples. under such circumstances, the reduction of imprecision in population estimates may be attempted through improvements in sampling methodologies, survey design, and the administering of the questionnaire. testing possible solutions is crucial, because most data sources currently used to develop disability estimates make use of sample rather than entire target populations. because the precision of disability estimates may impact the quality and accuracy of governmental funding, and because the health of the individuals is so closely linked with access to healthcare, more research is needed. references 1. reamer ad. surveying for dollars: the role of the american community survey in the geographic distribution of federal funds. washington d.c.: metropolitan policy program at brookings; 2010. 2. macdonald h. the american community survey: warmer (more current), but fuzzier (less precise) than the decennial census. journal of the american planning association. 2006;72:491-503. 3. swanson da, mckibben jn. new directions in the development of population estimates in the united states? population research and policy review. 2010;29:797-818. 4. brault m, stern s, raglin d. evaluation report covering disability. in: american community survey content test report p.4. washington d.c.: u.s. census bureau; 2007. 5. erickson w, lee c, von schrader s. disability statistics from the 2010 american community survey (acs). ithaca, ny: cornell university rehabilitation research and training center on disability demographics and statistics (statsrrtc); 2012. 6. us census bureau. a compass for understanding and using american community survey data: what researchers need to know. washington d.c.: us government printing office; 2009. 7. us census bureau. a compass for understanding and using american community survey data: what pums data users need to know. washington d.c.: us government printing office; 2009. 8. us census bureau. design and methodology american community survey. washington d.c.: us government printing office; 2009. 9. siordia c, young, r. methodological note: allocation of disability items in the american community survey. disability and health journal. forthcoming 2012. 10. griffin d. requests for alternative language questionnaires. american community survey discussion paper. washington d.c.: u.s. government printing office; 2006. 11. batalova j. asian immigrants in the united states. washington d.c.: migration policy institute; 2011. appendix a exact question wording for disability-related items in the american community survey self care difficulty because of a physical, mental, or emotional condition, does this person have difficulty doing errands alone such as visiting a doctor’s office or shopping? hearing difficulty is this person deaf or does he/she have serious difficulty hearing? vision difficulty is this person blind or does he/she have serious difficulty seeing even when wearing glasses? independent living difficulty does this person have difficulty dressing or bathing? ambulatory difficulty does this person have serious difficulty walking or climbing stairs? cognitive difficulty because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions? vitamin d receptor gene polymorphisms in susceptibility to tuberculosis in the kazakh population in almaty and almaty area new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. vitamin d receptor gene polymorphisms in susceptibility to tuberculosis in the kazakh population in almaty and almaty area maxat zhabagin1, zhannur abilova1, ayken askapuli1, saule rakhimova1, ulykbek kairov1, kulzhan berikkhanova1, assel terlikbayeva2, meruert darisheva2, arike alenova3, ainur akilzhanova1 1center for life sciences, nazarbayev university, astana, kazakhstan; 2the global health research center of central asia, almaty, kazakhstan; 3national center for tuberculosis problems, almaty, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.102 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ zhabagin this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.102 | http://cajgh.pitt.edu abstract introduction: vitamin d receptor (vdr) plays an important role in activating the immune response against various infectious agents. it is known that the active metabolite of ligand receptor vitamin d (1,25 – dihydroxyvitamin d) is encoded by vdr and helps mononuclear phagocytes to suppress the intracellular growth of m. tuberculosis. the vdr gene harbors approximately 200 polymorphisms, some of which are linked to differences in receptor vitamin d uptake and therefore can be considered as candidate disease risk variants. the relation between vdr gene polymorphisms and susceptibility to tb has been studied in different populations. there is not a great deal of information regarding the association of these snps with tb risk in the kazakh population. the four most commonly investigated vdr polymorphisms in association with different diseases, including susceptibility to tuberculosis, are located in exon 2 (rs2228570 or foki), intron 8 (rs1544410 or bsmi and rs7975232 or apai), and exon 9 (rs731236 or taqi). the aim of our study was to determine whether these four vdr gene single nucleotide polymorphisms were associated with tb and whether they were a risk for the development of tb in the kazakh population in almaty city and almaty area. methods: this study was a hospital-based case-control analysis of 283 individuals (99 tb patients and 184 healthy controls). genotyping was performed by taqman snp allelic discrimination using commercial taqman snp genotyping assays. statistical analysis was conducted using spss version 19.0 software. results: genotype frequencies for the kazakh population are close to world (hapmap) data on asian populations. foki and apai polymorphisms genotypes tend to be associated with tb risk under the co-dominant model [or=1.18; 95%ci: (0.68, 2.07), p=0.15] for foki and [or=1.33; 95%ci: (0.61, 2.91), p=0.6] for apai. no significant association between the disease and taqi, bsmi genotypes was observed. conclusions: in summary, we explored potential associations between snps in the vdr (foki, apai) gene and susceptibility to tuberculosis in the kazakh population, which requires further detailed analysis with a larger sample size and greater geographic diversity including other regions of kazakhstan. keywords: vitamin d receptors, immune response, tuberculosis, gene polymorphism, kazakhstan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx socio-structural barriers, protective factors, and hiv risk among central-asian female migrants in moscow socio-structural barriers, protective factors, and hiv risk among central-asian female migrants in moscow christopher zabrocki1, stevan weine1, stephanie chen1, ivana brajkovic1, mahbat bahromov2, sana loue3, jonbek jonbekov4, farzona shoakova4 1the university of illinois at chicago, chicago, illinois, usa; 2prisma research center, dushanbe, tajikistan; 3case western reserve university, cleveland, ohio, usa; 4prisma research center, moscow, russia abstract objective: this study aimed to build formative knowledge on socio-structural barriers, protective factors, and hiv sexual risk amongst central-asian female migrants in moscow. methods: data collection included ethnographic interviews in moscow with a purposive sample of 30 unmarried female migrants, 15 from kyrgyzstan and 15 from tajikistan. results: study participants reported difficulties with acquiring documents for legal status, financial insecurity, discrimination, sexual harassment, and lack of support. based on analysis of the cases, one pathway linked lack of legal documentation and instrumental support with elevated sexual risk. another pathways linked traditional cultural attitudes with both no and moderate sexual risk. conclusion: future hiv prevention efforts with central asian female migrants in moscow should be multilevel and include: increasing hiv and prevention knowledge and skills, promoting condom use with regular partners, identifying and supporting cultural attitudes that protect against hiv sexual risk behaviors, facilitating legal status, building community support, and increasing economic options. keywords: hiv/aids, women’s health, central asia, risk perception introduction women account for increasing numbers of labor migrants globally and approximately 15 to 30% of migrants to russia.1,2 between 2004 and 2008, approximately 800,000 migrants traveled to moscow from kyrgyzstan, and another 1.5 million from tajikistan.3 due to the high prevalence of hiv in moscow and the sexual practices of male migrants, public health experts are concerned that migrants could be a bridge for hiv transmission to their lower hiv prevalence home countries, including tajikistan and kyrgyzstan.4,5 female migrants may be at increased risk for acquiring hiv infection in multiple ways. away from their home countries’ traditional cultures that prohibit women from engaging in non-marital sexual relations, female migrants may be more sexually active with more partners.6-9 in moscow female migrants face greater difficulties with legal status than male migrants.10,11 these difficulties can increase their vulnerability to exploitation, reduce their access to services, and lead to higher sti and hiv.12-14 illegal status may confine female migrants to unregistered and low-wage positions.15 to survive, women often turn to formal sex work or to transactional sex, resulting in greater sexual risk for hiv.16-18 female migrants from developing countries often have limited hiv knowledge, may associate condoms with promiscuity, and may avoid condom use with regular sexual partners.19-24 on the other hand, home country religion, cultural values of abstinence, and having friends not engaged in sexual risk behavior may be protective factors for hiv risk.25-27 respect for parents’ beliefs and values and having plans for the future have been found to be protective against pre-marital sex.28 the who has shifted the emphasis of preventative health care with migrants from a focus on individual behavior to considering the social determinants of health.29 however, hiv risk among the growing number of female labor migrants globally, is presently under-investigated.30 there is a need for scientific investigations of female migrants that build knowledge on the social determinants of health and that could help to inform the development of hiv prevention for female labor migrants. this ethnographic study sought to learn about central asian female migrants’: 1) working and living conditions in moscow; 2) hiv/aids knowledge, attitudes and behaviors; and 3) hiv risk in relation to socio-structural barriers and protective factors. lastly, the study aimed to consider implications for future programs, policies, and research that address the social determinants of health among female migrants. methods sampling and recruiting the study purposively sampled thirty female migrants currently living in moscow. this sampling strategy maximized diversity on three axes: (1) age; (2) education; (3) employment in moscow. fifteen were from kyrgyzstan and fifteen were from tajikistan. eligibility required that the women be: (1) unmarried; (2) 18-35 years old; (3) in moscow for the first time; (4) living in moscow less than 1 year; (5) from tajikistan or kyrgyzstan; (6) able to give informed consent. in moscow, tajik female migrants were recruited through several tajik diaspora organizations and kyrgyz female migrants through the kyrgyz diaspora center. after describing the study, oral informed consent was obtained, as approved by the irbs of the university of illinois at chicago, the tajik ministry of health, the russian academy of arts and sciences, and case western reserve university. data collection with each migrant we conducted a single minimally structured interview in english with interpretation in either tajik or russian by bilingual team members.31 the interviews lasted between 60 and 150 minutes and were conducted in convenient locations for the participants, such as apartments, parks, cafes, or the research team’s office. participants were paid $20. these open-ended interviews focused on the women’s: (1) daily lives; (2) experiences with migration and life in moscow; (3) home country lives and family; (4) social support and network in moscow; (5) hiv/aids knowledge, attitudes, behaviors, and risk and prevention skills; and (6) access to healthcare and hiv testing. demographic information was also gathered (table 1). all interviews were audiotaped and transcribed into english. the initial study questions were refined through an iterative process of data collection and preliminary data analysis that followed standardized qualitative methods. table 1: demographic information tajik kyrgyz total average age 28.6 24.8 26.7 marital status single 10 (66%) 8 (53%) 18 (60%) widowed 3 (20%) 7 (47%) 10 (33%) divorced 2 (13%) 0 (0%) 2 (7%) children 0 8 (53%) 8 (53%) 16 (53%) 1 5 (33%) 4 (27%) 9 (30%) 2 1 (7%) 2 (13%) 3 (10%) pregnant 1 (7%) 2 (13%) 3 (10%) education secondary 8 (53%) 6 (40%) 14 (47%) some college 3 (20%) 3 (20%) 6 (20%) college 4 (27%) 5 (33%) 9 (30%) trade school 0 (0%) 1 (7%) 1 (3%) employment seller 6 (40%) 1 (7%) 7 (23%) cleaner 4 (27%) 7 (47%) 11 (37%) sex work 1 (7%) 1 (7%) 2 (7%) other 0 (0%) 3 (20%) 3 (10%) unemployed 4 (27%) 3 (20%) 7 (23%) total 15 15 30 data analysis the study utilized a grounded theory approach to qualitative analysis and atlas/ti computer software.32,33 after establishing coder reliability, all transcripts were coded. key variables, categories, processes, and theoretical claims emerged through pattern coding and memoing.34 the findings were reviewed by the entire team to check for contrary evidence. the determination of instrumental support and legal status was done by consensus rating of the entire research team based upon both established definitions and knowledge gained from the female migrants. for instrumental support we used the tilden and weinhart definition of the provision of tangible goods, services or aid.35 a female migrant was considered to have instrumental support if she identified someone who could provide her with food, money, or employment. regarding legal status, we learned from official sources and from the female migrants that it was important to consider migration documents, work permits, and registration.36 the female migrant was considered to have legal status only if she reported having acquired all these documents in moscow. regarding hiv sexual risk behaviors, the participants were classified into three sexual risk categories based on their reported current behavior as migrants: no risk (not currently sexually active), moderate risk (currently sexually active, monogamous), and elevated risk (currently sexually active, transactional sex or sex work). results surviving in moscow all of the women reported that the primary reason for leaving home and coming to moscow was to earn money. although some female migrants came with education and skills, most could only find work that was far below their skill level. one reported, “to work here within your profession is very difficult. i am educated in economics and have worked in a bank as a cashier in kyrgyzstan. it is impossible to work in such jobs here” (kyrgyz, 23a). most who were employed reported being paid too little and intermittently or not at all. one tajik migrant reported, “for almost one year i’ve worked in moscow, but i haven’t seen any money from employers. every time i have worked; the employer throws me out” (tajik, 31). others told of not being able to find work at all due to discrimination. “here i went to several places and they said you should be a citizen of russia, and besides, we take only slavic appearance” (kyrgyz, 35). without work or money, some women had to live on the street. one reported, “i took these clothes from the trash dump, because i didn’t have any money. i was suffering a lot and i’m suffering still, i have slept in the streets and in entrances, because there are not any good jobs and no salaries” (tajik, 31). many participants reported that workplace sexual harassment was commonplace. “some people would touch me and pinch my butt when walking through. i worked there almost eight months” (tajik, 19a). some reported employers withholding salaries unless migrants performed sexual favors. “in some places the employer man offered me to have sex with him, just after that he would pay me my salary, but i refused, i didn’t want to do that” (tajik, 31). when she refused, she became subject to further harassment by her employer: “for two days i worked there and everything was fine, but the other day the boss got drunk and wanted me to have sex with him. i didn’t agree and he started to beat me.” another said, “he wants me to have sex with him, but i don’t want to have such a sexual partner, therefore he always tries to hurt me and behaves badly towards me” (tajik, 32). many female migrants reported encountering deception, greed, and selfishness amongst other female and male migrants in moscow. one said, “you care about others there, and here you only care about yourself. you become an egoist, you stop caring about others” (kyrgyz, 23a). another said, “moscow makes people lie” (kyrgyz, 26). as a consequence they learned to think more negatively about others and themselves. “i think that everybody is going to cheat us again” (tajik, 31). with little community support, female migrants rely principally on themselves, “nobody except yourself can help you; you are alone in this big city” (kyrgyz, 27). not worried about hiv although several female migrants reported no knowledge of hiv, most knew something about aids, hiv transmission, and hiv prevention. many stated that hiv was present in russians and marginalized groups, such as sex workers, partiers, and the rich, but they did not believe that hiv/aids was as prevalent in persons from their home country. “i didn’t hear that this disease was among tajik women, but i know that it is spread among russian women” (tajik, 31). another stated, “the rich guy that spends money for fun is definitely infected. i am dating an ordinary simple man who is not infected” (kyrgyz, 28). another said, “i think all the street girls who work in public houses or in the street are all infected with stis and no man should have sex with them” (tajik, 19a). female migrants reported knowing that condoms could prevent hiv transmission; one said, “the big reason is to protect from stis, hiv and other infections that can be transmitted sexually” (tajik, 26). hiv infection was regarded as a death sentence and as a social stigma. one migrant said, “the man that is hiv+ is just a dead man. he is just a living body. he only has the end and nothing else” (kyrgyz, 28). current hiv sexual risk behaviors as migrants not currently sexually active (no risk) eighteen (60%) female migrants reported no current sexual activity. some of them were dedicated to lost partners: “the passion and the love i had with my marriage i lost, i had a good life with my husband, but i lost him long ago… but now my son is already a big boy and i have been without a husband for a long time and [being single] is normal for me” (tajik, 35). others wanted to remain a virgin until marriage. “we are muslims and we are not allowed to have sex before marriage” (tajik, 25). still others reported no sexual desire or an inability to find a suitable partner, “i haven’t found such a man that i could love yet” (tajik, 34). some told of being uninterested in relationships, “if you get married you have to do what your husband and his family says. i want to live independent and communicate with my friends when i want and where i want” (kyrgyz, 23a). others prioritized different goals. “i do not want anyone at all because if you have someone; you will not work” (tajik, 27a). regarding condoms, one woman said they were not for “love partners,” and she did not plan to use them when in a relationship, “those girls who do sex before marriage, i’ve heard that they use condoms. i think only ‘street girls’ can use condoms; not normal girls. when you love your man, why should you use it?” (tajik, 19b). based upon their reported current sexual behavior, as migrants these women were not considered to be at hiv risk. currently sexually active, monogamous (moderate risk) eight (27%) female migrants reported that they were sexually active, but monogamous with one partner in moscow, usually another migrant. these women reported that they were planning eventually to marry their sexual partner, “my attitude towards sex is that if you trust and love your boyfriend it is a benefit because the body requires it. when you are with one man, it is good.” (tajik, 19a). she continued saying, “many people have sex with condoms, but i think condoms are a disrespect to your body. why should i use a condom if i am having sex with my love.” another said, “i do not feel good when he uses condoms. for me, when he uses condoms, it is like he keeps away from me. i feel like he uses me if he uses a condom. like, he would use condoms with any girl” (tajik, 22). although the participants did not report suspecting that their partners had sexual relations with other women or sex workers, our knowledge suggests that this is very likely.11 although these women are currently monogamous, they are considered to be at moderate hiv risk. currently sexually active, transactional sex or sex work (elevated risk) four (13%) of the female migrants were involved in either transactional sex (n=2) or sex work (n=2). the women who performed transactional sex reported needing money or a place to stay. “in russia, it is normal to have sex for money, it is not shameful. though for us it is shameful to ask another for help this way” (tajik, 33b). their partners sometimes included married migrant men and drug users. both of the women engaged in transactional sex reported always using condoms, “when i have sex i use condoms, and thus i protect myself” (tajik, 33a). the sex workers reported working independently and saw mostly russian men. both of the migrants who did sex work reported inconsistent condom use. one sex worker always used a condom with her new clients, "they say they will pay more if i refuse to use a condom, but i do not pay attention to them. i say that i will use a condom. i understand that if i catch a disease, this money will not be enough to get cured" (kyrgyz, 30). another woman who did sex work said, "sometimes i use condoms. if i meet with a guy for the first time then i use it, but with the familiar guys i do not. i can trust the familiar ones" (tajik, 33b). due to their many concurrent sexual partners, and their inconsistent use of condoms, these migrants are considered at elevated hiv risk. roles of socio-structural barriers and protective factors qualitative findings were used to characterize the possible roles of socio-structural barriers and protective factors. socio-structural barriers as facilitators of sexual risk some female migrants lacked the proper documentation for migrants living and working in moscow. they most often mentioned problems obtaining work permits and moscow registration, stating they could not afford to pay twelve thousand rubles (approximately $400) for a work permit. one said, “to find work, you should have documentation, registration, and work permission. i made a registration when i came, but it was hard to do the work permission. i found that the work permission is very expensive. i found that i have to pay for everything, and it is difficult" (kyrgyz, 30). another reported, “when you do all your documents then you will find a job. if you don’t you won’t find a job” (kyrgyz, 23b). women said that without documents, they were more likely to be arrested and detained by the police, who would expect bribes or favors, or be sexually harassed and exploited by employers, “if you have no documents, you have no freedom” (kyrgyz, 27). some women reported giving in to the sexual demands of their employer in return for money. most female migrants reported lacking family or friends who could provide them with financial, material, or other tangible support. one stated, “i don’t have close friends in moscow, just girls whom we live together and we say each other just ‘hello’ and ‘goodbye’ and nothing more. i don’t have close friends to share something with” (tajik, 34). some women were recruited into sex work by female friends: “she did not tell me directly, she just invited me to her apartment. there were two men, and she introduced me to one. we talked and talked. she then said that he will help me and give me money, and he did” (tajik, 33b). cultural attitudes as protective factors against hiv sexual risk some migrants who were not involved in transactional sex or sex work expressed cultural attitudes towards sexual relations before marriage. these cultural attitudes were found in both tajik and kyrgyz migrants. one woman said, “i understand that at my age it is a normal time to have sex. but according to our oriental mentality, i try to protect myself from sexual contact till my wedding day” (tajik, 27b). another stated, “i was brought up by my parents in a way that i can’t have sexual relations with anybody until marriage. there can be anything before marriage” (kyrgyz, 27). those migrants who did not pursue transactional sex or sex work despite socio-structural barriers reported more traditional cultural attitudes towards sex work, health, and insecurity. again, these cultural attitudes were also found in both tajik and kyrgyz migrants. several were unwilling to do sex work because of its sinfulness. one stated, “i was offered several times but it is a great sin, therefore i refused. i don’t want to make me “haraam,” [arabic for “forbidden”] the “haraam” money makes no sense for me, and i don’t want to make my body dirty with dirty men” (tajik, 31). another stated, “i don’t want to do sex work; i want to earn my salary honestly (kyrgyz, 22).” others reported worries over the insecurity of transactional sex. one stated: “i know it is only temporary. they will use you … kick you out …you will again be alone. i do not want such things. i am only interested in my work” (tajik, 27a). of course cultural attitudes would not necessarily protect female migrants against forced sex, manipulation, or trafficking. hypothesized pathways involving socio-structural barriers and protective factors figure 1 represents hypothesized pathways connecting socio-structural barriers, possible protective factors, current sexual activity, and level of hiv sexual risk based upon the study findings. regarding risks, this figure indicates a hypothesized pathway linking legal documentation and instrumental support with elevated sexual risk. specifically, four (100%) of the women in current transactional sex or sex work had neither legal documentation nor instrumental support. in comparison, 2 of 8 (25%) currently sexually active, monogamous, and 4 of 18 (22%) not currently sexual active lacked instrumental support and legal status. regarding protective factors, this figure indicates how protective factors may partly explain why some female migrants exposed to socio-structural barriers exhibit none or moderate current sexual risk. specifically, of the 20 female migrants with either legal status or instrumental support, 12 (60%) were not currently sexually active, one possible indicator of protective factors. of those 10 female migrants lacking both legal status and instrumental support, 4 (40%) were not currently sexually active, and 2 (20%) were currently sexually active and monogamous, another possible indicator of protective factors. discussion central asian female migrants in moscow reported difficulties with acquiring documents for legal status, financial insecurity, discrimination, sexual harassment, and lack of support. these difficulties are viewed as consequences of socio-structural barriers which are shaped by underlying social, economic, and political phenomena, not individual inadequacies. this study also found qualitative evidence suggesting possible associations between socio-structural barriers (e.g. lacking both legal status and instrumental support) and current elevated hiv sexual risk. the study findings indicated that socio-structural barriers did not explain all hiv sexual risk. some women were sexually active and monogamous; however, their regular partners were migrants and thus likely to be sexually active with multiple partners concurrently.11 some women engaged in sex work or in transactional sex preferred not using condoms, despite their knowledge of hiv/aids and hiv prevention skills. this preference was especially true with regular clients, a pattern which has been found elsewhere.22 cultural attitudes regarding sex work, health, and insecurity could be protective in female migrants who chose not to do sex work or transactional sex. to lower risk behaviors, hiv preventive interventions may try to facilitate changes in female migrants’ cultural attitudes. however, this intervention model is limited by its focus on individual level change in ideology rather than contextual changes; a limitation previously noted in u.s.-derived hiv preventive interventions.37 several additional policy and program steps are warranted. through bilateral agreements between the russian federation and kyrgyzstan and tajikistan, legal steps could be taken to improve female migrants’ ability to obtain proper documentation for legal status in russia, thus enabling more to work and earn money through means other than sex work. health has been framed as a human right in multiple international human rights treaties including the convention on elimination of discrimination against women (cedaw), to which russia, tajikistan, and kyrgyzstan are each signatories. it stipulates the health rights of labor migrants, including hiv prevention and care.38 this treaty requires actions from each national government to protect female migrants’ health rights through providing health and social services at three times and locations: 1) prior to migration; 2) during their stay in the receiving country; 3) upon reintegration in the sending countries. in particular, hiv preventive interventions for female migrants should be conducted in the sending countries both pre and post migration, in transit, and in the receiving country. another priority is the establishment of community support networks in the receiving country that would provide needed instrumental, social, and emotional support for female migrants. this should include programs for income generation through cooperatives that would protect female migrants from unwilling entry into sex work or transactional sex, as well as to assist those wanting to leave sex work or cease transactional sex.39 these health and social service initiatives are the responsibility of the sending and receiving countries and require coordinated, joint actions. regarding research implications, this study produced a model linking health outcomes and social determinants that requires further investigation in order to support new program and policy initiatives for the growing global trend of female labor migrants who find themselves in high risk environments. key research questions regarding female labor migrants include: do socio-structural barriers predict sexual risk? what is the protective role of cultural attitudes? what are the pathways, over time, by which female migrants move into or out of sexual risk behaviors? what socio-structural barriers and cultural attitudes are potentially modifiable by multilevel interventions? how can the constraints upon community leaders, organizations, and policymakers best be managed? how can community collaborative approaches best be used to develop, implement, and evaluate new interventions and policies? rigorous, longitudinal, mixed method studies with both purposive and probabilistic samples are needed. this study has several limitations. first, there is possibility of misunderstanding due to interpretation. we addressed this challenge through a multi-lingual research team and ongoing review of translation. second, the sample was not representative of the entire female migrant population in russia, which includes women from other countries. third, because participants were recruited through organizations, those most isolated and perhaps with greater sexual risk were not included. fourth, because this study was cross-sectional, we could not follow women’s actual pathways regarding migration and hiv sexual risk over time. fifth, because there sample was purposive and the cells too small, we could not test the associations statistically. conclusions this study addresses the understudied global phenomenon of the feminization of labor migration and focuses on their hiv risk. it builds knowledge regarding the unique multi-level contextual variables involving structural, social, and cultural level factors that need to be understood in developing hiv preventive intervention for sexually active female migrants. future hiv prevention efforts with central asian female migrants in moscow should focus on facilitating legal status, building community support, promoting condom use with regular partners, identifying and supporting cultural attitudes that protect against hiv sexual risk behaviors, and rigorous research testing of these hypothesized pathways. references 1. oishi n. women in motion: globalization, state policies, and labor migration in asia. 1st ed. stanford university press; 2005. 2. unifem. estimate of needs and necessities of female labor migrants: central asia and russia. new york: unifem; 2005. 3. karimov a, maksudov m. economic crisis forcing central asian migrants to leave russia. 2010. available from: http://centralasiaonline.com/en_gb/articles/caii/features/main/2010/02/09/feature-01 4. kramer ma, van veen mg, de coul e, geskus rb, coutinho ra, van de laar mj, prins m. migrants travelling to their country of origin: a bridge population for hiv transmission? sex transm infect. 2008; 84:554-555. 5. marmot m, friel s, bell r, houweling ta, taylor s. closing the gap in a generation: health equity through action on the social determinants of health. lancet. 2008; 372:1661-1669. 6. magis-rodríguez c, lemp g, hernandez mt, sanchez ma, estrada f, bravo-garcía e. going north: mexican migrants and their vulnerability to hiv. j acquir immune defic syndr. 2009; 51(suppl. 1):s21-s25. 7. mmbaga ej, leyna gh, hussain a, mnyika ks, sam ne, klepp ki. the role of in-migrants in the increasing rural hiv-1 epidemic: results from a village population survey in the kilimanjaro region of tanzania. int j of infect dis, official publication of the international society for infectious diseases. 2008; 12:519-525. 8. puri m, cleland j. sexual behavior and perceived risk of hiv/aids among young migrant factory workers in nepal. j adolesc health. 2006; 38:237-246. 9. yang x, derlega vj, luo h. migration, behaviour change and hiv/std risks in china. aids care. 2007; 19:282-288. 10. o'conner w. russia: central asia's female labor migrants grapple with uncertainty. eurasianet; 2009. available from http://www.eurasianet.org/departments/insightb/articles/eav081209.shtml 11. weine sm, bahromov m, mirzoev a. unprotected tajik male migrant workers in moscow at risk for hiv/aids. journal of immigrant minority health. 2008; 10:461-468. 12. hong y, li x, yang h, fang x, zhao r. hiv/aids-related sexual risks and migratory status among female sex workers in a rural chinese county. aids care. 2009; 21:212-220. 13. ojeda vd, strathdee sa, lozada r, rusch ml, fraga m, et al. associations between migrant status and sexually transmitted infections among female sex workers in tijuana, mexico. sexually transmitted infection. 2009; 85:420-426. 14. zuma k, gouws e, williams b, lurie m. risk factors for hiv infection among women in carletonville, south africa: migration, demography and sexually transmitted diseases. international journal of std aids. 2003; 14:814-817. 15. kossoudji sa, ranney si. the labor market experience of female migrants: the case of temporary mexican migration to the u.s. the international migration review. 1984; 18:1120-1143. 16. bronfman mn, leyva r, negroni mj, rueda cm. mobile populations and hiv/aids in central america and mexico: research for action. aids. 2002; 16:s42-s49. 17. singh g. paradoxical payoffs: migrant women, informal sector work, and hiv/aids in south africa. new solutions a journal of environmental and occupational health policy. 2007; 17:71-82. 18. yang x, xia g. gender, migration, risky sex, and hiv infection in china. studies in family planning. 2006; 37:241-250. 19. bandyopadhyay m, thomas j. women migrant workers’ vulnerability to hiv infection in hong kong. aids care. 2002; 14:509-521. 20. cash k., anansuchatkul b, busayawong, w. understanding the psychosocial aspects of hiv / aids prevention for northern thai single adolescent migratory women workers. appl psychol. 1999; 48:125-137. 21. ford k., king g, nerenberg l, rojo c. aids knowledge and risk behaviors among midwest migrant farm workers. aids educ and prev. 2001; 13:551-560. 22. hirsch js, higgins j, bentley me, nathanson ca. the social constructions of sexuality: marital infidelity and sexually transmitted disease-hiv risk in a mexican migrant community. am j public health. 2012; 92:1227-1237. 23. islam mm, conigrave km, miah ms, kalam ka. hiv awareness of outgoing female migrant workers of bangladesh: a pilot study. j immigr minor health. 2010; 12:940-946. 24. organista kc, organista pb, garcia de alba je, castillo moran ma, carrillo h. aids and condom-related knowledge, beliefs, and behaviors in mexican migrant laborers. hisp j behav sci. 1996; 18:392-406. 25. kogan sm, brody gh, chen y, grange cm, slater lm, diclemente rj. risk and protective factors for unprotected intercourse among rural african american young adults. public health rep. 2010; 125:709-717. 26. mueller t, gavin l, oman r, vesely s, aspy c, tolma e, rodine s. youth assets and sexual risk behavior: differences between male and female adolescents. health educ behav. 2010; 37:343-356. 27. sychareun v, thomsen s, faxelid e. concurrent multiple health risk behaviors among adolescents in luangnamtha province, lao pdr. bmc public health. 2011; 11:36. 28. li n, boulay m. individual, familial and extra-familial factors associated with premarital sex among bangladeshi male adolescents. sex health. 2010; 7:471-477. 29. world health organization. epidemiological fact sheet on hiv/aids 2008. geneva: world health organization; 2008. 30. weine sm, kashuba ab. labor migration and hiv risk: a systematic review of the literature. aids behav. 2012; 16(6):1605-21. 31. sandelowski m. whatever happened to qualitative description? res nurs health. 2000; 23:334-340. 32. corbin j, strauss a. basics of qualitative research: techniques and procedures for developing grounded theory. thousand oaks, ca: sage publications; 2008. 33. muhr t. atlas/ti 5.0 user's manual and reference. version 5.0. berlin: scientific software development; 2004. 34. miles mb, huberman am. qualitative data analysis: an expanded sourcebook, 2nd ed. thousand oaks, ca: sage publications; 1994. 35. tilden vp, weinert c. social support and the chronically ill individual. nurs clin north am. 1987; 22(3):613-620. 36. russian federal migration services. paperwork. russian federal migration services; 2010 [retrieved 2011 feb 3]. available from http://www.fms.gov.ru/documents/ 37. hirsch js, wardlow h, smith dj, phinney h. the secret: love, marriage, and hiv. 1st ed. nashville, tn: vanderbilt university press; 2010. 38. united nations development fund for women (unifem). turning the tide, cedaw and the gender dimensions of the hiv/aids pandemic. new york: unifem; 2001. 39. busza j, baker s. protection and participation: an interactive programme introducing the female condom to migrant sex workers in cambodia. aids care. 2004; 16:507-518. the hupo human proteome project (hpp), a global health research collaboration the hupo human proteome project (hpp), a global health research collaboration gilbert s. omenn director, center for computational medicine and bioinformatics; professor of internal medicine, human genetics, and public health, university of michigan; chair, global human proteome project abstract the global human proteome project (hpp) was announced by the human proteome organization (hupo) at the 2010 world congress of proteomics in sydney, australia, and launched at the 2011 world congress of proteomics in geneva, switzerland, with analogies to the highly successful human genome project. extensive progress was reported at the september 2012 world congress in boston, usa. the hpp is designed to map the entire human proteome using available and emerging technologies. the hpp aims to create a molecular and biological foundation for improving health globally through better understanding of disease processes, more accurate diagnoses, and targets for more effective therapies and preventive interventions against many diseases. there are opportunities for individual investigators everywhere to access advanced datasets and to join hpp research teams. keywords: human proteome project, proteome introduction as described at biovision 2012 at the bibliotheca alexandrina in alexandria, egypt, in april 2012, the human genome project has dramatically increased knowledge of inherited diseases and the genetic contribution to all kinds of complex diseases.1 the biological and now clinical progress in genomics made feasible remarkable advances in technologies for sequencing and synthesizing nucleic acids and proteins and for manipulating genes and regulation of gene expression. genes, however, operate in large part through coding for the production of proteins. proteins are the major effector molecules of cells, acting as enzymes, receptors, structural components, oxygen carriers, intercellular signals, antibodies, and regulators of gene functions and cell division. now the international human proteome organization (hupo) has launched a global human proteome project (hpp). the foundation for the project lies in major knowledge bases with systematically organized data about proteins generated from mass spectrometry and from antibody-capture approaches. scientists in every country can access these open access data repositories to learn about proteins of interest and to initiate their own analyses with these data. one of the big surprises of the human genome project was the number of protein-coding genes. originally, the estimate was 50,000 to 100,000 or more; when the nearly complete human genome was published in 2001, the estimate was 35,000. now a much more reliable estimate is 20,300. how do we perform so many complex developmental, physiological, and disease-related functions with so few genes, in comparison with some other species? it turns out that, through evolution, individual genes can be transcribed into several different messenger rna transcripts by a process known as alternative splicing, and those mrnas can be translated into protein splice variants. moreover, proteins are covalently modified by addition of sugar, phosphate, acetyl, and other small molecules to the side chains, greatly modifying the functional properties of the initial protein structure. so, characterizing the human proteome (the term for all the proteins) is much more complex even than sequencing the human genome. in addition, while there are exactly two copies of nearly every gene in every nucleated cell of the 230 cell types of the body, the number of copies of a protein may vary enormously over time, in different organs and body fluids, and from protein to protein. this project will be important to global health since proteins are the molecular targets of most pharmaceuticals and are used in medicine and public health for diagnosis and for vaccines. in biotechnology, many of the most important new products are proteins, including antibodies. organization of the human proteome project legrain et al.2 described the aims and organization of the human proteome project. scientists from dozens of countries are engaged with specific roles on the hpp executive committee, the senior scientific advisory board, and the operating arms of the hpp (see figure 1). figure 1. schema showing the organization of the human proteome project (hpp) with a foundation of antibody, mass spectrometry, and knowledge base resource pillars and two major collaborative research initiatives, the chromosome-centric c-hpp and the biology and disease-driven b/d-hpp. as of this time, national and international teams of scientists have initiated studies of proteins coded by genes on individual chromosomes, including teams based in russia (chromosome 18) and in iran (chromosome y), with 23 of the 24 chromosomes now assigned (22 autosomes plus chromosomes x and y). other teams of investigators are pursuing a dozen biological and disease-based studies around the theme of the roles of proteins in biological networks from organ, biofluid, model organism, and stem cell proteomes. the executive committee and principal investigators council of the chromosome-centric c-hpp and the corresponding executive committee and principal investigators council of the biology and disease-driven b/d-hpp are shown in figure 1. the figure also shows the antibody-based, mass spectrometry-based, and knowledge-based resource pillar committees of the hpp. a web portal has been established at www.thehpp.org, with a corresponding working group. the website is a good place to learn about and link to data from the hpp. the web portal lists all the members and countries involved in the various components of the hpp. the portal also serves as a knowledge center for educational purposes, highlighting standardization of protocols used in the hpp. information about the hpp will also appear in the science supercourse (www.pitt.edu/~super1 or www.bibalex.org/supercourse/) which is a magnificent resource of powerpoint lectures created by dr. ronald laporte of the university of pittsburgh, usa, and now based at the biblioteca alexandria in egypt, led by dr. ismail serageldin.3 data from the human proteome project protein capture datasets based on antibodies and immunohistochemistry of human specimens are presented in the human protein atlas, with information about antibodies in antibodypedia.4 submission of ms-datasets is standardized through the proteomexchange, nextprot, pride, peptideatlas, and gpmdb. proteomexchange and pride are based at the european bioinformatics institute in hinxton, england, uk; nextprot is based at the swiss institute for bioinformatics in geneva, switzerland; peptide atlas is at the institute for systems biology in seattle, washington, usa; and gpmdb, in alberta, canada. peptide atlas provides uniform reanalysis using the transproteomicpipeline (tpp), with stringent criteria to minimize false identifications of proteins (1% false discovery rate, at the protein level). there are now peptide atlases for human and mouse plasma,5 the liver, kidneys, urine, and brain. a major advance in proteomics is a targeted approach, identifying and quantitating proteotypic (unique) peptides from each protein of interest, rather than trying to identify as many as possible of the proteins and having the peptides dominated by the most abundant proteins. this method is called selected reaction monitoring (srm). a peptideatlas for srm experimental libraries (passel) has been launched by the institute for systems biology in seattle, along with spectral libraries and peptide resources that facilitate and democratize srm studies by groups worldwide. the c-hpp and b/d-hpp programs collaborate in building the parts list of proteins corresponding to the 20,300 protein-coding genes, plus post-translational modifications (ptms), splice variants (see above), and polymorphic mutations or single nucleotide polymorphisms (snps). the c-hpp6-7 aims to reveal co-expressed proteins of co-located genes; the b/d-hpp is defining a framework of protein networks and interactions. hpp investigators will analyze unusual specimens (nasal epithelium, placenta, fetus, brain regions) to detect “missing proteins”, use ultrasensitive methods for low-abundance proteins, identify and differentiate protein families, splice variants, and ptms, and deduce the functional features of these proteins and their isoforms. figure 2. the research teams responsible for each of the chromosomes in the chromosome-centric c-hpp, by lead nation. deliverables the human proteome project will generate (a) structured information about human proteins (the protein parts list), including both the approximately 13,000 gene products for which some protein information is already known and the 7000 proteins for which there is no evidence yet at the protein level; and (b) reagents and tools for additional protein studies. the investigators will devise metrics to describe annually the extent of progress on identifying and characterizing the human proteome. within 3-5 years we expect to have srm-based spectral libraries for multiple proteotypic peptides for at least one protein product of each of the 20,300 protein-coding genes, with an srm atlas and stably labeled peptide standards. we expect to have an expanded human protein atlas with polyclonal antibodies to characterize the tissue expression and subcellular localization of more than 12,000 gene products; in fact, uhlen and colleagues have announced findings for 13,985 proteins at the 2012 hupo world congress of proteomics and have published detailed findings for the proteins coded for on chromosome 21.4 we will stimulate cross-comparisons of tissue expression by antibody and mass spectrometry methods, and datasets will be captured through proteomexchange in standardized formats, as noted above. over a period of up to 10 years we will extend srm analyses and knowledge bases to splice variants and post-translational modifications of proteins. we will have renewable protein capture methods and reagents (monoclonal antibodies; perhaps aptamers) for characterization of protein tissue expression and localization, including responses to physiological and pathological perturbations. we will have a greatly expanded set of data repositories. we expect that the hpp will enable and encourage other scientists, beyond the basic research community, to use or target proteins for diagnosis, prognosis, prevention, therapy, and cure of diseases. such applications will improve human health worldwide. conclusion completion of the human proteome project will enhance understanding of human biology at all levels, from individual cells to populations, and will lay a foundation for diagnostic, prognostic, therapeutic, and preventive applications. the human proteome organization urges each national scientific community and its research funding agencies to identify their preferred pathways to participate in aspects of this highly promising project. references 1. omenn gs. the new life sciences: understanding the essentials of life. a keynote address at the bibliotheca alexandrina. biovision 2012 (in press). 2. legrain p, aebersold r, archakov a, bairoch a, bala k, beretta l, et al. the human proteome project: current state and future direction. mol cell proteomics. 2011 jul;10(7): m111.009993. doi: 10.1074/ mcp.m111.009993-1 3. laporte re, omenn gs, serageldin i, cerf vg, linkov f. a scientific supercourse. science. 2006;312(5773):526. doi:10.1126/science.312.5773.526c 4. uhlen m, oksvold p, älgenäs c, hamsten c, fagerberg l, klevebring d, et al. antibody-based protein profiling of the human chromosome 21. mol cell proteomics. 2012 mar;11(3): m111.013458. doi: 10.1074/mcp.m111.013458 5. farrah t, deutsch ew, omenn gs, campbell ds, sun z, bletz ja, et al. a high-confidence human plasma proteome reference set with estimated concentrations in peptideatlas. mol cell proteomics. 2011 sep; 10(9):m110.006353. doi: 10.1074/mcp.m110.006353 6. paik yk, jeong sk, omenn gs, uhlen m, hanash s, cho sy, et al. the chromosome-centric human proteome project for cataloging proteins encoded in the genome. nat biotechnol. 2012 mar 7;30(3):221-223. doi: 10.1038/nbt.2152 7. paik yk, omenn gs, uhlen m, hanash s, marko-varga g, aebersold r, et al. standard guidelines for the chromosome-centric human proteome project. j proteome res. 2012 apr 6;11(4):2005-2013. doi: 10.1021/pr200824a antioxidant activity of the probiotic consortium in vitro new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. antioxidant activity of the probiotic consortium in vitro saule saduakhasova, almagul kushugulova, samat kozhakhmetov, gulnara shakhabayeva, indira tynybayeva, talgat nurgozhin, zhaxybay zhumadilov center for life sciences, nazarbayev university vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.115 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ saduakhasova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.115 | http://cajgh.pitt.edu abstract introduction: available evidence suggests that probiotics have different biological functions that depend on several mechanisms, such as antioxidant and dna-protective activities. the probiotic consortium includes bacterial cultures such as streptococcus thermophilus, lactococcus lactis, lactobacillus plantarum, and other bacterial cultures isolated from traditional kazakh dairy products (ayran, kumys, shubat, and healthy clinical material). the aim of this study was to investigate the total antioxidant activity of the consortium of probiotic bacteria and to determine the activity of superoxide dismutase, glutathione reductase, and dna-protective action. material and methods: in vitro comet assay was used to determine the antigenotoxicity of the probiotic consortium. total antioxidant activity was determined using a method of analysis with trolox as the equivalent. the analysis method of superoxide dismutase activity assesses the inhibition rate of the nitroblue tetrazolium reduction to formazan by superoxide dismutase. determination of glutathione reductase activity is based on the measurement of the nadph oxidation speed. results: a significantly high level of the total antioxidant activity of the probiotic consortium intact cells (15.3 mm/ml) was observed whereas the activity index of lysate was 11.1 mm/ml. the superoxide dismutase activity of probiotic consortium lysate was evaluated, with values that peaked at 0.24 u/mg protein. the superoxide dismutase activity of the consortium was lower in comparison to l.fernentum e-3 and l.fernentum e-18 cultures with values of 0.85 u/mg and 0.76 u/mg protein, respectively. sod activity of probiotic consortium whole cells was not observed, which is typical for lactic acid bacteria. glutathione reductase plays an important role in the optimal protection from oxidative stress. glutathione reductase activity of the studied probiotic consortium was low; moreover, the activity of the lysate was two times higher than the activity of the cells reaching 0.01 units/ml. investigations by dr. li have shown that the intracellular glutathione may give a significant protection of lactococcus from the damaging action of h2o2, even at very low concentrations. the data from our study suggests that the co-incubation of the epithelial cells with probiotic bacteria reduces the percentage of damaged cells (damage index–0.60). conclusion: the studied probiotic consortium has antigenotoxic and antioxidant activities. preparations and products of this probiotic consortium may serve as a protective component in the intestinal microbial ecosystem. keywords: antioxidant activity, probiotic bacteria http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx sailau abeldenov, murat saparbayev, bekbolat khassenov new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. biochemical characterization of mycobacterium tuberculosis dna repair enzymes – nfo, xtha and nei2 sailau abeldenov1, murat saparbayev2, bekbolat khassenov1 1national center for biotechnology, astana, kazakhstan; 2institut gustave roussy, villejuif, france vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.107 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ abeldenov this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.107 | http://cajgh.pitt.edu abstract introduction: tuberculosis (tb) is a human disease caused by mycobacterium tuberculosis (mtb). treatment of tb requires long-term courses of multi-drug therapies to eliminate subpopulations of bacteria, which sometimes persist against antibiotics. therefore, understanding of the mechanism of mtb antibiotic-resistance is extremely important. during infection, mtb overcomes a variety of body defense mechanisms, including treatment with the reactive species of oxygen and nitrogen. the bases in dna molecule are susceptible to the damages caused by reactive forms of intermediate compounds of oxygen and nitrogen. most of this damage is repaired by the base excision repair (ber) pathway. in this study, we aimed to biochemically characterize three mtb dna repair enzymes of ber pathway. methods: xtha, nfo, and nei genes were identified in mycobacteria by homology search of genomic sequences available in the genbank database. we used standard methods of genetic engineering to clone and sequence mtb genes, which coded nfo, xtha and nei2 repair enzymes. the protein products of mtb genes were expressed and purified in escherichia coli using affinity tags. the enzymatic activity of purified nfo, xtha, and nei2 proteins were measured using radioactively labeled dna substrates containing various modified residues. results: the genes end (rv0670), xtha (rv0427c), and nei (rv3297) were pcr amplified using genomic dna of mtb h37rv with primers that contain specific restriction sites. the amplified products were inserted into pet28c(+) expression vector in such a way that the recombinant proteins contain c-terminal histidine tags. the plasmid constructs were verified by sequencing and then transformed into the escherichia coli bl21 (de3) strain. purification of recombinant proteins was performed using ni2+ ions immobilized affinity column, coupled with the fast performance liquid chromatography machine akta. identification of the isolated proteins was performed by protein mass spectrometry by ion trap tandem ms/ms on nlc-esi-ion-trap platform. biochemical characterization of dna repair protein-catalyzed activity was carried out by measuring apurinic/apyrimidinic endonuclease, dna glycosylase, exonuclease, and 3'-repair diesterase functions. in addition, effect of the opposite base and the influence of metal ion cofactors were measured. conclusion: results of the ongoing study will help us define the role of dna repair enzymes in the emergence of mutations in the mycobacterial genome and, possibly, the origins of multi-drug resistance in mycobacteria. keywords: tuberculosis, dna sequencing, dna repair enzymes http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx evaluation of communication between physicians and patients in astana city hospital №1 new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. evaluation of communication between physicians and patients in astana city hospital №1. anara zhumadilova1, brett j. craig1, alexey tsoy2, alla gabdrakhmanova2, martin bobak3 1school of science and technology, nazarbayev university, astana, kazakhstan; 2astana city hospital #1, astana, kazakhstan; 3university college london, london, united kingdom vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.82 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ zhumadilova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.82 | http://cajgh.pitt.edu abstract introduction: communication between patients and health care providers is important for the effective functioning of health care systems. miscommunication often stems from discrepancies in expectations of both healthcare professionals and patients due to cultural and historical influences. we investigated the degree to which health care providers (doctors and nurses) and patients in kazakhstan believe that interaction between doctors and patients should be doctoror patient-oriented. material and methods: we conducted a cross-sectional study of 163 patients and 176 health care providers (71 doctors and 105 nurses) in a general hospital in astana, kazakhstan. the subjects completed a structured questionnaire containing the patientpractitioner orientation scale (ppos), and scales assessing life and job satisfaction, effort-reward balance of healthcare professionals, and the patients’ perceptions of communication practices. results: an overwhelming majority of doctors (81.7%), nurses (88.1%), and patients (92.3%) were doctor-oriented. among health care providers, ppos was not associated with age, sex, life and job satisfaction, or effort-reward imbalance. among patients, ppos was not associated with age, sex, or specialty of health care provider. however, higher ppos among patients (indicating preference for patient-oriented interaction) was associated with higher satisfaction with communication with health care providers and, less strongly, with their life satisfaction. conclusion: the main finding of this study is the very small proportion of doctors, nurses and patients who believe that interaction should be patient-oriented. these results highlight the necessity of improvement of communication among health care providers towards patient-oriented approach in order to decrease miscommunication with patients. the fact that most patients prefer doctor-oriented interaction may reflect historical stereotypes; educational/information interventions among patients may also be needed. keywords: doctor-patient interaction, communciation, ppos http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx frequency of nat2 and gstp1 polymorphisms in the kazakh population new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. frequency of nat2 and gstp1 polymorphisms in the kazakh population aisha iskakova1, aliya romanova1, elena zholdybayeva1, erlan ramanculov2, kuvat momynaliev1 1national center for biotechnology, astana, kazakhstan; 2nazarbayev university, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.83 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ iskakova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.83 | http://cajgh.pitt.edu abstract introduction: phase ii xenobiotic biotransformation enzymes perform detoxification of hydrophilic and often toxic phase i products through glutathionetransferase (gst), udp-glucuronosyltransferase (udf), n-acetyltransferase (nat) families and other enzymes. gst protein families metabolize a large number of electrophilic xenobiotics, by conjugating fusing them with glutathione. arylamine-n-acetyltransferase (nat) catalyzes the acetylation of the aromatic and heterocyclic amines. materials and methods: this study assesses the frequency of nat2 and gstp1 gene polymorphisms in 326 healthy individuals from different regions of kazakhstan by using real-time pcr and direct sequencing methods. results: the allele frequencies were calculated for nat2*5 (0.54) and gstp1 (0.27). gstp1 alleles were in the hardy– weinberg equilibrium (p > 0.05), while nat2*5 (p = 0.00) were not. the population differences between north, northeast and south kazakhstan regions were also analyzed. no statistically significant differences in the frequency of genotypes were found. conclusion: allelic polymorphisms of nat2*5 and gstp1 genes greatly varied indifferent populations. the kazakh population was significantly different from the asian, caucasoid, african-american and hispanic populations by nat2*5 and gstp1 genes. allelic variants of the nat2*5 had a low frequency in asian populations. allelic frequency in other world populations varied from 30 to 50%. the differences between kazakh (0.54) and the world population were statistically significant (p < 0.05). the frequency of gstp1 (rs1695) in the african american population was 42%. the frequency of gstp1 in asian populations varied from 11% to 23%. the frequency in caucasoid populations was around 30%. the differences between kazakh population (0.27) and other populations selected were statistically significant (p < 0.05). the study of mutations in gstp1 and nat2 genes is necessary in assessing the risk of the development of various diseases, such as cancer. information on allelic polymorphisms might also be useful for personal perscriptions such as cyclophosphamide, cisplatin, methotrexate, isoniazid, pyrazinamide, and rifampin. keywords: nat genes, gstp genes, genetic polymorphism, kazakh population http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx adolescent abortions: situational analysis based on official statistics conducted in kazakhstan during the last 5 years (2007-2011) new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this site is published by the university library system of the university of pittsburgh as part of its dscribe digital publishing program and is cosponsored by the university of pittsburgh press. adolescent abortions: situational analysis based on official statistics conducted in kazakhstan during the last 5 years (2007-2011) gulya nazarovna alimbayeva1, gulzhan narimbayevna chimbayeva2 1kazakh national medical university, almaty, kazakhstan; 2hospital of the president administration, astana, kazakhstan vol. 2, no. 2 (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.38 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ alimbayeva this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.38 | http://cajgh.pitt.edu abstract in recent decades, adolescent pregnancy has become an important health issue in a great number of both developed and developing countries.we have investigated the official statistics database of the national ministry of the health (moh) and their #13 statutory form (sf) and found the total number of abortions between 2007-2011 in kazakhstan decreased by 28%. the total number of adolescent (up to 15 plus 15-18 years old) abortions decreased by 52.7%. contrary to this decrease in the total number of adolescent abortions, spontaneous abortions have increased from 23.2% to 45.0%,. we found a tendency towards a decrease in the number of adolescents with the first pregnancy among adolescents 15-18 who had abortion between 2007-2011, from 51.3% to 35.8%. this clearly reflects the success of prevention activities among adolescents who have already had an abortion or child labor. during the analyzed period, there were two lethal outcomes from abortionsamong girls15-18 years old. there are some limitations in the assessment levels and dynamic changes of abortions among adolescents due to the division of age in the official statistical database. keywords: abortion, adolescent pregnancies, lethal outcomes, reproductive age, statistics database adolescent abortions: situational analysis based on official statistics conducted in kazakhstan during the last 5 years (2007-2011) gulya nazarovna alimbayeva1, gulzhan narimbayevna chimbayeva2 1kazakh national medical university, almaty, kazakhstan; 2hospital of the president administration, astana, kazakhstan short reports introduction the world health organization’s (who) definition of health, "health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" was adopted on 7 april 1948 and has not been amended.¹ but what is an unwanted pregnancy and abortion? is it health or illness? in recent decades, adolescent (<20 years of age) pregnancyhas become an important health issue in a number of developed and developing countries. however, pregnancy during adolescence is by no means a new phenomenon. in many countries, large numbers of adolescent pregnancies and births are reported. two decisive aspects of the adolescent period have strongly influenced this increase. the first is the decreasing age at menarche and the second is the increasing age of marriage. this widening gap is the basis of unwanted pregnancies during young ages. why is the issue of adolescent pregnancy so difficult to solve? if we investigate the definitions that cover this specific life period, we can determine that: a) according to the un convention on the rights of the children,² a child is an individual below the age of 18. b) adolesence is defined by who³ as individuals of 10-19. the who & adolescent health care http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.38 | http://cajgh.pitt.edu divides adolescence into three psychosocial developmental phases: 1. early adolescence: age of 10-13 years old 2. middle adolescence: age of 14-16 years old 3. late adolescence: age of 17-19 years old c) reproductive age for females: 15-44 years old. 4 pregnancy is a great burden for adolescents. a female in this age range may be simultaneously treated as a child, an adolescent, and a reproductive female. we can determine the causes of the increase in adolescent pregnancies if we consider their social backgrounds and that pregnancies may happen in children with reproductive potential. methods to gain an understanding of the issue of adolescent pregnancies in kazakhstan during the period of 2007-2011, we have investigated the official statistics database of the national ministry of the health (moh) and their # 13 statutory form (sf). we first investigatedabortion. the # 13 (sf) has long been in use in kazakhstan. 5 there are some limitations in the assessment levels and dynamical changes of the abortions among adolescents because databases are divided into several columns (e.g. less than 15 years of age, ages 15-18 and 19 and above). results there was a 28% reduction in the number of abortions between 2007 and 2011 in kazakhstan. on the other hand, the total number of adolescent (up to 15 plus 15-18 years old) abortions decreased by 52.7%. this happened as the result of prevention activities of medical specialists and social programs. figure 1 shows the dynamics of reduction for the specific weight of adolescent abortions among the total number of abortions. this figure illustrates a decreasing trend from 4.5% to 3.0%. contrary to the specific weight of adolescent abortions, the figure also indicates that abortions in adolescents under age 15 remains constant, with slight increase from 1.4%-1.6%. figure 1: dynamic changes of the specific weight of adolescent abortions compared to total amount of abortions during the period 2007-2011 figure 2 illustrates a decreasing trend in the specific number of first pregnancy abortions among adolescents ages 15-18, from 51.3% to 35.8%. this fact clearly reflects the effectiveness of prevention activities among adolescents who have already had abortion or labor. figure 2: dynamic of the specific weight adolescents with the first pregnancy among adolescents who had abortion during 2007-2011 against the background of a decrease in the total number of adolescent abortions, specific weight of spontaneous abortions has increased from 23.2% to 45.0%. this is difficult to explain and warrants further investigation. figure 3 illustrates this trend. figure 3: dynamic of specific weight of adolescents spontaneous abortions among total adolescents abortions during the period 2007-2011 during the analyzed period, there were two lethal outcomes from spontaneous abortions among females ages 15-18 (1 in 2008 and 1 in 2010). abortion http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx alimbayeva this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.38 | http://cajgh.pitt.edu lethality in adolescents reached 0.02% in 2008 and 0.03% in 2010. at the same time, the rate of total abortion lethality in kazakhstan has never exceeded 0.01%. this statistically confirmed database underlines the particular danger of unwanted pregnancy among adolescents. data on regional specifics of adolescent abortions were not available. conclusion this paper provides an overview of statistics on adolescent abortions, which is a serious public health concern in kazakhstan. despite modest improvements, adolescent abortions in kazakhstan remain burdensome for medical specialists and teachers, calling for the need to establish more effective public health programs to reduce the number of abortions in young and vulnerable population groups. adolescents who have had a previous abortion are at a higher risk of subsequent procedures as compared to those who have never had an abortion. considering that there were two deaths associated with abortions in 2008 and 2010, adolescents must be better educated about reproductive health. our paper demonstrates wide disparities in younger vs. older adolescent groups, with lesser success achieved in adolescents under the age of 15. methods that are currently used for reduction of the total number of adolescent abortions in kazakhstan need improvement, especially among females under 15 years of age. references 1. preamble to the constitution of the world health organization as adopted by the international health conference, new york, 19-22 june, 1946; signed on 22 july 1946 by the representatives of 61 states (official records of the world health organization, no. 2, p. 100) and entered into force on 7 april 1948. (http://www.who.int/about/definition/en/print.html) 2. convention on the rights of the child. london: child rights international network, 1989. (http://www.crin.org/resources/treaties/crc.asp) 3. adolescent growth and development. hong kong: hong kong polytechnic university, world health organization collaborative centre for community health services. (http://www.youthnet.org.hk/jobaid/module%201.pdf) 4. women’s health fact sheet. geneva: world health organization, 2009. (http://www.who.int/mediacentre/factsheets/fs334/en/) 5. medinform. medical statistics. almaty, kz. http://www.medinfo.kz/medstat.jsp http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/about/definition/en/print.html http://www.crin.org/resources/treaties/crc.asp http://www.youthnet.org.hk/jobaid/module%201.pdf http://www.who.int/mediacentre/factsheets/fs334/en/ http://www.medinfo.kz/medstat.jsp alimbayeva this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.38 | http://cajgh.pitt.edu figure 1: dynamic changes of the specific weight of adolescent abortions compared to total amount of abortions during the period 2007-2011 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx alimbayeva this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.38 | http://cajgh.pitt.edu figure 2: dynamic of the specific weight adolescents with the first pregnancy among adolescents who had abortion during 2007-2011 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.38 | http://cajgh.pitt.edu figure 3: dynamic of specific weight of adolescents spontaneous abortions among total adolescents abortions during the period 2007-2011 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx developing a supercourse help desk for india new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. developing a supercourse help desk for india mita lovalekar1, harish k. pemde2, babu l. verma3 1department of sports medicine and nutrition, university of pittsburgh; 2lady hardinge medical college, kalawati saran children's hospital, new delhi, india; 3maharani laxmi bai medical college & hospital, jhansi, india vol. 2, no. 2 (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.50 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ lovalekar this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.50 | http://cajgh.pitt.edu keywords: help desk, supercourse developing a supercourse help desk for india mita lovalekar1, harish k. pemde2, babu l. verma3 1department of sports medicine and nutrition, university of pittsburgh; 2lady hardinge medical college, kalawati saran children's hospital, new delhi, india; 3maharani laxmi bai medical college & hospital, jhansi, india editorial despite a vast majority of the world’s population residing in developing countries like india, only a small fraction of the total number of global scientific publications come from these countries. this is an unhappy situation, undesirable because of several reasons. in order to reduce the double impact of infectious and non-communicable diseases that are common in india, health care of the country needs to be based on evidence generated from research studies. research on diseases such as tuberculosis, malaria, dengue and their relationship with malnutrition and some other locally prevalent factors, can only be conducted locally. research capacity to investigate such endemic diseases in india is limited due to lack of adequate access of growing professionals to training in research methods, biostatistics, epidemiological methods, logical interpretation of public health concepts and also, medical research literature in journals. it is a well-known fact that developing countries have relatively fewer research articles submitted for publications to journals, and also, have a lower acceptance rate. whether enhancing professionals’ knowledge in research methods and biostatistics in developing countries like india, will produce increased research opportunities in terms of scientific contributions, is to be investigated and published. such research can incorporate local cultural practices that are unique to the country. in addition to these theoretical reasons for increasing research output in india, there is also an important practical reason. a commonly cited mantra in academia is publish or perish. similar to faculty in developed countries, medical teachers in india are under pressure to publish regularly. guidelines of the medical council of india (mci) – a government autonomous agency, responsible for regulation, control and monitoring standard of medical education in the country, issued in 1998, listed minimum qualifications for teachers in medical institutions in the country. 1 thus, as per the mci, for almost all teaching specialties, minimum of 4 research publications, indexed in index medicus/recognized national journals, is desirable for promotion to the post of reader/associate professor. in addition, for promotion to the post of professor in most teaching specialties, one publication in an international journal is desirable. furthermore, mci has made it mandatory for post graduate students to publish (sent for publication) at least one research paper before they will be eligible to appear in their final examination. these steps of mci have increased pressure on teaching faculty to publish. despite pressure to publish more journal articles, the publication output from india is much lower than expected (figure 1). in fact, during recent years, there has been an increase in productivity in india, as http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.50 | http://cajgh.pitt.edu compared to some other south asian countries (figure 1). however, there is still a wide scope for further improvement. in spite of being the second most populous country in the world, india is not among the top countries in the world in terms of research productivity. india, undoubtedly, has the potential to become a research giant in public health. figure 1: published documents, selected countries, 1996-2012. a recent article published in the international journal of epidemiology reviewed status of epidemiology in the who south-east asia region (sear). 2 the authors searched for peer-reviewed epidemiology publications in pubmed. less than 5% of these articles were from sear, with 54.9% of the sear articles being only from india. the authors accepted that the number of publications might have been under-estimated by their search criteria. further, the paper also describes a lack of adequate epidemiological and public health education, training and research in this region, though the situation is gradually improving. 2 pertinent to the issue of lack of training in epidemiology, a study on the quality of reporting statistics in two indian pharmacology journals revealed that inappropriate descriptive statistics were used in 78.1% of the articles, and information about checking assumptions was missing in many articles, among other issues. 3 a recent review report (2012) in the indian journal of public health on biostatistics education in india, 4 found that presently 19 institutions offer biostatistics education of different forms in the country. though this number has gradually progressed in recent years, such institutions are geographically unevenly distributed – mostly existent in the southern part of the country. authors noted that in health research, biostatistics has not been given proper importance in the country. many times, it does happen that a group of researchers start a study without including a biostatistician on board and involve them only at a late stage. by giving a citation, authors have pointed out that amongst medical colleges in india, biostatistics is considered to be one of those subjects which students dislike the most. it is important to look for the reasons as to why motivation for learning biostatistics by medical students has been so low in the country. this could be one of the reasons for poor biostatistical quality of medical papers from india, at times. the paper also speaks of need for capacity building efforts in the country, especially in the area of research methods and biostatistics. authors have also emphasized the need for availability of trained professionals in biostatistics to help health researchers and clinicians, and for biostatistical training including support of research methods for increasing research productivity in the country. the supercourse is an open source lecture library developed at the university of pittsburgh web server, and all supercourse lectures are available without charge to any one. 5,6 the supercourse team has developed the indian supercourse network as a part of the main supercourse. 7 the indian supercourse network is a collection of lectures in epidemiology, public health and community medicine, on topics of particular interest to teachers and students in india. currently, we have 6,700 collaborators in india, who are physicians, public health professionals, academicians and researchers. they have contributed more than 200 lectures. the indian supercourse allows a 2-way exchange of public health information from india to the rest of the world, and then back to india. the question is how can publications in public health by authors from india be increased? the solution lies in enhancing research knowledge and skills of indian researchers along with consistent guidance to improve research capabilities. a research methods “supercourse help desk” will provide the platform, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx lovalekar this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.50 | http://cajgh.pitt.edu needed for such support to researchers in india. the supercourse help desk was launched in june 2013. 8 we have a team of over 250 research methods experts who are ready to answer research methods and biostatistics questions. the indian supercourse help desk will connect researchers in india with research experts around the world. after a question is submitted on the help desk website, the client is directed to research methods lectures and bio-statistical lectures from the supercourse and also from other sources. after examining the background material, if the client still needs help, questions will be presented to the research methods experts. our help desk is thus, designed not only to answer specific help desk questions, but also to build capacity and teach basic research skills. the supercourse is uniquely poised to launch a research methods help desk for india due to the extensive network of indian supercourse faculty and local “buy in” for the supercourse from india. professional medical associations can play a critical role in extending these resources to their members. such steps are likely to improve patient care, based on locally produced health research based evidences. references 1. minimum qualifications for teachers in medical institutions regulations, 1998. available from http://www.mciindia.org/rulesandregulations/teacherseligibilit yqualifications1998. aspx. 2. dhillon pk, jeemon p, arora nk, mathur p, maskey m, sukirna rd, prabhakaran d. status of epidemiology in the who south-east asia region: burden of disease, determinants of health and epidemiological research workforce and training capacity. int. j epidemiol. 2012; 41(3): 847-60. 3. jaykaran, yadav p. quality of reporting statistics in two indian pharmacology journals. j pharmacol pharmacother. 2011; 2(2): 85-9. 4. singh r, zodpey sp, sharma k, bangdiwala si, ugade s. landscaping biostatistics education in india. indian j public health. 2012; 56(4): 273-80. 5. global health network supercourse. available from www.pitt.edu/~super1. 6. linkov f, omenn gs, serageldin i, cerf v, lovalekar m, laporte r. multilayer and multimetric quality control: the supercourse. j cancer educ. 2010; 25(4): 478-83. 7. lovalekar mt, linkov f, mathur sc, bhave sy. indian supercourse in epidemiology. j contin educ health prof. 2010; 30(4): 260. 8. supercourse and library of alexandria help desk (beta version). available from http://ssc.bibalex.org/staging/helpdesk/introduction.jsf. 9. scimago. (2007). sjr — scimago journal & country rank. available from http://www.scimagojr.com/countryrank.php. accessed august 29, 2013. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.mciindia.org/rulesandregulations/teacherseligibilityqualifications1998.%20aspx http://www.mciindia.org/rulesandregulations/teacherseligibilityqualifications1998.%20aspx http://www.pitt.edu/~super1 http://ssc.bibalex.org/staging/helpdesk/introduction.jsf http://www.scimagojr.com/countryrank.php lovalekar this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.50 | http://cajgh.pitt.edu figure 1: published documents, selected countries, 1996-2012.9 0 2,000 4,000 6,000 8,000 10,000 12,000 subject area: medicine; subject category: public health, environmental and occupational health united states india china pakistan bangladesh sri lanka http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx effects of amyloid beta peptide on neurovascular cells effects of amyloid beta peptide on neurovascular cells sholpan askarova1, andrey tsoy1,2, tamara shalakhmetova2, james c-m lee3 1nazarbayev university, center for life sciences, astana, kazakhstan; 2al-farabi kazakh national university, biology faculty, almaty, kazakhstan; 3department of biological engineering, university of missouri, columbia, mo abstract alzheimer’s disease (ad) is a chronic neurodegenerative disorder, which is characterized by the accumulation of amyloid plaques and neurofibrillary tangles in specific regions of the brain, accompanied by impairment of the neurons, and progressive deterioration of cognition and memory of affected individuals. although the cause and progression of ad are still not well understood, the amyloid hypothesis is dominant and widely accepted. according to this hypothesis, an increased deposition of amyloid-β peptide (aβ) in the brain is the main cause of the ad’s onset and progression. there is increasing body of evidence that blood-brain barrier (bbb) dysfunction plays an important role in the development of ad, and may even precede neuron degeneration in ad brain. in the early stage of ad, microvasculature deficiencies, inflammatory reactions, surrounding the cerebral vasculature and endothelial dysfunctions are commonly observed. continuous neurovascular degeneration and accumulation of aβ on blood vessels resulting in cerebral amyloid angiopathy is associated with further progression of the disease and cognitive decline. however, little is known about molecular mechanisms that underlie aβ induced damage of neurovascular cells. in this regards, this review is aimed to address how aβ impacts the cerebral endothelium. understanding the cellular pathways triggered by aβ leading to alterations in cerebral endothelial cells structure and functions would provide insights into the mechanism of bbb dysfunction and inflammatory processes in alzheimer’s, and may offer new approaches for prevention and treatment strategies for ad. introduction alzheimer’s disease is a chronic neurodegenerative disorder, which affects approximately 10% of the population at age 65 and 40% of people over the age 80. ad is characterized by the accumulation of amyloid plaques and neurofibrillary tangles accompanied by impairment of the neurons in specific regions of the brain. in particular, large neurons in the neurocortex, the entorhinal area, hippocampus, amygdale, nucleus basalis, anterior thalamus, and several brain stem monoaminergic nuclei are affected. in damaged regions, the neurons exhibit multiple abnormalities of cell structure and function, reduction in the level of synaptic proteins, and, finally, they die.1 the neuronal loss in ad brains is accompanied by progressive deterioration of cognition and memory of affected individuals. although the cause and progression of ad are still not well understood, the amyloid hypothesis is dominant and widely accepted.2 according to this hypothesis, an increased deposition of amyloid-β peptide, the main constituent of senile plagues, is the main cause of neuronal dysfunction and death in ad. the rest of the disease process, including formation of neurofibrillary tangles containing tau protein, is proposed to result from an imbalance between aβ production and aβ clearance. aβ is derived from amyloidogenic cleavage of membrane bound amyloid precursor protein (app) by band g-secretase.3 amyloidogenic processing of the app leads to the production of aβ peptides of different length, of which the aβ1-40 is the major species and the aβ1-42 is the most fibrillogenic and predominant component in ad plaques.4 there is major evidence which supports amyloid cascade hypothesis. the first comes from the link between ad and down’s syndrome. the app gene is localized on chromosome 21, and people with down syndrome (trisomy 21) who, thus, have an extra gene copy almost invariably develop ad-like neuropathology by the age of 40. secondly, inherited mutations in the app and presenilin genes (presenilin constitutes the catalytic site of the γ-secretase) cause early and aggressive forms of ad. and thirdly, transgenic mice with mutant form of human app develop amyloid fibrillar plaques and alzhemer’s like brain pathology.2 recent reports have suggested that the soluble oligomeric form of the peptide is the most toxic and responsible for the disruption of synaptic plasticity, neuronal death and decline of cognitive function.5,6 although precise mechanism of aβ oligomers neurotoxic effects remains unclear, in-vivo and in-vitro studies have demonstrated that aβ oligomers: a) induce apoptosis; b) initiate oxidative stress and free-radical degeneration in neuronal cells; c) disrupt calcium homeostasis and long-term potentiation; d) cause neurodegeneration by forming large, voltage independent, and nonselective ion channels.7,8 however, for the most cases of late-onset sporadic non-inherited ad (~95%), the reasons of increased aβ accumulation in brains remain unknown. in this regard, current theories imply that ad is mainly caused by vascular risk factors, and that vascular derived pathology is responsible for initiation and/or progression of ad.9,11 recent studies provided significant data supporting the notion that the pathophysiology of blood brain barrier (bbb) and imbalanced interaction between cerebral endothelial cells (cecs), glial cells and neurons may trigger the progressive destruction of cortical neurons in ad.10,12-21 1. blood-brain barrier disorder in ad the homeostasis of the central nervous system (cns) is maintained by the bbb, which separates the brain from the circulating bloodstream. the bbb is formed by a complex cellular system consisting of cecs, astrocytes, pericytes, perivascular macrophages, and a basement membrane (fig 1.).22 figure 1. the blood-brain barrier. cecs layer is a major component of the bbb which is comprised of high-density cells connected by tight junctions. cecs have a little number of endothelial pores, rich in mitochondria, and have a very low content of the pinocytic vesicles. the biomechanical properties of the cecs are critical to the regulation of many cellular functions, such as adhesion, signaling and morphology, and play a vital role for the maintenance of the bbb permeability, and brain parenchyma homeostasis. astrocytes, the most frequent cells of the brain, also play an important role in maintaining bbb function. their end feet tightly connected to the cecs influencing cerebrovascular tone and the barrier properties of endothelium.20 pericytes are characterized as contractile cells that surround the brain capillaries. pericytes play an important role in maintaining the stability of microvessels and modulation of cerebral blood flow (cbf). sporadic microglia can also be found in the surrounding pericapillary area in normal brain.16 there is increasing body of evidence that bbb dysfunction plays an important role in the development and progression of ad.14-17,23,24 vascular disorders like atherosclerosis, ischemia, hypertension, and stroke are among the risk factors for ad.18,20,21 in the early stage of ad, microvasculature deficiencies, inflammatory reactions, surrounding the cerebral vasculature and endothelial dysfunctions are commonly observed.25 the increased number of perivascular macrophages and hypertrophy of astrocytes and microglia is commonly observed in ad brain sections.26 numerous observations have indicated decreased cerebral blood flow, reduced total microvascular density, and low immunoreactivity of endothelial markers cd34 and cd3 in ad brains.27-32 light and electron microscopy studies have demonstrated decreased mitochondrial and increased pinocytotic vesicles content, swelling and degeneration of endothelial cells.33,34 in-vitro, amyloid beta peptide has been shown to induce significant dysfunctions in the cecs. specifically, aβ suppressed cecs proliferation and migration, affected tube formation in the human brain endothelial cells (hbec), induced endothelial autophagy through the dissociation of erk and akt signaling and intracellular regulation of class 3 phosphatidylinositol 3-kinase.35,36 physiological concentrations of soluble aβ (10-9 10-6 m) induced dose-dependent reduction of no production, decreased sensitivity of neurovasculature to an endothelium dependent vasodilator acetylcholine, increased cellular calcium level, initiated albumin transfer across ec monolayer and impaired ec glucose uptake.24,37-39 higher concentrations of aβ have been demonstrated to induce mitochondria dysfunction, nuclear chromatin condensation, dna fragmentation, and significant cerebral endothelial cell death.37,38,40 continuous neurovascular degeneration and accumulation of aβ on blood vessels resulting in cerebral amyloid angiopathy is associated with further progression of the disease and cognitive decline.14,15,17,41,42 2. oxidative stress, inflammation, and downstream cell signaling pathways in ad there is increasing evidence that oxidative stress is a main mechanism leading to cerebrovascular dysfunction in ad. several studies of transgenic mice over expressing app have demonstrated oxidative damage of cecs, up regulation of superoxide dismutase (sod) around brain micro vessels, and significant impairment of the cerebrovascular functions.43-45 at the same time, endothelial dysfunctions were not observed in mice over expressing both app and sod-1 or in a case when sod was directly applied to the cerebral cortex of the app mice.44 in-vitro, treatment of cecs with aβ increased free radical production and this effect was attenuated by free radical scavengers.43,46 the oxidative stress initiates a cascade of redox reactions which trigger apoptosis. several studies have indicated that aβ -induced cecs death had an apoptotic nature and was a result of the mitochondria dysfunction, activation of a caspase upstream, and proapoptotic proteins release38,40,47,48 induced oxidative stress also triggers downstream kinase cascades leading to neurovascular inflammation.49,50 study of the microvessels isolated from the ad patients brains have revealed significantly higher levels of interleukin-1β (il-1β), il-6, tumor necrosis factor α (tnf-α), microvessel-associated monocyte chemoattractant protein (mcp-1) and il-1βs.49 in-vitro the exposure of hbec to aβ induced induction of cd40 (a member of tnf receptor family), secretion of interferon-γ (ifn-γ) and il-1β, expression of of ifn-γ receptor (ifn-γr), and triggered inflammatory genes mcp-1, gro, il-1β and il-6 expression via jnk-ap1 signaling pathway.50-52 aβ-induced oxidative stress in cerebral epithelium is associated with overproduction of reactive oxygen species (ros).20,53-55 ros can be generated by several enzymatic systems, but there is evidence that superoxide-producing enzyme nadph oxidase a is major source of ros in the brain blood vessels.54-56 in a model of ad, inhibition of nadph oxidase has been found to abrogate aβ induced ros production and alteration of cerebrovascular functions.54 app transgenic mice lacking the nadph oxidase subunits gp91phox or nox2 did not develop oxidative stress, cerebrovascular dysfunction, and behavioral deficits.54,55 recent studies have indicated that the receptor for advanced glycation endproducts (rage) is a binding site for aβ.57-62 rage is a multiligand cell surface receptor which is normally expressed in brain endothelium and, at low levels, in microglia and neurons.15,60,61 however, in ad brains rage expression is increased by several-fold in cerebral endothelial cells, astrocytes, microglia, and neurons.60,61 ros have been reported to be generated by nadph oxidase through the rage in endothelial cells.62,63 inhibition studies have indicated that anti-rage igg significantly suppressed oxidative stress and inflammation induced by aβ in vascular cells and neurons.57 rage binding to aβ has been also demonstrated to regulate aβ transport across bbb, upregulate pro-inflammatory cytokines and adhesion molecules in cecs, and contribute to the transport of aβ from the cell surface into the intracellular space in cortical neurons.61,64,65 aβ-induced cytotoxic effects are also associated with the activation of mapk/erk1/2 cascade and that activated erks (extracellular-signal-regulated kinases) is the central target of rage.62,66-72 the erks are widely expressed protein kinases, part of a signal transduction system, through which extracellular stimuli are transduced. activation of the erks occurs in response to growth factor stimulation, cytokines, virus infection, transforming agents, carcinogens, and after the activation of high-affinity igg receptors.71 erks have been implicated in diverse cellular responses such as mitogenesis, differentiation, inflammation and cytotoxicity, and the overproduction of this enzyme is involved in many neurodegenerative diseases, including ad.67,73,74 thus, nadph oxidase, erks and rage have been suggested to be important therapeutic targets in ad. 3. permeability of cerebral endothelium in ad in the ad, an increased deposition of aβ in the cerebral vasculature has been found to correlate with accumulation of monocytes in the vessel walls and of activated microglia cells in the adjacent parenchyma.75-77 since peripheral monocytes can migrate across the bbb and differentiate into microglia,78 which, in turn, drives the disease development towards exacerbation of the oxidative and inflammatory conditions characteristic of the ad brain, several research groups have attempted to demonstrate the direct effect of aβ on endothelial functions leading to enhanced transmigration of monocytes. in-vitro studies have shown that soluble aβ interactions with rage and platelet-endothelial cell adhesion molecule-1 (pecam-1) at the apical surface and basolateral sides of monolayer of brain endothelial cells increased transendothelial migration of monocytic cells.79-81 based on the observation that the permeability of the monolayer toward dextran and inulin in the presence or absence of aβ42 remained unaltered,79 it has been concluded that enhanced transmigration of monocytes induced by aβ is not only due to nonspecific disruption of the barrier properties of the endothelial layer, but also is a consequence of aβ induced expression of the chemokines and adhesion molecules. since primary capture of the monocytes to endothelium and rolling are mediated by tethering on selectins and selectin ligands,82-84 the expression of adhesion molecules, mechanical properties of the membranes (fluidity, elasticity) and membrane-cytoskeleton interactions are critical for transmigration.85-90 atomic force microscopy and quantitative immunofluorescence microscopy studies have demonstrated that aβ oligomers induced pselectin expression, increased cell stiffness, decreased the apparent rupture force of selectin-ligand bonding due to dissociation of adhesion between the cytoskeleton and the bilayer membrane, and, thus, increased probability of adhesion. 91 the presence of the tight junctions of high electrical resistance and close cell-cell contact are important biomechanical factors maintaining brain homeostasis and bbb impermeability. tight junction is a complex of transmembrane proteins (occluding, claudins, junctional molecule-1) and submembrane molecules connected to actin network. in fact, the structure and functions of the tight junctions are strongly affected in the cerebrovascular cells of ad patients.92 in an animal model of ad, a cholesterol-enriched diet down-regulated the expression of the occluding and zo-1, which was strongly correlated with the elevated level of the bbb leakage.93 in-vitro, treatment of primary rat cecs with aβ1-42 for 3 days altered expression of occluding and claudin-1, caused relocation of plasma membrane subunits of claudin-5 and zo-2 to the cytoplasm. at the same time, the cytoplasmic zo-1 and zo-2 where evenly distributed along the plasma membrane at the points of the cell-cell contacts.94 apolipoprotein e4 (apoe4), a major risk factor for ad, has been shown to be involved in tight junction alteration as well.95 it has been shown that mice deficient in apoe have expressed bbb leakage. in-vitro study has demonstrated that the barrier functions of tight junctions was impaired when the cecs were reconstituted with primary astrocytes from apoe4-knock-in mice. in particular, the phosphorylation of occludin and the activation of protein kinase c (pkc)η in cecs were attenuated. these findings suggest that the effects of aβ on actin and tight junction protein complexes, as well as vascular risk factors cause the alteration of endothelial layer integrity and contribute to the enhanced transmigration of monocytes across the bbb. thus, studying the aβ-mediated alterations in endothelial adhesion and bbb permeability would provide insights into the mechanism of bbb dysfunction and may provide information for developing new targeted drug delivery vehicles96 for the ad brain. conclusion chronic neurovascular dysfunctions and degeneration of endothelium are observed in the all stages of ad. numerous in vivo and in vitro studies have demonstrated that vascular deposition of amyloid beta peptide induces oxidative stress in cerebral vasculature, triggers inflammatory processes and apoptosis, promotes expression of adhesion molecules, affects tight junctions, changes mechanical properties of the cecs membranes, and enhances transmigration of immune cells across bbb. continuous degeneration of cecs impairs bbb permeability and leads to leakage of blood cells, plasma components and neurotoxic substances into the brain parenchyma. breakdown of blood brain barrier functions drives the disease development towards exacerbation of the oxidative and inflammatory conditions characteristic of the ad brain and contributes to further progression of the disease. understanding the precise molecular mechanisms underlying ab-mediated oxidative stress in cecs, the effects of aβ42 on the bbb adhesion and permeability should prove to provide new insights into the development of preventive and treatment strategies for ad. references 1. kandel er, schwartz jh, jessel tm, editors. principles of neural science 4ed2000. 2. hardy j, selkoe dj. the amyloid hypothesis of alzheimer's disease: progress and problems on the road to therapeutics. science. 2002;297(5580):353-6. 3. vassar r. bace1: the beta-secretase enzyme in alzheimer's disease. j mol neurosci. 2004;23(1-2):105-14. epub 2004/05/06. 4. bernstein sl, wyttenbach t, baumketner a, shea j-e, bitan g, teplow db, et al. amyloid оі-protein:вђ‰ monomer structure and early aggregation states of aоі42 and its pro19 alloform. journal of the american chemical society. 2005;127(7):2075-84. 5. walsh dm, selkoe dj. aβ oligomers – a decade of discovery. journal of neurochemistry. 2007;101(5):1172-84. 6. dahlgren kn, manelli am, stine wb, baker lk, krafft ga, ladu mj. oligomeric and fibrillar species of amyloid-оі peptides differentially affect neuronal viability. journal of biological chemistry. 2002;277(35):32046-53. 7. resende r, ferreiro e, pereira c, resende de oliveira c. neurotoxic effect of oligomeric and fibrillar species of amyloid-beta peptide 1-42: involvement of endoplasmic reticulum calcium release in oligomer-induced cell death. neuroscience. 2008;155(3):725-37. 8. cleary jp, walsh dm, hofmeister jj, shankar gm, kuskowski ma, selkoe dj, et al. natural oligomers of the amyloid-[beta] protein specifically disrupt cognitive function. nat neurosci. 2005;8(1):79-84. 9. zlokovic bv. neurovascular pathways to neurodegeneration in alzheimer's disease and other disorders. nat rev neurosci. 2011;12(12):723-38. 10. stanimirovic db, friedman a. pathophysiology of the neurovascular unit: disease cause or consequence[quest]. j cereb blood flow metab. 2011;32(7):1207-21. 11. iadecola c. the overlap between neurodegenerative and vascular factors in the pathogenesis of dementia. acta neuropathol 2010 120(3):287-96. 12. liu r, zhang t-t, wu c-x, lan x, du g-h. targeting the neurovascular unit: development of a new model and consideration for novel strategy for alzheimer's disease. brain research bulletin. 2011;86(1вђ“2):13-21. 13. salmina a, inzhutova a, malinovskaya n, petrova m. endothelial dysfunction and repair in alzheimer-type neurodegeneration: neuronal and glial control. j alzheimers dis. 2010;22(1):17-36. 14. ruitenberg a, den heijer t, bakker sl, van swieten jc, koudstaal pj, hofman a, et al. cerebral hypoperfusion and clinical onset of dementia: the rotterdam study. ann neurol. 2005;57(6):789-94. epub 2005/06/02. 15. zlokovic bv. new therapeutic targets in the neurovascular pathway in alzheimer's disease. neurotherapeutics. 2008;5(3):409-14. epub 2008/07/16. 16. bell r, zlokovic b. neurovascular mechanisms and blood–brain barrier disorder in alzheimer’s disease. acta neuropathologica. 2009;118(1):103-13. 17. iadecola c. cerebrovascular effects of amyloid-beta peptides: mechanisms and implications for alzheimer's dementia. cell mol neurobiol. 2003;23(4-5):681-9. 18. de la torre jc. how do heart disease and stroke become risk factors for alzheimer's disease? neurological research. 2006;28:637-44. 19. deane r, zlokovic bv. role of the blood-brain barrier in the pathogenesis of alzheimers disease. current alzheimer research 2007(4):191-7. 20. girouard h, iadecola c. neurovascular coupling in the normal brain and in hypertension, stroke, and alzheimer disease. j appl physiol. 2006;100(1):328-35. 21. hofman a, ott a, breteler mmb, bots ml, slooter ajc, van harskamp f, et al. atherosclerosis, apolipoprotein e, and prevalence of dementia and alzheimer's disease in the rotterdam study. the lancet. 1997;349(9046):151-4. 22. bradbury mw. the blood-brain barrier. transport across the cerebral endothelium. circ res. 1985;57(2):213-22. 23. scheibel a, duong t, jacobs r. alzheimer's disease as a capillary dementia. ann med. 1989;21(2):103-7. 24. de la torre jc. is alzheimer's disease a neurodegenerative or a vascular disorder? data, dogma, and dialectics. the lancet neurology. 2004;3(3):184-90. 25. borroni b, akkawi n, martini g, colciaghi f, prometti p, rozzini l, et al. microvascular damage and platelet abnormalities in early alzheimer's disease. journal of the neurological sciences. 2002;203-204:189-93. 26. farkas e, luiten pgm. cerebral microvascular pathology in aging and alzheimer's disease. progress in neurobiology. 2001;64(6):575-611. 27. luc b, patrick r hof, andrй d. brain microvascular changes in alzheimer's disease and other dementiasa. annals of the new york academy of sciences. 1997;826(cerebrovascular pathology in alzheimer's disease):7-24. 28. berzin tm, zipser bd, rafii ms, kuo--leblanc v, yancopoulos gd, glass dj, et al. agrin and microvascular damage in alzheimer's disease. neurobiology of aging. 2000;21(2):349-55. 29. bailey tl, rivara cb, rocher ab, hof pr. the nature and effects of cortical microvascular pathology in aging and alzheimer's disease. neurological research. 2004;26:573-8. 30. kalaria rn, pax ab. increased collagen content of cerebral microvessels in alzheimer's disease. brain research. 1995;705(1-2):349-52. 31. ervin jf, pannell c, szymanski m, welsh-bohmer k, schmechel de, hulette cm. vascular smooth muscle actin is reduced in alzheimer disease brain: a quantitative analysis. journal of neuropathology & experimental neurology. 2004;63(7):735-41. 32. kalaria rn hp. differential degeneration of the cerebral microvasculature in alzheimer’s disease. neuroreport. 1995(6):477-80. 33. claudio l. ultrastructural features of the blood-brain barrier in biopsy tissue from alzheimer's disease patients. acta neuropathologica 1996; 91(1):6-14. 34. aliev g, seyidova d, lamb bt, obrenovich me, siedlak sl, vinters hv, et al. mitochondria and vascular lesions as a central target for the development of alzheimer's disease and alzheimer disease-like pathology in transgenic mice. neurological research. 2003;25:665-74. 35. magrane j, christensen ra, rosen km, veereshwarayya v, querfurth hw. dissociation of erk and akt signaling in endothelial cell angiogenic responses to [beta]-amyloid. experimental cell research. 2006;312(7):996-1010. 36. hayashi s-i, sato n, yamamoto a, ikegame y, nakashima s, ogihara t, et al. alzheimer disease-associated peptide, amyloid {beta}40, inhibits vascular regeneration with induction of endothelial autophagy. arterioscler thromb vasc biol. 2009;29(11):1909-15. 37. price jm, chi x, hellermann g, sutton et. physiological levels of -amyloid induce cerebral vessel dysfunction and reduce endothelial nitric oxide production. neurological research. 2001;23:506-12. 38. emmanuelle mb, michal t, robert jm, bernhard h. amyloid β-peptide induces cell monolayer albumin permeability, impairs glucose transport, and induces apoptosis in vascular endothelial cells. journal of neurochemistry. 1997;68(5):1870-81. 39. bhatia r, lin hai, lal r. fresh and globular amyloid {beta} protein (1-42) induces rapid cellular degeneration: evidence for a{beta}p channel-mediated cellular toxicity. faseb j. 2000;14(9):1233-43. 40. xu j, chen s, ku g, ahmed sh, xu j, chen h, et al. amyloid beta peptide-induced cerebral endothelial cell death involves mitochondrial dysfunction and caspase activation. j cereb blood flow metab. 2001;21(6):702-10. 41. selkoe djas, d. alzheimer's disease: molecular understanding predicts amyloid-based therapeutics. annu rev pharmacol toxicol. 2003;(43):545-84. 42. kalaria rn. cerebrovascular degeneration is related to amyloid-β protein deposition in alzheimer's disease. annals of the new york academy of sciences. 2006;826(issue cerebrovascular pathology in alzheimer's disease):263-71. 43. park l aj, forster c, kazama k, carlson ga, iadecola c. abeta-induced vascular oxidative stress and attenuation of functional hyperemia in mouse somatosensory cortex. joyrnal of cerebral blood flow metabolism. 2004;24(3):334-42. 44. iadecola c zf, niwa k, eckman c, turner sk, fischer e, younkin s, borchelt dr, hsiao kk, carlson ga. sod1 rescues cerebral endothelial dysfunction in mice overexpressing amyloid precursor protein. nature neuroscience. 1999;2(2):157-61. 45. tong x-k, nicolakakis n, kocharyan a, hamel e. vascular remodeling versus amyloid-beta-induced oxidative stress in the cerebrovascular dysfunctions associated with alzheimer's disease. j neurosci. 2005;25(48):11165-74. 46. abramov ay, duchen mr. the role of an astrocytic nadph oxidase in the neurotoxicity of amyloid beta peptides. philosophical transactions of the royal society b: biological sciences. 2005;360(1464):2309-14. 47. yin kj, lee jm, chen sd, xu j, hsu cy. amyloid-beta induces smac release via ap-1/bim activation in cerebral endothelial cells. j neurosci. 2002;22(22):9764-70. 48. hsu m-j, hsu cy, chen b-c, chen m-c, ou g, lin c-h. apoptosis signal-regulating kinase 1 in amyloid {beta} peptide-induced cerebral endothelial cell apoptosis. j neurosci. 2007;27(21):5719-29. 49. grammas p, ovase r. inflammatory factors are elevated in brain microvessels in alzheimer's disease. neurobiology of aging. 2001;22(6):837-42. 50. vukic v, callaghan d, walker d, lue l-f, liu qy, couraud p-o, et al. expression of inflammatory genes induced by beta-amyloid peptides in human brain endothelial cells and in alzheimer's brain is mediated by the jnk-ap1 signaling pathway. neurobiology of disease. 2009;34(1):95-106. 51. tan j, town t, suo z, wu y, song s, kundtz a, et al. induction of cd40 on human endothelial cells by alzheimer's [beta]-amyloid peptides. brain research bulletin. 1999;50(2):143-8. 52. suo z, tan j, placzek a, crawford f, fang c, mullan m. alzheimer's [beta]-amyloid peptides induce inflammatory cascade in human vascular cells: the roles of cytokines and cd40. brain research. 1998;807(1-2):110-7. 53. callaghan d, bai j, huang a, vukic v, xiong h, jones a, et al. p4-182: inhibition of abcg2 transport function by amyloid-beta peptide augments cellular oxidative stress and inflammatory gene expression in cells. alzheimer's and dementia. 2008;4(4, supplement 1):t724-t. 54. park l, anrather j, zhou p, frys k, pitstick r, younkin s, et al. nadph oxidase-derived reactive oxygen species mediate the cerebrovascular dysfunction induced by the amyloid {beta} peptide. j neurosci. 2005;25(7):1769-77. 55. park l, zhou p, pitstick r, capone c, anrather j, norris eh, et al. nox2-derived radicals contribute to neurovascular and behavioral dysfunction in mice overexpressing the amyloid precursor protein. proceedings of the national academy of sciences. 2008;105(4):1347-52. 56. cai h, griendling kk, harrison dg. the vascular nad(p)h oxidases as therapeutic targets in cardiovascular diseases. trends in pharmacological sciences. 2003;24(9):471-8. 57. yan sd, chen x, fu j, chen m, zhu h, roher a, et al. rage and amyloid-[beta] peptide neurotoxicity in alzheimer's disease. nature. 1996;382(6593):685-91. 58. arancio o, zhang hp, chen x, lin c, trinchese f, puzzo d, et al. rage potentiates a[beta]-induced perturbation of neuronal function in transgenic mice. embo j. 2004;23(20):4096-105. 59. chaney mo, stine wb, kokjohn ta, kuo y-m, esh c, rahman a, et al. rage and amyloid beta interactions: atomic force microscopy and molecular modeling. biochimica et biophysica acta (bba) molecular basis of disease. 2005;1741(1-2):199-205. 60. sasaki n, toki s, chowei h, saito t, nakano n, hayashi y, et al. immunohistochemical distribution of the receptor for advanced glycation end products in neurons and astrocytes in alzheimer's disease. brain research. 2001;888(2):256-62. 61. lue l-f, walker dg, brachova l, beach tg, rogers j, schmidt am, et al. involvement of microglial receptor for advanced glycation endproducts (rage) in alzheimer's disease: identification of a cellular activation mechanism. experimental neurology. 2001;171(1):29-45. 62. askarova s, yang x, sheng w, sun gy, lee jc-m. role of ab-receptor for advanced endproducts in oxidativestress and cytosolic phospholipase a2 activation in astrocytes and cerebral endothelial cells. neuroscience. 2011;199:375-85. 63. wautier m-p, chappey o, corda s, stern dm, schmidt am, wautier j-l. activation of nadph oxidase by age links oxidant stress to altered gene expression via rage. am j physiol endocrinol metab. 2001;280(5):e685-94. 64. giri r, shen y, stins m, du yan s, schmidt am, stern d, et al. beta-amyloid-induced migration of monocytes across human brain endothelial cells involves rage and pecam-1. am j physiol cell physiol. 2000;279(6):c1772-81. 65. takuma k, fang f, zhang w, yan s, fukuzaki e, du h, et al. rage-mediated signaling contributes to intraneuronal transport of amyloid-оі and neuronal dysfunction. proceedings of the national academy of sciences. 2009;106(47):20021-6. 66. zhu d, lai y, shelat pb, hu c, sun gy, lee jcm. phospholipases a2 mediate amyloid-beta peptide-induced mitochondrial dysfunction. j neurosci. 2006;26(43):11111-9. 67. stephenson dt, lemere ca, selkoe dj, clemens ja. cytosolic phospholipase a2 (cpla2) immunoreactivity is elevated in alzheimer's disease brain. neurobiol dis. 1996;3(1):51-63. epub 1996/02/01. 68. moses gs, jensen md, lue lf, walker dg, sun ay, simonyi a, et al. secretory pla2-iia: a new inflammatory factor for alzheimer's disease. j neuroinflammation. 2006;3:28. epub 2006/10/10. 69. dineley kt, westerman m, bui d, bell k, ashe kh, sweatt jd. {beta}-amyloid activates the mitogen-activated protein kinase cascade via hippocampal {alpha}7 nicotinic acetylcholine receptors: in vitro and in vivo mechanisms related to alzheimer's disease. j neurosci. 2001;21(12):4125-33. 70. young kf, pasternak sh, rylett rj. oligomeric aggregates of amyloid [beta] peptide 1-42 activate erk/mapk in sh-sy5y cells via the [alpha]7 nicotinic receptor. neurochemistry international. 2009;55(8):796-801. 71. mcdonald dr, bamberger me, combs ck, landreth ge. beta -amyloid fibrils activate parallel mitogen-activated protein kinase pathways in microglia and thp1 monocytes. j neurosci. 1998;18(12):4451-60. 72. shelat p, b. , chalimoniuk m, wang j-h, strosznajder j, b. , lee j, c. , sun a, y. , et al. amyloid beta peptide and nmda induce ros from nadph oxidase and aa release from cytosolic phospholipase a2 in cortical neurons. journal of neurochemistry. 2008;106(1):45-55. 73. stephenson d, rash k, smalstig b, roberts e, johnstone e, sharp j, et al. cytosolic phospholipase a2 is induced in reactive glia following different forms of neurodegeneration. glia. 1999;27(2):110-28. epub 1999/07/27. 74. sun gy, horrocks la, farooqui aa. the roles of nadph oxidase and phospholipases a2 in oxidative and inflammatory responses in neurodegenerative diseases. journal of neurochemistry. 2007;103(1):1-16. 75. maat-schieman ml vds, rozemuller aj, haan j, roos ra. association of vascular amyloid beta and cells of the mononuclear phagocyte system in hereditary cerebral hemorrhage with amyloidosis (dutch) and alzheimer disease. j neuropathol exp neurol. 1997(56):273-84. 76. uchihara t ah, kondo h, ikeda k. activated microglial cells are colocalized with perivascular deposits of amyloid-beta protein in alzheimer's disease brain. stroke. 1997(28):1948-50. 77. selkoe dj, schenk d. alzheimer's disease: molecular understanding predicts amyloid-based therapeutics. annual review of pharmacology and toxicology. 2003;43(1):545-84. 78. mezey e, chandross kj, harta g, maki ra, mckercher sr. turning blood into brain: cells bearing neuronal antigens generated in vivo from bone marrow. science. 2000;290(5497):1779-82. 79. giri r, selvaraj s, miller ca, hofman f, yan sd, stern d, et al. effect of endothelial cell polarity on beta -amyloid-induced migration of monocytes across normal and ad endothelium. am j physiol cell physiol. 2002;283(3):c895-904. 80. reyes barcelo a, gonzalez-velasquez f, moss m. soluble aggregates of the amyloid-beta peptide are trapped by serum albumin to enhance amyloid-beta activation of endothelial cells. journal of biological engineering. 2009;3(1):5. 81. gonzalez-velasquez fj, kotarek ja, moss ma. soluble aggregates of the amyloid-beta protein selectively stimulate permeability in human brain microvascular endothelial monolayers. j neurochem. 2008;107:466-77. 82. frijns cj, kappelle lj. inflammatory cell adhesion molecules in ischemic cerebrovascular disease. stroke. 2002;33(8):2115-22. 83. alon r, chen s, puri kd, finger eb, springer ta. the kinetics of l-selectin tethers and the mechanics of selectin-mediated rolling. j cell biol. 1997;138(5):1169-80. 84. alon r, hammer da, springer ta. lifetime of the p-selectin-carbohydrate bond and its response to tensile force in hydrodynamic flow. nature. 1995;374(6522):539-42. 85. dembo m, torney dc, saxman k, hammer d. the reaction-limited kinetics of membrane-to-surface adhesion and detachment. proc r soc lond b biol sci.1988;234(1274):55-83. 86. trache a, trzeciakowski jp, gardiner l, sun z, muthuchamy m, guo m, et al. histamine effects on endothelial cell fibronectin interaction studied by atomic force microscopy. biophys j. 2005;89(4):2888-98. 87. sun m, northup n, marga f, huber t, byfield fj, levitan i, et al. the effect of cellular cholesterol on membrane-cytoskeleton adhesion. j cell sci. 2007;120(13):2223-31. 88. sun m, graham js, hegedьs b, marga f, zhang y, forgacs g, et al. multiple membrane tethers probed by atomic force microscopy. 2005;89(6):4320-9. 89. girdhar g, shao j-y. membrane tether extraction from human umbilical vein endothelial cells and its implication in leukocyte rolling. biophysical journal. 2004;87(5):3561-8. 90. girdhar g, chen y, shao j-y. double-tether extraction from human umbilical vein and dermal microvascular endothelial cells. biophysical journal. 007;92(3):1035-45. 91. lee jcm, askarova s, sun z, sun gy, meininger ga. p4-293: oligomeric amyloid-оі peptide on sialyl lewisx-selectin bonding at the cerebral endothelial cell surface. alzheimer's & dementia : the journal of the alzheimer's association. 2008;4(4):t757. 92. bednarczyk j, lukasiuk k. tight junctions in neurological diseases. acta neurobiol exp. 2011;71(4):393-408. 93. chen x, gawryluk j, wagener j, ghribi o, geiger j. caffeine blocks disruption of blood brain barrier in a rabbit model of alzheimer's disease. journal of neuroinflammation. 2008;5(1):12. 94. marco s, skaper sd. amyloid [beta]-peptide1-42 alters tight junction protein distribution and expression in brain microvessel endothelial cells. neuroscience letters. 2006;401(3):219-24. 95. nishitsuji k, hosono t, nakamura t, bu g, m. m. apolipoprotein e regulates the integrity of tight junctions in an isoform-dependent manner in an in vitro blood-brain barrier model. j biol chem. 2011;286(20):17536-4. 96. omolola eniola a, hammer da. in vitro characterization of leukocyte mimetic for targeting therapeutics to the endothelium using two receptors. biomaterials. 2005;26(34):7136-44. the case of nrens in central asia the case of nrens in central asia robert franciscus janz1, askar kutanov2 1centre for information technology, university of groningen, the netherlands; 2national academy of sciences, kyrgyz republic, regional coordinator for ec caren project perspective abstract national research and education network organizations (nrens) provide advanced information and communication technology (ict) services for the academic community of their country. their focus is often on providing affordable high speed bandwidth amongst their members and to other research networks, but nrens also provide other advanced services such as electronic repositories, educational environments and supercomputing facilities. higher education and research institutions have to play an active role in the transformation to the “knowledge society”. a recent (2010) report of the international telecommunication union has identified nrens as important vehicles in reaching the goals of the world summit of the information society. it is also demonstrated that the central asian countries score very low in the networked readiness indices of the world economic forum, including areas where strong nrens could improve the status quo. nrens therefore have a role that is also important for the nation itself and therefore claims for government support are legitimate. about 62% of the countries of the world already have an nren and there are four characteristics that are common to these nrens. in nearly all of the cases the nren is a not-for-profit organization that not only serves the academic community, but is also owned by the same community. four out of five central asian countries have an active nren and these nrens all participate in the ec funded caren project that aims to set up a sustainable regional network for the academic communities in the participating countries. today, the central asian research and education network (caren) is upgrading the ancient silk road to a 21st-century high-speed internet highway for research and educational institutions through the region. operational since july 2010, caren currently interconnects scientists and students from kazakhstan, kyrgyzstan, tajikistan, and turkmenistan. keywords: nren, information and communication technology introduction national research and education network (nrens) are organizations that provide a wide range of common and advanced information and communication technology (ict) services for primarily the higher education and research sector of a country. in europe every country has its own nren; however, the governance and funding models, organizational structure, types of member institutions, and services that are provided differ. the central asian countries also have nrens, but their role is not always recognized in the same context as their european peers: they are usually seen as internet service providers (isps) for a special user group (higher education and research). in most of the countries there is hardly any (financial) government support (turkmenistan is the only exception) and the nrens have to compete with commercial isps. in this article we will demonstrate that nrens have a broader role than merely an isp and advocate that government as well as the higher education and research institutions should provide more support for the nren of their country. the need for ict in higher education and research before understanding the need of nrens is it important to emphasize the need of ict in (higher) education and research. the central asian countries, like many other countries in the world, are transforming into a “knowledge society”. this process is part of achieving the goals of the world summit of the information society (wsis) that was initiated in 2003 in geneva with a follow-up in 2005 in tunis. in the wsis context ict is identified as a driving force in transforming to the knowledge society as is visualized in figure 1: ict drives educational reform that leads to innovation and then through the development of new services to the knowledge society. figure 1 the wsis goals themselves are part of a much broader initiative to reduce extreme poverty in the world: the united nations millennium declaration that was adopted in september 2000. one of the targets of this declaration is “in cooperation with the private sector, make available the benefits of new technologies, especially information and communications”. in 2010 the international telecommunication union (itu) published a midterm review of the accomplishments towards reaching this specific target. in this review nrens were identified as important vehicles in reaching four out of the ten wsis goals, and it was stressed that “… governments must work with nrens to ensure that they are fully embedded within the national innovation system and that they serve the needs of the local research community.” so if a country has underwritten the wsis goals (and the central asian countries have done so) then it is only natural that they should take an active role in supporting the nren. the central asian countries have expressed the ambition to reach the millennium goals, but they still have a poor ranking among the 142 countries in the networked readiness index of the world economic forum1. this readiness index is calculated from indices of various sub variables, of which some are listed in table 12. the overview in this table presents only a small subset of the indices that were used to determine the overall readiness and were chosen to demonstrate area’s where higher education can contribute in improving the readiness of the central asian countries. for comparison the calculated indices of the countries of the commonwealth of independent states (cis) are presented in the most right column. table 1 key variables are the poor penetration of internet usage under the adult population and the poor business and innovation environment. these factors are of course beyond the direct influence of the hei sector. however factors that drive these indicators, such as infrastructure and digital content, availability of the latest technology, and skills to make effective use of ict are within the domain of the hei sector and two of these indices for the central asian countries are nearly the lowest in the world. by joining forces in the area of ict support the hei sector can contribute to the wsis goals of central asia as mentioned earlier. as said, an nren is an important vehicle in this process, which demonstrates why strong central asian nrens are more than necessary. characteristics of nrens in 2010, 62% of the countries in the world had an nren3. although in most of these cases there is a strong collaboration with the government, nrens themselves are usually separate entities with common characteristics. there are four common denominators of all nrens: nrens provide services for a closed user group. as said the primary user group is the higher education and research sector, but there are variants that also provide services for secondary and sometimes even primary education. also hospitals and libraries are members of an nren in some countries. most nrens confine their members to public organizations (with the exception of private he institutions). nrens are not-for-profit organizations the mission of most nrens is to provide (advanced) services at the lowest possible tariffs for their users. any profits that might occur are funneled back to the members. nrens should also be not-for loss, meaning that they will have to have a sound financial basis with sufficient funding for investments and operational expenses. nrens provide at least national and international connectivity the core business, and most often the reason why nrens are established, is to provide high speed communication services for their members. the nrens operate a national network with international connectivity to other research and education networks and also to commodity internet. the nrens are never responsible for the ict environment within the member institutions. additional nren services besides connectivity nrens provide other services for their user constituency, such as library services, electronic learning environments, ict tools for research, hosting and housing for smaller institutions, security platforms and many other ict related services. the common base for these services is that they make use of the national network that is being provided for by the nren. nrens are most usually set up as separate organizations with a governance model that ensures that the member organizations have control of the activities of the nren. in some countries (e.g. belnet in belgium) the nren is part of government, but this model is very rare. for funding most nrens are, in varying degrees, dependent of their government. the rationale behind this is that there is proof that nrens are an asset for economic growth and prosperity of the country as a whole (as presented earlier). nrens are the motor of innovation and they actively support the transfer of this innovation to society and industry. most often the funding model is a mix of government funding and tariff-based funding from the members. the running costs of the nren are funded by user tariffs and long term infrastructural investments and the development of advanced services are funded by government (or other donors). in some cases even industry participates in and co-funds nren activities. telecom operators for example collaborate with nrens in developing new services that are not yet fit for market. the organizational structure of the nren is closely related to the strategic decision whether to setup an organization that actually runs the network and the services that are provided or to create an organization that is only responsible for the functional operation of the network and services and subcontracts the actual operations to other companies or public organizations. in the first case a large organization might evolve that has the technical expertise at hand but will easily lose its flexibility to meet the rapidly changing demands from its users. on the other hand an organization that outsources most of the actual ict operations needs a specific human capacity that is focused on contract management and this may lead to cost disadvantages. of course a mixed strategy is also possible: if a service is available, at a reasonable tariff, in the market then outsource it, otherwise develop and deploy the service within the nren. with regard to the services that are provided there is a (healthy) tension between user demands and technology push. the, often short term, user demands are mostly directed towards cheap tariffs for national and international connectivity. long-term validity of having an nren is however more directed towards providing advanced services that have their impact on society, either in terms of the valorization of innovation or in terms of closing the digital gap. the nren management will have to provide a balance in this tension4. in relation to the services that are being provided by an nren it should be emphasized that in first instance the nren provides a national network for science and education. internet connectivity is just one of the services that are available on this network. this clear distinction between infrastructure (the national network) and the services (including internet) is an important characteristic of the business model of the nren. the central asian nrens the central asian nrens have a long history: in 2001 they were established as part of the nato funded silk project that provided satellite based connectivity to the higher education and research sectors of the central asian countries. the silk project demanded that the central asian research and higher education communities set up an nren as beneficiary partner and the nrens were made responsible for the distribution of the connectivity within their user constituencies by setting up national networks. over the years the nrens have evolved to relatively strong organizations that provide services for their users. satellite technology has been abandoned and since 2010 international fiber-optic-based connectivity is provided by the ec funded caren project. besides connectivity the nrens are providing support for applications that run on the network, such as disaster prevention systems, telemedicine applications, video conferencing, distance education, and supercomputing facilities. disaster prevention is priority for regional cooperation in central asia. a major part of the central asian countries’ territory is located in the seismically active zone and is prone to hazardous natural processes and phenomena. it requires organizing detailed study of hazardous natural processes and phenomena practically in the whole territory of central asian countries. such kinds of studies are based on the integrated monitoring of the seismic situation, tectonic structures movement, geodynamics of processes, and phenomena development, as well as changes of environmental parameters. without active nrens such a regional approach to disaster prevention would be impossible. telemedicine is another important area for collaboration among central asian nrens due to the shortage of qualified medical doctors and services in rural areas. figure 2 although the nrens have grown, they are in most cases still mainly dependent on user tariffs for their financial sustainability, with little to no support from their governments. the exception is turena, the turkmen nren that is fully funded by its government. the kyrgyz nren (krena) receives support from its government for the international connectivity. the kazakh nren (kazrena) and tajik nren (tarena) receive no support from their governments. the uzbek nren (uzscinet) is even worse off as they not only receive no support from their government, but also do not participate in the caren project due to lack of government support for the caren project. the intention is that the current caren project will evolve to a sustainable regional network organization for the central asian countries. the caren nrens are currently developing business models that will demonstrate their worth for the higher education sectors in their countries. these business models will show that government support is essential for the sustainability of the nrens. the caren project itself will evolve into a regional organization that represents the interests of the central asian nrens. by combining forces, the central asian nrens, through caren, can contribute significantly in reaching the wsis goals, but of course only if the higher education and research institutions fully support the nren of their country. relevant urls: dante caren page: http://caren.dante.net icaren portal: http://www.icaren.org/ world summit of information technology: http://www.itu.int/ world economic forum, the global information technology report 2012: http://www.weforum.org/reports notes 1source: world economic forum, the global information technology report 2012 2remarks in relation to table 1: data were published in may 2011 are presumably from 2010 if not specified the index values are in a scale from 1 to 7 the indices are all in the range 1 to 142 as base line the index values of the cis countries is used in the right column. for some reason there were no data for turkmenistan and uzbekistan cells with “?” indicate missing data 3source: “monitoring the wsis targets”, of the itu, 2010 4a quote of henry ford, the founder of ford automobiles is very relevant here: “if i had listened to my customers i would have given them a faster horse”. in vivo biotinylation based method for the study of protein-protein proximity in eukaryotic cells new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. in vivo biotinylation based method for the study of proteinprotein proximity in eukaryotic cells arman kulyyassov1, erlan ramanculov2, vasily ogryzko3 1national center for biotechnology, almaty, kazakhstan; 2interdisciplinary instrumentation center, nazarbayev university, astana, kazakhstan; 3institut gustave roussy, villejuif, france vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.96 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kulyyassov this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.96 | http://cajgh.pitt.edu abstract introduction: the spatiotemporal order plays an important role in cell functioning and is affected in many pathologies such as cancer and neurodegenerative diseases. one of the ultimate goals of molecular biology is reconstruction of the spatiotemporal structure of a living cell at the molecular level. this task includes determination of proximities between different molecular components in the cell and monitoring their timeand physiological state-dependent changes. in many cases, proximity between macromolecules arises due to their interactions; however, the contribution of dynamic self-organization in generation of spatiotemporal order is emerging as another viable possibility. specifically, in proteomics, this implies that the detection of protein-protein proximity is a more general task than gaining information about physical interactions between proteins, as it could detail aspects of spatial order in vivo that are challenging to reconstitute in binding experiments in vitro. methods: in this work, we have developed a method of monitoring protein-protein proximity in vivo. for this purpose, the bira was fused to one of the interaction partners, whereas the bap was modified to make the detection of its biotinylation possible by mass spectrometry. results: using several experimental systems, we showed that the biotinylation is interaction dependent. in addition, we demonstrated that bap domains with different primary amino acid structures and thus with different molecular weights can be used in the same experiment, providing the possibility of multiplexing. alternatively to the changes in primary amino acid structure, the stable isotope format can also be used, providing another way to perform multiplexing experiments. finally, we also demonstrated that our system could help to overcome another limitation of current methodologies to detect protein-protein proximity. for example, one can follow the state of a protein of interest at a defined time after its interaction with another protein has occurred. this application should be particularly useful for studying multistep intracellular processes, where the proximities between proteins and protein properties typically changed in a sequential manner. conclusion: this approach has promised in adding temporal dimension in addition to helping reconstruct cell topology in space. keywords: spaciotemporal structure, protein-protein proximity, spectometry http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx is the supercourse useful for latin america? is the supercourse useful for latin america? nicolas padilla-raygoza1, faina linkov2, eugene shubnikov3, ron e. laporte4, rosalina diaz-guerrero1 1departament of nursing and obstetrics, division of health sciences and engineering, campus celaya salvatierra, university of guanajuato; 2division of cancer prevention and population science, university of pittsburgh cancer institute; 3institute of internal medicine, novosibirsk, russian federation; 4department of epidemiology, graduate school of public health, university of pittsburgh cancer institute abstract background: the success of the supercourse showed that the effort was needed in latin america. but would a spanish language version be better for the region? methods: google analytics was used to determine website usage. a custom evaluation form was created to get user feedback on the usefulness of both the english language and spanish language supercouse lectures. results: over a year's span from june 2009 to june 2010 there were 257,403 unique visits and 448,939 page views. the overall average rating of lectures was 4.87 with the spanish language lectures getting even higher ratings. conclusion: supercourse lectures in spanish were a great success in latin america. this success shows the need for this information and similar success could be found in central asia. keywords: supercourse, education, latin america introduction the global health network supercourse project was launched in the late 1990’s to help with the difficult task of providing high quality teaching materials to instructors of the world who wanted to teach about global health and prevention (www.pitt.edu/~super1). the supercourse group argued that cooperation in higher health education was needed to prevent duplicate efforts and a waste of resources.1 in addition, it has been found that the vast majority of the materials used in classes were at least 5 years old, which is far behind the fast pace of science. thus, the supercourse was developed in order to speed up the translation of research information from labs to classrooms. this initiative was originally supported by nasa and the national institutes of health and it had great success, reaching 174 countries of the world. in the mid 2000’s the supercourse effort started to spread to the countries of central asia as well as mexico. as these efforts spread in these two very different geographic areas, we found that the challenges were surprisingly similar: a lack of english skills among local faculty members, a lack of time, and simply low awareness about this global effort. thus, we view the development of the supercourse in mexico and central asia as sister efforts. the supercourse model empowers public health teachers worldwide by offering more than 4700 high quality lectures free of charge, distributing them through the internet and via dvds, with the invitation to join and expand the network. one of the main goals of the supercourse is to help professors and instructors diminish the time spent developing a lecture for his or her class through the availability of the slides of lectures in the supercourse.2 thus, a teacher could use 5 slides from an expert in cancer, 10 from an expert in diabetes, and 8 of their own. the “recycling” of slides markedly improves the quality of lectures, as the slides come from the world’s experts, as well as the efficiency, as one does not have to make slides and lectures from scratch. moreover, as the majority of the slides are developed in leading academic institutions, they are quite up to date. the supercourse remains a very active and highly visited website today. in the first step of project development, the supercourse team established a network of collaborators, then began to collect lectures from recognized authors from the university of pittsburgh. little by little, it grew until it reached approximately 50,000 faculty members in 174 countries, with nobel prize laureates in medicine donating several lectures to the supercourse.3 through collaboration with the network of scientists in mexico, the supercourse website and its materials became accessible to spanish speaking faculty members. under the direction of nicolas padilla, a new version of the supercourse has successfully been built: the latin american supercourse (www.feoc.ugto.mx/super/curso.php). the initial success of the supercourse was demonstrated by the number of daily site hits and the search tools in google®, where the lectures from the supercourse are in the first ten among millions of results, and at one point receiving recognition as one of the top webpages in the area of health by pcmagazine as well as science magazine.3 eight years ago, the school of nursing and obstetrics of celaya, from the university of guanajuato, mexico, began to translate some lectures from english to spanish in order to overcome the language barrier and to ensure that global health knowledge reaches more health professionals in spanish speaking countries, including those of latin america. health professionals in latin american countries have little or no access to continuing education materials in the field of public health because of high costs, the need to travel, a lack of english language skills, etc. this is especially true when it comes to obtaining training in global health and prevention, as medical schools traditionally focus on clinical work. the supercourse and the latin american supercourse overcome this difficulty because materials are updated and offered via the internet free of charge. the supercourse uses low bandwidth technology, allowing for easy access in regions with slow or expensive internet connections. because of the growing interest in spanish language content, the next logical step was to launch the latin american supercourse on epidemiology, internet and global health on may 3th, 2007.4 lectures chosen for translation into spanish were those that were identified to be the most valuable for spanish speaking faculty members in celaya, mexico. the goal of this paper is to report the progress of the development of the latin american supercourse and to explore preliminary data about its usage. it is our belief that our findings will have very interesting implications for the countries of central asia and that our study can encourage the development of similar assessments in the region. methods website utilization: google analytics google analytics (ga) has been used to collect basic information about the utilization of the supercourse website in terms of number of visits per country, per language, etc. ga is a free service offered by google that generates detailed statistics about the visitors to a website. ga is currently in use at around 57% of the 10,000 most popular websites. ga can track visitors from all referrers, including search engines, display advertising, pay-per-click networks, email marketing, and digital collateral such as links within pdf documents. lecture evaluation: lecture review form the lecture review forms utilized in this effort (see figure 1) have the following questions: name, position, organization, e-mail address, have you ever taught an introductory epidemiology course (yes or no), rate the lecture on content, presentation, relevance, and overall rating (the rating scale for these last four items: 5 = excellent, 4 = above average, 3 = average, 2 = below average, 1 = poor). in may 2004, dr. songer suggested that an “expectation” rating of the lecture may provide many important insights into quality measurement for the supercourse. in august 2004, an additional question was added to all of the supercourse peer review forms: “how does the quality of the lecture compare with your expectations about it?” (the rating scale for this item also utilizes likert scales: 5 = well above what i expected, 4 = above what i expected, 3 = same as expected, 2 = somewhat below what i expected, 1 = well below what i expected.) figure 1: lecture review form, supercourse project results using google analytics® from june 10th, 2009 to june 10th, 2010, there were 257,403 unique visits to the main webpage of the supercourse, with 448,939 page views. this means that on average, a visitor accessed 1.74 lectures. table i demonstrates the number of visits to the supercourse webpage from 212 countries/territories; the visits were mainly from united states of america, india, and united kingdom. it is interesting to point out that the biostatistics course by nicolas padilla, lecture #15 on correlation, is the 5th most visited lecture in the supercourse as of october 2010. table i: visits to supercourse webpage by country/territory country n % united states 110,299 42.8 india 14,875 5.8 united kingdom 13,595 5.3 canada 10,845 4.2 australia 6,470 2.5 phillipines 4,781 1.9 malaysia 3,937 1.5 pakistan 3,568 1.4 mexico 3,305 1.3 egypt 3,224 1.3 other 82,504 32.0 total 257,403 100.00 table ii presents the number of accesses of the supercourse webpage by countries and languages. it is important to point out that most popular languages were english and spanish. the number of visits is a very low estimate of the usage of the supercourse, as these numbers include visits only to the main server in pittsburgh. due to technical limitations, it is not possible to assess the number of visits to the mirror server sites, the number of lectures downloaded in powerpoint format, and the number of lectures presented in front of classrooms. table ii: languages of lectures from the supercourse webpage language country n % english united states of america 206,348 80.2 spanish latin american countries 7,133 2.8 english great britain 6,602 2.6 english other countries 4,267 1.7 chinese taiwan 2,934 1.1 chinese china 2,782 1.1 french france 2,610 1.0 german germany 2,412 0.9 spanish spain 2,344 0.9 russian russia 2,207 0.9 other other 17,764 6.8 total 257,403 100.0 lecture evaluations filled out in spanish can be used as a surrogate measure of interest of spanish language speakers in certain areas. based on this assessment, it appears that the ten most interesting topics to latin american faculty members include: addictions, diabetes, global warming, disasters and just-in-time lectures, statistics, nursing, infectious diseases, epidemiology, public health, and cancer. this appears to be somewhat similar to the interest of english language faculty members, who are also interested in just-in-time lectures, cancer, and statistics, while the difference between these groups is that english speaking faculty members appeared to be less interested in infectious disease. for the 3,233 evaluations we obtained, content had a mean score of 4.82±0.61, relevance had a mean score of 4.84±0.55, and presentation had a mean score of 4.78±0.69, with the overall average rating being 4.87±0.47 and the expected quality average rating being 4.80±0.58. clearly the lectures are most appreciated. the mean scores for lectures translated into spanish were at least 0.5 points higher than scores for the main supercourse lectures in english. the latin american supercourse was divided into areas (see table iii) to make searching easier. in three years, the supercourse had almost 30,000 webpage accesses to the front page alone, and the latin american supercourse database had faculty members from almost all latin american countries. each month, members of the network received a newsletter from the latin american supercourse with news about new lectures, changes in the lecture of the week, or updates about new important lectures, such as those for influenza a (h1n1) or hurricanes.5,6 these messages were regularly sent to over one thousand of e-mails contacts from the supercourse latin american network. table iii: areas of concentration for latin american supercourse and numbers of lectures available in these areas area number of lectures by year total 2007-2008 2009 2010 o t o t o t o t addictions 6 9 2 0 1 0 9 9 cancer 0 11 0 1 0 0 0 12 global warming 1 2 1 0 0 0 2 2 disasters 0 15 0 2 0 0 0 17 diabetes 2 3 0 0 0 0 2 3 cardiovascular diseases 10 3 0 1 0 0 10 4 infectious diseases 5 10 1 0 0 0 6 10 nursing 104 0 4 2 0 0 108 2 statistics 0 8 16 0 0 1 16 9 epidemiology 1 81 2 1 0 1 3 83 nutrition and obesity 0 8 0 4 0 0 0 12 global health 3 11 2 3 0 0 5 14 maternal and childhood health 5 62 0 0 5 0 10 62 public health 9 15 2 0 0 0 11 15 supercourse,internet, and technology 11 27 0 1 0 2 11 30 just in time 0 25 0 1 0 3 0 29 total 157 290 30 16 6 7 193 313 conclusions large numbers of public health instructors, especially spanish speaking instructors, are using the supercourse lectures as a source of information from the world’s leaders in public health and medicine. the efforts of the supercourse and the latin american supercourse teams are giving “fruit” in the form of better, up to date education for public health professionals. the selection of translated lectures in the latin american supercourse potentially represents gaps in the existing materials available to mexican faculty members, such as biostatistics, infectious disease epidemiology, and just-in-time knowledge on disasters. the challenges involved in the development of the latin american supercourse include identifying collaborators and identifying a supporting mechanism for sustainable development of this effort. another big challenge is that many faculty members of the latin american based institutions do not have the websites of their schools available on the internet, and thus they are difficult to find for initial contact. additionally, many faculty in latin american countries do not speak english, making international collaboration hard to initiate. as we mentioned in our introduction, similar challenges have been found in central asia. the parent supercourse and the supercourse translations into spanish are having a great impact on health professionals from latin american countries, demonstrated by the number of webpage accesses and page views. interest in the spanish language supercourse is also demonstrated by evaluations, which are scored even higher than english language supercourse lectures. it is likely that the latin american supercourse lectures are teaching more students about global health and prevention than any other lectures, especially in latin american countries. the latin american supercourse will also continue to work on developing advanced quality control methodologies, building on the existing publications in this area.7-11 expansion of the latin american supercourse is an important and much needed effort. since the situations in latin america and central asia are similar, we would argue that it would be important to develop more efforts into getting the supercourse translated into russian and the other languages utilized in central asia. the popularity and high ratings of the translated lectures show that this information is desired but unavailable to those who do not speak english. these translation efforts would greatly improve the reach of public health information in the region and globally. references 1. the supercourse faculty. global cooperation in higher education: supercourse. n nat med. 2000; 6(4): pp. 358. 2. laporte r. red de salud global [spanish]. supercourse 2007 january 8. accessed 2010 june 4. http://www.pitt.edu/~super1/lecture/lec28191/index.htm 3. supercourse on epidemiology, internet and global health 2010. accessed 2010 june 1. http://www.pitt.edu/~super1/~super1/index.htm 4. latin american supercourse on epidemiology, internet and global health. accessed 2010 june 4. http://www.feoc.ugto.mx/super/curso.php 5. chotani r. just-in-time lecture. influenza pandemic a(h1n1)(swine flu). latin american supercourse; 2009 december. accessed 2010 june 24. http://www.feoc.ugto.mx/super/jit/j0025/1.htm 6. ardalan a, laporte r, shubnikov e, linkov f, russel m, noji e. hurricanes. latin american supercourse; 2008. accessed 2010 june 24. http://www.feoc.ugto.mx/super/jit/j0006/1.htm 7. linkov f, laporte r, lovalekar m, dodani s. web quality control for lectures: supercourse and amazon.com. croat med j. 2005;46(6):875-8. 8. linkov f, lovalekar m, laporte r. scientific journals are "faith based": is there science behind peer review? j r soc med. 2006;99(12):596-8. 9. linkov f, lovalekar m, laporte r. quality control of epidemiological lectures online: scientific evaluation of peer review. croat med j. 2007;48(2):249-55. 10. linkov f, omenn gs, serageldin i, cerf v, lovalekar m, laporte r. multilayer and multimetric quality control: the supercourse. j cancer educ. 2010. 11. linkov f, shubnikov e, husseini as, lovalekar m, laporte r. globalisation of prevention education: a golden lecture. lancet. 2003;362(9395):1586-7. pre-conception preparation at the antiphospholipid syndrome as way to improve reproductive health new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. pre-conception preparation at the antiphospholipid syndrome as way to improve reproductive health gulyash tanysheva, saule kabylova, sholpan kinayatova, aizat zhumazhanova semey state medical university, semey, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.104 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ tanysheva this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.104 | http://cajgh.pitt.edu abstract introduction: reproductive health is characterized by the condition of the woman in association with the course of pregnancy and childbirth. in this case, the absence of disease plays a fundamental role. unfortunately, conditions that can negatively impact reproductive health and cause deterioration of pregnancy and delivery outcomes are frequent in women of reproductive age. antiphospholipid syndrome (aps) is one of the leading conditions that can negatively affect reproductive health and lead to various complications in pregnancy including fetal loss. materials and methods: we assessed the effectiveness of pre-conception preparing, including traditional therapy of aps in conjunction with system enzyme therapy (set) and plasmapheresis sessions. we conducted a study in two groups: women with aps and pre-conception preparing (n = 49) and the control group were women without pre-conception preparing (n = 46). results: the effect of pre-conception preparing in women with aps was assessed by the course and outcome of pregnancy. the total number of women with complications of pregnancy were 39.1% lower in the study group compared to the control group. risk of miscarriage in the basic group observed 68.7 % less frequently compared to the control group. the frequency of preeclampsia was 63.5 % less in the study group compared to the control group. we observed significantly lower rates of placental insufficiency in the study group and the difference in this parameter reached 65.2%. the risk of pre-term birth was 59.4 % lower in the study group compared to the control group. conclusion: we concluded that pre-conception preparing in women with aps increases the possibility of physiological course pregnancy. pre-conception preparing reduces the incidence of miscarriage, pre-term labor, and the development of pre-eclampsia, and placental insufficiency. keywords: antiphospholipid syndrome, pre-conception http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cardiovascular risk factors in young male adults: impact of physical activity and parental education cardiovascular risk factors in young male adults: impact of physical activity and parental education serap çuhadar1, ayşenur atay1, gülcan sağlam1, mehmet köseoğlu1, levent çuhadar2 1ataturk training and research hospital, department of clinical biochemistry, izmir, turkey; 2ataturk training and research hospital, department of general surgery, izmir, turkey abstract background: this study was conducted to assess whether choices of physical activity, smoking status, and parental education and income were correlated with the health status of young adult males which are important for preventive health policy. methods: 491 18-29-year old males from lower socioeconomical districts in turkey participated in this study. information about demographic characteristics, parental education, household income, smoking status, and physical activity was obtained by means of a standardized questionnaire. bmi and metabolic parameters (serum lipid profile) were assessed. results: mean total cholesterol, ldl, hdl and triglyceride levels were in the normal range. the physically active group displayed a better lipid profile. no relationship was found between parental education and serum lipids. smoking was slightly correlated with household income (r=103, p=0.022). conclusion: young adult males who participate in relatively high levels of physical activity are at lower chd risk than less active ones. the present study also showed that lower socioecnomic status does not always correlate with higher levels of cardiovascular risk factors. in conclusion, data supports that while family history cannot be changed, hdl levels can be modulated by lifestyle factors as in other populations and that with the determined benefits of increasing physical activity and thus, hdl levels, policy reform in schools to promote physical activity are warranted. keywords: educational status, lipoproteins, physical education and training, smoking, social class, turkey. research introduction mortality rates from coronary heart disease (chd), which rose during the twentieth century, started declining in most industrialized regions such as in united states and in europe during the 1960s because of preventive studies.1-4 in turkey,5 the prevalence of chd is higher than in the us and europe. as a developing country, rapid lifestyle changes (fast food, obesity, physical inactivity), lower socieconomic status (ses), and high smoking prevalence are major factors in the development of chd. notably, turks have low levels of hdl (10-15 mg/dl lower than in europeans and north americans)6 which appear to have genetic origin.7,8 however, though genetically determined to a significant extent, these low hdl levels can be modulated by lifestyle factors, as in other populations. cardiovascular diseases typically occur in middle age or later, however lifestyle behaviors are learned in early life and maintained throughout adulthood.9,10 physical activity levels and dietary habits are important health related factors that, learned in early ages, are screening tools to identify young subjects at risk for later chd development.11 reports have shown that excess weight and sedentary lifestyle among young adults are associated with high prevalence of cardiovascular risk.12 low parental education has been shown to contribute to an individual’s risk for chd development.13 in the current study, analyses were conducted to assess whether choices of physical activity, smoking status, and parental education and income were correlated with the health status of young adult males, which are important for preventive health policy. materials and methods study design this study consisted of 491 healthy male volunteers between the ages of 18 and 29. the study group was from different regions of turkey whose families are mostly immigrants from lower ses parts of the country. the participants were recruits for the police academy and were attending our hospital for health reports. the blood samples collected during routine check up were used for this studyno additional sample was taken. the procedures were in accordance with the guidelines of the helsinki declaration of human experimentation. all participants provided written informed consent. the study was conducted between march and september 2011. blood samples were taken and information on smoking habits, physical activity, family income, and parental education were collected by trained staff using a self-administered questionnaire. body mass index (bmi) was calculated as weight (kg)/height (m2). height was measured to within 0.5 cm and weight to within 0.1 kg. measurements after an overnight fast, blood samples were obtained to measure levels of triglycerides (tg), total cholesterol (tc) and high-density lipoprotein cholesterol (hdl). serum lipids were measured on the abbott architect analyzer (abbott, wiesbaden, germany). concentration of low-density lipoprotein cholesterol (ldl-c) was calculated using the friedewald formula14 ([ldl-chol]=[total chol] [hdl-chol] ([tg]/2.2) where all concentrations are given in mmol/l. coefficients of variation for the measured serum lipids were <3.3% (bio-rad laboratories, milano, italy). information on smoking habits, physical activity and parental education was collected from the questionnaire. age was calculated based on date of birth from hospital data. the questionnaire contained the school-based and extracurricular physical activity questions used in the present analysis. participants who perform moderate to vigorous physical activity 3 or more times per week for 60 min or above, minimum duration of 1 year, were classified as active. remaining participants were classified as inactive. in the questionnaire, current smoking status was considered to be smokers (current or past smoking), and non-smokers (never smoked). household income, paternal and maternal education were used as indicators of ses. household income was assessed by total montly income for a family unit living together. income was classified into three groups: low: ≤ $500/month, middle: $500-1,000, high: >$1,000. parental education level was classified into three groups: low(1): none + elementary school; intermediate(2): middle + high school; and high(3): college + university. the education levels of the study group were high school and college or university graduate, therefore, the education level of the participants was not considered useful for the purposes of this study. statistical analyses risk factors were analyzed as continuous variables including age, bmi, total cholesterol, ldl, hdl, triglycerides, and the ratio of tc to hdl. household income, parental education, smoking, and physical activity were analyzed as categorical variables. we used an independent samples t-test for comparison of quantitative variables. for qualitative variables, cross-tabulation and x2 tests were used. a p value <0.05 (two-tailed) was considered significant. normality of quantitative variables was verified by kolmogorov-smirnov test. qualitative variables were expressed as a percentage with a confidence interval of 95%. pearson and spearman correlation coefficients were used as appropriate. analysis of covariance (mancova) analysis was used; age, bmi, smoking were included as covariates if needed. all statistical analyses were conducted with spss, version 15.0 (spss inc., chicago, il, usa). results demographic and biochemical characteristics of the participants are presented in table 1. table 1: demographic and biochemical characteristics of study participants. variable males n=491 mean age (range)* 21(18-29) body mass index (sd, kg/m2)† 23.3(2.24) bmi >25 25.3% mean age (range)* 21(18-29) total cholesterol (sd, mmol/l) 3.94(0.75) hdl-cholesterol (sd, mmol/l) 1.20(0.25) ldl-cholesterol (sd, mmol/l) 2.28(0.65) triglycerides (range, mmol/l)* 0.87(0.23-4.09) total cholesterol/hdl (sd) cholesterol ratio 3.5(1.0) cigarette smoking (%)‡ 25.1 physically inactive (%) 18.7 paternal education (%) lower 39.3 medium 22.6 higher 38.1 maternal education (%) lower 76.8 medium 14.5 higher 8.8 household income (%)§ lower 47.5 intermediate 40.3 higher 12.2 abbreviations: hdl, high density lipoprotein; ldl, low density lipoprotein. values are means±standard deviation or percentages. means were compared by t-test, and percentages were analyzed by x2-test.statistically significant p values are marked in bold. * median(min-max) values for non-gaussian distributions † weight (kg)/height (m)2 ‡one or more cigarettes per day §according to turkish statistical institude during september 2011 the average turkish net income was €790. 25.3% of the subjects (only 2 of them were obese) were overweight (bmi>25) according to the definition by world health organization.15 no associations were found between serum lipids, bmi and parental education. the comparisons of physical activity and other risk factors are presented in table 2. table 2. analysis of covariance assessing the effects of physical activity using lipids as dependent variables, physically activation group as fixed factors, and age as a covariate (mancova). tc/hdl-c between groups were determined by independent samples t-test. physically inactive (n=91) physically active (n=399) f p total cholesterol (mmol/l) 4.07(3.92-4.22) 3.91(3.85-3.98) 3.57 0.059 triglyceride (mmol/l)* 1.05(0.95-1.16) 0.89(0.84-1.08) 9.11 0.003** hdl-cholesterol (mmol/l) 1.10(1.05-1.15) 1.22(1.19-1.24) 16.13 0.000** ldl-cholesterol (mmol/l) 2.44(2.32-2.57) 2.24(2.18-2.30) 7.92 0.005** total cholesterol/hdlcholesterol 4.20(±1.32) 3.27(±0.86) 44.47 0.000** values of lipids are means with 95% confidence intervals in parenthesis and the ratio data are mean ± sd. *data on triglycerides log10 transformed before analysis and untransformed mean values were reported here. **p<0.05 in physically active adult group, a better lipid profile was determined (table 2). subjects’ smoking was not related to parental education, physical activity, bmi or age. a statistically significant but weak correlation was found only between with smoking and income (r=.103*, p=0.022*) (spearman). lower hdl levels were found in subjects that cigarette smoking than non-smoking (table 3). table 3: analysis of covariance assessing the effects of smoking using lipids as dependent variables, smoking as fixed factors, and age, bmi as covariates. (mancova). smoking (n=123) non-smoking (n=367) f p total cholesterol (mmol/l) 3.91(3.79-4.03) 3.95(3.88-4.02) 0.29 0.591 triglyceride (mmol/l)* 0.96(0.86-1.06) 0.90(0.86-0.96) 0.53 0.466 hdl-cholesterol (mmol/l) 1.16(1.11-1.20) 1.21(1.18-1.23) 4.42 0.036** ldl-cholesterol (mmol/l) 2.28(2.17-2.38) 2.28(2.22-2.34) 0.00 0.982 ** p<0.05 discussion we observed a better lipid profile among turkish young adults than the turkish heart study16 within the same age group, as we demonstrated a higher mean concentration of hdl cholesterol (9.2 mg/dl higher). for these educated young adults, low parental education caused no impact on their health status. obesity and overweightness are important problems in industrialized countries. in greece,17 40% of male young medical students are overweight (bmi>25.0 kg/m2). according to a study,18 a higher rate of obesity was established in a turkish population relative to european countries. in the present study, the mean bmi was calculated as 23.3 kg/m2. bmi of the adults is thought to be influenced by environmental factors related to parental education as well as by genetic factors. in studies,19,20 bmi was found to be related to the parental education, however in the current study no relationship was found between. it is recommended that school-age youth had to participate in physical activitiy approximately 60 min/day or more and had to reduce sedentary behaviours to < 2 hours per day for health promotion.21 previous studies22-24 of the turkish young population suggested rather high incidence of sedentary lifestyle and relatively low levels of occupational physical activity. because the participants of this study were among the recruits for the police academy, the rate of the sports activity was very high (81.3%) which may have introduced some selection bias, resulting in participants being healthier. cigarette smoking influences cardiovascular system because of carbon monooxide and nicotine leading to a reduction in myocardial o2 intake.25 although smoking is associated with low hdl, it did not account for the markedly low levels of hdl in turks.6,16 regarding smoking status of participants, a lower rate of smoking rate was found compared to previous studies.25-27 paavola et al.28 considered that, smoking status between the ages of 13-28 was not related to parental education, occupation, or income. in this study, smoking prevalence showed no relationship between parental education. however, others concluded that, parental education and participants’ own education were the strongly related factors affecting their own smoking.29 in populations at high risk for chd caused by low hdl, the tc/hdl ratio predicts chd risk regardless of absolute ldl and hdl.30 in the current study, with a population in low household income, the ratio was found as 3.5, where it was found as 4 among turks with similar income.6 in contrast to a study,16 we observed that higher salary was associated with lower hdl. this may be due to unhealthy dietary habits as it was showed in several studies among turks.12,23 one limitation of this study is that the participants’ duration and intensity of physical activity were evaluated according to their self reports in the questionnaire. however, in randomized or nonrandomized studies,21 supervised programs are used for the evaluation of physical activities, generally. another limitation is that the recruits for the police academy are usually more prone to physical activity compared with the same age group. therefore this study group does not reflect their age-matched counterparts’ lifestyle and lipid profile, however, we had a chance to compare the physically active young group with sedentary ones. in conclusion, parental education has a lesser effect on the educated young adults’ health statuses. because hdl levels and physical activity rates were higher than in previous studies, we recommend a need to reform public health policies, especially in regards to physical activity programs because of the determined benefits. references 1. ford es, capewell s. proportion of the decline in cardiovascular mortality disease due to prevention versus treatment: public health versus clinical care. annu rev public health. 2011;32:5-22. 2. young f, capewell s, ford es, critchley ja. coronary mortality declines in the u.s. between 1980 and 2000 quantifying the contributions from primary and secondary prevention. am j of prev med. 2010;39:228-34. 3. unal b, critchley ja, capewell s. explaining the decline in coronary heart disease mortality in england and wales between 1981 and 2000. circulation. 2004;109:1101-7. 4. bots ml, grobbee de. decline of coronary heart disease mortality in the netherlands from 1978 to 1985: contribution of medical care and changes over time in presence of major cardiovascular risk factors. j cardiovasc risk. 1996;3:271-6. 5. onat a. risk factors and cardiovascular disease in turkey. atherosclerosis 2001;156:1-10. 6. mahley rw, can s, ozbayrakçi s, et al. modulation of high-density lipoproteins in a population in istanbul, turkey, with low levels of high-density lipoproteins. am j cardiol 2005;96:547-55. 7. lüttmann s, von eckardstein a, wei w, et al. electrophoretic screening for genetic variation in apolipoprotein c-iii: identification of a novel apoc-iii variant, apoc-iii(asp45➝asn), in a turkish patient. j lipid res. 1994;35: 1431-40. 8. bersot tp, vega gl, grundy sm, et al. elevated hepatic lipase activity and low levels of high density lipoprotein in a normotriglyceridemic, nonobese turkish population. j lipid res. 1999;40:432-8. 9. nicklas ta, webber ls, berenson gs. studies of consistency of dietary intake during the first four years of life in a prospective analysis: bogalusa heart study. j am coll nutr. 1991;10 :234-41. 10. eriksson jg, forsén t, tuomilehto j, et al. early growth and coronary heart disease in later life: longitudinal study. bmj. 2001;322:949-53. 11. farajian p, renti e, manios y. obesity indices in relation to cardiovascular disease risk factors among young adult female students. br j nutr 2008;9:918-924. 12. mahley rw, arslan p, pekcan g, et al. plasma lipids in turkish children: impact of puberty, socioeconomic status, and nutrition on plasma cholesterol and hdl. j lipid res. 2001;42:1996-2006. 13. leino m, raitakari ot, porkka kv, et al. associations of education with cardiovascular risk factors in young adults: the cardiovascular risk in young finns study. int j epidemiol. 1999;28:667-75. 14. friedewald w, levy r, fredrickson d. estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. clin chem. 1972;18: 499-502. 15. obesity: preventing and managing the global epidemic. report of a who consultion on obesity, geneva, world health organization,2003. 16. mahley rw, palaoğlu ke, atak z, et al. turkish heart study: lipids, lipoproteins, and apolipoproteins. j lipid res. 1995;36:839-59. 17. bertsias g, mammas i, linardakis m, kafatos a. overweight and obesity in relation to cardiovascular disease risk factors among medical students in crete, greece. bmc public health 2003;3:3. 18. iseri a, arslan n. obesity in adults in turkey: age and regional effects. eur j public health 2009;19:91-4. 19. burke gl, jacobs dr jr, sprafka jm, et al. obesity and overweight in young adults: the cardia study. prev med 1990;19:476-88. 20. gonzalez a, boyle mh, georgiades k, et al. childhood and family influences on body mass index in early adulthood: findings from the ontario child health study. bmc public health. 2012; 12: 755. 21. strong wb, malina rm, blimkie cj, et al. evidence based physical activity for school-age youth. j pediatr 2005; 146(6):732-7. 22. uçar b, kiliç z, colak o, et al. coronary risk factors in turkish schoolchildren: randomized cross-sectional study. pediatr int 2000;42:259-67. 23. manios y, dimitriou m, moschonis g, et al. cardiovascular disease risk factors among children of different socioeconomic status in istanbul, turkey: directions for public health and nutrition policy. lipids health dis 2004;3:11. 24. daskapan a, tuzun eh, eker h. perceived barriers to physical activity in university students. j sports sci med 2006;5:615-20. available from: http://www.jssm.org. 25. yıldız l, kılıç h. the clinical and biochemical effects of cigarette smoking. j med sci 2000;20:306-12. 26. van oort fv, van der ende j, crijnen aa, et al. determinants of daily smoking in turkish young adults in the netherlands. bmc pub health. 2006;6:294. 27. ertas n. factors associated with stages of cigarette smoking among turkish youth. eur j public health 2006;17:155-61. 28. paavola m, vartiainen e, haukkala a. smoking from adolescence to adulthood: the effects of parental and own socioeconomic status. eur j public health 2004;14:417-21. 29. kestila l, koskinen s, martelin t, rahkonen o. influence of parental education, childhood adversities, and current living conditions on daily smoking in early adulthood. eur j public health 2006;16(6):617-626. 30. bersot tp, pépin gm, mahley rw. risk determination of dyslipidemia in populations characterized by low levels of high-density lipoprotein cholesterol. am heart j. 2003;146:1052-9. concurrent brucellosis and q fever infection: a case control study in bamyan province, afghanistan new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. concurrent brucellosis and q fever infection: a case control study in bamyan province, afghanistan khwaja mir islam saeed1, jamalludin ahadi1, mohammad nadir sahak2, ahmad farid ghiasi2, rana jawad ashgar3 1afghanistan national public health institute, ministry of public health, kabul, afghanistan; 2world health organization, kabul, afghanistan; 3national institute of health, islamabad, pakistan vol. 2, no. 2 (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu abstract background: more than 500,000 people are affected by brucellosis each year while the incidence of q fever is poorly recorded. consistent outbreaks of brucellosis have been reported in afghanistan, affecting social and economic life. this study aimed to determine the means of propagation of brucellosis and q-fever and establish appropriate control measures for both. methods and materials: an outbreak of 1,317 cases of brucellosis and q fever was investigated from may 2011 to the end of 2012 in bamyan province of afghanistan. a total of 100 cases were selected by random sampling with equal number of neighbor controls. data were collected through structured questionnaire. results: the average age was 30 years ±14 years. of those sampled, 62% were female, 38% were male, and resided in three districts: punjab, yakawlang and waras. using multivariate analysis, being a housewife (or=7.36), being within proximity of kitchens to barns (or= 2.98), drinking un-boiled milk (or= 5.26), butchering (or= 3.53) and purchasing new animals in the last six months (or= 3.53) were significantly associated with contraction of brucellosis and q fever. conclusion: health educators should focus on families dealing with animals, especially on females. pasturing, healthy milking, dunging, and slaughtering practices, along with use of safe dairy products should be the focus of preventive measures. keywords:brucellosis, q fever, afghanistan, zoonoses concurrent brucellosis and q fever infection: a case control study in bamyan province, afghanistan khwaja mir islam saeed1, jamalludin ahadi1, mohammad nadir sahak2, ahmad farid ghiasi2, rana jawad ashgar3 1ministry of public health, kabul, afghanistan; 2world health organization, kabul, afghanistan; 3national institute of health, islamabad, pakistan research introduction brucellosis is caused by bacteria of the genus brucella; species considered important agents for human disease are b. melitensis, b. abortus and b.suis. 1 it is an old disease with minimal mortality and remains the most common zoonotic disease worldwide. 2 the incubation period for brucellosis is variable and difficult to ascertain; however, it is usually 5-60 days and occasionally several months after exposure. 3 the world health organization (who) estimates that 500,000 brucellosis cases occur each year worldwide, 45,000 of which occur in the eastern mediterranean region. for every case diagnosed, there are four cases that go undetected. 4 brucellosis is a major public and animal health problem in many regions of the world, particularly where livestock are a major source of food and income. despite control programs, it remains endemic in most developing countries. 5 the who considers brucellosis to be a neglected zoonosis because, despite its widespread distribution and effects on multiple species, it is not prioritized by national and international health systems. 6 human cases continue to occur following traditional use of raw milk products and close contact with infected animals. central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu according to a case-control study in saudi arabia, the consumption of unpasteurized dairy products derived from sheep and goats as well as assistance in animal parturition were greatly associated with brucellosis. 8 in a similar study in yemen, being a farmer, shepherd, or microbiologist, and drinking fresh milk and buttermilk were significantly associated with brucellosis. socio-economic and educational factors were also independent risk factors. 9 in iran, the same type of study revealed that significant risk factors for infection were related to the existence of another case of brucellosis in the home and consumption of unpasteurized dairy products. 10 investigations carried out in africa support these findings. risk factors, such as assisting parturition during abortion and living in close proximity to other households affected with brucellosis, were identified. 11 another study, which was conducted to identify the potential risk factors for human brucellosis infection in samarqand, uzbekistan showed that brucellosis was highly associated with contact with aborted animals, slaughtering/butchering animals in the household, consumption of raw milk, and being in a family that had brucellosis sharing the same exposure. 13 in a study from kyrgyzstan, results of multivariate analysis indicated that brucellosis was associated with exposure to aborted farm animals in the household and consumption of home-made milk products obtained from bazaars or neighbors. knowledge of the mode of brucellosis transmission appeared to be protective against disease transmission. 14 alongside other endemic communicable diseases, query fever (q-fever) is also common in developing countries. q fever is caused by the bacteria coxiellaburnetii and can affect the lungs, liver, heart, and other parts of the body. it is found around the world and affects sheep, goats, cattle, dogs, cats, birds, rodents, and several other types of animals. infected animals shed these bacteria in birth products, feces, milk, and urine. humans usually contract q fever by breathing in contaminated droplets released by infected animals. drinking raw milk has also caused infection in rare cases. people at highest risk for this infection are farmers, laboratory workers, sheep and dairy workers, and veterinarians. 15 initially described in australia in 1937, it is prevalent in southern france and spain and is the second most common cause of community-acquired pneumonia, causing 5-8% of the endocarditis cases. infected dairy goat farms are believed to be the source of the outbreak among humans. 16 few studies have been conducted in afghanistan regarding the prevalence and risk factors of communicable diseases. brucellosis has been counted among the endemic diseases in afghanistan. 17 in a global incidence report, afghanistan is categorized in the group of 2-8/1,000,000; 18 whereas according to a oie (world organization for animal health) report in 2005, the incidence of brucellosis was 3.8 per millionin country. 19 moreover, outbreaks of brucellosis have consistently been detected and investigated in bamyan province, especially punjab district. in august 2007 in punjab district of bamyan province, 35 cases were detected. five samples were collected, and 3 were positive for brucellosis. in september 2007 in punjab district of bamyan province, 43 cases were detected, 10 samples were collected, and 8 samples were positive. in june 2008 in punjab district of bamyan province, 10 cases were detected, 4 samples were collected, and all were positive for brucellosis. 20 however, data regarding the burden of q-fever are not published in afghanistan, but extrapolation of the incidence rate for q fever is estimated at 38 per 1,000,000 nationally. 21 a report from a hospital in the uk shows that some members of the army who came back from afghanistan were diagnosed with q-fever. 22 it is confirmed by another report from the us army, which found that after the deployment of thousands of american troops in afghanistan since 2001, some common and chronic infections have persisted, including q fever, brucellosis, and parasitic infections. 23 saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu the co-infection of both brucellosis and qfever is poorly recorded in the literature. the aim of this study is to investigate the outbreak and determine the risk factors associated with brucellosis and q-fever acquisition in the central province of bamyan and to provide recommendations for control of brucellosis in bamyan province. methods and materials study area on may 29 th , 2011, the mobile health unit and district health officer at yakawlang district reported the suspected outbreak of brucellosis to the provincial public health directorate in bamyan province. the outbreak was in the border area between two districts of yakawlang and punjab, separated by only a hilly mountain. the residents of these districts are primarily livestock keepers who practice traditional pastoralism and follow a semi-nomadic lifestyle. a team consisting of an epidemiologist, a medical doctor, a veterinarian, and a laboratory technician was dispatched to the area. cases definitions and blood sampling operational case definition was developed prior to data collection. those who had recurrent or continuous fever, joint pain/swelling, and general body malaise or backache in the area were considered to be suspected cases while those who exhibited the above symptoms and had contact with animals were thought as probable cases. finally, those suspected and/or probable cases that were verified by laboratory testing (rose bengal test) were considered to be confirmed cases. initially in june 2011, a total of 147 subjects were line listed; blood was sampled and tested for brucellosis from 39 suspected cases at the district level. twentyeight samples were shared with the food and agriculture organization supported laboratory at the ministry of agriculture, irrigation and livestock (mail) to test for brucellosis and q-fever. study design as part of the outbreak investigation, a case control study was conducted to identify the associated factors for brucellosis and q-fever in order to formulate health education and preventive measures. cases were defined as those showing at least two of the following clinical features: recurrent or continuous fever, sweating, joint pain, joint swelling, general body malaise, or backache. a total of 100 cases were identified. for every case, a control was selected randomly, irrespective of exposure from neighbors. cases were given appropriate treatment and referred to hospital if necessary. health education sessions were conducted during investigation and cases were managed clinically at the district hospital. data collection and analysis a questionnaire asking for demographics and risk factors was developed by research team and used to collect data from both cases and controls. data collection was completed in july 2011 and was entered in epi info 3.5.3. after cleaning, the data was analyzed using ibm statistical package for the social sciences (spss) statistical software version 20. 24 data were analyzed by time, person and place along with clinical information. logistic regression analysis was used to analyze the data at univariate and multivariable levels. results descriptive analysis: all age groups within the population were affected by the infection; however, those who were 15 to 30 years of age were most commonly affected compared to the other age groups. of 39 blood samples central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu collected initially and tested using the rose bengal test at the local level, 59% (n=23) of the samples from punjab district hospital and 16 samples from yakawlang district hospital tested positive for brucellosis. of the 28 samples, which were tested in the ministry of agriculture laboratory using the rose bengal test, all were positive for brucellosis. after conduction of a laboratory tests for q-fever in mail, it was found that 96.4% (n=27) samples were also positive for q-fever on pcr. a wide range of clinical signs and symptoms including fever (100%), general body pain (96%), back pain (93%), joint pain (92%), chills (78%), sweating (86%), anorexia (95%), and tremor (66%) were common among cases. the majority had contact with animals and/or their products. the team was of the opinion that this was potentially the beginning of a more extensive outbreak. this was confirmed after the first round of investigation by a case-control study conducted from july to september 2011. line listing continued until the december 31, 2012. 1,317 total cases were line listed until november 31, 2012. the updated epidemic curve, which includes the cases for 2010 to 2012, is reflected in figure 1. the first peak is due to the outbreak while the second peak might be due to delivery of medical supplies for treatment of disease in the province. figure 1: epidemic curve of brucellosis and q fever outbreak in bamyan province the ages of cases during the outbreak varied from one year to 75 years, with an average age of 30 years. 62% were female and 38% (498) were male. the mean age of the cases was 29.5 years ± 14 sd and the mean age of the controls was 25.7 ± 16.6 years. however, this difference in age was not statistically significant. education status of both cases and controls was low, with 69% being illiterate and 49% housewives. out of the study participants, 83% did not have knowledge about brucellosis and q fever, while 96% owned animals at their home. 57% had sick animals within a one-year period. almost 80% had less than 5 cows. 82% had less than 30 sheep and less than 8 goats at their stables. more than 90% of them had contact with animals, including feeding, watering, pasturing, milking, dunging, slaughtering, and butchering. more than 90% used at least one of the following animal products: butter, cream, milk, yogurt, or other local products. approximately 93% did not wash their hands with soap after handling animals. table 1 describes the distribution of demographic and socio-economic variables as a whole among study participants. table 1: frequency distribution of the sociodemographic characteristics of study participants in bamyan provinceafghanistan in july 2011 (n=200) univariate analysis: there was a significant difference among age groups. those aged less than 15 years were used as a reference group. it seems that the higher age groups were at higher risk than the lowest age group. similarly, there was a significant difference between cases and controls by sex, with an odds ratio of 2.40 and 95 % confidence interval of 1.37 to 4.44. level of education (as a proxy for socio economic status) showed significant differences between illiteracy and secondary education (or=2.27 and 95% ci=1.13 – 4.58). this difference was not significant between primary and secondary education. there was no significant difference between employees of the government and students or between those owning a small business and farmers. however, those working as housewives were significantly different from others with an odds ratio of 8.32 and 95% ci of 3.40 to 20.43. there was no association with having or not having knowledge of diseases among cases and controls. table 2 shows the saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu association of socio-demographic factors with brucellosis and q fever. table 2: statistical analysis of the risk factors (socioeconomic) associated with brucellosis and q fever in bamyan province in july 2011 we found a significant difference among cases and controls with respect to having sick animals at home in the last six months with an odds ratio of 3.89 and 95 % ci of 2.14 to 7.05. likewise, there was a significant association between those who had more than 5 cows and more than 30 sheep with an odd ratios of 3.03 (95% ci = 1.55 – 7.07) and 2.86 (95% ci = 1.40 – 5.90) respectively. there was no association between the number of goats between cases and controls. there were significant differences among cases and controls with respect to pasturing (or= 2.63 and 95% ci = 1.35 – 5.10), milking (or= 3.04 and 95% ci = 1.71 – 5.42), dunging (or= 3.81 and 95% ci = 2.10 – 6.96), butchering (or= 3.03 and 95% ci = 1.70 – 5.40), and assisting deliveries in animals (or= 3.80 and 95% ci = 2.11 – 6.85). approximately all cases and control were using different dairy products and it was not possible to test the difference among groups. cases were 3.82 (95% ci = 2.12 – 6.90) times more likely to be exposed to aborted materials as compared to controls. there was a significant difference in the frequency of boiling milk between cases and controls. the odds ratio of drinking milk without boiling was 7.04 (95% ci = 3.43 – 14.46) times higher among cases as compared to controls. cases had 2.12 (95% ci = 1.19 – 3.77) and 2.27 (95% ci = 1.10 – 4.65) times more odds of exposure in slaughtering animals or living in close proximity with animals at home as compared to control groups. the cases had 4.55 (95% ci = 2.15 – 9.61) times more odds of living within 10 meters of their animals as compared to controls. table 3 shows detailed information regarding the association of these risk factors to contraction of brucellosis and q fever. table 3: statistical analysis of behavioral risk factors associated with brucellosis and q fever in bamyan province in july 2011 multivariate analysis: multiple logistic regression analyses method was used to adjust for confounding. we used the biological as well as statistical significance (p ≤ 0.25) as criteria for inclusion in our model. table 4 shows multivariate analysis results with adjusted or and 95 % confidence intervals (ci). table 4: multivariate analysis of risk factors associated with brucellosis and q fever in bamyan province according to multivariate analysis, housewives are 7.36 (95% ci = 3.05 – 17.78) times as likely to be infected compared to students and government employees. infected individualswere 3 times (95% ci = 1.21 – 7.35) as likelyof living in close proximity to animals (>10 meter) as compared to those controls. in addition, we found significant association with drinking un-boiled milk (or= 5.26, 95% ci = 2.30 – 12.02), being a butcher (or = 3.53, 95% ci = 1.56 – 8.10), and purchasing new animals in the last six months (or= 3.53, 95% ci = 1.42 – 8.53) with infection of brucellosis and q fever. discussion concurrent infection of brucellosis-q fever has been detected in an outbreak in which all cases have been in contact with animals and their products. according to the findings of our study using univariate central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu analysis, gender and age group is significantly associated with brucellosis and q fever infections. we expected that males, due to their professions, should have been affected more often by brucellosis than females. 25 this has been supported by a sero-prevalence study of human brucellosis in turkey in which a statistically significant correlation found between seropositivity and age, sex, and consuming fresh cheese and cream made from un-boiled milk. 12 in addition, illiteracy was another significant risk factor for infection at this level. this may be due to less concern with being healthy or lower awareness of preventive and control measures. housewives in afghanistan are busy with the management of animal products, and this maybe the reason for the significance of the relationship between this occupation and infection. more important is contact with aborted materials, which is thought to be the source of infection. the study showed significant association with assisting deliveries and brucellosis infection. the finding that contact with livestock during parturition is a strong risk factor for brucellosis is consistent with results from other studies, which demonstrate an increased risk in association with assisted parturition. 26 protective measures such as using gloves, gowns and masks should be used while touching these materials, and the product should be discharged safely. hands should be washed with soap after handling animals. before purchasing animals, buyers should ensure that the animals are healthy. the stables of animals should be away from residential areas or at least substantial distance from rooms and kitchens. however, using multivariate analysis, being a housewife, having a kitchen in close proximity to animals, drinking and using un-boiled milk, involvement in butchering activities, and purchasing new animals in last six months were significantly related to infection. it seems that housewives are in more contact with animals and animal products compared to other groups. this should be a focus for health education activities. in addition, the boiling of milk before using or drinking should be promoted, if not enforced. the butchers and slaughterers should have more information on disease to avoid unprotected contacts with animals. the new animals’ movement and marketing should be managed by veterinary services in the province as well as the country in general. the approach to control, prevention, or eradication of brucellosis in a country or region will depend on many factors, such as the level of infection in the herds or flocks, type of husbandry, economic resources, public health impacts, and potential international trade implication. 7 the implementation of control measures, including sustained enhanced surveillance and required case management activities, is expected to pose a challenge to the national public health system. there is a need to expand and enhance the surveillance system and strengthen collaborations and coordination with veterinary services. effective control of brucellosis requires a long-term commitment from many governmental agencies and assistance from international animal and human health organizations. an educational program is needed for high risk groups for zoonosis about the prevention of infection. references 1. young ej. an overview of human brucellosis.clin infect dis. 1995; 21:283–90. 2. pappas g, akritidis n, bosilkovski m, tsianos e. brucellosis. n engl j med. 2005; 352:2325–36. 3. american public health association.control of communicable disease manual, 19ed.2008:88. 4. sadrizadeh b. communicable disease control programmes in the eastern mediterranean region of the world health organization. archives of iranian medicine.1999; 2:28–37. 5. corbell jm. brucellosis: an overview. emerg infect dis. 1997; 2:213-21. 6. world health organization. the control of neglected zoonotic diseases. in: report of the first meeting on the saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu control of neglected zoonotic diseases. geneva, switzerland; 2006. 7. robinson a. guidelines for coordinated human and animal brucellosis surveillance. fao animal production and health paper 156. rome: emergency prevention system, food and agriculture organization of the united nations; 2003. 8. cooper cw. risk factors in transmission of brucellosis from animals to humans in saudi arabia. department of community medicine, university of sydney, croydon, nsw, australia. 9. al-shamahy ha, whitty cj, wright sg. risk factors for human brucellosis in yemen: a case control study. faculty of medicine & health sciences, university of sana'a, yemen. 10. sofian m, aghakhani a, velayati aa, banifazl m, eslamifar a, ramezani a. risk factors for human brucellosis in iran: a case-control study. arak medical university, arak, iran. 11. john k, fitzpatrick j, french n, kazwala r, kambarage d, mfinanga gs, macmillan a, cleaveland s. quantifying risk factors for human brucellosis in rural northern tanzania.plos one. 2010; 5(4):e9968. 12. cetinkaya z, aktepe oc, ciftci ih, demirel r. seroprevalence of human brucellosis in a rural area of western anatolia, turkey.j health populnutr. 2005 jun;23(2):137-41. 13. earhart k, vafakolov s, yarmohamedova n, michael a, tjaden j, soliman a. risk factors for brucellosis in samarqand oblast, uzbekistan.int j infect dis. 2009 nov;13(6):749-53. 14. turatbek b. kozukeev, ajeilat s, maes e, favorov m. risk factors for brucellosis--leylek and kadamjay districts, batken oblast, kyrgyzstan, january-november, 2003. mmwr morb mortal wkly rep. 2006 apr 28;55 suppl 1:31-4. 15. marrie tj, raoult d. coxiellaburnetii (q fever). in: mandell gl, bennett je, dolin r, eds. principles and practice of infectious diseases. 7th ed. philadelphia, pa: elsevier churchill livingstone; 2009:ch 189. 16. centers for disease control and prevention. potential for q fever infection among travelers returning from iraq and the netherlands. available at http://www2a.cdc.gov/han/archivesys/viewmsgv.asp?alertnu m=00313. accessed 12 may, 2010. 17. wallace mr, hale br, utz gc, olson pe, earhart kc, thornton sa, hyams kc. endemic infectious diseases of afghanistan. clin infect dis. 2002 jun 15;34(suppl 5):s171207. 18. pappas g, papadimitriou p, akritidis n, christou l, tsianos ev. the new global map of human brucellosis.a review paper in lancet infect dis 2006; 6: 91–99 19. world organisation for animal health. handistatus ii: zoonoses (human cases): global cases of brucellosis in 2004. http://www.oie.int. accessed 13 nov, 2011. 20. outbreak reports. disease early earning system/surveillance department, afghan public health institute, ministry of public health, kabul, afghanistan. 21. statistics by country for q fever. accessed atwww.wrongdiagnosis.com. 22. glennie js, bailey ms. uk role 4 military infectious diseases at birmingham heartlands hospital in 2005-9.j r army med corps. 2010 sep;156(3):162-4. 23. aronson ne, sanders jw, moran ka. in harm's way: infections in deployed american military forces.clin infect dis. 2006 oct 15;43(8):1045-51. 24. ibm spss statistics for windows [computer program]. version 20.0. armonk, ny: ibm corporation; 2011 25. minas m, minas a, gourgulianis k, stournara a. epidemiological and clinical aspects of human brucellosis in central greece. jpn j infect dis. 2007 nov;60(6):362-6. 26. bikas c, jelastopulu e, leotsinidis m, kondakis x.epidemiology of human brucellosis in a rural area of northwestern peloponnese in greece. eur j epidemiol. 2003;18(3):267-74. http://www2a.cdc.gov/han/archivesys/viewmsgv.asp?alertnum=00313 http://www2a.cdc.gov/han/archivesys/viewmsgv.asp?alertnum=00313 http://www.oie.int/ file:///c:/users/freesek/appdata/local/microsoft/windows/temporary%20internet%20files/content.ie5/0h07aq0p/www.wrongdiagnosis.com saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu table 1: frequency distribution of the socio-demographic characteristics of study participants in bamyan provinceafghanistan in july 2011 (n=200) sociodemographicvariables n (%) age (years) <15 53 (26.5) 15-30 72 (36.0) 30-45 46 (23.0) >45 29 (14.5) sex male 77 (38.5) female 123 (61.5) education status illiterate 138 (69.0) primary education 18 (09.0) secondary education 44 (22.0) occupation government employee & student 36 (28.0) small business holder 25 (12.5) farmers 41 (20.5) housewife 98 (49.0) knowledge of brucellosis and q fever yes 34 (17.0) no 166 (83.0) residence (districts) panjab 150 (75.0) waras 50 (25.0) saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu table 2: statistical analysis of the risk factors (socio-economic) associated with brucellosis and q fever in bamyan province in july 2011 variable cases controls or 95 % ci age <15 16 37 1 reference 15 <30 42 30 3.23 1.52 – 6.85 30 <45 27 19 3.28 1.43 – 7.53 ≥45 15 14 2.47 0.97 – 6.31 sex male 51 49 1 reference female 49 51 2.4 1.37 – 4.44 education status illiterate 78 60 2.27 1.13 – 4.58 primary education 12 12 0.87 0.27 –2.78 secondary education 10 28 1 reference occupation housewife 69 29 8.32 3.40 – 20.43 farmer 17 24 2.48 0.91 – 6.75 small business 6 19 1.1 0.33 – 3.69 student 8 28 1 reference knowledge of diseases yes 16 18 1 reference no 84 82 0.86 0.41 – 1.81 central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu table 3: statistical analysis of behavioral risk factors associated with brucellosis and q fever in bamyan province in july 2011 variables cases controls or 95 % ci having a sick animal in the last 6 months no 27 59 1.00 reference yes 73 41 3.89 2.14-7.05 types and number of animals cattle group ≤ 4 71 89 1.00 reference > 4 29 11 3.03 1.55-7.07 sheep group ≤ 30 70 87 1.00 reference > 30 30 13 2.86 1.40-5.90 goat group ≤ 8 79 58 1.00 reference > 8 21 14 1.63 0.77-3.40 type of activities in animal husbandry pasturing no 23 65 1.00 reference yes 17 35 2.63 1.35-5.10 milking no 67 40 1.00 reference yes 33 60 3.04 1.71-5342 dunging no 75 44 1.00 reference yes 25 56 3.81 2.10-6.96 butchering no 61 34 1.00 reference yes 39 66 3.03 1.70-5.40 assisting delivery no 70 38 1.00 reference saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu yes 30 62 3.63 2.02-6.52 contact with aborted products no 29 61 1.00 reference yes 71 39 3.82 2.12-6.90 boiling of milk before drinking yes 51 88 1.00 reference no 49 12 7.04 3.43-14.46 slaughtering animals no 32 50 1.00 reference yes 68 50 2.12 1.19-3.77 living in close proximity to animals no 9 32 1.00 reference yes 91 68 2.27 1.10-4.65 distance from kitchen >10 meters yes 11 36 1.00 reference no 89 64 4.55 2.15-9.61 purchasing new animals in last 6 months no 70 88 1.00 reference yes 30 12 3.14 1.50-6.58 central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu table 4: multivariate analysis of risk factors associated with brucellosis and q fever in bamyan province variables adjusted or 95% ci p-value working status/job category housewives 7.36 3.05-71.78 >0.001 farmers 1.19 0.42-3.34 0.738 students/govt. employees 1.00 reference distance from kitchen <10 meters 2.95 1.21-7.35 >0.05 >10 meters 1.00 reference drinking milk after boiling no 5.26 2.30-12.02 >0.001 yes 1.00 reference involvement in butchering activities yes 3.53 1.56-8.10 >0.05 no 1.00 reference purchasing new animals in the last 6 months yes 3.53 1.42-8.53 >0.05 no 1.00 reference saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.58 | http://cajgh.pitt.edu figure 1: epidemic curve of brucellosis and q fever outbreak in bamyan province 0 20 40 60 80 100 120 140 n u m b e r o f ca se s time in months from 2010 to 2012 epi curve of brucellosis and q-fever 2010-2012 cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. heart and lungs protection technique for cardiac surgery with cardiopulmonary bypass vladimir pichugin1, nikolay melnikov2, farkhad olzhayev3, alexander medvedev1, sergey jourko2, alishir gamzaev2, vladimir chiginev2 1nizhny novgorod state medical academy, russia; 2cardiac and vascular surgery centre, nizhny novgorod, russia; 3center for life sciences, nazarbayev university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.169 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ pichugin this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.169 | http://cajgh.pitt.edu abstract introduction: cardioplegic cardiac arrest with subsequent ischemic-reperfusion injuries can lead to the development of inflammation of the myocardium, leucocyte activation, and release of cardiac enzymes. flow reduction to the bronchial arteries, causing low-flow lung ischemia, leads to the development of a pulmonary regional inflammatory response. hypoventilation during cardiopulmonary bypass (cpb) is responsible for development of microatelectasis, hydrostatic pulmonary edema, poor compliance, and a higher incidence of infection. based on these facts, prevention methods of these complications were developed. the aim of this study was to evaluate constant coronary perfusion (ccp) and the “beating heart” in combination with pulmonary artery perfusion (pap) and “ventilated lungs” technique for heart and lung protection in cardiac surgery with cpb. methods. after ethical approval and written informed consent, 80 patients undergoing cardiac surgery with normothermic cpb were randomized in three groups. in the first group (22 patients), the crystalloid cardioplegia without lung ventilation/perfusion techniques were used. in the second group (30 patients), the ccp and “beating heart” without lung ventilation/perfusion techniques were used. in the third group (28 patients), the ccp with pap and lung ventilation techniques were used. clinical, functional parameters, myocardial damage markers (ck mb level), oxygenation index, and lung compliance were investigated. results. there were higher rates of spontaneous cardiac recovery and lower doses of inotrops in the second and third groups. myocardial contractility function was better preserved in the second and third groups. the post-operative levels of ck-mb were lower than in control group. three hours after surgery ck-mb levels in the second and third groups were lower by 38.1% and 33.3%, respectively. eight hours after surgery, ck-mb levels were lower in the second and third groups by 45.9% and 47.7%, respectively. 24 hours after surgery, ck-mb levels were lower in the second and third groups by 42.0% and 42.6%, respectively, and lower by 29.7% and 27.4% 48 hours after surgery, respectively. normalization of ck-mb levels were registered earlier in second and third groups (within 24 hours) than the control group. oxygenation index and lung compliance were significantly higher in the third group after cpb. conclusion. our technique improved myocardial and lung function in patients, but larger prospective randomized trials are needed to definitively assess the protective effects of this technique. keywords: constant coronary perfusion, pulmonary artery perfusion, cardiopulmonary bypass http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx the central asian journal of global health to increase scientific productivity new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. the central asian journal of global health to increase scientific productivity kyle freese1, eugene shubnikov2, ron laporte1, shalkar adambekov3, sholpan askarova3, zhaxybay zhumadilov3, faina linkov1 1university of pittsburgh, pittsburgh, pa; 2institute of internal medicine, novosibirsk, russia; 3center for life sciences, nazarbayev university, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.108 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ freese this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.108 | http://cajgh.pitt.edu abstract the who collaborating center at the university of pittsburgh, usa partnering with nazarbayev university, developed the central asian journal of global health (cajgh, cajgh.pitt.edu) in order to increase scientific productivity in kazakhstan and central asia. scientists in this region often have difficulty publishing in upper tier english language scientific journals due to language barriers, high publication fees, and a lack of access to mentoring services. cajgh seeks to help scientists overcome these challenges by providing peer-reviewed publication free of change with english and research mentoring services available to selected authors. cajgh began as a way to expand the supercourse scientific network (www.pitt.edu/~super1) in the central asian region in order to rapidly disseminate educational materials. the network began with approximately 60 individuals in five central asian countries and has grown to over 1,300 in a few short years. the cajgh website receives nearly 900 visits per month. the university of pittsburgh's “open access publishing system” was utilized to create cajgh in 2012. there are two branches of the cajgh editorial board: astana (at the center for life sciences, nazarbayev university) and pittsburgh (who collaborating center). both are comprised of leading scientists and expert staff who work together throughout the review and publication process. two complete issues have been published since 2012 and a third is now underway. even though cajgh is a new journal, the editorial board uses a rigorous review process; fewer than 50% of all submitted articles are forwarded to peer review or accepted for publication. furthermore, in 2014, cajgh will apply to be cross referenced in pubmed and scopes. cajgh is one of the first english language journals in the central asian region that reaches a large number of scientists. this journal fills a unique niche that will assist scientists in kazakhstan and central asia publish their research findings and share their knowledge with others around the region and the world. keywords: central asia, scientific productivity, scientific journals http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. asymptomatic bacteriuria in pregnant women in outpatient facilities maral g. nogayeva & svetlana a. tuleutayeva asfendiyarov kazakh national medical university, almaty, kazakhstan vol. 4, no. 1 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.53 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ nogayeva this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.53 | http://cajgh.pitt.edu abstract urinary tract morbidity has increased by 7% in kazakhstan between 2007 to 2011. pregnant women with extragenital pathologies or kidney diseases had the greatest prevalence of morbidity. asymptomatic bacteriuria (ab) is one of the most important risk factors of pyelonephritis development in pregnant women, and it can affect the course and outcome of pregnancy, delivery, and postnatal period. ab prevention requires prevention of pregnancy complications including early diagnostic of urinary tract infections, timely optimization of therapy at outpatient facilities, and dynamic follow-up. keywords: asymptomatic bacteriuria, pregnancy, antibiotic resistance, prevention asymptomatic bactreriuria in pregnant women at outpatient facility maral g. nogayeva & svetlana a. tuleutayeva asfendiyarov kazakh national medical university, almaty, kazakhstan short report extragenital pathology in pregnant women remains one of the most urgent issues in health care. previous research has indicated that urinary system infections are identified only in 15 to 30 % of all cases.1 one particular risk factor associated with an increase of urinary system infections and related complications is asymptomatic bacteriuria (ab). ab is an important risk factor in the development of pyelonephritis in pregnant women. ab means that a certain amount of bacteria is identified in properly collected urine samples taken from those who have no signs or symptoms of urinary system diseases in two consecutive tests taken within an interval of 1 to 2 weeks.2,3 even when no clinically significant pyelonephritis is observed, ab may result in pre-term delivery, development of anemia in pregnant women, preeclampsia, low weight of newborn child, or fetal intrauterine retardation.2,4,5 although there are numerous complications associated with ab, little attention is paid to ab and latent pyelonephritis in pregnant women. delayed diagnostics and inadequate treatment of pyelonephritis and ab can result in chronic kidney disease, and over time, in chronic renal insufficiency.6,7 the aim of this study was to examine the diagnosis and treatment of ab in pregnant women in city polyclinic no. 5 (cp 5). methods medical examination was performed on 140 pregnant women between 19 and 42 years of age. these women were patients of the prenatal clinic of cp 5 in the almaly district, almaty, kazakhstan. informed consent was obtained from all participants. the following tests were performed for all pregnant women: general medical examination, full blood count, general urine test, urine test by nechiporenko method, bacterioscopic and urine culture test, antibiotics sensitivity of urinary microflora (performed at invivo® laboratory), biochemical blood assay for total protein, sugar, alt, ast, cholesterol, creatinine, urea, blood coagulability, and ultrasound http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.53 | http://cajgh.pitt.edu examination of kidneys using aloka 1400 unit. urinary infection was treated to ensure both effective eradication of the causative agent of the specific diseases and safety of the fetus. ab was treated based on gestational period, causative agent, and antibiotic sensitivity. safety of the treatment was evaluated according to side effects, allergic reactions, and individual intolerance. fetal ultrasound was performed before and after treatment. evaluation of the effectiveness of therapy was evaluated at the beginning of therapy, 10 days post-therapy, and 30 days posttherapy. bacteriological test results were evaluated during each visit on the following criteria: recovery (sterile urine culture or bacteria in the urine at a concentration of less than 10 ³ cfu / ml); persistence of infection (detection of the same pathogen in the urine at 10 ³ cfu / ml or more); and reinfection (detection in the urine of a new species of bacteria at 10 ³ cfu / ml or more during any visit). results the average age of the 140 participants was 33.2 ± 2.53 years. all participants with ab were classified by gestation periods: first trimester – 74 women (52.8%), second trimester – 62 (44.3%), and third trimester – 4 (2.9%). during the reporting period, there was an overall slight decrease in the number of diagnosed urinary tract diseases among pregnant women at cp 5; however, in 2010, the proportion of women with the disease went up to 29.5% compared to 24% in 20082009. these can be further seen in figure 1. figure 1: number of diagnosed urinary tract diseases among pregnant women from the urinary system diseases at cp5 prenatal clinic of almaty from 2008 to 2011 bacteriuria (≥105 cfu/ml) was detected in 38.5% of participants, and ab prevailed in the first trimester of pregnancy at a rate of 52.8%. ultrasound examination of the kidneys identified a dilatation of the renal collecting system in 69 (49.3%) women and hydronephrotic transformation in 25 (17.9%) pregnant women with ab. 88% of participants with ab had asiderotic anemia of slight and medium degree. 2% had arterial hypertension, exhibited as general faintness, headaches, and dizziness, 27.8% had history of pyelonephritis, and 20.7% had previously diagnosed cystitis. tests for various types of urinary microflora and antibiotic sensitivity of the isolated microflora revealed optionally anaerobic commensal flora with prevalence of еscherichia coli and streptococcus faecalis, which can be further explored in figure 2. in all cases, the isolated microflora was resistant to more than one antibiotic, specifically amoxiccillin; however, it was sensitive to cephalosporins and fluoroquinolones. figure 2. frequency of urinary bacterial microflora a complex therapy included antibacterial drugs (cefuroxime, 750 mg, twice a day, 5 days), urinary antiseptics (furazidin, 1 tablet, 4 times a day), vitamin and mineral supplements (depending on gestation period), and antiplatelet medication (dipiridamol, 25 mg, 2 pills 4 times a day). alternative therapy using third generation cephalosporin was performed in 2 women against urinary pathology strains resistant to cefuroxime. in women with ab, high resistance of microorganisms, and allergies, an alternative method of treatment was combined with herbal supplement canefron n, (2 pills or 50 droplets, three times a day during a month). as a result of the treatment, all pregnant women reported improvement of health, decrease of general weakness, and weight loss in 12 women (8.5%) for 14http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx nogayeva this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.53 | http://cajgh.pitt.edu 17 days at 2-3 kg, due to the reduction or disappearance of edema. recurrence of the treated bacteriuria and preeclampsia in our study was not observed. discussion according to annual reports of the ministry of health, overall urinary disease morbidity rate in population of kazakhstan increased by 7 % from 2007 to 2011,8 which indicates the need for awareness as the majority of the cases are asymptomatic. ab mainly prevails in the first trimester of pregnancy, which also confirmed the presence of chronic diseases in the urinary system before pregnancy. the main risk factors for the high prevalence of ab in the outpatient setting are cystitis and pyelonephritis in previous medical history,1,6 which should be also given special attention in family planning process. according to ultrasound examination of the kidneys, dilatation of the renal collecting system is a risk factor in renal inflammation, which means that the inflammatory process was prolonged. this can cause adverse events for the mother and fetus. еscherichia coli was the primary cause in most cases which are resistant to amoxiclav. according to medical scientific sources, citobacterkoseri is sensitive to such antibacterial drugs as nifuroxazid and levofloxacin, which are contraindicated for pregnant women. in our study, pregnant women took cefalosporins, which are hardly active against this microorganism; however, they were combined with canefron, which gave such positive outcome as elimination of causative agent. therapeutic tactics of treatment of pregnant women with ab includes timely complex treatment, control of sterility of urine at each visit to the doctor for the purpose of testing urine sterility in every trimester of pregnancy to prevent any complications in mothers and fetuses, and testing of the male partner for concealed bacteriospermia. references 1. delzell je, lefevre ml. urinary tract infections during pregnancy. am fam physician. 2000;61(3):713-720. 2. colgan r, nicolle le, mcglone a, hooton tm. asymptomatic bacteriuria in adults. am fam physician. 2006;74(6):985-990. 3. mires g, williams f, howie p. randomised controlled trial of cardiotocography versus doppler auscultation of fetal heart at admission in labour in low risk obstetric population. bmj. 2001;322(7300):1457-1460. 4. graham jc, leathart jbs, keegan sj, pearson j, bint a, gally dl. analysis of escherichia coli strains causing bacteriuria during pregnancy: selection for strains that do not express type 1 fimbriae. infect immun. 2001;69(2):794-799. 5. davison jm. renal disorders in pregnancy. curr opin obstet gynecol. 2001;13(2):109-114. 6. wing da, fassett mj, getahun d. acute pyelonephritis in pregnancy: an 18-year retrospective analysis. am j obstet gynecol. 2014;210(3):e1-e6. 7. tomilina na, bikbov bt. epidemiology of chronic renal failure. new approaches to classification and assessment of severity of chronic progressive renal diseases. ter arkh. 2005;77(6):87-92. 8. republic of kazakhstan ministry of health. public health in the republic of kazakhstan, and activities of healthcare organizations in 2009, 2010. astana: republic of kazakhstan ministry of health;2011. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.53 | http://cajgh.pitt.edu figure 1: number of diagnosed urinary tract diseases among pregnant women from the urinary system diseases at cp5 prenatal clinic of almaty from 2008 to 2011 1770 1718 1651 1578 426 413 487 345 0 500 1,000 1,500 2,000 2,500 2008 2009 2010 2011 number of pregnant women with urinary tract diseases number of pregnant women observed during reporting period http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx nogayeva this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.53 | http://cajgh.pitt.edu figure 2. frequency of urinary bacterial microflora 57% 23% 5% 6% 4% 5% еscherichia coli streptococcus faecalis staphylococcus epidermidis citrobacterkoseri streptococcus haemolyticus enterococcus faecalis http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx prevalence of risk factors for non-communicable diseases in adult population of urban areas in kabul city, afghanistan new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. prevalence of risk factors for non-communicable diseases in the adult population of urban areas in kabul city, afghanistan khwaja mir islam saeed afghanistan national public health institute, ministry of public health, kabul, afghanistan vol. 2, no. 2 (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu abstract background: non-communicable diseases (ncds) are a major global problem. this study aims to estimate the prevalence of common risk factors for ncds among the adult population in urban areas of kabul city, afghanistan. methods and materials: this study was conducted from december 2011 through march 2012 and involved a survey of 1169 respondents, aged 40 years and above. multistage cluster sampling was used for participant selection, followed by random sampling of the participants. the world health organization stepwise approachfor surveillance (steps) was modified and used for this study. results: the overall prevalence of smoking was 5.1% (14.7% men versus 0.3% women) and using mouth snuff was 24.4% in men and 1.3% in women. the prevalence of obesity and hypertension were 19.1% and 45.2 % in men and 37.3% and 46.5% in women. prevalence of diabetes was 16.1% in men and 12% in women. the overall prevalence of obesity, hypertension and diabetes mellitus was 31.2%, 46% and 13.3%, respectively. on average, subjects consumed 3.37 servings of fruit and 2.96 servings of leafy vegetables per week. mean walking and sitting hours per week (as proxies for physical activity) were 19.4 and 20.5, respectively. a multivariate model demonstrated that age was a significant risk factor for obesity (or=1.86), diabetes (or=2/09) and hypertension (or=4.1). obesity was significantly associated with sex (or=1.65). conclusion: these results highlight the need for interventions to reduce and prevent risk factors of non-communicable diseases in urban areas of kabul city, afghanistan. keywords: non-communicable diseases, risk factors, hypertension, obesity, who steps prevalence of risk factors for noncommunicable diseases in adult population of urban areas in kabul city, afghanistan khwaja mir islam saeed afghanistan national public health institute, ministry of public health, kabul, afghanistan research non-communicable diseases (ncds) consist of a vast group of non-infectious medical conditions; however emphasis has been on cardiovascular disease, cancer, diabetes, and chronic respiratory diseases. despite being included in the recent, global development agenda, 1 the world health assembly also endorsed an important, new health goal to reduce avoidable mortality from ncds 25% by 2025. 2 in 1990, there were 26.6 million deaths worldwide from ncds, which increased to 34.5 million in 2010. 3 furthermore, in 2008 approximately 63% (36 million) of all deaths were due to ncds. 4 likewise, the total number of disability-adjusted life-years (dalys) increased from 43% in 1990 to 54% in 2010 worldwide. 5 the global economic burden of ncds is large, estimated at us $6.3 trillion in 2010, anticipated to rise to $13 trillion by 2030. 6 due to rapid demographic and epidemiologic transitions, south asian life expectancy is increasing and fertility rate is reducing, which has led to an increased health burden of ncds. 7 the leading risk factors for the development of non-communicable disease are high blood pressure, high cholesterol, inadequate intake of fruit and vegetables, overweight or obesity, physical inactivity, and tobacco use. 8 it has central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu been indicated that the prevalence of smoking varies in south asian countries from 16-32%, alcohol consumption (3-41%), eating less than five servings of fruits and vegetables (81-99%), physical inactivity (424%), overweight and obesity (9-44%), elevated blood pressure (8-42%), elevated fasting blood sugar (4-9%), and elevated blood cholesterol (13-54%). 9 in a recent indian study, it was shown that those living in urban areas were at higher risk for developing ncds as compared to their rural counterparts. 10 hypertension affects nearly one billion people worldwide and it is expected to increase to 1.5 billion by the year 2025. 11 the global prevalence of hypertension is estimated to be 30% among adults, with variations existing between economically developed and developing countries. 12 in the eastern mediterranean region (emr), the prevalence of hypertension is approximately 29%, affecting approximately 125 million individuals. 13 in iran, the estimated prevalence of hypertension in those aged 30–55 and more than 55 years was approximately 23% and 50%, respectively. 14 in a pakistani study, the overall prevalence of hypertension was 26%, with changes in sex as well as age. 15 global diabetes prevalence was 2.8% in 2000 and is projected to grow to 4.4% by 2030. 16 developing countries are increasingly vulnerable to obesity and diseases associated with excess adipose tissue. 17,18 in another pakistani study, the prevalence of diabetes was 12.1% in males and 9.8% in females, 19 while the national prevalence of diabetes in iran in 2005 was 7.7% with 8.3% of females and 7.1% of males affected. 20 complete information of the morbidity and mortality associated with ncds is not fully available in afghanistan due to low attention and years of conflict. however, the afghanistan mortality survey (ams) in 2010 revealed that 33.3% of all deaths are attributed to ncds compared to 42.6% due to communicable, maternal, perinatal, and nutritional conditions. cardiovascular diseases, malignant neoplasms, diabetes, respiratory diseases, and digestive diseases are the leading causes of deaths due to ncds. 21 based on a world health organization (who) estimate, in 2000 there were 468,000 people with diabetes in afghanistan. this number is expected to rise to 1,403,000 by 2030, representing nearly a threefold increase. 22,23 smoking prevalence among men 15 years and older in kabul city was reported as 35%, 24 compounded by the fact that kabul ranked as one of the dirtiest cities in the world in terms of ambient air quality, potentially increasing the burden of respiratory diseases and different types of cancer among humans. 25 the stepwise approach to surveillance (steps) developed by who has been used by different countries in order to identify and monitor the prevalence of ncd risk factors. 26 in the emr, more than half of member states (56%) have already conducted and established surveillance systems for ncds using steps. 27 unfortunately, there is no experience of surveillance of ncds in afghanistan. this study aims to describe the prevalence and risk factors for ncds among adults aged 40 years and older in kabul city, afghanistan using standardized survey methodology, steps, 28 and to provide information for public health actions. methods and materials setting this cross-sectional study was conducted among residents 40 years old and above in kabul city, the capital of afghanistan. the city has approximately 534,900 households and 3,289,000 inhabitants, with a slightly higher male population (51.8%). 29 administratively, kabul city is divided into 22 districts, in 16 of which people reside. districts are further divided into clusters or neighborhoods (gozar). initially, we officially requested that the kabul municipality provide us the list of all neighborhoods, local representative leaders, and its estimated saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu populations; we were able to obtain information on 13 districts. sample size the statistical software program epi info was used to calculate the sample size for this study. by taking into account a precision level of 5%, confidence interval of 95%, and proportion of risk factors in research studies such as diabetes, blood pressure, physical activity, dietary behavior, obesity, age, level of education, and smoking status in diseased and nondiseased people in similar settings, the number of subjects in this study was raised to 600 individuals. to balance considerations of cost, resources, and time without compromising the representativeness of the sample, a three-phase cluster sampling technique was planned. lastly, after taking into account the design effect (de=2) of cluster sampling, the final sample size reached (2 x 600) = 1,200, which was reasonable for achieving study objectives within limited resources and funding support. participants eligible subjects were selected by multistage sampling; in the first stage, a sample of neighborhoods was selected randomly from each district. in the second stage in each neighborhood a main masjid was selected as a hallmark and heads of households around the masjid were asked to approach the team settled there. in the third stage, one adult person was selected from each household randomly and interviewed after consent was taken. of our target 1,200 individuals, 1,193 records were available for entry. seven were lost during fieldwork or transportation. ten subjects were excluded due to being less than 40 years old, and 14 others were excluded due to unavailability of data for either height or weight for calculation of bmi. therefore, 1,169 individuals were included in analysis. the study was approved by the institutional review board (irb) of the ministry of public health, afghanistan. data collection and measurement data collection was carried out from december 2011 to march 2012. data collected by questionnaire consisted of demographic characteristics, socioeconomic factors, and behavioral risk factors such as smoking, fruit and vegetable consumption, and physical activity. the questionnaire was modified with expanded and optional questions to suit local needs. extended questions were in the steps instrument modified by adding locally relevant responses. optional questions were added to the instrument because they were deemed locally important; for example, snuff use was included due to its high prevalence in the area. the questionnaire was translated into the dari language and tested prior to actual data collection. physical measurements included weight in bare feet with usual clothing, height in bare feet without headwear, waist circumference at the narrowest point between the lower costal border and the iliac crest measured using a constant tension tape, and blood pressure at the midpoint of the arm after participants had rested for at least five minutes. two blood pressure readings were obtained for all participants. a third reading was taken if there was a difference of more than 20 mmhg for systolic blood pressure or 10 mmhg for diastolic blood pressure between the first two readings. the mean of all measures was used and recorded. biochemical measures included random and blood glucose measured in capillary blood using a glucometer. data collection staff consisted of paramedical doctors and experienced surveyors. they underwent intensive training and supervision provided by the afghan national public health institute. a pilot study including 20 participants from moph staff was conducted, which helped us to reword some questions and estimate the timing of the interview. blood pressure instruments were tested against each other and showed no differences in central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu measurement. questionnaires were administered by face-to-face interviews. definitions of risk factors overweight was defined as bmi 25-29.9 kg/m 2 , and obesity as bmi ≥30 kg/m 2 . 30 waistcircumference ≥94 cm in men and ≥80 cm in women was taken as the cutoff point to define central obesity. 31 consumption of fruits and vegetables were measured as the frequency of servings per week as raw leafy vegetables and one medium-sized and seasonal piece of fruit. physical activity was defined as walking, sport, or strong physical activity in minutes per day, hours per day, and/or per week. hypertension was diagnosed if systolic blood pressure was ≥140 mm of hg and/or diastolic pressure ≥90 mm of hg, or diagnosed cases taking antihypertensive drugs. 32 pre-hypertension is defined as 120-139 mm hg systolic blood pressure and/or 80-89 mm hg diastolic pressure. 33 individuals with a random blood sugar of ≥ 200mg/dl were later confirmed by fasting blood sugar (fbs). 34,35 an fbs of ≥ 126mg/dl were considered diabetic. 35 statistical software responses in the questionnaire were coded and entered into epi info software version 3.5.1. 36 statistical analyses were performed using spss software version 20. 37 results descriptive analysis the mean age of study subjects was 49.5 ± 10.2 years, while according to recent survey in 2010 women and men are now living past age 60 years. 66.5% were female due to low availability of males during daytime at home. the majority of participants (58%) were less than 50 years of age. illiteracy, being 79.4%, was the main concern in women. fifty-two percent of the participants had a monthly income of less than 200 usd. nearly 5% of participants reported being current smokers, and 9% reported using mouth snuff. reflecting cultural practice, the prevalence of cigarette smoking and mouth snuff used were much higher in men than in women. selected socio-economic and demographic characteristics of the participants are shown in table 1. table 1. frequency distribution of the background characteristics of study participants (n=1,169). two-thirds of families reported using solid ghee for cooking in the kitchen. fifty percent of participants ate red meat 1-2 times per week while 90% consumed rice 1-2 times per week. consuming leafy vegetables and fresh fruits with lunch or dinner was less common due to economic problems; close to 60% consumed three servings or less with or after meals. table 2 presents data on behavioral risk factors for males and females. the adult population, particularly women, in kabul city performed little physical activity. approximately 15% of respondents reported 10-30 minutes of different kinds of physical activity daily while the rest reported being sedentary. walking as a proxy for physical activity was a better habit among citizens. one hour of daily walking for various purposes was quite common (31%) among respondents. table 2. frequency distribution of the behavior factors evaluated (n=1,169). overall, 69.3% of study participants were either overweight or obese (38.1% overweight and 31.2% obese). being overweight and obese was slightly more prevalent in women as compared to men. furthermore, 57.8% were centrally obese using waist circumference. the average bmi was 27.85 ± 5.17 saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu kg/m 2 and ranged from 15.2 to 62.2 kg/m 2 . 33%, 48.5%, and 18.5% were hypertensive, pre-hypertensive and normotensive, respectively. table 3 shows the prevalence of pathophysiological risk factors. table 3. frequency distribution of pathophysiological risk factors for ncds of study participants (n=1,169). the prevalence of diabetes mellitus was 13.3% and was more common in women (59.5%) as compared to men (40.4%). some study subjects had only one risk factor while the others had two or more, which were categorized as risk factors groups. for instance, having risk factors of diabetes mellitus, blood pressure, and obesity at the same time were categorized as triple risk factor group. having double risk factors of diabetes and obesity was 5.2%, diabetes and hypertension was 7.8%, and hypertension and obesity was 18.3%. trip risk factors were present in 3.6% of the participants. the greater the number of risk factors, the higher the probability of ncds among the adult population. statistical analysis multivariate logistic regression was performed for common risk factors versus pathophysiological risk factors such as diabetes mellitus, hypertension and obesity in order to find independent associations,as reflected in table 4. age was a significant risk factor for all three conditions with an adjusted odds ratio (aor) and confidence interval (ci) of (aor=1.86, 95% [1.29, 2.66]), (aor=2.09, 95% ci [1.32, 3.31], (aor=4.1, 95% ci [2.97, 5.65]), respectively for obesity, diabetes and hypertension. there were no significant associations between sex and diabetes mellitus and hypertension. however, obesity was significantly associated with sex, with females more likely to be obese as compared to males (or=1.65, 95% ci [1.08, 2.52]). illiterate participants were less likely to be diabetic (or=0.55, 95% ci [0.34, 0.88]) as compared to literate participants. table 4. multivariate analysis risk factors associated with obesity, hypertension, and diabetes mellitus. there were significant associations between diabetes and obesity (or=1.66, 95% ci [1.04, 2.65]) as well as obesity and hypertension (or=2.08, 95% ci [1.49, 2.90]). central obesity was significantly associated with hypertension (or=1.72, 95%ci [1.25, 2.36]). proxies for physical activities were daily walking, mode of transportation for getting to the workplace, and sitting time at work or living place. walking in ‘hours per week’ was significantly associated with obesity, and proxies were associated with hypertension and diabetes mellitus. diet was categorized by using reported habits of eating red meat or chicken, type of kitchen fat, rice, and fruits and vegetables by weekly or monthly frequencies. consuming chicken as lunch or dinner was associated with obesity and hypertension while eating red meat as a meal was significantly associated with diabetes mellitus. cooking meals with liquid ghee was a protective factor for diabetes (or=0.35, 95% ci [0.22, 0.54]), although we did not find any association of cooking fat with obesity and hypertension. consuming rice as a meal is considered a luxury in the country. frequently eating rice as a meal was significantly associated with diabetes (or=2.3, 95% ci [1.48, 3.58]) and hypertension (or=1.43, 95% ci [1.06, 1.93]). we found a significant association between frequency of consuming fruits and hypertension (or=1.43, 95% ci [1.03, 1.96]) but no association between fruits and vegetables with obesity and diabetes mellitus. central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu discussion maternal health, malnutrition, vaccine preventable diseases, and communicable diseases are the main concerns in afghanistan on which the government and its partners are focusing over the last decade. however, epidemiological studies focusing on risk factors for ncds are of great importance to fill the gap of information and knowledge existing in the country. our study presented the ncd risk factor burden using who-steps tool estimated prevalence of diabetes, smoking, snuff use (smokeless tobacco), obesity, blood pressure, and physical inactivity among the urban population of kabul city. it could be used as a baseline for newly established ncd department at moph to develop policies and strategies and plan of actions against them. according to our findings, two thirds of the adult (age ≥40) urban citizens of kabul city, the capital of afghanistan, are overweight or obese with nearly one third of them meeting the criteria for obesity. in addition, more than half of the adult population has central obesity. although no information is available to assess the trends of obesity, the economic condition of urban citizens is getting better. moreover, culturally being overweight and obese is perceived as healthy, and people are not interested in losing weight; particularly fat women are considered to be beautiful. increasing age has a negative effect on the level of obesity at bivariate as well as multivariate levels. based on recent studies the life expectancy is 62 years in the country. 38 since the study was conducted on upper age groups, it can be justified that older ages suffering from chronic diseases, which are attributed to low appetite and being on a diet, are not gaining weight. likewise, gender as a nonmodifying factor has a relationship at both level of analysis. as females are mostly confined at home as housewives and are less likely to be physically functional, they are not as obese as compared to males. therefore, health promotion strategies should focus on obesity as a problem of productive groups. the proportion as well as the effect of age and gender on obesity is comparable with other studies. 39-45 the independent significant association of obesity and blood pressure as well as diabetes depict that the factors are related to each other and combined intervention concentrating on multiple factors is beneficial. with the prevalence of hypertension and diabetes found here, we can posit that the country has already entered an epidemic of non-communicable diseases, which requires strengthening efforts for its control and prevention. the health education campaigns should be tailored to cover all of them. walking as a proxy for physical activity is a protective factor against obesity as well as other ncds. community awareness and establishment of sport centers and jogging lots, which is lacking in urban settings particularly for women, should be encouraged and discussed with relevant sectors. this statement was proved by this study as well as other studies. 19,46,47 our study shows the higher percentage of blood glucose in people who are equal to or more than 40 years of age (13.57%) in kabul city. as there is no data regarding prevalence of diabetes in the country, this information can fill the gap of information and help the newly established ndc department at moph to plan and focus on target groups. the diabetic control center should be strengthened in the country, and they should focus on older productive age groups with preventive and modifying interventions of life style. using bivariate analysis, age was a significant non-modifiable factor, which influenced the prevalence of diabetes by change of 9% from lower to higher age groups. high prevalence of diabetes in older age groups who also have other aging diseases will put them in a vicious circle, which could lead to overburdening the health system in the country. working ahead of time for such diseases, not only reduces the economic burden on health system but also improves the life style of productive groups. men are at more risk than women, which is not a modifying factor and could be due to genetic makeup. these findings are saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu consistent with national studies in neighboring countries and other nations in the region. 23,48-50 based on our findings, the prevalence of smoking and snuffing is much higher in men versus women that are probably due to cultural unacceptability and less freedom of smoking among women versus men. as the baseline for smoking is not available it is not supposed to higher. in summary, according to multivariate model we are recommending strategic actions to be concentrated on older ages, education level, cousin marriage to reduce history of diabetes in the family, using liquid oil in kitchen, and short daily walking. focusing on these factors certainly will lead to reduction of cases in future. according to the findings of this study, approximately half of the adult population in kabul city has hypertension. results of an iranian study support these findings, in which the overall prevalence rate of hypertension was 27.1% with higher rates in men (32.3%) as compared to women (22.5%). it provides a baseline, or a trigger point, for policy makers to focus upon and take it seriously for future planning and potential interventions. in addition, there was a positive correlation between the hypertension prevalence and age as well as education. the link between education and health is now well established, and growth in literacy rates, particularly among women, has been shown to have a positive impact on health. it seems that non-communicable diseases are occurring as a combined syndrome in adult population. convenient modes of transportation to the workplace and sedentary lifestyle (including decreased physical activity) have a negative impact on health and the risk of hypertension. the prevalence of diabetes and obesity, either central or general, is affecting the level of blood pressure at the bivariate level of analysis and needs to be considered as comorbidity while managing hypertension. it means that some screening program, if established, will prevent the development of raised blood pressure. multivariate analysis revealed higher age, education level as socioeconomic factors, consuming chicken, rice, fruits and walking habits as behavioral factors are significantly and independently affecting the level of blood pressure, diabetes and obesity among the adult population in kabul city. this small study hypothesize that the country is entering in critical situation of ncds while still no attention is given to them. other research conducted in angola and china found similar findings that older age, lower level of education, retirement/unemployment and higher body mass index were significantly associated with hypertension. 51-55 it seems that the factors are mostly associated with each other and/or concurrently present in one individual at the same time. the interventions are needed to target a group of risk factors rather than just one or two factors. this study, despite of having limitations, has provided useful baseline information for policy development and design of interventions. inclusion of upper age groups has limited the application of findings to population. in the present study, two thirds of participants were females, which are likely had an influence on the results for women because data were not weighted for age and sex to national population. the under representation of men in this age group was due to some being away from home at the time of the survey. however, the findings of our study illustrated for the first time the prevalence of main ncd risk factors in an urban setting of the country. the main limitation of the study was financial resources for covering cost, which might have affected the result of the study by not going door to door and randomly interviewing individuals or performing glucose tolerance test instead of testing fasting blood sugar. the technique used for recruiting the study participants could encourage participation of those with chronic diseases and leading to possible overestimated prevalence of chronic diseases including obesity. not withstanding this study demonstrates the impact of noncommunicable diseases such as diabetes, blood pressure, and obesity on a population already central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu significantly burdened by communicable and preventable diseases. research institutions and the moph to develop more rigorous research and national studies to assess the impact of non-communicable diseases in afghanistan may use these findings. suffering from noncommunicable diseases such as diabetes, high blood pressure, and obesity requires concerted interventions aimed toward prevention. the findings obtained from this study can contribute in formulation of more advanced and national studies to have a generalized picture of non-communicable diseases and their risk factors in the country. it also will assist policy makers to develop a strategy for appropriate control and prevention of non-communicable diseases in the afghan urban population. competing interests the author declares that they have no competing interests. acknowledgement i would like to thank the field epidemiology training program (feltp) pakistan for contribution in concept and design of the study as well as feltp afghanistan and ministry of public health for financial support of data collection. references 1. united nations. resolution adopted by the general assembly. 66/2: political declaration of the high-level meeting of the general assembly on the prevention and control of noncommunicable diseases. in: united nations, ed. new york; 2012. 2. world health organization. prevention and control of non-communicable diseases. in: organization wh, ed. 65th world health assembly. geneva; 2012. 3. lozano r, naghavi m, foreman k, et al. global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. lancet. 2012;380(9859):2095-2128. 4. world health organization. the global burden of diseases 2004 update. in: who, ed. geneva; 2008. 5. murray cj, vos t, lozano r, et al. disability-adjusted life years (dalys) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the global burden of disease study 2010. lancet. 2012;380(9859):2197-2223. 6. world health organization. global status report on noncommunicable diseases 2010. geneva: world health organization;2011. 7. engelgau m, el-saharty s, kudesia p, rajan v, rosenhouse s, okamoto k. capitalizing on the demographic transition: tackling noncommunicable diseases in south asia. washington, d.c.: world bank; 2011. 8. world health organization. the world health report 2002: reducing risk promoting healthy life. geneva: world health organization;2002. 9. salehuddin m, choudhury kn, islami n, zillurahman m, gosh s, majib m. burden of non-communicable diseases in south asia. university heart journal. 2010. 10. bhagyalaxmi a, atul t, shikha j. prevalence of risk factors of non-communicable diseases in a district in gujarat, india. j health popul nutr. 2013;31(1):78-85. 11. kearney pm, whelton m, reynolds k, muntner p, whelton pk, he j. global burden of hypertension: analysis of worldwide data. lancet. 2005;365(9455):217-223. 12. medscape cardiology. hypertension, but not "prehypertension," increases stroke risk: global prevalence of hypertension may be close to 30%. 2004; http://www.medscape.com/viewarticle/471536_8 13. world health organization. non-communicable diseases: hypertension. 2011; http://www.emro.who.int/ncd/hypertension.htm. 14. haghdoost ak, behnam sadeghirad b, rezazadehkermani m. epidemiology and heterogeneity of hypertension in iran: a systematic review. arch iranian med. 2008;11(4):444-452. 15. safdar s, omair a, faisal u, hasan h. prevalence of hypertension in a low income settlement of karachi, pakistan. j pak med assoc. 2004;54(10):506-509. 16. international diabetes federation. international diabetes federation estimation. 2011. http://www.medscape.com/viewarticle/471536_8 http://www.emro.who.int/ncd/hypertension.htm saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu 17. friedrich mj. epidemic of obesity expands its spread to developing countries. jama. 2002;287:1382-1386. 18. reddy ks, yusuf s. emerging epidemic of cardiovascular disease in developing countries. circulation. 1998;97:596-601. 19. shera as, basti a, fawwad a, et al. pakistan national diabetes survey: prevalence of glucose intolerance and associated factors in the punjab province of pakistan. prim care diabetes. 2010;4(2):79-83. 20. esteghamati a, meysamie a, khalilzadeh o, et al. third national surveillance of risk factors of non-communicable diseases (surfncd-2007) in iran: methods and results on prevalence of diabetes, hypertension, obesity, central obesity, and dyslipidemia. bmc public health. 2009;9:167. 21. afghan public health institute ministry of public health (aphi/moph) [afghanistan], central statistics organization (cso) [afghanistan], icf macro iiohmrii, [egypt] whoroftemwe. afghanistan mortality survey 2010. maryland, usa: calverton; 2011. 22. world health organization. prevalence of diabetes in the who eastern mediterranean region. in: programme d, ed. 23. shaw je, sicree ra, zimmet pz. diabetes atlas: global estimates of the prevalence of diabetes for 2010 and 2030. diabetes res clin pract. 2010;87(1):4-14. 24. mohmand ka, sharifi k, bahram aa. smoking prevalence survey in kabul city. 2010 (in press). 25. sediqi a. a preliminary assessment of air quality in kabul. http://www.afghanweb.com/environment/kabul_air_quality.pdf. 26. bonita r, decourten m, dwyer t, k. j, winkelmann r. surveillance of risk factors for non-communicable disease: the who stepwise approach. geneva: world health organization;2002. 27. world health organization. steps country reports. 28. world health organization. the steps manual 2005. geneva2005. 29. central statistics organization, islamic republic of afghanistan , population statistics, population estimation 20122013 30. world health organization. obesity: preventing and managing the global epidemic; report of a who consultation. geneva: world health organization;2000. 31. international diabetes federation. the idf consensus worldwide definitions of the metabolic symdrome. 2006; http://www.idf.org/webdata/docs/idf_meta_def_final.pdf. 32. whitworth ja, world health organization, international society of hypertension writing group. 2003 world health organization (who)/international society of hypertension (ish) statement on management of hypertension. j hypertens. 2003;21(11):1983-1992. 33. federal occupational health. hypertension and prehypertension. http://www.foh.dhhs.gov/nycu/hypertension.asp. 34. rutledge t, braden al, woods g, herbst kl, groesz lm, savu m. five-year changes in psychiatric treatment status and weight-related comorbidities following bariatric surgery in a veteran population. obesity surgery. nov 2012;22(11):17341741. 35. world health organization. diabetes: fact sheet #312. who media center. 2009. 36. epi info [computer program]. version 3.5.12008. 37. ibm spss statistics for windows [computer program]. version 20.0. armonk, ny: ibm corporation; 2011. 38. sandefur j. here's the best thing the us has done in afghanistan. the atlantic. 2013; http://www.theatlantic.com/international/archive/2013/10/here s-the-best-thing-the-us-has-done-in-afghanistan/280484/. 39. musaiger ao. overweight and obesity in eastern mediterranean region: prevalence and possible causes. j obes. 2011;2011:1-17. 40. yalcin bm, sahin em, yalcin e. prevalence and epidemiological risk factors of obesity in turkey. mejfm. 2004;6(6). 41. musaiger ao, al-mannai ma. weight, height, body mass index and prevalence of obesity among the adult population in bahrain. ann hum biol. 2001;28(3):346-350. 42. al-nuaim aa, bamgboye ea, al-rubeaan ka, al-mazrou y. overweight and obesity in saudi arabian adult population, role of socio-demographic variables. j community health. 1997;22(3):211-223. 43. sibai am, hwalla n, adra n, rahal b. prevalence of and covariates of obesity in labanon: finding from the first epidemiological study. obes res. 2003;11:1353-1361. 44. azadbakht l, mirmiran p, shiva n, azizi f. general obesity and central adiposity in a representative sample of tehranian adults: prevalence and determinants. int j vitam nutr res. 2005;75(4):297-304. 45. gutiérrez-fisac jl, guallar-castillón p, díez-gañán l, lópez garcía e, banegas banegas jr, rodríguez artalejo f. http://www.afghan-web.com/environment/kabul_air_quality.pdf http://www.afghan-web.com/environment/kabul_air_quality.pdf http://www.idf.org/webdata/docs/idf_meta_def_final.pdf http://www.foh.dhhs.gov/nycu/hypertension.asp http://www.theatlantic.com/international/archive/2013/10/heres-the-best-thing-the-us-has-done-in-afghanistan/280484/ http://www.theatlantic.com/international/archive/2013/10/heres-the-best-thing-the-us-has-done-in-afghanistan/280484/ central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu work-related physical activity is not associated with body mass index and obesity. obes res. 2002;10(4):270-276. 46. lahti-koski m, pietinen p, heliovaara m, vartiainen e. association of body mass index and obesity with physical activity, food choices, alcohol intake and smoking in the 19821997. am j clin nutr. 2002;75:809-817. 47. zafar j, bhatti f, akhtar n, et al. prevalence and risk factors for diabetes mellitus in a selected urban population of a city in punjab. j pak med assoc. 2011;61(1):40-47. 48. ramachandran a. urban india: a breeding ground for diabetes. diabetes voice. 2002;47(1):18-20. 49. ning f, pang zc, dong yh, et al. risk factors associated with the dramatic increase in the prevalence of diabetes in the adult chinese population in qingdao, china. diabet med. 2009;26(9):855-863. 50. sahraki mr, mirshekari h, sahraki ar, mohammadi m, sahraki e, khazaei feizabad a. hypertension among 30+ yearold people in zahedan (southeast of iran). shiraz e-medical journal. 2011;12(3). 51. khan rj, stewart cp, christian p, et al. a cross-sectional study of the prevalence and risk factors for hypertension in rural nepali women. bmc public health. 2013. 52. pires je, sebastião yv, langa aj, nery sv. hypertension in northern angola: prevalence, associated factors, awareness, treatment and control. bmc public health. 2013;13(1):90. 53. sit jw, sijian l, wong em, et al. prevalence and risk factors associated with prehypertension: identification of foci for primary prevention of hypertension. j cardiovasc nurs. 2010;25(6):461-469. 54. meshram ii, arlappa n, balkrishna n, rao km, laxmaiah a, brahmam gn. prevalence of hypertension, its correlates and awareness among adult tribal population of kerala state, india. j postgrad med. 2012;58(4):255-261. 55. ordinioha b. the prevalence of hypertension and its modifiable risk factors among lecturers of a medical school in port harcourt, south-south nigeria: implications for control effort. niger j clin pract. 2013;16(1):1-4. 56. weiss ha, quigley ma, hayes rj. male circumcision and risk of hiv infection in sub-saharan africa: a systematic review and meta-analysis. aids (london, england). oct 20 2000;14(15):2361-2370. saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu table 1: frequency distribution of the background characteristics of study participants (n=1,169). variables categories male (%) female (%) total (%) age in years (missing values =17) 40 – 49 152 (22.2) 532 (77.8) 684 (58.5) 50 – 59 108 (45.6) 129 (54.4) 237 (20.3) 60 – 69 88 (55.7) 70 (44.3) 158 (13.7) 70 and over 39 (53.4) 34 (46.6) 73 (6.3) level of education illiterate 138 (20.6) 531 (79.4) 669 (57.2) primary/unofficial education 59 (50.4) 58 (49.6) 17 (10.0) secondary school 116 (54.7) 96 (45.3) 212 (18.2) high school and more 79 (46.2) 92 (53.8) 171 (14.6) monthly income (afghanis) (missing=181) ≤ 10000 187 (36.1) 331 (63.9) 518 (52.4) 10000 20000 96 (33.0) 195 (67.0) 291 (29.5) 20000 – 30000 33 (41.8) 46 (58.2) 79 (8.0) ≥ 30000 53 (53.0) 47 (47.0) 100 (10.1) work status government employee 120 (46.7) 137 (53.3) 257 (22.0) business 52 (88.1) 7 (11.9) 59 (5.0) farmer/worker 52 (85.2) 9 (14.8) 61 (5.2) jobless 63 (13.5) 404 (86.5) 467 (39.9) unable to work 37 (94.9) 2 (5.1) 39 (3.3) housewife 68 (23.8) 218 (76.2) 286 (24.5) smoking status (missing=9) current smoker 57 (96.6) 2 (3.4) 059 (05.1) ever smoker 85 (89.5) 10 (10.5) 095 (08.2) never smoker 246 (24.5) 760 (75.5) 1,006 (86.7) mouth snuff use status (missing =10) central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu current user 95 (90.5) 10 (9.5) 105 (9.0) ever user 23 (92.0) 2 (8.0) 25 (2.2) never user 271 (26.3) 758 (73.7) 1,029 (88.8) saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu table 2: frequency distribution of the behavior factors evaluated (n=1,169). variables categories male (%) female (%) total (%) type of kitchen oil solid oil 56 264 (32.6) 547 (67.4) 811 (69.4) solid oil (no) 128 (35.8) 230 (64.2) 358 (30.6) liquid oil 56 120 (35.8) 215 (64.2) 335 (28.7) liquid oil (no) 272 (32.6) 562 (67.4) 834 (71.3) frequency of eating red meat in a month (missing=8) 3 times per month 102 (33.7) 201 (66.3) 303 (26.1) 3-6 times/month 164 (28.2) 418 (71.8) 582 (50.1) 6-9 times/month 61 (38.1) 99 (61.9) 160 (13.8) frequency of eating rice in a month (missing=88) 3 times per month 140 (26.3) 392 (73.7) 532 (49.2) 3-6 times/month 173 (40.6) 253 (59.4) 426 (39.4) >6 times/month 56 (45.5) 67 (54.5) 123 (11.4) frequency of taking vegetables per week once of a week 50 (21.2) 186 (78.8) 236 (20.2) twice a week 81 (28) 208 (72) 289 (24.7) thrice a week 61 (28) 102 (62.6) 163 (13.9) more than 3 times a week 200 (41.6) 281 (58.4) 481 (41.1) frequency of taking fruits per week once of a week 59 (33.5) 117 (66.5) 176 (15.1) twice a week 76 (28.7) 189 (71.3) 265 (22.7) thrice a week 77 (33.3) 154 (66.7) 231 (19.8) more than 3 times a week 180 (36.2) 317 (63.8) 497 (42.5) frequency of physical activity per day in minutes central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu 10 minutes per day 319 (31.6) 691 (68.4) 1,010 (86.4) 10-30 minutes/day 61 (46.6) 70 (53.4) 131 (11.2) >30 minutes/day 12 (42.9) 16 (57.1) 28 (02.4) frequency of sedentary lifestyle per week in hours 10 hours per week 100 (42.6) 135 (57.4) 236 (20.1) 10-30 hours/week 220 (27.4) 583 (72.6) 804 (68.7) >30 hours/week 71 (55.0) 58 (45.0) 129 (11.0) frequency of walking per week in hours (missing=7) 10 hours per week 133 (35.8) 238 (64.2) 371 (31.9) 10-30 hours/week 181 (29.2) 439 (70.8) 620 (53.4) >30 hours/week 74 (43.3) 97 (56.7) 171 (14.7) saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu table 3: frequency distribution of pathophysiological risk factors for ncds of study participants (n=1,169). variables categories male (%) female (%) total (%) basic mass index (in kg/m square) underweight 6 (46.2) 7 (53.8) 13 (1.1) normal weight 144 (41.6) 202 (58.4) 346 (29.6) overweight 167 (37.5) 278 (62.5) 445 (38.1) obese 75 (20.5) 290 (79.5) 365 (31.2) central obesity (missing=14) yes 234 (48.9) 245 (51.1) 479 (41.0) no 155 (22.9) 521 (77.1) 676 (57.8) blood pressure normotensive 181 (31.9) 386 (68.1) 567 (48.5) pre-hypertensive 105 (49.1) 109 (50.9) 214 (18.3) hypertensive 106 (27.3) 282 (72.7) 388 (33.2) diabetes mellitus no 329 (32.5) 684 (67.5) 1,013 (86.7) yes 63 (40.4) 93 (59.6) 156 (13.3) diabetes mellitus and obesity both factors 18 (29.5) 43 (70.5) 61 (5.2) one factors 102 (25.6) 297 (74.4) 399 (34.1) no factors 272 (38.4) 437 (61.6) 709 (60.7) diabetes mellitus and hypertension both factors 36 (39.6) 55 (60.4) 91 (7.8) one factors 168 (32.8) 344 (67.2) 512 (43.8) no factors 188 (33.2) 378 (66.8) 566 (48.4) hypertension and obesity both factors 36 (16.8) 178 (83.2) 214 (18.3) one factors 180 (37.9) 295 (62.1) 475 (40.6) central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu no factors 176 (36.7) 304 (63.3) 480 (41.1) hypertension, obesity and diabetes mellitus all 3 factors 10 (23.8) 32 (76.2) 42 (3.6) one or 2 factors 225 (32.5) 468 (67.5) 693 (59.3) no factors 157 (36.2) 277 (63.8) 434 (37.1) saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu table 4: multivariate analysis risk factors associated with obesity, hypertension, and diabetes mellitus. obesity diabetes mellitus hypertension variables aor (95% ci) p-value a or (95% ci) p-value aor (95% ci) p-value age group <50 years 1 reference 1 reference 1 reference >50 years 1.86 1.29 2.66 <0.01 2.09 1.32 3.31 <0.01 4.10 2.97 5.65 <0.001 sex male 1 reference 1 reference 1 reference female 1.65 1.08 2.52 <0.01 0.88 0.52 1.47 >0.05 0.93 0.63 1.35 >0.05 education level literate 1 reference 1 reference 1 reference illiterate 1.24 0.86 1.80 >0.05 0.55 0.34 0.88 <0.01 1.35 0.97 1.88 >0.05 diabetes mellitus no 1 reference 1 reference yes 1.66 1.04 2.65 <0.05 1.19 0.76 1.86 >0.05 blood pressure no 1 reference 1 reference yes 2.08 1.49 2.90 <0.05 0.82 0.52 1.28 >0.05 obesity ( bmi>30) central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu no 1 reference 1 reference yes 1.64 1.02 2.63 >0.05 2.16 1.55 3.01 <0.001 central obesity no 1 reference 1 reference 1 reference yes 5.45 3.76 7.89 <0.001 1.18 0.73 1.88 >0.05 1.72 1.25 2.36 <0.001 walking habit per week >30 hours 1 reference 1 reference 1 reference <30 hours 0.81 1.10 2.99 <0.05 1.37 0.70 2.70 >0.05 1.33 0.86 2.04 >0.05 sitting 10 hours per week <10 hours 1 reference 1 reference 1 reference >10 hours 1.12 0.74 1.70 >0.05 3.52 1.78 6.96 <0.001 1.13 0.86 2.04 >0.05 mode of transportation (using car for going to work) no 1 reference 1 reference 1 reference yes 0.86 0.42 1.76 >0.05 2.16 1.04 4.48 <0.01 1.17 0.59 2.28 >0.05 using chicken as meal <3 times per month 1 reference 1 reference 1 reference >3 times per month 0.62 0.46 0.88 <0.01 0.80 0.52 1.22 >0.05 1.36 1.01 1.83 <0.05 using liquid ghee in kitchen no 1 reference 1 reference 1 reference yes 1.08 0.75 1.56 >0.05 0.35 0.22 0.54 <0.001 1.04 0.74 1.45 >0.05 red meat 3 times per month saeed this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.69 | http://cajgh.pitt.edu <3 times per month 1 reference 1 reference 1 reference >3 times per month 1.04 0.72 1.50 >0.05 1.81 1.14 2.87 <0.05 1.05 0.75 1.45 >0.05 rice 3 times per week <3 times per week 1 reference 1 reference 1 reference >3 times per week 0.85 0.65 1.19 >0.05 2.30 1.48 3.58 <0.001 1.43 1.06 1.93 <0.05 fruits twice a week <twice a week 1 reference 1 reference 1 reference >twice a week 0.92 0.65 1.30 >0.05 0.62 0.38 1.02 >0.05 1.43 1.03 1.96 <0.05 vegetable once a week <once a week 1 reference 1 reference 1 reference >once a week 0.95 0.62 1.44 >0.05 0.85 0.45 1.56 >0.05 1.28 0.87 1.88 >0.05 smoking status no 1 reference 1 reference 1 reference yes 1.66 1.04 2.65 <0.05 2.32 0.97 5.50 >0.05 1.13 0.55 2.33 >0.05 total and high-molecular-weight adiponectin levels in relation to insulin resistance among overweight/obese adults new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. total and high-molecular-weight adiponectin levels in relation to insulin resistance among overweight/obese adults sushama d. acharya1,2, rhobert w. evans2, maria m. brooks2, faina linkov2,3, lora e. burke1,2 1school of nursing, university of pittsburgh, 2graduate school of public health, university of pittsburgh, 3school of medicine, university of pittsburgh vol. 2, no. 2 (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ acharya this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu abstract objective: to determine whether baseline levels or intervention-associated changes in total and high molecular weight (hmw) adiponectin levels were associated with insulin resistance after six months of behavioral treatment for weight loss. design: an ancillary study to a behavioral weight loss trial; the intervention was delivered in group sessions. methods: participants included 143 overweight/obese adults with a mean bmi of 33.7 kg/m2. the sample was 88% female, 67% white, and 44.2 ± 8.5 years old. circulating adiponectin levels (total and hmw) and the homeostasis model assessment (homa) of insulin resistance were measured and evaluated. results: at baseline, there was significant inverse associations between total adiponectin and homa (p < 0.001) and between hmw adiponectin and homa (p < 0.001) independent of weight. at 6-mo, there was a 17% improvement in homa, 8% increase in total adiponectin, 17% increase in hmw adiponectin levels, and 8.72% weight loss (p's for all< 0.001). there was also a significant inverse association between changes in total adiponectin and homa (p = 0.04) that was independent of baseline weight and weight loss. in contrast, the association between changes in hmw adiponectin and homa was attenuated after adjustment for weight loss. conclusions: an increased level of total adiponectin was associated with improved insulin sensitivity, regardless of baseline weight and weight loss. however, baseline total and hmw adiponectin levels were more strongly associated with homa than changes in these measures at six months. hmw adiponectin level was not related more closely to insulin resistance than total adiponectin level. keywords: adiponectin, high molecular weight adiponectin, insulin resistance, homeostasis model assessment of insulin resistance (homa), weight loss and adiponectin levels total and high-molecular-weight adiponectin levels in relation to insulin resistance among overweight/obese adults sushama d. acharya1,2, rhobert w. evans2, maria m. brooks2, faina linkov2,3, lora e. burke1,2 1school of nursing, university of pittsburgh, 2graduate school of public health, university of pittsburgh, 3school of medicine, university of pittsburgh research obesity is a significant public health problem with recent data indicating more than 1.4 billion overweight adults worldwide and nearly two-thirds of the global population living in countries where overweight and obesity affect mortality more than underweight. 1 as obesity is a major risk factor for the development of insulin resistance (ir) and associated metabolic diseases including hypertension, hyperlipidemia, atherosclerosis, and certain types of cancer, significant research has been conducted to understand obesity mechanisms related to pathogens of these diseases. it is now evident that adipose tissue is no longer considered an inert tissue mainly devoted to energy storage but is now recognized as an active http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu endocrine organ secreting several hormones and a diverse range of other protein factors. 2 adiponectin is one of the many hormones secreted by adipose tissue as the adipokine in the human body. ir and obesity are both associated with lower plasma adiponectin concentrations suggesting its important physiological role. 3 improvements in ir, glucose uptake in skeletal muscles and hepatic fatty acid oxidation upon administration of adiponectin in animal studies suggest that adiponectin may provide a link between adiposity, ir and diabetes. 4 figure 1 depicts a proposed mechanism linking adiposity and adiponectin with ir and diabetes. figure 1. proposed link among adiposity, adiponectin, insulin resistance and diabetes. a strong inverse relationship between adiponectin and ir has been reported in population cross-sectional studies. 5-7 moreover, longitudinal data also suggest a relationship between lower adiponectin levels and the development of ir and diabetes. in a study of pima indians, those with high adiponectin concentration were found to be at a lower risk of developing diabetes than those with a low concentration, suggesting a potential role of adiponectin in the pathogenesis of diabetes. 8 similarly, an inverse association between adiponectin and diabetes risk was reported among a large population of healthy women, 9 a middle-aged population cohort, 10 and adults with insulin-resistance. 11 mather et al. reported baseline adiponectin as a better marker of diabetes prevention than changes in adiponectin levels over one year in the diabetes prevention program (dpp). 12 however, no association was found between adiponectin and ir despite improved insulin sensitivity in response to weight loss among obese women, 13 obese adults, 14 and insulin resistant adults who were not diabetic. 15 additionally, part of the difficulty also is that despite short term weight loss, successful long-term weight loss maintenance is extremely difficult as most individuals regain most of their weight with a few years. 16 because of these variations due to population, sample size, differences in baseline degree of insulin resistance, and adiponectin, the evidence provided by these studies on the relationship between ir and adiponectin in the presence of weight loss remains equivocal. adiponectin exists in circulation in three distinct forms: low molecular weight (lmw), medium molecular weight (mmw), and high molecular weight (hmw) forms. 3,17 hmw adiponectin has been suggested to be the most active form of adiponectin and more closely associated with ir with an ability to enhance insulin action. 18,19 however, a major limitation of many epidemiological and intervention studies is the measurement of only total adiponectin level. thus, little is known about how the relationship between hmw adiponectin and ir might differ from the relationship between total adiponectin and ir. hence, the aims of this study were to determine whether baseline levels or intervention-associated changes in total and hmw adiponectin levels were associated with ir after 6 months of behavioral treatment for weight loss. materials and methods study design this was an ancillary study to the prefer trial, an 18-month behavioral weight loss study designed to evaluate the effects of treatment preference (preference-yes vs. preference-no) and two dietary treatment options, standard calorie restricted low fat diet (std-d) vs. lacto-ovo-vegetarian diet (lov-d). participants were randomly assigned first to one of the two preference conditions (yes or no). if assigned to the preference-no condition, they were further randomly assigned to one of the two diet conditions, std-d or http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx acharya this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu lov-d. if assigned to preference-yes condition, they were assigned to the diet they indicated as preferred at screening. the design, recruitment, and randomization procedures for the prefer trial have been described in detail elsewhere. 20 refer to figure 2 for the number of participants at each stage. the study protocol was approved by the university of pittsburgh institutional review board; all participants provided written informed consent. the prefer trial was conducted between 2000 and 2005, and unthawed aliquots of serum samples were stored at -80 0 c. the current analysis was limited to the 143 participants whose sera samples were available from baseline and 6-month assessments. figure 2. prefer trial flowchart (included only 6-mo assessment). participants the study population included adults between 18 and 55 years of age, a body mass index (bmi) between 27 and 43 kg/m 2 inclusively, and adequately completed a 5-day food diary at screening. individuals were excluded if they had diabetes or a medical condition requiring physician supervision of diet or physical activity, were pregnant, participated in a behavioral or pharmacological weight-loss program in the last 6 months, reported alcohol intake of ≥ 4 drinks per day, and reported abstention from eating meat, poultry, or fish in the past month. intervention all four treatment groups received the same standard behavioral intervention. the only difference between the diet groups was that the lov-d participants were instructed to eliminate meat, poultry, and fish form their diet by the 6th week of the program. details of the intervention have been reported elsewhere. 20 in brief, all participants received a daily energy and fat gram goal based on gender and baseline body weight as described in table 1. participants were instructed to increase their physical activity gradually, primarily via walking, until they reached a goal of 150 minutes by week 6. as an alternative to walking, aerobic activities such as bicycling, swimming, and jogging were encouraged. use of frequent, short bouts to meet one’s exercise goal, for example exercising for 10–15 minutes three times per day, was also promoted. the intervention group sessions were held weekly during the first six months. the cognitive-behavioral intervention used several strategies from models of motivation and behavior change. all participants received nutritional and behavioral counseling and were provided with practical hands-on experience to develop skills to implement a healthy lifestyle. all participants self-monitored their daily energy and fat intake, as well as physical activity (duration and type) they performed during the study period. table 1. daily dietary goals. measures baseline demographic characteristics were collected via a self-administered, standardized questionnaire. all anthropometric, biochemical, and adiponectin measurements were obtained at baseline and 6 months. weight was measured on a digital scale (tanita corporation of america, inc., il) in light clothing and without shoes. height was measured with a wall-mounted stadiometer. the physical activity assessment was conducted via a self-administered paffenbarger activity questionnaire. 21 this questionnaire has been shown to have good test-retest reliability. a metabolic equivalent value was assigned to each leisure activity, from which the total energy http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu expenditure was calculated. blood samples, obtained following a 12-hour fast were assayed at the heinz nutrition laboratory, university of pittsburgh. plasma glucose was measured with the use of the hexokinaseglucose 6-phosphate dehydrogenase enzymatic assay (sigma diagnostics, st. louis, mo), and insulin concentration was measured by a radioimmunoassay kit (linco research, st. charles, mo). insulin resistance was assessed by homeostasis model assessment of insulin resistance (homa-ir) and was calculated as fasting insulin concentration (u/ml) x fasting glucose concentration (mmol/l)/22.5. homa is a mathematical assessment of the balance between hepatic glucose output and insulin secretion and has been widely validated and applied for quantifying insulin resistance and β-cell function. serum levels of total and hmw adiponectin were determined using the elisa technique (alpco diagnostics, salem, nh). the intraassay and inter-assay cvs were 6.4% and 12.7% for total adiponectin and 6.4% and 12.6% for hmw adiponectin, respectively. all samples were assayed in duplicate. statistical analysis statistical analyses were performed using sas (version 9.2; sas institute inc, cary, nc). all continuous variables were checked for normality. basic statistics were expressed as mean ± sd or as proportions, unless otherwise specified. for all continuous variables, comparisons between baseline and 6-month measures were examined using a paired sample’s t-test. a chi-square test was performed for comparing the categorical variables at baseline. associations between continuous variables were assessed using the pearson or spearman correlation coefficient. separate multiple linear regression models were used for homa at baseline and change in homa score (6-month – baseline scores) as the dependent variables to examine associations between total and hmw adiponectin at baseline and 6 months. the models were adjusted for age, gender, race, baseline weight, baseline energy expenditure, changes in weight, and energy expenditure. all tests performed were twosided, and significance level was set at p < 0.05. results of the 176 participants randomized at baseline, 151 completed the 6-month assessment, and the sera samples of 143 (95%) participants were available from both baseline and 6-month assessments. the majority of participants were female (88%), white (67%), currently married or living with a partner (65%), and employed (94%). the mean age was 44.2 ± 8.5 years old with a bmi range of 26.71 to 42.56 kg/m 2 (mean= 33.78 kg/m 2 ) and, on average, 15.3 years of formal education. no differences in baseline characteristics were found between participants who were excluded and those included in the analysis. there was no significant difference in homa between the two diet groups; stdd vs. lov-d (4.28 ± 2.15 vs. 4.62 ± 2.32; p = 0.3), nor were there differences by the two preference groups; preference-yes vs. preference-no (4.60 ± 2.18 vs. 4.28 ± 2.27; p = 0.4). additionally, there were no significant differences in total adiponectin level by diet group (7.82 ± 3.74 vs. 7.64 ± 2.87 ug/ml; p = 0.7) or preference group (7.76 ± 3.57 vs. 7.62 ± 7.66 ug/ml; p = 0.7), nor did hmw adiponectin level differ by diet group (3.33 ± 2.21 vs. 3.23 ± 1.68 ug/ml; p = 0.8) or preference group (3.30 ± 1.97 vs. 3.23 ± 20.01; p = 0.8). since there were no significant differences between the two diet groups and the two preference groups, further analyses were conducted as a single sample without regard to randomized diet or preference condition. at baseline, homa did not differ by gender (female vs. male: 4.36 ± 2.23 vs. 4.97 ± 2.24; p = 0.3) or race (white vs. non-white: 4.47 ± 2.34 vs. 4.33 ± 20.00; p = 0.7). however, females had significantly higher http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx acharya this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu total (7.85 ± 3.32 vs. 6.31 ± 2.58 ug/ml; p = 0.04) and hmw adiponectin levels (3.37 ± 2.9 vs. 2.39 ± 1.43 ug/ml; p = 0.03) than males. figure 3 describes the baseline and 6-month measures of the studied variables. from baseline to 6 months, there was a 17% reduction in homa (p < 0.001), 8% increase in total adiponectin (p = 0.001), and 17% increase in hmw adiponectin levels (p < 0.001). further, there was a significant weight loss (8.72%) at 6 months (p < 0.001). there were highly significant correlations between total and hmw adiponectin levels at baseline (r = 0.95; p < 0.001) and also at 6 months (r = 0.95; p < 0.001). at baseline and 6 months, weight, bmi, glucose, and insulin showed significant positive associations with the homa score while total and hmw adiponectin levels showed significant negative association with homa (p for all < 0.001). figure 3. measures at baseline and 6-month assessments. separate multiple regression analyses were performed for both baseline and 6-month measures with baseline homa and the change in homa scores as the dependent variables, respectively. the final model, with baseline measures adjusted for weight, indicated significant inverse associations between total adiponectin and the homa score (p < 0.001) and between hmw adiponectin and homa (p < 0.001). the estimates for total and hmw adiponectin still remained highly significant after adjustment for baseline weight (table 2). at 6 months, the final regression model revealed a significant inverse association between changes in total adiponectin and homa (p = 0.04) that was independent of baseline weight and weight loss. in contrast, higher hmw adiponectin was associated with improvements in the homa score without weight loss in the model (p = 0.02), but the association was no longer significant after adjustment for weight loss (table 3). additional adjustment for energy expenditure at baseline and 6 months did not alter the results. table 2: multiple regression models of total and hmw adiponectin levels on baseline homa measure (n = 143). table 3: multiple regression models of total and hmw adiponectin levels on change in homa measure at 6 months (n = 143). discussion a better understanding of the extent of the association of adiponectin with ir in obesity might help clarify mechanisms of insulin sensitivity, which in turn, might be beneficial in identifying preventive approaches to enhance insulin sensitivity and thereby reduce the risk for developing diabetes. the study's findings revealed that the higher baseline levels of total and hmw adiponectin levels were significantly associated with lower homa score, independent of body weight. at 6 months there were significant reductions in the homa score and weight, which paralleled the improvements in total and hmw adiponectin levels. the increase in total adiponectin was inversely associated with a decrease in the homa score independent of baseline weight and weight change. however, the significant association between changes in hmw adiponectin level and the homa score was attenuated after adjustment for weight change. there were significant inverse associations of total and hmw adiponectin levels with the homa score at baseline, even after adjusting for baseline weight, indicating an independent association of total and hmw adiponectin levels with the homa score http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu regardless of the degree of obesity. the association between total adiponectin and homa is consistent with findings from previous studies among individuals with type 2 diabetes, 22 a representative community adult population, 6 and a community-based cohort with and without the metabolic syndrome. 5 the dpp study also reported an inverse association between baseline total adiponectin levels and future diabetes independent of baseline adiposity among individuals at increased risk for diabetes. 12 the findings suggest the persistence of an independent role of not only total adiponectin but also hmw adiponectin levels in relation to ir among a generally healthy overweight/obese population with no diabetes or clinical vascular disease. the association between changes in total and hmw adiponectin levels and homa scores were examined separately after 6 months of intervention. the degree of univariate association between homa and total and hmw adiponectin levels at both baseline and 6 months remained unchanged. there were intervention-associated significant reductions in weight, the homa score and improvements in total, and hmw adiponectin levels. the increase in total and hmw adiponectin was associated with the change in weight suggesting that change in total and hmw adiponectin levels might reflect body weight change. the multiple regression analysis showed that an increased level of total adiponectin contributed to improved insulin sensitivity independent of baseline weight and change in weight. although the estimate for change in total adiponectin decreased by 34% when change in weight was added to the model, these results indicate that improvements in total adiponectin level contributed to improved insulin sensitivity above the usual clinical markers of diabetes. the present study highlights the importance of adiponectin in the development of ir and subsequent development of type 2 diabetes. thus, interventions, such as the one used in this study, that target weight loss and increase total adiponectin levels may improve insulin sensitivity and reduce the risk of diabetes for overweight individuals. a few studies have reported hmw adiponectin to have a stronger association than total adiponectin level in the incidence of type 2 diabetes 23,24 and insulin sensitivity. 17-19,25 most of these studies either had only a single measurement of hmw adiponectin level, 19,23-25 were limited by the small sample size, 15,17,18 or had a pharmacological intervention. 26 there was a highly significant association between total and hmw at baseline. bluher et al. reported no superiority of hmw adiponectin over total adiponectin values in predicting insulin sensitivity. 27 likewise, the study results also showed a similar magnitude of correlations between both total and hmw adiponectin levels with the homa score at baseline suggesting no clinical differences between total and hmw adiponectin levels in relation to insulin resistance. at 6 months, the significant association between changes in hmw adiponectin level and homa was attenuated after adjustment for change in weight and was no longer significant, despite an increase in hmw adiponectin that was more than double the increase in total adiponectin. this finding indicates a possible threshold level of hmw adiponectin that might be needed to have an independent effect on change in the homa score. alternatively, a different pathway of an interventionassociated change in hmw adiponectin level from the baseline hmw adiponectin level could not be ruled out as a possibility. regardless of the mechanism, the study refutes the hypothesis of a predominant role of hmw adiponectin level over total adiponectin level in relation to ir. the study also provided a unique opportunity to examine if baseline or intervention associated changes in total and hmw adiponectin levels were more strongly associated with ir. the degree of association between total and hmw adiponectin level were stronger at baseline than the relationship between http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx acharya this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu changes in total adiponectin and the homa score at 6 months. moreover, the significant association between change in hmw adiponectin level and homa score was taken over by weight loss. consistent with the findings of mather et al., 12 baseline total and hmw adiponectin levels were more closely related to ir than the changes in these measures at 6 months. the potential mechanism of how plasma adiponectin levels influence ir is still not known. a higher level of adiponectin level has been reported to increase fatty acid oxidation with subsequent reduction of triglycerides thereby directly sensitizing the body to insulin and reserving ir in animal models of obesity and diabetes 28 and in humans. 25 through in vitro studies, adiponectin has been shown to trigger the protein kinase, an insulin independent enzyme known to stimulate glucose use and increase fatty acid oxidation in skeletal muscle. 4 it has been reported that some inflammatory markers, such as tumor necrosis factor-α, interleukin-6 or c-reactive protein have an adiponectin inhibitory effect, which in turn may lead to ir. 7,29 it is possible that the levels of these markers decrease with the corresponding increase in adiponectin levels with weight loss and may improve insulin sensitivity. a main limitation of the study included a measure of ir with a surrogate marker. however, homa derived from the mathematical model has been shown to be an adequate indicator of ir and has been used in many epidemiological and clinical studies. also, the generalizability of these findings may be limited due to the relatively homogenous study population; however, the minority representation exceeded that of the local community. the strengths of the study included the measurements of both total and hmw adiponectin. an additional strength was its longitudinal design and examination of the relationship between total and hmw adiponectin levels with ir cross-sectionally and over time. moreover, the clinical measures were obtained via a standardized protocol and assays were performed with good precision and the study included a larger sample than what has been reported in the literature. conclusions an increased level of total adiponectin contributed to improved insulin sensitivity regardless of baseline weight and weight loss. however, the association of change in total adiponectin and homa score was modest compared to baseline measures suggesting that the cross-sectional measure of total adiponectin might be a comparable indicator of ir and subsequent risk of developing diabetes among overweight or obese adults. these findings provide support for the importance of adiponectin levels and a need for their improvements to prevent diabetes. thus, interventions that enhance adiponectin secretion or action may have potential for diabetes risk reduction. improvements in the hmw adiponectin level were largely explained by the weight loss suggesting the role of hmw adiponectin level is no more important than that of total adiponectin in relation to improved insulin sensitivity. these findings provide evidence for the importance of weight loss as a significant public health preventive measure to enhance adiponectin levels among the studied population, which could impact the progression of atherosclerosis and associated metabolic diseases. acknowledgements thank you to the participants of the smart trial for their time; the project director, mindi styn, phd and the data manager, edvin music, msis. the ancillary study was supported by the 5 th annual epidemiology small grant program, university of pittsburgh graduate school of public health, department of epidemiology. the parent study was http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu supported by the following grants: niddk, #ro1dk58631 and partial support by nih k24 award, nr010742. the conduct of the study was also supported by the data management core of the center for research in chronic disorders nih-ninr #p30nr03924, the obesity and nutrition research center nih-niddk #dk-046204, and the general clinical research center, nih-ncrr-gcrc #5mo1-rr00056 at the university of pittsburgh. a poster based on these data was presented at the 50 th annual american heart association epidemiology and prevention council/nutrition physical activity and metabolism conference in san francisco, ca on 5 th march 2010. references 1. world health organization. obesity and overweight fact sheet. http://www.who.int/mediacentre/factsheets/fs311/en/. accessed 2013 aug 10. 2. trayhurn p, wood is. adipokines: inflammation and the pleiotropic role of white adipose tissue. br j nutr. 2004 sep;92(3):347-355. 3. arita y, kihara s, ouchi n, et al. paradoxical decrease of an adipose-specific protein, adiponectin, in obesity. biochem biophys res commun. 1999 apr 2;257(1):79-83. 4. yamauchi t, kamon j, minokoshi y, et al. adiponectin stimulates glucose utilization and fatty-acid oxidation by activating amp-activated protein kinase. nat med. 2002 nov;8(11):1288-1295. 5. hivert mf, sullivan lm, fox cs, et al. associations of adiponectin, resistin, and tumor necrosis factor-alpha with insulin resistance. j clin endocrinol metab. 2008 aug;93(8):3165-3172. 6. hung j, mcquillan bm, thompson pl, beilby jp. circulating adiponectin levels associate with inflammatory markers, insulin resistance and metabolic syndrome independent of obesity. int j obes (lond). 2008 may;32(5):772-779. 7. mojiminiyi oa, abdella na, al arouj m, ben nakhi a. adiponectin, insulin resistance and clinical expression of the metabolic syndrome in patients with type 2 diabetes. international journal of obesity. 2007;31(2):213-220. 8. lindsay rs, funahashi t, hanson rl. adiponectin and development of type 2 diabetes in the pima indian population. lancet. 2002;360:57-58. 9. heidemann c, hoffmann k, spranger j, et al. a dietary pattern protective against type 2 diabetes in the european prospective investigation into cancer and nutrition (epic)-potsdam study cohort. diabetologia. 2005 jun;48(6):11261134. 10. saltevo j, laakso m, jokelainen j, keinanenkiukaanniemi s, kumpusalo e, vanhala m. levels of adiponectin, c-reactive protein and interleukin-1 receptor antagonist are associated with insulin sensitivity: a populationbased study. diabetes metab res rev. 2008 julaug;24(5):378-383. 11. o'leary vb, jorett ae, marchetti cm, et al. enhanced adiponectin multimer ratio and skeletal muscle adiponectin receptor expression following exercise training and diet in older insulin-resistant adults. am j physiol endocrinol metab. 2007 jul;293(1):e421-427. 12. mather kj, funahashi t, matsuzawa y, et al. adiponectin, change in adiponectin, and progression to diabetes in the diabetes prevention program. diabetes. 2008 apr;57(4):980986. 13. polak j, kovacova z, jacek m, et al. an increase in plasma adiponectin multimeric complexes follows hypocaloric diet-induced weight loss in obese and overweight premenopausal women. clin sci (lond). 2007 jun;112(11):557565. 14. xydakis am, case cc, jones ph, et al. adiponectin, inflammation, and the expression of the metabolic syndrome in obese individuals: the impact of rapid weight loss through caloric restriction. j clin endocrinol metab. 2004 jun;89(6):2697-2703. 15. abbasi f, chang sa, chu jw, et al. improvements in insulin resistance with weight loss, in contrast to rosiglitazone, are not associated with changes in plasma adiponectin or adiponectin multimeric complexes. am j physiol regul integr comp physiol. 2006 jan;290(1):r139-144. 16. wing rr, phelan, s. long-term weight loss maintenance. am j clin nutr. 2005;82(suppl.):222s-225s. 17. bobbert t, rochlitz h, wegewitz u, et al. changes of adiponectin oligomer composition by moderate weight reduction. diabetes. 2005 sep;54(9):2712-2719. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/mediacentre/factsheets/fs311/en/ acharya this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu 18. fisher ff, trujillo me, hanif w, et al. serum high molecular weight complex of adiponectin correlates better with glucose tolerance than total serum adiponectin in indo-asian males. diabetologia. 2005 jun;48(6):1084-1087. 19. hara k, horikoshi m, yamauchi t, et al. measurement of the high-molecular weight form of adiponectin in plasma is useful for the prediction of insulin resistance and metabolic syndrome. diabetes care. 2006 jun;29(6):1357-1362. 20. burke le, choo j, music e, styn ma, steenkiste ar, warziski m. prefer study: a randomized clinical trial testing treatment preference and two dietary options in behavioral weight management-rationale, design and baseline characteristics. contemp clin trials. 2006;27:34-48. 21. ainsworth be, haskell wl, whitt mc, et al. compendium of physical activities: an update of activity codes and met intensities. med sci sports exerc. 2000 sep;32(9 suppl):s498504. 22. weyer c, funahashi t, tanaka s, et al. hypoadiponectinemia in obesity and type 2 diabetes: close association with insulin resistance and hyperinsulinemia. j clin endocrinol metab. 2001 may;86(5):1930-1935. 23. heidemann c, sun q, van dam rm, et al. total and highmolecular-weight adiponectin and resistin in relation to the risk for type 2 diabetes in women. ann intern med. 2008 sep 2;149(5):307-316. 24. nakashima r, kamei n, yamane k, nakanishi s, nakashima a, kohno n. decreased total and high molecular weight adiponectin are independent risk factors for the development of type 2 diabetes in japanese-americans. j clin endocrinol metab. 2006 oct;91(10):3873-3877. 25. lara-castro c, luo n, wallace p, klein rl, garvey wt. adiponectin multimeric complexes and the metabolic syndrome trait cluster. diabetes. jan 2006 jan;55(1):249-259. 26. salani b, briatore l, andraghetti g, adami gf, maggi d, cordera r. high-molecular weight adiponectin isoforms increase after biliopancreatic diversion in obese subjects. obesity (silver spring). 2006 sep;14(9):1511-1514. 27. bluher m, brennan am, kelesidis t, et al. total and highmolecular weight adiponectin in relation to metabolic variables at baseline and in response to an exercise treatment program: comparative evaluation of three assays. diabetes care. 2007 feb;30(2):280-285. 28. haluzik m, parizkova j, haluzik mm. adiponectin and its role in the obesity-induced insulin resistance and related complications. physiol res. 2004;53(2):123-129. 29. bruun jm, lihn as, verdich c, et al. regulation of adiponectin by adipose tissue-derived cytokines: in vivo and in vitro investigations in humans. am j physiol endocrinol metab. 2003 sep;285(3):e527-533. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx acharya this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu table 1. daily dietary goals. baseline weight (lbs) prescribed daily goals energy intake (kcal) total fat intake (g)* male female male female < 200 1500 1200 42 33 ≥ 200 1800 1500 50 42 * 25% of the total energy intake for everyone. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx acharya this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu table 2: multiple regression models of total and hmw adiponectin levels on baseline homa measure (n = 143). models baseline homa r 2 models baseline homa r 2 estimate s.e. p estimate s.e. p model 1 adiponectin (ug/ml) -0.28 0.05 < 0.001 0.17 model 1 hmw (ug/ml) -0.42 0.09 < 0.001 0.14 model 2 adiponectin (ug/ml) gender race age (yr) -0.29 -0.12 -0.40 -0.02 0.05 0.55 0.37 0.02 < 0.001 0.83 0.28 0.27 0.18 model 2 hmw (ug/ml) gender race age (yr) -0.45 -0.10 -0.52 0.01 0.09 0.56 0.38 0.02 < 0.001 0.85 0.17 0.40 0.15 model 3 adiponectin (ug/ml) gender race age (yr) weight (kg) -0.26 0.45 -0.46 0.02 0.06 0.05 0.34 0.01 0.02 0.01 < 0.001 0.39 0.18 0.20 < 0.001 0.30 model 3 hmw (ug/ml) gender race age (yr) weight (kg) -0.38 0.44 0.55 0.02 0.06 0.09 0.54 0.36 0.02 0.01 < 0.001 0.42 0.12 0.32 < 0.001 0.27 hmw= high molecular weight; homa= homoeostasis model assessment of insulin resistance. reference groups: gender-males, racewhite http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu table 3: multiple regression models of total and hmw adiponectin levels on change in homa measure at 6 months (n = 143). models change in homa r 2 models change in homa r 2 estimate s.e. p estimate s.e. p model 1 adiponectin δ (ug/ml) -0.25 0.09 0.004 0.06 model 1 hmw δ (ug/ml) -0.34 0.14 0.02 0.04 model 2 adiponectin δ (ug/ml) gender race age (yr) -0.25 0.95 0.38 0.01 0.08 0.43 0.29 0.01 0.005 0.03 0.20 0.9 0.11 model 2 hmw δ (ug/ml) gender race age (yr) -0.32 0.99 0.33 0.0003 0.15 0.43 0.30 0.01 0.03 0.02 0.28 0.98 0.09 model 3 adiponectin δ (ug/ml) gender race age (yr) baseline weight (kg) -0.26 0.64 0.44 -0.000 -0.03 0.09 0.43 0.29 0.02 0.009 0.003 0.14 0.13 0.97 0.003 0.16 model 3 hmw δ (ug/ml) gender race age (yr) baseline weight (kg) -0.34 0.68 0.38 -0.001 -0.03 0.15 0.44 0.29 0.02 0.009 0.02 0.12 0.19 0.92 0.003 0.14 model 4 adiponectin δ (ug/ml) gender race age (yr) baseline weight (kg) weight δ (kg) -0.17 0.06 0.46 0.0005 -0.03 0.10 0.08 0.42 0.27 0.01 0.009 0.02 0.04 0.88 0.09 0.97 0.005 < 0.0001 0.27 model 4 hmw δ (ug/ml) gender race age (yr) baseline weight (kg) weight δ (kg) -0.18 0.10 0.40 0.000 -0.02 0.10 0.14 0.48 0.27 0.01 0.008 0.02 0.21 0.82 0.14 0.99 0.006 < 0.0001 0.26 hmw=high molecular weight; homa= homoeostasis model assessment of insulin resistance; δ=change. changes values were defined as 6 months baseline. reference groups: gender-males, racewhite http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx acharya this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu figure 1. proposed link among adiposity, adiponectin, insulin resistance and diabetes. obesity ↑ adiposity ↓ adiponectin ↓ glucose uptake ↑ gluconeogenesis (muscle) (liver) insulin resistance diabetes http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu figure 2. prefer trial flowchart (included only 6-mo assessment). screened for eligibility by phone (n=932) sent screening packets (n=425) returned 5-day food diary (n=218) invited to information session (n=298) attended baseline assessment (n=204) randomized (n=200) prefer no prefer yes sbt (n=48) completed 6-month assessment (n=42, 87.5%) sbt+lov (n=35) completed 6month assessment (n=29, 82.9%) (n=29, 82.9%) (n=29, 82.9%) sbt (n=48) completed 6-month assessment (n=41, 85.4%) (n=41, 85.4%) sbt+lov (n=45) completed 6-month assessment (n=39, 86.7%) (n=39, 86.7%) discarded (n=15) ineligible (n=9) included in this ancillary study (n=143)* std-d = standard diet; lov-d = lacto-ovo-vegetarian diet *blood samples on 94.7% of participants who attended the 6-mo assessment were stored and analyzed http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx acharya this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.55 | http://cajgh.pitt.edu figure 3. measures at baseline and 6-month assessments. 1 10 100 1000 baseline 6-mo weight (kg) bmi (kg/m2) glucose (mg/dl) insulin (uu/mg) homa adiponectin (ug/ml) hmw (ug/ml) * * o * * * * * * * + http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx the central asian supercourse to increase scientific productivity the central asian supercourse to increase scientific productivity faina linkov1, robert guzman2, sean soisson3, kyle e. freese1, aamir h. sheikh4, eugene shubnikov5, ronald e. laporte6 1magee-women’s research institute, university of pittsburgh; 2ischool, university of pittsburgh; 3gynecologic oncology, magee-women’s hospital; 4dietrich school of arts and sciences, university of pittsburgh; 5research scientist, institute of internal medicine, novosibirsk, russia; 6graduate school of public health, department of epidemiology, university of pittsburgh editorial keywords: supercourse, central asia, caren, mobile global health introduction to central asia the central asian countries of uzbekistan, turkmenistan, kazakhstan, tajikistan and kyrgyzstan are tied together with similar histories and genetic heritage. historically, these countries formed from nomadic populations along the silk road with common cultures, religions, and languages. they also have similar health patterns and life expectancies (uzbekistan, 67.2, kazakhstan, 67.0, tajikistan, 66.7, kyrgyzstan, 65.9 and turkmenistan, 63.2) which are near to the global average life expectancy.1 figure 1: the countries of central asia since world war ii, central asian countries have demonstrated a rapid increase in life expectancy, although there is still a large gap between genders.2 each country underwent the epidemiological transition, where life expectancy rose due to a major reduction of infectious diseases and an unmasking of chronic diseases including: diabetes,3 cardiovascular disease, cancer, stroke, copd, and injuries. mortality patterns are virtually the same across central asia4 with variations attributed mainly to differences in lifestyles.5 research in central asia overall, these countries have had little research collaboration despite sharing similar geographic locations environments, and migration patterns. central asian scientific productivity was determined by examining the publication rates for the five central asian countries (table 1). every country is well below the average worldwide publication rate of countries across the world. countries such as ukraine (ranked 38 among all un recognized countries), malaysia (43), and kenya (65) have substantially higher productivity than central asian countries.6 table 1: the rate of publication for the central asian countries and their ranking worldwide. country ranking number of scientific publications uzbekistan 80 6021 kazakhastan 91 4153 krygyzstan 141 735 tajikistan 145 676 turkmenistan 186 123 the publication numbers presented in table 1 represent data from 1993-2010. there are only about 450 publications per year from uzbekistan and only nine per year from the entire country of turkmenistan. the five central asian countries average only 180 articles per year. in contrast, the annual rate of publication in the u.s. is 409,430 per year, over 2,200 times greater than the average publications per year in each of the central asian countries. as presented in figure 2, there are countries that are adjacent to central asian countries, such as iran, with 40 times the number of articles published (9,257 per year) and pakistan with 11 times more, 2,944 per year).6 figure 2: comparison of number of publications from countries adjacent to central asia and the countries of central asia. the scientific disciplines of these publications are similar across these countries. the majority are in physics, chemistry, mathematics, and to a lesser extent, agriculture. there is a paucity of publications in medicine, public health, and social sciences. clearly, it is important to boost the scientific culture of these countries, especially in the little represented areas. scientific hope despite the rates of publications being low, there has been a significant increase since 1993, as shown in figure 3. in uzbekistan and kazakhstan, the rise has been substantial, with close to a 100% increase in the number of publications. moreover, scientists in all five countries have begun collaborating with each other in other countries in the region, as seen in figure 4. this has nearly doubled international collaboration for all countries in the region. additionally, over 50% of the articles produced have authors from more than one country. this clearly demonstrates that there is an interest and desire for regional collaboration.6 figure 3: articles published in the central asian countries by year. figure 4: the percentage of articles written in the central asian countries which are written with a co-author from another country. the general conclusion is that rates of scientific productivity are relatively low in central asia and that focus has been almost exclusively on the "hard sciences" with little global health and behavioral research. however, we are seeing a rise in scientific productivity as well as an interest in international collaboration. the supercourse team’s role our mission is to build capacity to improve scientific productivity in central asian countries. we hope to double the number of publications coming from the region in the next five years through building a global network of scientists, fostering research training, and providing access to broadband connectivity for scientific communication and the sharing of knowledge. the first element required to improve scientific productivity is to provide networking for the universities in this region. this will lead to the free flow of ideas within and across borders. secondly, it it is necessary to build a system that will provide training in research. this will be accomplished by creating programs and bolstering classroom research training by creating a central asian supercourse. finally a human scientific network in these countries will enable people to learn from each other within their countries, the region, and with the world. caren: (central asian research and education network) the implementation of fiber optic networking for universities in the region will facilitate collaboration between investigators at multiple institutions and will improve research capacity. launched in january 2009, the central asian research and education network (caren) is a high-capacity regional research and education network that provides high-speed internet for universities and research centers. the caren project, which evolved from the silk project funded by the european commission (ec), is nearing completion. the goal of this project is to improve research collaboration within the region and worldwide. this fiber optic backbone provides the superhighway for research and training programs.7 to date, caren has networked over one-million users in more than 200 universities and facilitates joint regional and global projects. the user communities for caren include: distance learning, environmental studies, seismology, telemedicine, and textile research. the caren project will next link central asia and europe to connect researchers across the world, increasing the collaboration and fostering development.4 the central asian supercourse supercourse is a unique combination of a human network and a digital network containing state of the art content about global health and prevention the supercourse model is very simple. the central asian scientific supercourse team has built a global network of over 50,000 primarily academic faculty members from 174 countries. the network contains 4855 powerpoint lectures including: 77 from nobel prize laureates, 300 from iom/nas members, several lectures from the past two directors of the nih and cdc, and the us surgeon general. on average, each of the authors in the supercourse has published 100 articles.8 these lectures can be distributed to faculty across the world, and can be used to compile cohesive lectures and presentations from disparate sources. for example, and educator using supercourse might select five slides from peter bennett, an expert on diabetes, eight from their own lectures, and ten from scientists in europe. through the supercourse, teachers are empowered by having access to current, state-of-the-art lecture material. there are 31 different languages represented in the supercourse, with over 200 lectures in russian, and several in uzbek and turkmen. the central asian journal of global health (cajgh.pitt.edu) is a product of extensive scientific networking and capacity of the supercourse project. utilization of supercourse in central asia scientists from central asia are already participating in the supercourse. over 60 faculty members from the region are involved (200 accessing the site within the past 12 months), with most of the lectures from within the region coming from kazakhstan. in addition, all of the medical schools in the region are connected with the supercourse and to each other via caren. supercourse is a two-way street on which scientists in central asia and around the globe share their knowledge. we have already seen the benefits of this exchange through the 46 outstanding lectures prepared by participating faculty. these lectures were of interest to the world as they received 913 page views from outside the region, primarily from europe and the u.s. clearly, there is an interest in building research capacity as well as in sharing knowledge within the region. the central asian supercourse facilitates network fulfills this need. the origins of the central asian supercourse can be found at: http://www.pitt.edu/~super1/faculty/centralasia.htm. its growth will be monitored as it becomes connected to the caren network. mobile global health the field of "mobile global health" represents the applications of cellular telephone technology to global health and prevention. it is expected that the number of cell phones will be equal to the number of people on earth in the next five years, which means that the vast majority of the global population will be accessible via cell phone. there are especially exciting implications for this trend in central asia, where cell phone use is already rising as shown in figure 5.9,10 figure 5: the number of cell phone subscriptions (in millions) for each of the central asian countries. furthermore, supercourse developer eric marler has been capturing all the phone applications pertaining to science.11 in just the last few months, nine applications have appeared from central asia; however, none of these are for science, and instead are focused on the travel industry. conclusion the central asian countries of uzbekistan, turkmenistan, kazakhstan, tajikistan and kyrgyzstan are primed for an increase in scientific productivity, measured by anticipated increase in peer reviewed scientific publications. since the use of cellular/mobile devices is increasing in central asia, we support establishing a new field called "mobile global health". with the help of the caren project and our central asian supercourse team, the region will be able to utilize computer and human networks in order to share scientific research and reach out to each other and around the world. references 1. life expectancy at birth. the world factbook [internet]. 2009 [cited 2013 mar 15]. available from: https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html. 2. cashin c, borowitz m, zuess o. the gender gap in primary health care resource utilization in central asia. health policy plan. 2002;17(3):264-72. 3. danaei g, finucane mm, lu y, singh gm, cowan mj, paciorek cj; et al. national, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. lancet. 2011 jul 2;378(9785):31-40. 4. laporte re. epidemiologic transition [internet]. pittsburgh, pa: university of pittsburgh; 2000 [updated 2006 mar 3; cited 2013 mar 15]. available from: http://www.pitt.edu/~super1/lecture/lec0022/. 5. cockerham wc, hinote bp, abbott p, haerpfer c. health lifestyles in central asia: the case of kazakhstan and kyrgyzstan. social science & medicine. 2004;59(7):1409-21. 6. scimago. sjr — scimago journal & country rank. 2007 [cited 2013 mar 15]. available from: http://www.scimagojr.com/countryrank.php. 7. dante. caren. [cited 2012 mar 15]. available from: http://caren.dante.net. 8. supercourse. available from: http://www.pitt.edu/~super1/index.htm. 9. international telecommunition union. key global telecom indicators for the world telecommunication service sector. 2011 [updated 2012 jun 29; cited 2013 mar 15]; available from: http://www.itu.int/itu-d/ict/statistics/at_glance/keytelecom.html. 10. the world bank. mobile cellular subscriptions 2012 [cited 2012 mar 15]; available from: http://data.worldbank.org/indicator/it.cel.sets/countries/1w?display=default. 11. marler e. directory of apps for mobile phones by academic discipline. [updated 2012 jun 25; cited 2013 mar 15]; available from: http://www.pitt.edu/~super1/globalhealth/appsmobilephones.htm. lifestyle intervention as a treatment for obesity among school-age-children in celaya, guanajuato: an experimental study lifestyle intervention as a treatment for obesity among school-age-children in celaya, guanajuato: an experimental study nicolas padilla-raygoza1, rosalina diaz-guerrero2, ma. laura ruiz-paloalto3 1department of nursing and obstetrics, health sciences and engineering division, celaya-salvatierra campus, university of guanajuato, 2department of clinical nursing, health sciences and engineering division, celaya-salvatierra campus, university of guanajuato, 3division of health sciences and engineering, campus celaya salvatierra, university of guanajuato abstract introduction: obesity is a risk factor in chronic diseases, and its frequency among children in mexico is increasing. objective: to determine the effect of lifestyle intervention as a treatment for obesity in school-age-children from celaya, mexico. methodology: for this experimental study, four schools were randomly selected. children and parents participated voluntarily and signed consent forms. two schools were chosen as the experimental group and the other two formed the control group. age, gender, weight, height, bmi and blood pressure were recorded for each participant. intervention: children and parents were asked to walk in their schools for 30 minutes a day monday through friday and to attend 8 instructional sessions over a period of four months dedicated to the selection and preparation of meals. statistical analysis: the or and 95% ci were calculated to determine the effect of the intervention; a z-test for two proportions for overweight and obesity in the control and experimental groups were carried out for comparison. results: 157 children were included in the experimental group and 144 in the control group. to compare the proportions of the overweight and the obese between the groups, a z-test = 0.36 (p-value 0.72) were obtained showing no effect of the intervention in lifestyle; or =1.09, 95% ci (0.67, 1.77). it was adjusted according to the attendance to the sessions resulting in an or = 2.00, 95% ci (0.69, 5.77), demonstrating that not attending the sessions was a confounder. conclusions: intervention in lifestyle should be measured over a longer period of time in order to determine what effects it may have on changes in body mass index. keywords: hypertension; physical activity; meals introduction obesity is a chronic condition that contributes to many diseases and affects more children and adolescents each day. one of the most important concerns is the emergence of type-ii diabetes and metabolic syndrome at earlier ages.1 obesity is the result of an imbalance between energy consumption and expenditure due to diets high in caloric density and low in fiber, as well as high consumption of sugary drinks accompanied by little or no physical activity.2 in mexico, according to the national surveys on health and nutrition, the frequency of obesity in male and female children and adolescents has increased from 18.6% in 1999 to 26% in 2006, the percentage of overweight children and adolescents has also increased from 12.9% in 1999 to 21.2% in 2006.3,4 in the united states, the centers for disease control and prevention (cdc) is also concerned with this issue. their studies show that no state reported an obesity rate above 15% in children and adolescents in 1990, but in 1995 more than half the states reported an obesity rate between 15 and 19 %. by the year 2000, over 22 states had rates higher than 20%, and in 2005 17 states had rates above 25%.5 from 2003 to 2004, the national health and nutrition examination survey (nhanes) reported that 33.6% of children and adolescents had some degree of obesity; 17.1% were obese and 16.5% at risk of obesity.6 early weaning, increased intake of processed foods with a high caloric density, a decrease in consumption of low caloric density foods (fruits and vegetables), urbanization, mechanization of transport and use of technology, a decrease in energy expenditure, less time spent on leisure activities, and decreased time and intensity in physical education and sports at school all contribute to obesity at an early age.3 an obese patient is 2.5 times more likely to develop coronary heart disease, 4 times more likely to develop hypertension, 3-4 times more likely to develop type-ii diabetes and at 5 times higher risk of stroke than a person with a bmi in the normal range.7 the percentage of newly-enrolled elementary school students in mexico who are obese has increased by a factor of three, suggesting that approximately 26% of mexican children reach obesity before the onset of puberty.3 the effects of obesity and being overweight among children are numerous, leading to conditions such as: glucose intolerance, insulin resistance, type-ii diabetes, hypertension, dyslipidemia, hepatic steatosis, sleep apnea, orthopedic problems, low self-esteem, negative body image and depression, discrimination, negative stereotypes, anorexia and bulimia, among others. these effects prove an overwhelming burden to the healthcare system. therefore, we must seek strategies to prevent or decrease the number of obese and overweight children. the objective of this study was to apply an educational and physical activity intervention program to treat or prevent increased weight in order to lower the frequency of this syndrome in school age children from celaya, guanajuato, mexico. we developed the following hypothesis: children in the experimental group will have a 10% decreased frequency of overweightness/obesity compared with the control group. materials and methods the protocol was reviewed and approved by bioethics committee from the school of nursing and obstetrics of celaya, university of guanajuato. type of study: this prospective, controlled, longitudinal study was carried out in public elementary schools from celaya, guanajuato, mexico. population: male and female school-age-children, enrolled in celaya public elementary schools incorporated to the guanajuato ministry of education. inclusion criteria: children 6 to 13 years old, male or female enrolled in public elementary schools, whose parents accepted their participation in the study by signing the corresponding consent form. exclusion criteria: children with diseases that inhibited physical activity, children whose parents did not sign the consent form, and children over the age of 8 who did not consent. sampling: four schools were selected at random from the 168 existing public schools in celaya in 2007. two schools randomly formed the experimental group and the other two were the control group. at each school, parents were invited to an informative meeting where the objectives of the study were explained. parents were asked to sign a consent form allowing their children to participate in the study. children 8 or older were asked to sign an additional form demonstrating their own wish to participate. all participants answered questions in reference to their age, gender, residence, and socioeconomic level (seli).8 participants were weighed using the medidata serie ms ® digital scale. they wore only essential clothing and did not wear shoes. they stood on the scale looking forward while both weight and height appeared on the screen of the scale. blood pressure was measured 3 times using a digital monitor. the average of the three readings was calculated. a correlation between measurements was established by measuring the blood pressure of 30 children using a digital and a mercurial monitor (adjusting the cuff to the age of the participant). the correlation was r= 0.79. body mass index (bmi) was calculated by dividing weight in kilograms by height (in centimeters) squared. the mothers of the children answered a questionnaire on food habits (snut)9 and a software was used to process the snut and obtained the daily average of calorie consumption. all measurements were carried out at the beginning of the study and at sixteen weeks. the results found in the control and experimental groups were used to define the impact of the lifestyle intervention program. intervention: it was decided that the lifestyle intervention program be administered at the schools to avoid contamination of the control group by the experimental group in a non-school environment. the lifestyle intervention program in the experimental group had two phases: phase 1: all school-age-children, whose parents agreed to participate in the study, had monitored 30-minute walking sessions at school from monday through friday where attendance was checked. to maximize the participation in the walking sessions, they were carried out at the end of their school day (12:30 pm). phase 2: 8 instructive sessions with the children´smothers were carried out. in these sessions, mothers were taught to prepare and select healthy meals for their children. the sessions took place every two weeks throughout the 16 weeks of the study. two nutritionists were in charge of the sessions. table 1 shows the descriptive content of the sessions. attendance was checked at each session. table 1: descriptive chart of contents from instructional sessions with mothers to help to select and prepare meals, celaya, gto. 2009 session topic objective teaching strategy 1 growth and development to know the importance of foods in childhood lecture with slides 2 nutrients needed for growth and development to recognize which are the most important nutrients for growth and development in children lecture with slides 3 foods groups to familiarize mothers with the food groups for an appropriate nutrition. workshop style and collaborative group work. 4 food portions to recognize the appropriate food portions for each child. workshop style and collaborative group work. 5 practical advice to learn practical ways to get your child to eat healthy meals. lecture with slides 6 myths and realities about feeding to answer frequently asked questions about child nutrition. lecture with slides 7 food preparation workshop i to empower mothers in preparing nutritious meals. preparation and tasting of healthy meals 8 food preparation workshop ii to empower mothers in preparing nutritious meals. preparation and tasting of healthy meals follow-up: after sixteen weeks, anthropometric measurements and blood pressure were measured. the snut survey was then applied to both the experimental and control groups. the control group did not receive any lifestyle intervention. however, after the study was over, a meeting was held with the mothers of the control group to instruct them on the advantages of physical activity and selection and preparation of healthy meals as preventive measures to avoid overweight/obesity. this was done in order to meet the bio-ethical principles of justice. outcome measurements: “overweight” was defined as a bmi between the 75th and 84th percentile in accordance with the cdc 2000 curves by age and gender”.10 “obesity” was defined as a bmi in the 85th-96th percentile in accordance with the cdc 2000 curves, by age and gender”.10 “severe obesity” was defined as a bmi above the 97th percentile in accordance with the cdc 2000 curves, by age and gender”.10 “hypertension” was defined as pressure levels higher than the 95th percentile in the blood pressure charts, by gender, age and height”.11 sample size: the expected proportion of overweight/obese was 26% in the control group and 16% in the experimental group. the minimum sample size with a 95% of precision and an 80% of power is 101 in each group. an increase to 150 should be considered due to conglomerate sampling (design factor 1.5) (epiinfo 2000 version 1.1 cdc, atlanta, ga, eua). statistical analysis: children were classified as overweight/obese, or appropriate weight. another classification was hypertensive or with appropriate blood pressure. the proportion of overweight/obese in each group was compared with the z-test and p-value to test the hypothesis. the same test was used to compare rates of hypertension between the experimental and control groups. to measure the effects of the lifestyle intervention program, the odds ratio (or) and 95% confidence intervals (ci) between groups were calculated for overweight/obese and for hypertension. it was adjusted in accordance with the attendance to the walking sessions and the preparation and selection of meals sessions. as a second step, the subjects were classified by status of obesity: low/adequate weight, overweight, obese, and severely obese. proportions between the experimental and control group were compared with the z-test for two proportions and p-value. using a chi-squared test and p-value, tabulation was elaborated comparing the status of hypertension and the status of obesity to determine if there was a relationship between variables. mean differences in weight, height, bmi, systolic blood pressure, diastolic blood pressure, and daily calorie intake before and after the intervention were calculated with the z-test and p-value. in all cases, the p-value used to demonstrate statistical significance was 0.05. all statistical analysis was calculated using stata 10.0® (stata corp, texas, eua). results 400 parents from the 4 selected schools were invited to attend the informational meetings. among these 400 parents, 297 (74.25%) permitted their children to participate in the study and signed the consent form. the experimental group was comprised of 157 children and the control group of 144. qualitative baseline characteristics in each group are shown in table 2. table 2: qualitative baseline characteristics of both groups, celaya,gto., 2009 (n= 301) variables experimental group n=157 control group n=144 n % n % age group (years) 6-8 78 49.68 61 42.36 9-11 67 42.68 75 52.08 12-14 12 7.64 8 5.56 gender male 90 57.32 68 47.22 female 67 42.68 76 52.78 seli low 0 0 1 0.69 regular 11 7.01 8 5.56 high 136 92.99 135 93.75 source: questionnaires from this study seli = socioeconomic level index in terms of age, x2 = 1.16, df = 2, p = 0.6, point to no significant difference in the groups. in terms of gender, there was also no significant difference among groups with x2 = 2.68, df = 1, p = 0.1. in terms of the socioeconomic level index, the z-test for two proportions between height (seli), was z = 0.03, p = 0.97. in the walking sessions, the mean of the absences of children was 2.71±1.25 and in the instructional sessions for mothers on selecting and preparing the children’s meals was 14±0.35. no participant had more than 20% absence in both activities. table 3: attendance to walking sessions and instructional sessions in to select and prepare meals in experimental group, celaya, gto, 2009 (n=154) n % absences in walking sessions 0 2 1.30 1 24 15.58 2 42 27.27 3 50 32.47 4 25 16.23 5 7 4.55 6 3 1.95 7 1 0.65 absences to instructional sessions 0 132 85.71 1 22 14.29 source: checklist of attendance table 4 shows the quantitative baseline characteristics between the experimental and the control groups. the z-test was calculated for two independent means. in terms of age, the average difference was z = -0.47, p = 0.64; in terms of weight in kilograms, the average difference was 1.85 with z = 1.24 and p = 0.2. height was measured in meters and the difference was 0 with z = 0 and p = 1.0. the differences in these variables were not statistically significant. on the other hand, when measuring systolic blood pressure in mm hg, the difference was 4.96, with z = 3.18, p = 0.001. the difference in diastolic blood pressure was 4.45 with z = 3.45, p = 0.0006; in terms of bmi, the difference in the mean was 1.21 with z = 2.25, p = 0.03. with regards to daily consumption of calories, the average difference was 465 with z = 4.88, p = 0.0000. these differences were statistically significant. table 4: quantitative baseline characteristics of both groups, celaya, gto., 2009 (n=301) variables by group range mean ± sd age (in years) experimental (n=157) 6 to 13 8.74 ± 1.93 control (n=144) 6 to 13 8.84 ± 1.73 systolic blood pressure (mmhg) experimental (n=157) 80 to 100 115.06 ± 16.03 control (n=144) 85 to 155 110.12 ± 10.68 diastolic blood pressure (mmhg) experimental (n=157) 42 to 125 75.24 ± 12.44 control (n=144) 46 to 122 70.79 ± 9.59 weight (kg) experimental (n=157) 17.850 to 84.950 37.28 ± 13.87 control (n=144) 17.800 to 76.950 35.43 ± 12.79 height (mt) experimental (n=157) 0.82 to 1.64 1.32 ± 0.13 control (n=144) 1.06 to 1.61 1.32 ± 0.12 body mass index (kg/m2) experimental (n=157) 13.52 to 42.24 20.88 ± 4.84 control (n=144) 13.49 to 33.75 19.67 ± 4.47 mean of daily calorie consumption experimental (n=157) 1471.23to 6909.62 2803.75 ± 859.52 control (n=144) 755.05 to 6049.45 2338.29 ± 790.80 source: questionnaires of study, snut survey sd = standard deviation three children from the experimental group (1.9%) and two from the control group (1.4%) decided to drop out from the study. to test the hypothesis of comparing the proportions of the overweight/obese between experimental and control groups, a z-test resulting in -0.36 was calculated and p = 0.72. this demonstrates that there is no significant statistical difference between both groups and that the lifestyle intervention program had no effect, with or = 1.09 and a 95% ci = 0.67 to 1.77. when adjusting the or with absences to the walking and instructional sessions on selecting and preparing meals, the or adjusted was 2.00 [ci 95% (0.69, 5.77)], showing that the attendance to the walking sessions and instructional sessions were factors of confusion. proportions of overweight/obese children, bmi, and hypertension were compared before and after the intervention program. table 5: comparison before and after intervention by overweight/obesity status and hypertension, celaya, gto, 2009 (n=301) before after difference of proportions z p-value n % n % experimental overweight/obesity 115 73.25 100 64.94 0.0831 1.59 0.11 without overweight/obesity 42 26.75 54 35.06 -0.0831 -1.59 0.11 control overweight/obesity 84 58.33 95 66.90 -0.0857 -1.50 0.13 without overweight/obesity 60 41.67 47 33.10 0.0857 1.50 0.13 experimental severe obesity 60 38.22 40 25.97 0.1225 2.31 0.02 obesity 35 22.29 45 29.22 -0.0693 -1.40 0.16 overweight 20 12.74 15 9.74 0.03 0.84 0.40 without overweight 42 26.75 54 35.06 -0.0831 -1.59 0.11 control severe obesity 34 23.61 32 22.54 0.0107 0.21 0.83 obesity 36 25.00 37 26.06 -0.0106 -0.21 0.83 overweight 14 9.72 26 18.31 -0.0859 -2.09 0.04 without overweight 60 41.67 47 33.10 0.0857 1.50 0.13 experimental hypertension 20 12.74 0 0 0.1274 4.58 0.0000 without hypertension 137 87.26 154 100.0 -0.1274 -4.58 0.0000 control hypertension 4 2.78 1 0.70 0.0208 1.34 0.18 without hypertension 140 97.22 141 99.30 -0.0208 -1.34 0.18 source: questionnaires of the study statistically significant differences were found in the hypertension category in the experimental group, in the overweight/obesity category, and in the bmi categories (p<0.05). in pre and post-intervention analysis of the quantitative variables, we calculated the differences between the first and the second measurements, the mean of the differences, the standard deviation, the paired t-test, and p-value. table 6: comparison of quantitative parameters pre and post-intervention, per group, celaya, gto, 2009 (n=301) before after δ ± sd t-paired df p-value mean ± s mean ± s (ic95%) weight(kg) experimental 37.28±13.87 38.39±13.93 -1.25±1.23 (-1.45 to -1.05) -12.61 153 0.0000 control 35.43±12.79 38.05±14.77 -2.75±5.89 (-3.73 to -1.77) -5.56 141 0.0000 height(mt) experimental 1.32±0.13 1.35±0.14 -0.04±0.02 (-0.04 to -0.036) -24.82 153 0.0000 control 1.32±0.12 1.34±0.13 -0.02±0.06 (-0.04 to -0.037) -23.83 141 0.0000 bmi experimental 20.88±4.84 20.41±4.59 -0.46±0.96 (-0.61 to -0.31) -5.95 153 0.000 control 19.67±4.47 20.09±4.33 -0.45±1.65 (-0.72 to -0.18) -3.25 141 0.001 sat(mmhg) esperimental 115.06±16.03 109.97±8.69 5.05±14.85 (2.69 to 7.41) 4.22 153 0.0000 control 110.12±10.68 112.14±8.25 -1.95±7.64 (-3.22 to -0.68) -3.04 141 0.003 dat(mmhg) experimental 75.24±12.44 71.86±6.24 3.21±11.88 (1.32 to 5.10) 3.35 153 0.001 control 70.79±9.59 72.69±5.68 -1.81±8.96 (-3.30 to -0.32) -2.41 141 0.017 mdic experimental 2803.75±859.52 1988.41±639.51 803.25±879.42 (663.25 to 943.25) 11.33 153 0.0000 control 2338.29±790.80 2502.67±661.65 -164.16±522.91 (-250.91 to -77.41) -3.74 141 0.0003 bmi= body mass index δ± sd mean of differences ± standard deviation sat= systolic blood pressure dat= diastolic blood pressure mdic= mean daily intake of calories in terms of weight, a significant statistical difference was found between the groups (p < 0.05). for height, differences between the experimental and the control group were statistically significant as well (p < 0.05). the same was obtained in the bmi (p < 0.05), in systolic blood pressure (p < 0.05), and in diastolic blood pressure (p < 0.05) for both groups; and the same was obtained for the average of daily consumption of calories in the experimental and control group (p < 0.05) (table 6). discussion the sample of schools was obtained by random selection, which helps control for potential bias; however, the children participating were invited to partake. this introduces a possibility of bias since the parents that were interested in the study and accepted the invitation to participate probably had obese children. evidence for this can be seen in the difference in baseline values between groups (table 4). 3 subjects (1.9% of the group) from the experimental group and 2 (1.4% of the group) from control group decided to drop out of the study, but this did not affect the analysis of the data. results obtained from this study do not support the hypothesis that children in the experimental group will have a 10% decrease compared with the control group (table 5). the percentages of 64.94% in the experimental group and 66.90% in the control group were higher than those reported by the national survey on health and nutrition in mexico during 2006 of 26%4. 115 (73.25%) children in the experimental group were already overweight / obese before the lifestyle intervention program began. after the intervention program only 100 (64.94%) children were overweight / obese. although this may not be statistically significant, there was a substantial decrease in this particular group. the control group started out with 84 (58.33%) children that were overweight / obese and after the 16 weeks it increased to 95 (66.90%) children. (table 5). it can also be observed that obese and overweight children in the experimental group lost weight after the lifestyle intervention program (p < 0.05), and that the number of children with appropriate weight increased. this demonstrates, in a way, that our lifestyle intervention program was effective. in the control group, the number of students with appropriate weight decreased from 60 to 47 (p > 0.05) and the increase in overweight school children was statistically significant (p < 0.05) (table 5). an important and unexpected finding was the frequency of hypertension, 12.74% in the experimental group and 2.78% in the control group, since in mexico the hypertension rate is considered to be at 1% in children.12 in the experimental group, it was detected that after 4 months of the application of the intervention program, there were no children with hypertension in the experimental group and only 1 child with hypertension in the control group (table 5). these results could be biased because in the first visit, the children were unfamiliar con observers and maybe they felt stress; this could decrease after 16 weeks. steinberger et al. reported an association between obesity and hypertension in children and adolescents13. physical activity at least 30 minutes, 3 times/week, reduces blood pressure in youth with mild essential hypertension.14 the intervention of physical activity and adequate preparation and selection of meals proved to be effective. the experimental group showed an average increase of 1.25 kg, in weight; whereas the control group had an average increase of 2.75 kg after the four months of the study. there was also a change in height after the follow-up time, but this may be due to the natural growth of the children. (table 6). average difference in bmi was similar; 0.45 in the experimental group and 0.46 in the control group, (table 6). systolic blood pressure in the experimental group had an average decrease of 5.05 mmhg after the lifestyle intervention program, while in the control group it increased 1.95 mmhg. there were also differences in the diastolic blood pressure; the average decrease in the experimental group was 3.21 mmhg; there was an average increase of 1.81 mmhg in the control group (table 6). even though the analyses performed before and after the intervention program were statistically significant for both groups, the results were less significant in the experimental group as compared to the control group. it must be pointed out that the experimental group showed positive differences in systolic and diastolic blood pressure, indicating the second measurements were lower than the first measures. in contrast, the control group had a negative difference, indicating that the second measurements were higher than the first (table 6). average daily calorie intake decreased by 823 calories in the experimental group, while the control group increased their intake by 164 calories (table 6). even though in the analyses made before and after the intervention program for both groups were statistically significant, the experimental group showed positive differences for daily mean intake of calories, indicating that the second measurements were lower than the first measures. in contrast, the control group had a negative difference, indicating that the second measurements were higher than the first (table 6). klesges et al. monitored a group of females for 2 years whom were following an intervention program designed to prevent obesity. the major foci of the program were: drinking more water, increasing the consumption of vegetables and fruits, and lowering the intake of sweetened beverages. they measured the bmi of the experimental and control groups and significant differences were not found.15 the intervention program in our study lasted four months. bmi was slightly modified in the experimental and control groups but the change was not statistically significant. the world health organization recommends that changes in lifestyle (such as increased physical activity) is an important part in the prevention and treatment of hypertension and also helps in the treatment of obesity.16,17 conclusions the null hypothesis could not be rejected because the differences in proportions of school children with in the experimental and control group were not statistically significant. with physical activity intervention and changes in the selection and preparation of meals, the number of children with hypertension decreased. both increased physical activity and changes in food selection and preparation should be studied over a longer period of time because four months did not show sufficient effect on bmi. an important effect of the intervention was a decrease in blood pressure. these results warrant further investigation of the effects of healthy lifestyles on changes in bmi in school children because of the far-reaching benefits that may come from improving the health of young people. acknowledgements thanks to promep from the ministry of education in mexico, for the support for this study with the 103.5/08/5163 grant; also, thanks to antonia vazquez raya y carolina trejo mancera for their help in this study. references 1. martorell r. results and implications of the incap follow-up study. j nutr. 1995; 125:1127s-1138s. 2. popkin b. an overview on the nutrition transition and its health implications: the bellagio meeting. public health nutr. 2002; 5(1a):93-103. 3. calzada r. prevalence and etiopathogeny [spanish]. in: calzada r, editor. obesity in children and adolescents. editores de textos mexicanos, méxico, d.f., 2003, p. 99-120. 4. olaiz-fernández g, rivera-dommarco j, shamah-levy t, rojas r, villalpando-hernandez s, hernandez avila m, sepúlveda-amor j. national survey on health and nutrition. 2006. instituto nacional de salud pública, cuernavaca, 2006. 5. satcher d. cdc’s 60th anniversary; director’s perspective. mmwr. 2007; 56:579-82. 6. ogden cl, carroll md, curtin rl, mcdowell ma, tabak cj, flegal km. prevalence of overweight and obesity in the united states, 1999—2004. jama. 2006; 295:1549-55. 7. fanghänel sg. obesity: main problem of health in new century [spanish]. rev endocrinol nutr. 2001; 9:49. 8. bronfman m, guiscafre h, castro v, castro r, gutierrez g. measuring inequality: a methodological strategy, analysis of the socioeconomic characteristics of the sample [spanish]. arch invest med (mex). 1988; 19:351-60. 9. hernandezavila je, gonzalez-aviles l, rosales.mendoza e, parra-cabrera s, hernandez-avila m, romieu i, willet w, madrigal h. evaluation system of nutritional habits and intake of nutrients [spanish]. centro de investigacion en salud poblacional. direccion de informatica. instituto nacional de salud publica, mexico, 2003 (http://www.insp.mx/snut2003/index.php) (accesed july 11, 2008). 10. barron c. controversies to establish the diagnosis [spanish]. in: calzada r, editor. obesity in children and adolescents. editores de textos mexicanos, méxico, d.f., 2003, p. 99-120. 11. national high blood pressure education program working group on high blood pressure in children and adolescents. the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. pediatrics. 2004; 114:555-76. 12. halabe a. arterial hypertension in childhood:importance of measure arterial pressure in ambulatory care [spanish]. rev fac med unam. 2002; 45:245-247. 13. steinberger j, stephen r. obesity, insulin resistance, diabetes and cardiovascular risk in children. circulation. 2003; 107:1448-1453. 14. strong wb, malina rm, slimkie cjr, daniels sr, dishman rk, gutin b, hegenroeder ac, et al. evidence based physical activity for school-age youth. the journal of pediatrics. 2005; 146(6): 732-737. 15. klesges rc, obarsonek e, kumanyika s, murray dm, klesges lm, relyea ge, stockton mb, lanctot jq, beech bm, mcclanahan bs, sherrill-mittleman d, slawson dl. the memphis girls’ health enrichement multi-site studies (gems). an evaluation of the efficacy of a 2-year obesity prevention program in african-american girls. arch pediatr adolesc med. 2010; 164(11): 1007-1014. 16. kathib omn, sayed egm. clinical guidelines for the management of hypertension. emro technical publication series 27. world health organization, geneva, 2005:48-52. 17. national high blood pressure education program working group on high blood pressure in children and adolescents. fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. pediatrics. 2004; 114 (suppl. 2): 557-576. alcohol use, risk taking, leisure activities and health care use among young people in northern vietnam new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this site is published by the university library system of the university of pittsburgh as part of its dscribe digital publishing program and is cosponsored by the university of pittsburgh press. alcohol use, risk taking, leisure activities and health care use among young people in northern vietnam le thi kim thoa1,2, dang h. hoang1, nguyen dang vung1, pham h. tien2, m.a. plant3 1ha noi medical university, vietnam; 2center for health and development in vietnam; 3alcohol & health research unit, university of the west of england, bristol, united kingdom vol. 2, no. 2 (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ thoa this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu abstract alcohol consumption is associated with a wide range of health and social consequences. it is also associated with a number of risk taking behaviours. these include illicit drug use and unsafe sex. alcohol consumption appears to be increasing in vietnam. the purpose of this paper is to examine the patterns of alcohol consumption and its relationship with a number of other risk taking behaviours amongst young people. information was also obtained concerning leisure activities and use of health care. the paper also sets out to examine possible gender differences in relation to alcohol consumption and risk behaviour and to propose the development and implementation of alcohol monitoring and prevention programs in vietnam. the study involved a crosssectional, community survey using a standardised interview. this was conducted during face-to-face interviews with 1,408 young people aged 10-19 years. respondents were recruited randomly through the lists of the households from 12 selected communes in three areas in northern vietnam. the findings presented here were part of a larger health risk behaviour survey. levels of alcohol use were low. overall, 16.5% of participants were experienced drinkers, and only 4% of them were current drinkers. males were significantly more likely than females to report drinking. this study also showed that rates of alcohol consumption were associated with age, education, geographical area, gender, tobacco smoking, involvement in violence, watching television, computer use and playing computer games, wearing safety helmets and use of health services. alcohol consumption tended to increase with age for both males and females. alcohol and its effects on young people are clearly a growing public health issue in vietnam. because of this, more detailed behavioral research should be conducted into the relationship between alcohol consumption and other risky behaviours amongst young people. it is also recommended that alcohol harm reduction policies should be implemented and integrated into measures to reduce levels of other health problems such as hiv/aids and non communicable diseases. such policies should ideally be evidence-based and evaluated. keywords: alcohol, young people, vietnam, risk taking, leisure, health care. alcohol use, risk taking, leisure activities and health care use among young people in northern vietnam le thi kim thoa1,2, dang h. hoang1, nguyen dang vung1, pham h. tien2, m.a. plant3 1ha noi medical university, vietnam; 2center for health and development in vietnam; 3alcohol & health research unit, university of the west of england, bristol, united kingdom research introduction alcohol consumption and tobacco smoking are associated with cardiovascular diseases, cancers, chronic obstructive pulmonary diseases and diabetes. 1-7 alcohol consumption is associated with “disinhibition” and possibly with sexually transmitted diseases, including hiv/aids, and the hazardous and harmful use of alcohol has now become one of the most important risks to health: it is the leading risk factor in developing countries with low mortality rates and ranks third in developed countries (according to the world health report 2002). evidence suggests that heavy drinkers may be inclined to take risks, regardless of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu whether or not they drink on a particular occasion. 8,9 moreover, the possible connection between drinking and sexual behaviour is at least partly attributable to the fact that many people meet their sexual partners in bars and other places where alcohol is consumed socially. 10,11 alcohol consumption, often involving home made drinks, is commonplace in vietnam. 12 drinking is widespread amongst vietnamese young people whose health has been considered a low priority. 13 heavy drinking by young people is associated with health and social problems, tobacco and illicit drug use and a range of other risky behaviours. 8,14 furthermore, when drinking and smoking are adopted by younger children, this behaviour appears to enhance risks of later alcohol and drug dependence, obesity, high blood pressure and other illnesses and problems. 15 in the usa and elsewhere there has been an increasing body of literature that suggests a strong link between alcohol consumption and engagement in sexual risk behaviours. 16 analysis of youth health risk behavior data indicates that the youth who use alcohol are seven times more likely to be sexually active than the youth who do not drink alcohol, a figure higher than that for young people using illicit substances. another recent report indicates that among sexually active high school students 39 percent of those consuming alcohol regularly have had sex with four or more partners, compared to 29 percent of non-drinkers. 16 in addition a u.s. national survey indicated that almost 25 percent of sexually active young people and young adults (15 to 24 years) have engaged in unprotected sex while using alcohol or drugs. one survey showed that respondents who drank alcohol were seven times more likely to have sex as respondents who did not drink. finally, a study of college students found that 40.7 percent of males and 27.8 percent of females stated that they had engaged in sexual intercourse under the influence of drugs and/or alcohol when they would not otherwise have engaged in these behaviours. 18 socio-cultural and demographic studies of alcohol use and abuse patterns have been conducted in asia, including china and thailand. recent research in asia also includes studies that examine alcohol consumption among young people. among these, a study in japan reveals that the youth are beginning to drink at a younger age, and rates of drinking have been on the rise among 13 to 17 year olds. 19 among south korean young people, a fairly high rate of alcohol consumption has been demonstrated, with one study showing 43 percent of young people drinking regularly, and that boys are more likely to drink than girls. 20 in addition, among a sample of 1,040 young people in grades 6, 8, and 10 in beijing, china, approximately 70 percent have reported prior alcohol consumption. again, males were significantly more likely to drink alcohol than females. even so, 61% of females reported prior use of alcohol. another study among senior high school students in china reported that 83.5 percent of boys and 54.9 percent of girls had consumed alcohol. 21 there is, however, there is significantly less information available for southeast asia. studies in thailand have linked paternal drinking with subsequent alcohol use by their adult children and other studies examined links between alcohol consumption and hiv risk behaviors. 22 “official figures” indicate that per capita alcohol consumption in vietnam is very low (0.9 litres of alcohol). this compares with 1.5 litres for cambodia, 5.6 litres for thailand and 7.6 litres for japan. 23 these figures do not include unrecorded alcohol, including home made drinks. however, it is evident that there has been an increase in alcohol consumption. the world health organization has noted that the recorded alcohol consumption in vietnam rose from approximately 0.7 litres in 1961 to more than 1.3 litres in 2001. 24 it further estimated that the unrecorded alcohol consumed amounted to one litre of alcohol per head of those older than 15 years. the world health organization also reported that 69.5% of vietnamese adults were lifetime abstainers, 2.9% were heavy and hazardous drinkers, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thoa this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu and 4.7% were heavy episodic (or binge) drinkers. moreover, it reported that 80% of those aged 18-24 years were drinkers, of whom 3.7% were heavy episodic drinkers. evidence suggests that as countries develop economically, there is an increase in alcohol consumption. 25 for example, in thailand, the rate of alcohol consumption increased 334 percent from 1.93 litres in the early 1970s to 8.64 litres in 1996. with limited socio-religious restrictions in vietnam on drinking, one could anticipate that alcohol consumption will continually increase as economic conditions improve. there has, however, been little research in vietnam on alcohol use within the adolescent population. this paper examines alcohol consumption and its association with gender in relation to a number of risky behaviours and use of health services amongst young people in vietnam. the paper also seeks to examine possible gender differences in relation to these variables. methods this study involved a cross-sectional population survey of young people who were identified from the updated list of all households at commune level. this list was used to select a stratified sample of addresses. fieldwork (including pilot work) took place between june 1st and august 30th, 2004 in ha noi city, ha nam and thai nguyen province, vietnam. participants the participants were young people in twelve communes of three sites. young people were between 10 and 19 years of age. they agreed to participate in the survey. fieldworkers conducted short interviews with parents before conducting interviews with the young people to get some family information including some details of parental drinking and smoking. parents were not present during interviews with their children. the response rate for parents was high; no one refused to take part. all interviews were carried out in private. sample design and sampling the sample design utilised in this study is shown in table 1. it was a multi-stage stratified sample that was representative of young people aged 10 to 19 years. in the first stage, three sites (one city and two provinces), were selected from 64 provinces and cities in vietnam. these sites represent three geographically well-defined areas in the north. ha noi city is in the urban area located in the red river delta and is also the capital of vietnam with 3,082,800 inhabitants (in 2004). ha nam province is in the rural area with its population of 820,100 (in 2004) and thai nguyen province is in the mountainous midland area with a population of 1,095,400 (also in 2004). twelve commune units (scus) were selected during the second sampling stage. the population of each scu ranged from 5,000 to 10,000. in the final stage of the design, all households which included young people in the target age group in these selected communes were eligible to participate in the survey. the list of all households with such young people was provided by health workers working in local health centers. all the young people were randomly selected for interview, resulting in the sample size of 1,442 individuals. table 1: sample design all individuals aged from 10 to 19 randomly sampled were single and available at home during the survey. (most people in vietnam marry after the age of 20, except some cases in rural and mountainous areas). http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu the participants were randomly selected by stata software program. out of a total of 1,440 people who were contacted, 1,408 young people (97.8%) participated in the survey. a total of 32 individuals (2.2%) declined to participate. the data from these 12 scus applied only to young people participating in the survey. research procedure before conducting this survey, the investigators conducted a qualitative research (individual interview and focus groups) as a pilot study. they tested both the questionnaire and survey procedure with boys and girls from the general population. questionnaire development the questionnaire was developed in three stages. the first stage involved a qualitative research including 30 individual interviews, using both the unstructured interview guidelines and the semistructured interviews form. these interviews were conducted to explore the perceptions of young people about healthy and risky behaviors. they also examined perceptions of risk practices and solutions to prevent such behaviours among young people. the information obtained from these interviews identified health behaviours and other related factors. the most commonly reported seven risk behaviours perceived by young people included drug use, fighting, motorcycle racing, alcohol consumption, tobacco smoking, lack of exercise or sporting activities, eating snacks in the street, driving bicycle or motorcycle without a helmet and unprotected sex. the second stage involved three focus group discussions (fgds) with both male and female young people. these groups each included between ten and eighty participants. participants were asked for advice about the form and content of questionnaire. those taking part in fgds suggested that the instrument should be divided into two versions. the first version should be used for all participants (10-19 years old). the second version (including items about hiv/aids knowledge and sexual practices) should be used for participants from 15 or older. the participants in fgds reported that the questions in version 2 would be too sensitive for very young people. in the last stage, the adolescent health risk behavior survey (ahrbs) components of the questionnaire included five main components: 1) demographic information; 2) alcohol consumption details; 3) tobacco use; 4) watching television, using a computer or playing computer games; 5) violence associated with drinking; 6) riding bicycle and motorbicycle and helmet use; 7) use of medical services. data collection and analysis participation in the study was informed and voluntary. data collection was anonymous. the surveys were conducted by health staff using face-to-face interviews carried out in respondents’ homes. respondents typically completed interviews in one hour. their responses were recorded directly onto the questionnaire. the core questionnaire contained 65 multiple-choice questions. before the survey was administered, local consent procedures were followed. collaborating with the city/provincial bureau of health, the investigators selected the communes as well as certain admission criteria. the administrators at each selected locality first asked permission from the ha noi medical university and the local health administration. this specific study was approved by the scientific and ethical committee for medical research, hanoi medical university and the local authorities. before the interviews were conducted, local parental permission procedures were followed. for surveying participants younger than 18 years of age their parents agreed for their children to participate in advance. informed http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thoa this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu consent was also were obtained from all respondents before interviews were conducted. the data entered into the epiinfo 6.04. spss, version 15.0 for windows for analyzing frequencies, proportions (percentages), odds ratio (or) and using χ2 test with 95% confident interval (ci). multiple regression analyses were estimated for the relationship between alcohol use and other variables. results characteristics as noted above, information was elicited from 1,408 young people. a total of 673 males (48%) and 735 females (52%) were included in the sample obtained. all these young people were unmarried. the mean age of the sample was 14.35 years (sd = 2.6) years. mean age was 14.27 years (sd = 2.6) years for males and 14.43 years (sd = 2.6) for females. most young people were the kinh (94%). other ethnic minorities (4%) included tay, nung and san diu groups. most of these ethnic groups lived in the mountainous areas. no difference was found in age and gender between the two groups (χ2: 1.04, d.f. = 2, p = 0.307). approximately 94% of the young people reported that they were attending school at the time of the survey. among those who were not in school (86) the number was the lowest in urban (2.6%) areas and higher in rural areas (10.7%). no difference in school attendance was evident between the two gender groups (χ2: 0.48, d.f. = 2, p = 0.488). there were no statistically significant differences in gender (p > 0.1), age, education levels and georgraphical study sites (see table 2). table 2: demographic characteristics of the sample self report alcohol use in general, most of young people surveyed, 83.5%, reported that they had never consumed alcohol. the proportion of female non-alcohol users was higher than males (89.4% vs 77%). overall, 16.5% (233) of the sample reported they had consumed alcohol. a total of 23% of males reported drinking more than females (10.6%) (or= 2.52; 95% ci, 1.86 – 3.42; p = 0.001). alcohol consumption was significantly higher amongst of older males (37.1%) than among younger males (12%) (or = 4.98, 95% ci, 3.25 – 7.63; p = 0.000). this age difference was also evident amongst females (7.8%) (or = 6.97, 95% ci, 4.38 – 11.13; p = 0.000). young people who were not attending school (24.6%; n = 17/69) were significantly more likely to drink alcohol than were in-school respondents (or = 1.26; 95% ci, 0.70 – 2.25, p = 0.01). among the 233 drinkers, 97% (n = 226), reported that they had never consumed alcohol daily. only five boys and two girls reported they had ever drunk on a daily basis. a significantly greater proportion of young drinkers came from the mountainous areas, compared to those from the rural and urban areas (χ2 =15.55, d.f. = 2, p = 0.0004). the proportion of young people reporting alcohol use was higher among out of school respondents (24.6%; n = 17/69) compared to young people who were at school (or = 1.26; 95% ci, 0.70 – 2.25, p = 0.01). alcohol use tended to increase by age (10-11 age: 6.3%; 12-13 age: 11.3%; 14-15 age: 11.0%; 16-17 age: 27.8%; and 18-19 age: 29.5%), and also with education level (primary: 7.6%; secondary: 12.5%; high: 28%; university: 35.7%). there was a significant different amongst males in the 10-11 age group (6.8%) and the 18-19 age group (53%) (or = 15.46; 95% ci, 6.58 – 37.32, p = 0.000). this difference was also evident by gender in most subpopulations (see table 3). table 3: alcohol consumption and demographic factors http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu age of first frequent drinking respondents were asked when they had “first started drinking frequently.” most (77%) of those who had consumed alcohol reported that they had “never drunk regularly.” the proportion of the females (84%) who replied in this manner (“never drunk regularly”) was higher than that of males (74%). amongst drinkers, 23% (52) reported drinking as frequently as once a month or more. for those under 14 years of age, drinking regularly was not a common practice. however, among the 233 drinkers, four males and three females reported having begun to drink frequently at “10 years of age or younger.” five of these individuals had started to drink frequently at 10 to 14 years of age. two young people reported that they started to drink at “15 to 19 years of age” and 43 did not answer (the response rate for this question was 81.2%). current drinking current drinking was reported by only 55 (3.9%) of the young people who were surveyed. amongst this small group two young people (one male and one female) were drinking daily. past week’s alcohol consumption. respondents were asked to provide details of any alcohol they had consumed in the past week. most (82.8%) reported that they did not drink at all (82.8%) and only 40 (2.8%) reported that they had consumed alcohol during the past week. the latter included 33 males and 7 females. the proportion of male young people reported on drinking alcohol in the past seven days was four times higher than females, but threequarters of them only drank once. among drinkers, the percentage of those who reported drinking twice or more during the past seven days was 4.3%. factors associated with alcohol consumption tobacco smoking overall, 37 (2.6%) respondents had smoked using filter cigarettes. none of the females had ever smoked. the proportion of smokers was higher among older boys (11.2%) compared to younger boys (0.5%) (or = 22.25; 95% ci: 5.17134.92; p = 0.000). drinkers were significantly more likely to smoke than non-drinkers (or = 9.09; 95% ci: 4.26–20.61; p = 0.000). there was a strong association between alcohol use and smoking in both older and younger boys (or = 10.05; 95% ci: 1.37–206.44; p = 0.002). the majority, 71.4% (n = 25/35), of smokers also reported having consumed alcohol (or = 5.11; 95% ci: .23 – 11.94; p = 0.000). television and computer use ninety per cent of the young people who were surveyed reported that they watched television, used computers or played computer games on a daily basis. a total of 502 respondents, (39.6%), reported spending at least three hours each day on these activities. the amount of time spent on these activities did not differ by gender (see table 4). table 4: television and, computer and computer game use alcohol-related violence in all three study sites, 24.1% (340) of young people were involved in physical fighting at least once during the previous year. males were significantly more likely (29.4%) than females to report such experience (19.3%) (or = 1.74; 95% ci: 1.35–2.27; p = 0.000). fighting amongst younger male drinkers was significantly more likely than younger male nonhttp://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thoa this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu drinkers (or = 1.51; 95% ci: 0.89–2.58; p = 0.106). consistent with this, fighting was also more common place amongst older male drinkers than amongst older males who did not drink (or = 140; 95% ci: 0.78–2.50; p = 0.222). fighting among female drinkers was also significantly more likely than amongst females who did not drink alcohol (or = 1.29; 95% ci: 0.71–2.33; p = 0.374). use of helmets by bicycle and motorcycle riders the proportion of young people using bicycles and motorcycles was very high (86%; n = 1210) in all study sites. the riders included 572 males (85%) and 665 females (70%). the practice of wearing helmets was very low (n = 268; 22.1%). overall only 27.3% of respondents reported that they ‘always’ wore helmets. those young people who wore helmets at least sometimes (13.3%) were significantly more likely than those who ‘never’ wore helmets (3.6%) to report alcohol use (χ2 =45.31, d.f. = 2, p = 0.000). these findings are elaborated in table 5. there was a significant difference for alcohol use difference by gender for all helmet users compared with non helmet wearers. table 5: helmet use amongst bicycle and motorbicycle riders medical check up the proportion of young people who had received a medical check up one or more times in the past year was 56.6%. the proportion of those receiving such check ups was not significantly associated with gender (or = 1.14; 95% ci: 0.92 – 1.42; p = 0.221). even so, the probability of having had a medical examination was significantly associated with alcohol consumption. there was a strong association between alcohol use and frequency of medical check up in the past year (or = 1.80; 95% ci: 1.34 – 2.42; p = 0.000). a disproportionate number, 110 out of 123 (89%) of those who had not received medical check ups also reported drinking on two occasions or more per year (or = 1.77; 95% ci: 1.32 – 2.37; p = 0.000). overall, young people who had not had medical check ups were significantly more likely than non-drinkers to be recent drinkers (or =1.77, 95% ci: 1.32 – 2.37; p = 0.000). drinkers appeared to care less for their health, so they had fewer regular check ups. routine health check ups for young people are conducted once or twice a year. these do not depend upon the individual being unwell. conclusion and discussion in general, this study showed that alcohol consumption (and tobacco smoking) were much less commonplace among vietnamese young people than amongst young people in some other countries, such as those in europe. 26 but when we look at the gender and age factors, it was found that the percentage of alcohol drinkers and smokers is very high amongst adolescents of 18-19 age (29.5%), particular among the oldest ones (52%). moreover, none of the vietnamese girls surveyed reported that they smoked tobacco. this striking finding contrasts with the situation in some counties such as in europe where girls are more likely to smoke (and in some cases to engage in ‘heavy episodic’ or ‘binge’ drinking) than boys. 26-28 in fact, the levels of youthful alcohol use reported in this study were lower than those noted by earlier research in vietnam. 29 it should be noted that the present study related only to north vietnam. it is possible that alcohol consumption is heavier in other parts of the country. drinking rates for all ages of sub populations remain different, but these rates are increasing in older groups and particularly amongst male populations, so alcohol use in young people is as much a public health http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu problem as in adults. 30 as in many other south and east asian countries, it is common for groups of men to go out socially at night and drink alcohol. 31 it is also a reminder that an increase in alcohol consumption also exerts a considerable economic burden worldwide. 32 at the same time, compared to other asian and western countries, drinking rates in vietnam still remain relatively low, but the prevalence of alcohol consumption among older male young people and currently drinking in this study is a little higher than other studies. 33 in vietnam, drinking is a social activity and occurs at family events such as religious memorials in honour of parents or grandparents who have died (cung gio cha me ong ba), or at parties, wedding days and birthdays. ‘special occasions’ are increasing with economic development. young people regularly take part in these events. most males are encouraged to drink by others. some use the expression: “a man without alcohol is like a flag without wind” (dan ong khong ruou nhu co khong phong). several studies in asia have noted that there has been rapid industrialization over the past three decades and south korea. 34,35 this change has resulted in greater prosperity. a study, conducted in northeastern india amongst 13-15-year old school students, concluded that the prevalence of smoking was 8.5 per cent-19.6 per cent amongst boys and 2.9-7.7 per cent amongst girls. the latter has been accompanied by increased production of alcoholic beverages and increased regular drinking, particularly beer and wine. 36 vietnam has no minimum legal age for purchasing alcohol and it is very easy for young people to get alcohol anywhere that it is on sale. initiation into alcohol consumption occurred at an early age, even before the age of 18, particularly amongst males. the findings of the present study are a reminder that young people who begin drinking before they reach the age of 15 are significantly more likely to become heavy or dependent drinkers than those who begin drinking when they are older. 22,37,38 with these economic and social changes, young people have had greater access to recreational activities and social meeting places such as cafes, small restaurants, karaoke, and bars. 33 the leisure activities of young people include watching tv and playing video games. the latter often include acts of violence while under the influence of alcohol. advertising funded by the beer and wine producers. 39 while vietnam is still among the poorest countries in asia, young people have more opportunities and threats in health. 40 in the current research, the relationship between alcohol use and relevant factors suggests a link between alcohol use and risk behavior reduction prevention education and gender. 41 as the country continues to undergo social and economic changes, it is essential to increase awareness of behaviours of alcohol use and its associated risks. 42 due note should be taken of both the short and long-term consequences of alcohol consumption among young people and the general population. recommendations this study showed that many both girls and boys were drinking. the young people surveyed had started to drink very early. alcohol consumption was also related to risk taking, leisure activities and failure to access to health care services. longitudinal research on alcohol use amongst vietnamese young population should be conducted in vietnam. this could monitor the trends of alcohol use and its related consequences. this could serve to guider the development of evidencebased policies to prevent, manage and minimize alcohol-related problems in vietnam. as similar research conducted in other asian countries such as thailand and india has benefited prevention programmes. 43,44 it is also recommended that alcohol harm reduction policies should be implemented and integrated into measures to reduce levels of other health problems such as hiv/aids and non communicable diseases. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thoa this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu such policies should ideally be evidence-based and evaluated. acknowledgements this study was funded by the faculty of public health, ha noi medical university, vietnam. additional support for writing this paper was provided by the university of the west of england, bristol, united kingdom. mrs jan green is thanked for editorial assistance. the authors thank sean p. soisson for comments on an earlier version of this manuscript. references 1. ma s, cutter j, tan ce, chew sk, tai es. associations of diabetes mellitus and ethnicity with mortality in a multiethnic asian population: data from the 1992 singapore national health survey. american journal of epidemiology. 2003; 158:543-55. 2. nakanishi n, suzuki k, tatara k. alcohol consumption and risk for development of impaired fasting glucose or type 2 diabetes in middle-aged japanese men. diabetes care. 2003; 26: 48-54. 3. rehm j, room r, graham k, monteiro m, gmel g, sempos ct. relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. addiction. 2003; 98:1209-1228. 4. wannamethee sg, camargo jr ca, manson je, willett wc, rimm eb. alcohol drinking patterns and risk of type 2 diabetes mellitus among younger women. archives of internal medicine. 2003; 163: 1329-1336. 5. world health organization. global status report on alcohol. geneva: world health organization; 2004. 6. plant ml, plant ma. addiction: major themes in health and social welfare. london: routledge; 2007. (volume ii) 7. british medical association. tackling alcohol misuse in the uk. london: british medical association; 2008. 8. plant ma, plant ml. risktakers: alcohol, drugs, sex and youth. london: tavistock; 1992. 9. stall r, leigh b. understanding the relationship between drug or alcohol use and high risk sexual activity for hiv transmission: where do we go from here? addiction. 1994; 89(2): 131-134. 10. cavan s. liquor license: an ethnography of bar behavior. chicago: aldine; 1966. 11. green j, plant ma. (2007) bad bars: a review of risk factors. journal of substance use. 2007; 12(3): 157-189. 12. nam vinh n, viet tinh d. (2001) alcohol consumption in vietnam. the globe. 3&4. http://www.ias.org.uk/what-wedo/publication-archive/the-globe/issue-4-2001-32001/alcohol-consumption-in-vietnam.aspx 13. goodburn ea, ross da. young people’s health in developing countries: a neglected problem and opportunity,” health policy and planning. 2000; 15(2): 137-144. 14. jessor r, jessor sl. problem behavior and psychosocial development: a longitudinal study of youth. new york: academic press; 1977. 15. hingson rw, kenkel d. (2004) social, health and economic consequences of underage drinking. in: national research council and institute of medicine. reducing underage drinking: a collective responsibility, background papers, committee on developing a strategy to reduce and prevent underage drinking, division of behavioral and social sciences and education. washington, dc: the national academies press; 2004. 16. coleman lm, cater sm. (2005) a qualitative study of the relationship between alcohol consumption and risky sex on young people. archives of sexual behaviour. 2005; 34(6):64961. 17. kaiser family foundation. (2002) fact sheet: substance use and sexual health among teens and young adults in the us. washington, dc: the henry kaiser family foundation. available from: http://www.kff.org//content/2002/3213/cas afact-sheet.pdf. 18. piombo m, piles m. (1996) the relationship between college females' drinking and their sexual behaviors. women's health issues. 1996; 6: 221-228. 19. desapriya eb, iwase n, shimizu s. adolescents alcohol related traffic accidents and mortality in 1999-2000--problem and solutions [japanese, abstract]. nihon arukoru yakubutsu igakkai zasshi. 2002 jun;37(3):168-78. 20. han s, choe mk, lee ms, lee sh. risk taking behavior among high school students in south korea. journal of adolescence. 2001; 24(4): 571-574. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.ias.org.uk/what-we-do/publication-archive/the-globe/issue-4-2001-3-2001/alcohol-consumption-in-vietnam.aspx http://www.ias.org.uk/what-we-do/publication-archive/the-globe/issue-4-2001-3-2001/alcohol-consumption-in-vietnam.aspx http://www.ias.org.uk/what-we-do/publication-archive/the-globe/issue-4-2001-3-2001/alcohol-consumption-in-vietnam.aspx http://www.kff.org/content/2002/3213/cas%20afact-sheet.pdf http://www.kff.org/content/2002/3213/cas%20afact-sheet.pdf central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu 21. li x, fang x, stanton b, feigelman s, dong q. (1996) the rate and pattern of alcohol consumption among chinese adolescents. journal of adolescent health. 1996; 19: 353-361. 22. assanangkornchai s, geater af, saunders jb, mcneil dr. (2002). effects of paternal drinking, conduct disorder and childhood home environment on the development of alcohol use disorders in a thai population. addiction. 2002; 97(2): 217226. 23. world health organization. core health indicators. geneva: world health organization; 2007. 24. berg-kelly k. adolescent health, school health activities, community contexts, and health surveys in sweden. journal of adolescent health. 2003; 33: 226-30. 25. hibell b, andersson b, bjarnasson t, ahlström s, balakireva o, kokkevi a, morgan m. the 2003 espad report: alcohol and other drug use among students in 30 european countries. stockholm: swedish council for information on alcohol and other drugs; 2004. 26. johnston l, o’malley pm, bachman jg, schulenberg je. monitoring the future: national survey results on drug use 1975-2003, volume ii, college students and young adults. bethesda, md: national institute on drug abuse; 2004. 27. plant ma, plant ml. binge britain: alcohol and the national response. oxford: oxford university press; 2006. 28. world health organization. country profiles – vietnam. geneva: world health organization; 2004. 29. giangi kb, spak f, dzungi tv, allebeck p. the use of audit to assess level of alcohol problems in rural vietnam. alcohol and alcoholism. 2005; 40(6):578-583. 30. son bt, bain dl, colby dj, thinh t, giang lt, mandel js. vietnam needs a strategy to address risky sexual behavior following alcohol consumption. international conference on aids. 2004 july 11-16; 15: abstract no. d11253. http://gateway.nlm.nih.gov/meetingabstracts/102277956.html. 31. baumberg b. the global economic burden of alcohol: a review and some suggestions. drug and alcohol review. 2006; 25(6): 537-551. 32. kaljee l, genberg b, minh tt, tho lh, thoa ltk, stanton b. alcohol use and hiv risk behaviors among rural young people in khanh hoa province, vietnam,” health education research. 2004. retrieved 2004 jun 15 from http://her.oupjournals.org/. 33. yeh ek, hwu hg. (1992) alcoholism in taiwan chinese communities. in: helzer je, canino gj, eds. alcoholism in north america, europe and asia. new york: oxford university press; 1992: 214-246. 34. lee ck. alcoholism in korea. in: helzer je, canino g, eds. alcoholism in north america, europe and asia. new york: oxford university press; 1992: 247-263. 35. grube jw. preventing sales of alcohol to minors: results from a community trial. addiction. 1997; 92: s251-s260. 36. califano ja. focus on adolescent services: alcohol and teen drinking. the national center on addiction and substance abuse at columbia university; 2007. 37. pitkänen t, lyyra a-l, pulkkinen l. age of onset of drinking and the use of alcohol in adulthood: a follow-up study from age 8-42 for males and females. addiction. 2005; 100: 652-661. 38. snyder lb, milici ff, slater m, sun h, strizhakova y. effects of alcohol advertising exposure on drinking among youth. archives of pediatric and adolescent medicine. 2006; 160:18-24. 39. ehrhardt a, exner t. (2000) prevention of sexual risk behavior for hiv infection with women. aids. 2000; 14(suppl2): s54-s58. 40. bowd a, loos c. gender difference in adoption of aids preventive behaviors: implications for women’s aids education programs. women’s health issues. 1995; 5(1): 21. 41. herdt g, boxer a. ethnographic issues in the study of aids. journal of sex research. 1991; 28(2): 171. 42. vantamay s. alcohol consumption among university students: applying a social ecological approach for multi-level preventions. southeast asian j trop med public health. 2009 mar; 40(2): 354-69. 43. sivaram s, latkin ca, solomon s, celentano dd. (2006). hiv prevention in india: focus on men, alcohol use and social networks. harvard health policy review. 2006; 7(2): 125-134. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://gateway.nlm.nih.gov/meetingabstracts/102277956.html http://her.oupjournals.org/ thoa this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu table 1: sample design site stage 1st 2nd 3rd province/city commune households urban (ha noi) 1 4 120 rural (ha nam) 1 4 120 mountain (thai nguyen) 1 4 120 total 3 12 1 440 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu table 2: demographic characteristics of the sample variable overall (n = 1408) male (n = 673) female (n = 735) or p age groups 10-14 age 729 (51.8%) 358(53.2%) 371(50.5%) 1.12 0.3078 15-18 age) 679(48.2%) 315(46.8%) 364(49.5%) 0.90 0.3078 in-school 1322 (94%) 635 (94.3%) 687(93.5%) 1.01 0.902 primary 312(24%) 153(24%) 159(23%) 1.05 0.6843 secondary 596(45%) 289(46%) 307(45%) 1.03 0.7633 high school 400(30%) 187(29%) 213(31%) 0.93 0.5384 college 14(1%) 6(1%) 8(1%) 0.81 0.6967 sites urban 491(34.9%) 223(33.1%) 268(37%) 0.86 0.1906 rural 477(33.9%) 236(35.1%) 241(33%) 1.11 0.3670 mountain 440(31.3%) 214(31.8%) 226(31%) 1.05 0.6712 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thoa this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu table 3: alcohol consumption and demographic factors characteristics overall n (%) male n (%) female n (%) or p age 10-14 67 (9.2) 38 (10.6) 29 (7.8) 1.4 0.191 15 -19 166 (24.4) 117 (37.1) 49 (13.5) 4.4 0.000 out-school 17 (19.8) 13 (34.2) 4 (8.3) 4.1 0.014 in-school 166 (12.5) 142 (22.3) 74 (10.8) 2.1 0.000 primary 24 (7.7) 14 (9.2) 10 (6.3) 1.4 0.350 secondary 75 (12.6) 49 (16.9) 26 (8.5) 2.0 0.005 high school 112 (28) 76 (40.6) 36 (16.9) 2.4 0.000 college/university 5 (36) 3 (50) 2 (25) 2.0 0.509 areas urban 65 (13.2) 41 (17.6) 24 (8.9) 2.05 0.007 rural 70 (14.7) 45 (19.1) 25(10.4) 1.84 0.02 mountain 98 (22.3) 69 (32.2) 29 (12.8) 2.51 0.000 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu table 4: television and, computer and computer game use characteristics overall n (%) male n (%) female n (%) or p do nothing 141(10) 66 (9.8) 75 (10.2) 0.96 0.804 less than 1 hour 123 (8.7) 56 (8.3) 67 (9.1) 0.90 0.597 1-2 hours 642 (45.6) 316 (46.9) 326 (44.3) 1.11 0.327 3-4 hours 411 (29.1) 189 (28) 222 (30.2) 0.89 0.335 5 or more hours 91 (6.5) 46 (6.8) 45 (6.1) 0.90 0.597 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thoa this work is licensed under a creative commons attribution-noncommercial -no derivative works 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.10 | http://cajgh.pitt.edu table 5: helmet use amongst bicycle and motorbicycle riders variable overall n (%) male n (%) female n (%) or p use bicycle/motorbicycle 1210 (86) 572 (85) 665 (70) 0.60 0.001 always use 861 (61.2) 407 (60.5) 454 (61.8) 0.95 0.618 sometimes 349 (24.8) 165 (24.5) 184 (25.0) 0.97 0.822 never use 198 (14.1) 101 (15.0) 97 (13.2) 1.16 0.329 wear helmet 268 (19.5) 134 (20.3) 134 (18.7) 1.12 0.422 always 55 (6.4) 28 (4.2) 27(3.7) 1.14 0.637 sometimes 213(15.1) 106(15.8) 107(14.6) 1.10 0.532 never 1104(78.4) 523(77.7) 581(79.0) 0.92 0.542 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. prevalence of hypertension and associated factors in jalalabad city, nangarhar province, afghanistan khwaja mir islam saeed afghanistan national public health institute, ministry of public health, kabul, afghanistan vol. 4, no. 1 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu abstract background: hypertension affects an estimated one billion people, worldwide. it is a public health challenge characterized by increased morbidity, mortality, as well as cost to the community and health systems. the goal of this study is to determine the prevalence of hypertension and characterize associated risk factors in an urban setting in afghanistan. methods: a cross-sectional study of adults aged 25-65 years was conducted in jalalabad city from may to june 2013 using the world health organization stepwise approach to surveillance (who steps). a multistage technique was used to enroll 1,200 participants in the study. demographic and socio-economic variables were collected via individual interviews using the who steps survey, after which blood samples were collected using a locally developed standard operating procedure (sop). bivariate and multivariable analyses were performed to explore the association between hypertension and associated factors. results: a total of 1,180 adults (40% males, 60% females) of 25-65 years of age were surveyed. the response rate was 98.5 % and the prevalence of hypertension was 28.4. independent risk factors of hypertension were found to be: age ≥ 50 (aor = 3.42, 95% ci: 2.50 – 4.76); sex (aor = 0.58, 95% ci: 0.38 – 0.88); obesity (aor = 2.1, 95% ci 1.49 – 2.94); and diabetes (aor = 1.75, 95% ci: 1.10 – 2.79). independent protective factors were physically demanding occupations (aor = 0.55, 95% ci: 0.36 – 0.85); physical activity itself (aor = 0.69, 95% ci: 0.47 – 0.99) and consuming more vegetables (aor = 0.59, 95% ci: 0.38 – 0.93). conclusion: this urban setting in afghanistan evidenced a high prevalence of hypertension; age, obesity, and diabetes were identified as risk factors and physical activity and consuming more vegetables were protective. these findings have implications for future public health intervention and clinical efforts. keywords: prevalence, associated factors, hypertension, urban, afghanistan prevalence of hypertension and associated factors in jalalabad city, nangarhar province, afghanistan khwaja mir islam saeed afghanistan national public health institute, ministry of public health, kabul, afghanistan research hypertension (htn) is a global public health problem, affecting approximately one billion people worldwide, a figure that is predicted to increase to 1.5 billion by the year 2025.1 the global prevalence of htn is approximately 30% among adults; in developed countries, prevalence is beginning to stabilize or decrease, while in the developing regions, proportions continue to rise (between 20-50%).2,3 htn is a global problem with some of the commen risk factors reported in the litearature being genetics, family history, advanced age, race, obesity, physical inactivity, lifestyle, cigarette smoking, excessive salt and alcohol intake, and dietary habits.4-7 htn prevalence has been reported to be 1535% in asia,8 20-33% in africa,9 18-22% in the usa,10 44% in some european countries,10 44% in turkey,4 26.3% in egypt,11 32.2% in india,12 and 32.1% in qatar.13 in the eastern mediterranean region (emr), the prevalence of htn has been estimated to be 29%, affecting approximately 125 million individuals.14 in afghanistan, due to years of war and conflict, few studies have been conducted to estimate the burden of hypertension. according to our previously published study of chronic disease risk factors in kabul, in a sample http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu of individuals aged 40+, the overall prevalence of obesity, htn, and diabetes mellitus was 31.2%, 46%, and 13.3%, respectively.15 however in neighboring countries such as iran, the overall prevalence of htn in the adult population was 23%, with 50% of those aged >55 years affected.16 previously published research from pakistan reported an overall prevalence of htn of 26% which diffiered by 34% among males and 24% in females.17 according to anecdotal reports from clinicians in kabul, the number of people with htn is increasing. in addition, the recent afghan mortality survey (ams 2010) survey indicated that 35% of all-cause mortality in afghanistan is due to non-communicable disease, particularly cardiovascular disease and cancer.18 as of 2014, afghanistan suffers from lack of reliable information on the burden of non-communicable disease, including htn, due to the fact that high priority is given to the investigation of infectious diseases. the purpose of this study is to estimate the burden of htn and associated risk factors among the adult population in afghanistan’s eastern city, jalalabad. this information is essential to provide evidence to support strategic decisions such as resource allocation and public health interventions to reduce risk factors and decrease the burden of disease. methods and materials we conducted a cross-sectional study using the world health organization stepwise approach to surveillance (who steps)19 to estimate the prevalence and factors for non-communicable diseases in jalalabad city, afghanistan. steps was initiated by the who to establish the surveillance of risk factors for noncommunicable diseases. the survey tool collects information on behavioral, physical and biochemical measurements as a part of the core, expanded, and optional modules.19 each country can use and modify the modules and steps based on their needs. setting jalalabad is a city in the nangarhar province on the eastern border of afghanistan. five districts were selected for assessment while one was excluded due to safety concerns. inclusion criteria included: ages 25-64 (adult population, as outlined in who survey tool), city residents during study period, and consent to participate. exclusion criteria included: refusal to participate and temporary residency. in addition, all five districts were classified into clusters, sub-clusters, target areas, and then households. in the series of households, every third household and one eligible adult in each household was selected for research assessment. the response rate was 98.5% with a 1.5% refusal to participate. temporary residents (less than six months) and those living in institutionalized settings along with unsafe areas were excluded from the survey. we excluded temporary residents because our goal was to obtain a reliable data about permanent residents, not migrant populations. population over 60% of the participants were female. thus, we adjusted for sex in our analyses. after informing the community representatives, we approached all four clusters (a, b, c, d) and 20 sub-clusters of epi, including five city districts, to obtain the target population. our primary sampling unit (psu) was subclusters, secondary sampling units (ssu) were streets/areas, tertiary sampling units (tsu) were households, and ultimate sampling units (usu) were respondents more than 25 years of age in the household. the interviewer was instructed to find a the famous masjid as a fixed landmark or a very populated street within the boundaries of the selected location and following the bottle rotating rule to proceed to series of households. at last level random selection was carried out by writing the name of target members on a separate piece of paper and then drawing the names. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu measures as mentioned above, the who steps was used to collect demographic, socio-economic, clinical, and behavioral data via face-to-face interviews. weighing scales and tension tape were used to measure body weight and height. a body mass index (bmi, hereafter reported without units) ≥ 30 kg/m2 were considered as obese, 25-29.9 was considered as overweight, and 18.5-24.9 was considered normal weight.20 a waist circumference ≥ 94 cm for men and ≥80 cm for women was considered as central obesity.21 cuff type sphygmomanometers were used to measure systolic and diastolic blood pressure twice with five minutes between each measurement at a sitting or lying position by our trained surveyors. systolic blood pressure levels ≥ 140 mmhg and diastolic pressure levels ≥ 90 mmhg were considered hypertensive.22 htn in this study was defined as having a previous diagnosis of htn or having a bp of htn status. blood samples were collected and processed by lab technicians under supervision of lab coordinator. after shipment of samples to the central public health laboratory (cphl) in kabul, they were stored at -80°c until glucose measurement was completed. close monitoring of all study steps by core group of investigator was implemented to enhance quality of data at all research stages. the study protocol was approved by institutional review board (irb) at the ministry of public health, afghanistan. informed consent was provided by all study participants. statistical considerations data entry was performed using epi info version 3.5.1.23 analyses were performed using ibm spss software version 20.24 as data regarding risk factor prevalence in this province were not available, we assumed the highest prevalence and 95% confidence interval and band of error of 5%. to balance considerations of non-response rate, cost, resources, and time without compromising the representativeness of the sample, a two-phase cluster sampling technique was used. the sample size was calculated to be able to determine the effect of risk factors on non-communicable diseases. the resulting sample size was 1,200. data were collected may-june 2013. participants with missing data for blood pressure were excluded from the final analysis, which incorporated 1,180 participants. pregnant women were also excluded from obesity-related analyses. logistic regression was used to examine the association of relevant variables adusting for all other vaiables and to calculate the adjusted odds ratio (aor). results descriptive analysis: the average age this sample was 39.16 ± 11.5 years. the overall prevalence of htn was 28.4% among age group of 25-65 years. mean systolic blood pressure and standard deviation (sd) was 122 ± 20 mmhg and ranged from 70 to 220 mmhg. mean diastolic blood pressure was 79 ± 13 mmhg and ranged from 40 to 130 mmhg. overall, 4% of hypertensive participants were previously diagnosed or were under treatment for htn, which is very low and could be due to latent htn or asymptomatic htn. more than half (66.9%) were illiterate and 66.2% had income of less than 10,000 afn (200usd) per month (refer to table 1 for details on demographic variables). table 1: participant characteristics among those surveyed using the who steps in jalalabad, nangarhar, afghanistan the mean height, weight and waist circumference were 161.4 cm, 69.3 kg and 85.4 cm respectively. the mean and sd of body mass index was http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu 26.8 ± 6.8 kg/m2. descriptive statistics demonstrated that 7.6% of respondents were current smoker and on average they smoked 12 cigarettes daily. 13.3% were mouth snuff users which are almost double of cigarettes smoker. around 54% of study participants were using solid oil in their kitchen for cooking. as we had data on number of days per week that research participants consumed fruit (average number of fruit servings per day), these data were categorized dichotomous by cut of three days per week. data shows 65% of participants were consuming fresh fruits less than three days per week as compared to 27% who were consuming fruits more than three days per week. these variables have been described in table 2. table 2: distribution of behavioral risk factors among those surveyed using the who steps in jalalabad, nangarhar, afghanistan the study demonstrates that 32% of respondents were employed at jobs that required high level of physical activity and 49% moderate physical activity. farmers, workers and business were categorized as high physical work and the office related jobs categorized low physical group. the proportions of pathophysiological factors potentially associated with htn were diabetes (11%), overweight (30%), obesity (23%), and central obesity (50%). the biochemical measurements findings shows the mean and sd total triglycerides, cholesterol, hdl, ldl and fasting blood sugar were 187.5 ± 76.5, 198.5 ± 42, 39.16 ± 8, 122.3 ± 41.6, and 92.3 ± 39.5 mg/dl, respectively. inferential analysis: according to bivariate analysis, hypertensive status increased incrementally with age with highest prevalence in age group of 45-55 years old (table 3). table 3: bivariate analysis of bio demographic and socioeconomic factors and hypertension among those surveyed using the who steps in jalalabad, nangarhar, afghanistan there was a significant association between htn and sex; females were two times more likely to be affected by htn than males. in terms of education status, those who were illiterate were 1.3 times (95% ci: 1.01 – 1.76) at greater risk for developing htn. we found significant associations between the level of income and proxies of physical activities with hypertension. smoking habits, mouth snuff use and diet were associated with htn but it was not statistically significant. overweight and obesity were significantly associated with htn (overweight or = 2.52, 95% ci: 1.28 – 4.98), (obesity or = 4.55, 95% ci: 2.30 – 8.99). those who were htn had 2.32 (95% ci: 1.61 – 3.36) times higher odds of being diabetic compared with normal blood pressure. we did not find any significant relationship between level of blood lipids and htn (table 4). table 4: bivariate analysis of pathophysiologic factors and hypertension among those surveyed using the who steps in jalalabad, nangarhar, afghanistan multivariate analysis (table 5) demonstrated that older age (aor = 3.42, 95% ci: 2.50 – 4.76), sex (aor = 0.58, 95% ci: 0.38 – 0.88), physically demanding jobs (aor = 0.55, 95% ci: 0.36 – 0.85), general obesity (aor = 2.1, 95% ci: 2.11 – 2.94), diabetic status (aor = 1.75, 95% ci: 1.10 – 2.97), physical activity (aor = 0.69, 95% ci: 0.47 – 0.99), and consuming more vegetables (aor = 0.38, 95% ci: 0.38 – 0.93) were independently associated with htn. sex was not associated with htn. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu table 5: multivariable analysis of risk factors and hypertension among those surveyed using the who steps in jalalabad, nangarhar, afghanistan discussion this is one of the few published studies on htn prevalence in afghanistan. our findings suggest that htn, which affected one third of this sample, is a growing public health challenge in the urban setting of jalalabad. however, comparing with other regions, it was lower than in kabul, the capital of the country.15-17 almost 60% of the study participants were female compare to 49% in general population. the main reason for this difference was employment of men outside the house during day time and not available for study assessment. females were at higher risk of htn, a finding that other investigations support.17,25 this disparity may be explained by females engaging in less physical activities at home or evidencing higher proportions of obesity; however additional studies are needed to test this hypothesis. health care systems should be strengthened so they have the capacity for early detection and the means for effective treatment of those affected with htn. results shows 7.6% of respondents were smoking currently daily while double of that were mouth snuff users. it could be due to low cost of snuff as compare to cigarettes. the saturated (solid) ghee for kitchen considered a risk factor for htn and obesity while the unsaturated (liquid) ghee was considered to have lower risk. physical activity and diet rich in vegetables were protective factors against htn in this study. these findings have been corroborated by other authors exploring hypertensive disease in various parts of the world.13,26 in addition, obesity and diabetes were found to be the independent risk factors for htn in this study, which is supported by previously published studies.27-29 based on this study, a baseline understanding of htn prevalence in the region could be established for jalalabad city, while further studies and public health programs can be established to compare rates in other geographic settings and evaluate interventions. screening individuals over the age of 40, particularly for females, is recommended based on findings of this study for urban settings of afghanistan. policy changes are essential to reduce risk of htn in various populations within afghanistan, including public education to improve dietary habits and enhance physical activity. furthermore, prevention strategies should focus on risk factors for metabolic syndrome, such as obesity and diabetes. due to the government’s focus on communicable diseases, lesser emphasis is given to noncommunicable disease such as htn.30 recently, the national strategy for non-communicable diseases has been finalized in the country.31 therefore, prevention and control of htn needs political will, combined with community support and behavioral change on the part of the individuals and their families. competing interests the author declares that he has no competing interests. acknowledgement i would like to thank afghan national public health institute at ministry of public health and world health organization for technical and financial support as well as surveillance staff for data collection and management in the field. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu references 1. kearney pm, whelton m, reynolds k, muntner p, whelton pk, he j. global burden of hypertension: analysis of worldwide data. lancet. 2005;365(9455):217-223. 2. mohan v, seedat yk, pradeepa r. the rising burden of diabetes and hypertension in southeast asian and african regions: need for effective strategies for prevention and control in primary health care settings. int j hypertens. 2013. 3. medscape cardiology. hypertension, but not "prehypertension," increases stroke risk: global prevalence of hypertension may be close to 30%. 2004; http://www.medscape.com/viewarticle/471536_8 4. erem c, hacihasanoglu a, kocak m, deger o, topbas m. prevalence of prehypertension and hypertension and associated risk factors among turkish adults: trabzon hypertension study. j public health (oxf). 2009;31(1):47-58. 5. fauci as, braunwald e, kasper dl, et al. harrison's principles of internal medicine. 17th ed: the mcgraw-hill companies; 2008. 6. the american heart association. factors that contribute to high blood pressure. http://www.americanheart.org/presenter.jhtml?identifier=4650 . 7. world health organization. a global brief on hypertension: silent killer, global public health crisis. 2013; http://apps.who.int/iris/bitstream/10665/79059/1/who_dco_ whd_2013.2_eng.pdf?ua=1. 8. singh rb, suh il, singh vp, et al. hypertension and stroke in asia: prevalence, control and strategies in developing countries for prevention. j hum hypertens. 2000;14(1011):749-763. 9. unwin n, setel p, rashid s, et al. noncommunicable diseases in sub-saharan africa: where do they feature in the health research agenda? bull world health organ. 2001;79(10):947-953. 10. wolf-maier k, cooper rs, banegas jr, et al. hypertension prevalence and blood pressure levels in 6 european countries, canada, and the united states. jama. 2003;289(18):23632369. 11. ibrahim mm, rizk h, appel lj, et al. hypertension prevalence, awareness, treatment, and control in egypt. results from the egyptian national hypertension project (nhp). nhp investigative team. hypertension. 1995;26(6 pt 1):886-890. 12. puavilai w, laorugpongse d, prompongsa s, et al. prevalence and some important risk factors of hypertension in ban paew district, second report. j med assoc thai. 2011;94(9):1069-1076. 13. bener a, al-suwaidi j, al-jaber k, al-marri s, dagash mh, elbagi ie. the prevalence of hypertension and its associated risk factors in a newly developed country. saudi med j. 2004;25(7):918-922. 14. world health organization. non-communicable diseases: hypertension. 2011; http://www.emro.who.int/ncd/hypertension.htm. 15. saeed kmi. prevalence of risk factors for noncommunicable diseases in the adult population of urban areas in kabul city, afghanistan. cajgh. 2013;2(2). 16. haghdoost ak, behnam sadeghirad b, rezazadehkermani m. epidemiology and heterogeneity of hypertension in iran: a systematic review. arch iranian med. 2008;11(4):444-452. 17. safdar s, omair a, faisal u, hasan h. prevalence of hypertension in a low income settlement of karachi, pakistan. j pak med assoc. 2004;54(10):506-509. 18. afghan public health institute ministry of public health (aphi/moph) [afghanistan], central statistics organization (cso) [afghanistan], icf macro iiohmrii, [egypt] whoroftemwe. afghanistan mortality survey 2010. maryland, usa: calverton; 2011. 19. bonita r, decourten m, dwyer t, k. j, winkelmann r. surveillance of risk factors for non-communicable disease: the who stepwise approach. geneva: world health organization;2002. 20. world health organization. obesity: preventing and managing the global epidemic; report of a who consultation. geneva: world health organization;2000. 21. international diabetes federation. the idf consensus worldwide definitions of the metabolic symdrome. 2006; http://www.idf.org/webdata/docs/idf_meta_def_final.pdf. 22. whitworth ja, world health organization, international society of hypertension writing group. 2003 world health organization (who)/international society of hypertension (ish) statement on management of hypertension. j hypertens. 2003;21(11):1983-1992. 23. epi info [computer program]. version 3.5.12008. 24. ibm spss statistics for windows [computer program]. version 20.0. armonk, ny2011. 25. yoon ss, burt v, louis t, carroll md. hypertension among adults in the united states, 2009–2010. nchs data brief, no 107. 2012; hyattsville, md. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.medscape.com/viewarticle/471536_8 http://www.americanheart.org/presenter.jhtml?identifier=4650 http://www.americanheart.org/presenter.jhtml?identifier=4650 http://apps.who.int/iris/bitstream/10665/79059/1/who_dco_whd_2013.2_eng.pdf?ua=1 http://apps.who.int/iris/bitstream/10665/79059/1/who_dco_whd_2013.2_eng.pdf?ua=1 http://www.emro.who.int/ncd/hypertension.htm http://www.idf.org/webdata/docs/idf_meta_def_final.pdf saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu 26. gudina ek, michael y, assegid s. prevalence of hypertension and its risk factors in southwest ethiopia: a hospital-based cross-sectional survey. integr blood press control. 2013;6:111-117. 27. yadav s, boddula r, genitta g, et al. prevalence of prehypertension, hypertension and cardiovascular risk factors in a belarus urban population. indian j med res. 2008;128(6):indian j med res. 28. pooja ym. prevalence of hypertension and its determinants in an urban area of uttarakhand. ajbps. 2013;3(21):12-16. 29. prabakaran j, vijayalakshmi n, venkatarao e. prevalence of hypertension among urban adult population (25-64 years) of nellore, india. int j res dev health. 2013;1(2). 30. the world bank. ncds policy brief afghanistan. 2011; http://siteresources.worldbank.org/southasiaext/resources/ 223546-1296680097256/77074371296680114157/ncd_af_policy_feb_2011.pdf. 31. ministry of public health afghanistan. national strategy for prevention and control of noncommunicable diseases (ncds) 2013-2018. 2013; http://www.iccpportal.org/sites/default/files/plans/ncdstrategy_draft_final_fro m%20af%20moh.pdf. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://siteresources.worldbank.org/southasiaext/resources/223546-1296680097256/7707437-1296680114157/ncd_af_policy_feb_2011.pdf http://siteresources.worldbank.org/southasiaext/resources/223546-1296680097256/7707437-1296680114157/ncd_af_policy_feb_2011.pdf http://siteresources.worldbank.org/southasiaext/resources/223546-1296680097256/7707437-1296680114157/ncd_af_policy_feb_2011.pdf http://www.iccp-portal.org/sites/default/files/plans/ncdstrategy_draft_final_from%20af%20moh.pdf http://www.iccp-portal.org/sites/default/files/plans/ncdstrategy_draft_final_from%20af%20moh.pdf http://www.iccp-portal.org/sites/default/files/plans/ncdstrategy_draft_final_from%20af%20moh.pdf saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu table 1: participant characteristics among those surveyed using the who steps in jalalabad, nangarhar, afghanistan variables categories un-weighted weighted n % n % age 25 34 445 37.7 450 38.2 35 44 305 25.8 281 23.9 45 54 207 17.5 211 17.9 54 and over 128 10.8 144 12.3 missing 95 8.1 91 7.7 sex female 579 49.1 715 60.6 male 600 50.9 465 39.4 level of education illiterate 841 71.3 779 66.9 primary/unofficial education 140 11.9 163 13.8 secondary school 135 11.4 158 13.4 university and more 53 4.5 65 5.5 missing 11 0.9 13 1.1 residence district 1 176 14.9 196 16.7 district 2 163 13.8 138 11.8 district 3 299 25.3 275 23.3 district 4 302 25.6 354 30.1 district 5 240 20.3 214 18.1 work status official employee 109 9.2 131 11.2 business 78 6.6 101 8.6 farmer/worker 222 18.8 287 24.5 homemaker 632 53.6 506 43.2 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu unable to work/retired 80 6.8 102 8.7 refused 54 4.6 45 3.9 missing 5 0.4 5 0.4 monthly income (afghanis) ≤ 10,000 698 59.2 736 62.5 10,000 – 20,000 41 3.5 42 3.6 ≥ 20,000 42 3.6 34 2.9 refused 398 33.7 363 30.9 missing 1 0.1 1 0.1 marital status single 88 7.5 95 8.1 married 1,039 88.1 1,036 88 widow/widower 44 3.7 38 3.2 refused 9 0.8 8 0.7 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu table 2: frequency distribution of behavior risk factors of those surveyed using the who steps in jalalabad, nangarhar, afghanistan variables categories female (%) male (%) total (%) smoking status* no 535 (51.3) 507 (48.7) 1,042 (92%) yes 1 (1.1) 89 (98.9) 92 (8.0) smoking duration in years < 10 years 0 (0.0) 58 (100.0) 58 (43.3) 10 – 20 years 3 (6.1) 46 (93.9) 49 (36.6) > 20 years 0 (0.0) 27 (100.0) 27 (20.1) mouth snuff use* no 536 (54.6) 446 (45.4) 982 (86.2) yes 3 (1.9) 154 (98.1) 157 (13.8) fruit servings consumed in days per week* ≤ 3 days 399 (52.2) 366 (47.8) 765 (70.2) > 3 days 143 (44.1) 181 (55.9) 324 (29.8) vegetable servings consumed in days per week* ≤ 3 days 150 (65.2) 80 (34.8) 230 (19.7) > 3 days 418 (44.7) 517 (55.3) 935 (80.3) type of kitchen oil used* liquid 365 (77.8) 104 (22.2) 469 (42.1) solid 170 (26.4) 475 (73.6) 645 (57.9) vigorous physical activity* no 305 (40.6) 446 (59.4) 751 (66.8) yes 223 (59.6) 151 (40.4) 374 (33.2) moderate physical activity* no 190 (44.2) 240 (55.8) 430 (42.4) yes 326 (55.9) 257 (44.1) 583 (57.6) pedal or bicycle for 10 minutes daily* no 498 (67.1) 244 (32.9) 742 (66.5) yes 23 (6.1) 351 (93.9) 374 (33.5) sitting in hours per day http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu ≤ 3 hours 296 (45.7) 352 (54.3) 648 (64.9) > 3 hours 145 (41.3) 206 (58.7) 351 (35.1) note. *marks a significant difference between males and females p < 0.05 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu table 3: bivariate analysis of bio demographic and socio-economic factors and hypertension among those surveyed using the who steps in jalalabad, nangarhar, afghanistan variables categories hypertensive normotensive odds ratio 95% ci age 25 34 72 (16.0) 379 (84.0) 1 reference 35 44 85 (30.1) 197 (69.9) 2.28 1.59 3.26 45 54 97 (46.0) 114 (54.0) 4.46 3.08 6.46 55 and over 62 (43.1) 82 (56.9) 4 2.64 6.06 sex female 207 (35.7) 373 (64.3) 1 reference male 128 (21.3) 472 (78.7) 2.05 1.58 2.65 level of education illiterate 237 (30.3) 546 (69.7) 1 reference literate 94 (24.5) 289 (75.5) 1.33 1.01 1.76 monthly income (afghanis) ≤ 10,000 192 (26.1) 544 (73.9) 1 reference > 10,000 34 (44.7) 42 (55.3) 0.44 0.27 0.70 smoking no 289 (27.7) 754 (72.3) 1 reference yes 19 (21.1) 71 (78.9) 1.43 0.85 2.42 fruit servings consumed in days per week ≤ 3 days 214 (28.0) 551 (72.0) 1 reference > 3 days 88 (27.2) 236 (72.8) 1.04 0.78 1.40 vegetable servings consumed days per week ≤ 3 days 67 (29.1) 163 (70.9) 1 reference > 3 days 264 (28.2) 671 (71.8) 1.04 0.76 1.44 type of kitchen oil liquid 156 (33.3) 313 (66.7) 1 reference solid 156 (24.2) 489 (75.8) 1.76 1.31 2.37 vigorous physical activity http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu no 231 (30.8) 520 (69.2) 1 reference yes 75 (20.1) 298 (79.9) 1.04 0.78 1.40 moderate physical activity no 145 (33.7) 285 (66.3) 1 reference yes 133 (22.8) 450 (77.2) 1.72 1.30 2.27 sitting in hours per day ≤ 3 hours 164 (25.3) 483 (74.7) 1 reference > 3 hours 113 (32.1) 239 (67.9) 0.72 0.54 0.95 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu table 4: bivariate analysis of pathophysiologic factors and hypertension among those surveyed using the who steps in jalalabad, nangarhar, afghanistan variables categories hypertensive normal odds ratio 95% ci basic mass index underweight 11 (14.3) 66 (85.7) 1 reference normal weight 74 (18.9) 317 (81.1) 1.4 0.70 2.79 overweight 105 (29.6) 250 (70.4) 2.52 1.28 4.98 obese 119 (43.1) 157 (56.9) 4.55 2.30 8.99 central obesity no 86 (19.1) 365 (80.9) 1 reference yes 214 (35.7) 385 (64.3) 0.42 0.32 0.57 diabetes mellitus diabetic 61 (45.5) 73 (54.5) 1 reference no diabetic 270 (26.4) 752 (73.6) 2.32 1.61 3.36 total cholesterol <190 mg/dl 142 (26.1) 402 (73.9) 1 reference ≥190 mg/dl 189 (30.9) 422 (69.1) 0.8 0.61 1.02 low density lipoprotein (ldl) <100 mg/dl 87 (30.9) 195 (69.1) 1 reference ≥100 mg/dl 244 (27.9) 629 (72.1) 1.15 0.86 1.54 high density lipoprotein (hdl) borderline 40 mg/dl for male and 50mg/dl for female <40 and 50mg/dl 264 (28.5) 661 (71.5) 1 reference ≥40 and 50mg/dl 70 (27.6) 184 (72.40) 1.05 0.77 1.43 triglycerides <150 mg/dl 95 (26.2) 267 (73.8) 1 reference ≥150 mg/dl 236 (29.8) 557 (70.2) 0.84 0.63 1.11 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.134 | http://cajgh.pitt.edu table 5: multivariable analysis of risk factors and hypertension among those surveyed using the who steps in jalalabad, nangarhar, afghanistan variables categories adjusted odds ratio 95% ci p-value age ≤ 40 years 1 reference > 40 years 3.42 2.50 4.76 <0.01 sex female 1 reference male 0.58 0.38 0.88 <0.05 job nature non-physical 1 reference physical 0.55 0.36 0.85 <0.01 central obesity bmi < 30 1 reference bmi ≥ 30 2.1 1.49 2.94 < 0.01 diabetes mellitus no 1 reference yes 1.75 1.10 2.79 < 0.05 physical activity no 1 reference yes 0.69 0.47 0.99 < 0.05 vegetable servings consumed in days per week ≤ 3 days 1 reference > 3 days 0.59 0.38 0.93 < 0.05 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx brca1 and brca2 gene mutations screening in sporadic breast cancer patients in kazakhstan. brca1 and brca2 gene mutations screening in sporadic breast cancer patients in kazakhstan. ainur r. akilzhanova1,2, bagdat nyshanbekkyzy2, zhannur m. nurkina1,2, ivan i. shtephanov3, abay k. makishev3, tasbolat a. adylkhanov4,5, tolebay k. rakhypbekov4,5, erlan m. ramanculov2, kuvat t. momynaliev2 1center for life sciences, nazarbayev university, astana, kazakhstan; 2national center for biotechnology, astana, kazakhstan; 3state medical university astana, astana oncological center, astana, kazakhstan; 4semey oncological center, semey, kazakhstan; 5semey state medical university, semey, kazakhstan abstract background: a large number of distinct mutations in the brca1 and brca2 genes have been reported worldwide, but little is known regarding the role of these inherited susceptibility genes in breast cancer risk among kazakhstan women. aim: to evaluate the role of brca1/2 mutations in kazakhstan women presenting with sporadic breast cancer. methods: we investigated the distribution and nature of polymorphisms in brca1 and brca2 entire coding regions in 156 kazakhstan sporadic breast cancer cases and 112 age-matched controls using automatic direct sequencing. results: we identified 22 distinct variants, including 16 missense mutations and 6 polymorphisms in brca1/2 genes. in brca1, 9 missense mutations and 3 synonymous polymorphisms were observed. in brca2, 7 missense mutations and 3 polymorphisms were detected. there was a higher prevalence of observed mutations in caucasian breast cancer cases compared to asian cases (p<0.05); higher frequencies of sequence variants were observed in asian controls. no recurrent or founder mutations were observed in brca1/2 genes. there were no statistically significant differences in age at diagnosis, tumor histology, size of tumor, and lymph node involvement between women with breast cancer with or without the brca sequence alterations. conclusions: considering the majority of breast cancer cases are sporadic, the present study will be helpful in the evaluation of the need for the genetic screening of brca1/2 mutations and reliable genetic counseling for kazakhstan sporadic breast cancer patients. evaluation of common polymorphisms and mutations and breast cancer risk in families with genetic predisposition to breast cancer is ongoing in another current investigation. introduction breast cancer is the most common malignancy in females and one of the leading causes of death from cancer in women worldwide.1 it accounts for 23% of all cancers among women and is the second most common cancer overall when both sexes are considered. breast cancer showed the biggest proportional increase in the number of new cases in women from 2006-2011 and remains the leading form of cancer in women in kazakhstan.2 germline mutations in brca1 and brca2 genes account for genetic predisposition and increased risk of breast and ovarian cancers.3 two major breast cancer susceptibility genes are brca1 (mim 113705, genbank accession no. u14680) and brca2 (mim 600185, genbank accession no. u43746), located on the long arms of chromosomes 174 and 13,5 respectively, and both apparently function as tumor suppressor genes. brca1 is a large protein of 1863 amino acids and brca2, with 3418 amino acids, is even larger. both proteins are involved in the control of homologous recombination (hr) and double-strand break repair in response to dna damage.6-11 brca1/2 have been shown to serve as important central components in multiple biological pathways that regulate cell-cycle progression, centrosome duplication, dna damage repair, cell growth, and apoptosis.12 evidence that the loss of brca1 alleles or low expression of brca1 in a large proportion of sporadic breast cancer cases supports the role of brca1 in the development of sporadic breast cancer.13-15 genetic linkage analysis4 and refine mapping16,17 provided the evidence of the location of penetrance as having a germline mutation; it was found that the most commonly encountered sporadic forms of breast cancer vary among different populations.18-20 this contributory variation may be attributed to their different gene pool make and also due to low penetrance gene involvement. however, some studies have pointed out that germline mutations in brca1/2 contribute little to the induction of breast cancer in some countries.21,22 mutations in the brca1 and brca2 genes were first reported in conjunction with their identification in 199423 and 1995.24,25 during last decade brca1 and brca2 have been extensively screened for mutations; numerous mutations have been reported to be clearly associated with cancer susceptibility and have been registered in the breast cancer information core database (bic).26 most of these are frameshift or nonsense mutations leading to truncated and therefore, inactive brca1/2 proteins. these mutations have a pathogenetic role and are characterized by a high penetrance. furthermore, they are thought to increase the lifetime risk of developing breast cancer 50% by age 50 and 85% by age 70.27-29 hundreds of alterations have been reported for brca1/2 genes, but not all are able to confer a higher risk of developing breast cancer with age27,28 and, indeed, the pathogenetic effect of a significant number of single amino acid changes is still unknown. this is particularly true for polymorphisms, naturally occurring gene sequence variations, often affecting only a single nucleotide, that have recently been associated with altered cancer risk.30-32 there are also a certain number of single amino acid changes that have been identified and classified as non-characterized variants. it is not known whether these variants may affect brca1 function and thus bring about an increased risk for breast and/or ovarian cancer. disease-associated mutations are distributed over the entire coding regions of these genes, and these demonstrate considerable ethnogeographic variation.33 for example, in the ashkenazi jewish34,35 or in the icelanders36 breast cancer predisposition has been demonstrated to be due to recurrent mutations (founder mutations) originating from a single ancestor. molecular analysis of brca1/2 in different populations has demonstrated a very large mutational spectrum and variable mutation prevalence related to the different techniques employed, selection criteria, and ethnic origin of the patients. in families with no prior history of breast cancer, frequency of brca mutation was found significantly low from 0.02% to 10%.33 in asia, the prevalence of brca1/2 mutations among unselected breast cancer cases was reported at 5.1% in philippines,37 and 2.5%–3.1% in korea.38,39 the frequency of brca1 mutations in chinese women with breast cancer without family history was 5.4%.40 on the other hand, 2% of breast cancer cases in the largest breast cancer population-based study in a uk population showed association with brca genes with 0.7% attribution of brca1 (anglian breast cancer study group, 2000).41 several hospital-based series of unselected breast cancers implicate brca1 and brca2 in 2–5% and 0–2% of all cases, respectively.41 this variation may be attributed to differences on the genome level among various ethnic and population heterogeneity. the reason of marginally low penetrance of brca1/2 germline mutations may be attributed to the polygenic involvement and heterogeneity of samples origin too. as in asia, the overall prevalence of germline mutation varies from 0.8% in japanese42 to 8.0% in singapore region,43 indicating involvement of other genes and population response with respect to various types and origin of cancers. moreover, inter-individual variation does exist among the ethnic groups in association with various risk factors as reported by peto et al.44 showing mutation prevalence as 3.5% before age 35 declining to 0.49% in ≥ 50 years. studies on brca gene mutations have been mainly performed in western populations and the majority of these have involved hereditary breast and ovarian cancer families. thus, studies focusing on sporadic breast cancer and data collection in asians, especially in the kazakh population, remain relatively sparse. to our knowledge, this is the first study to evaluate the frequency and type of sequence alterations of brca1/2 genes in kazakhstan breast cancer patients. in order to evaluate the role of brca1 and brca2 germline mutations in the kazakhstan population, 156 sporadic breast cancer patients were analyzed for mutations throughout the entire coding regions of the brca1 and brca2 genes by using direct sequencing. materials and methods patients prior to this study, ethical approval was obtained from the ethical committees of semey state medical university and in national center for biotechnology. a total of 156 kazakhstan women with pathologically confirmed breast cancer; 83 women operated in oncological center in semey, semey, kazakhstan from 1984-2005 year and 73 women operated in astana oncological center, astana, kazakhstan from 2008-2011; year were enrolled in this study (breast cancer group). family histories were obtained through individual interviews and only cases without family history of affected firstor second-degree relatives with breast and/or ovarian cancer were included in this study. clinical and pathological characteristics such as: age at diagnosis (operation), histological subtype (who histological classification)45 histological grade, t stage (tnm clinical classification, and lymph node involvement were obtained from medical records. control subjects, matched to cases based on age and ethnicity were randomly selected from the community in semey and astana (n=112). none of the controls had a personal history of malignancy at the time of ascertainment. before the study, written informed consent was obtained from all participants. both cases and controls were divided in to two groups by race (by first name of study participants and their parents): caucasian (n=88 and 40 cases and controls, respectively) and asian (n=68 and 72 cases and controls, respectively). blood sample collection peripheral blood samples (ca.10 ml) were collected into vacutainers with k2edta. dna extraction genomic dna was extracted from whole blood samples from cases with breast cancer as well as controls using a master pure dna purification kit (epicentre biotechnologies, usa) and dna extraction kit (promega, usa) in accordance with the manufacturer’s protocols. polymerase chain reaction: for pcr amplification of the 22 coding regions of brca1 and the 26 coding regions of brca2, primers using primer 3 v. 0.4.0 program were designed (available from authors on request). since exon 11 of brca1 varies by 3426 base pairs, we amplified 10 overlapping regions of this exon; for exon 10 of brca2, we designed 2 pairs of primers and for exon 11 of brca2 3 pairs of primers. amplification of dna fragments was performed in tetrad biorad thermal cycler (bio rad, usa) in 25μl of solution containing 150 mm tris–hcl (ph 8.0), 500 mm kcl, 25 mm mgcl2, 10 mm each dntp, 10 pmol of primers, 25–125 ng of genomic dna, and 2 units of amplitaq gold dna polymerase. the pcr was performed according to the following conditions: initial denaturation at 95°c for 10 minutes, followed by 35 cycles of 95°c for 15 seconds, 58°c for 30 seconds, and 72°c for 30 seconds. the quality of amplification was determined by separation of the pcr products on a 1.5% agarose gel. the pcr products were purified using exosap-it (usb, usa) and incubated at 37°c for 40 min, 80°c for 20 min, and stored at 4°c. purified pcr products were further used in the sequencing reaction process. dna sequencing all amplified products were sequenced in forward and reverse directions using the bigdye terminator v3.1 cycle sequencing kit (applied biosystems, usa) on an abi 3130xl dna analyzer (applied biosystems, foster city, ca, usa). the pcr products were sequenced using the same primers as the ones used for pcr amplification. sequence pcr products were cleaned using sefadex 50 and multiscreen filtration colons (millipore corporation, usa). a chromatographic tracing of each amplicon was analyzed by proprietary sequence analysis software (sequence analysis 5.3.1, seqscape v.2.6, finch tv v1.3.1) followed by visual inspection and confirmation. the sequence was compared with the breast cancer information core, bicdatabase; http://research.nhgri.nih.gov/bic), human genome mutation database (http://www.hgmd.cf.ac.uk/ac/index.php) and the national center for biotechnology information database (http:// www.ncbi.nlm.nih.gov). mutation nomenclature approved recommendations of nomenclature for the description of sequence variants were adopted ((http://www.hgvs.org/mutnomen/). numbering according to genbank accession no. nm_007294.1 for brca1 and nm_000059.1 for brca2, the a of the atg translation initiation codon is +1, according to approved guidelines were used. also, traditional mutation nomenclature used in bic database26 where nucleotide numbers refer to the wild type cdna sequence of brca1 (refseq accession number u14680) with numbering starting at the a of the first atg at the position 120 and to the wild type cdna sequence of brca2 (refseq accession number u43746) with numbering starting at the a of the first atg at the position 229 were used. we used the term "sequence variation" and “sequence alteration” to prevent confusion with the terms "mutation" and "polymorphism", mutation meaning "change" or "disease-causing change" and polymorphism meaning "non disease-causing change" or "change found at a frequency of 1% or higher in the population". single-nucleotide polymorphisms may fall within coding sequences of genes, non-coding regions of genes, or in the intergenic regions (regions between genes). snps within a coding sequence do not necessarily change the amino acid sequence of the protein that is produced, due to degeneracy of the genetic code. a snp in which both alleles produce the same polypeptide sequence is called a synonymous polymorphism (sometimes called a silent mutation). if a different polypeptide sequence is produced, the polymorphism is a replacement polymorphism. a replacement polymorphism change may be either missense, which results in a different amino acid, or nonsense, which results in a premature stop codon. over half of all known disease mutations come from replacement polymorphisms.24 a variation in a genetic sequence whose association with disease risk is unknown is also called a variant of uncertain significance, unclassified variant, and vus (an alteration in the normal sequence of a gene, the significance of which is unclear until further study of the genotype and corresponding phenotype in a sufficiently large population). statistical analysis clinical and pathological characteristics and brca mutation results were analyzed using spss 19.0 (spss, tokyo, japan). differences in categorical variables between mutation-positive and mutation-negative group were compared using chi-square analysis, cross tables or fisher’s exact test. a probability value of less than 0.05 was considered to indicate significance. results mean age of breast cancer patients and controls was 51.2±9.5 years and 57.8±9.1 years, respectively. sixty-eight women with breast cancer were asian and eighty eight – caucasian. among healthy women, 72 were asian and 40 caucasian. all breast cancer cases were distributed by size of primary breast carcinoma (tnm clinical classification45): t1, t2, t3, t4 – 15, 96, 39, 6 cases respectively, 14 cases with n1 lymph node metastasis, 15 women with n1 lymph node metastasis, and 5 women had n3 lymph node involvement. a summary of patient characteristics can be found in: table 1: characteristics of study participants breast cancer cases (n=156) controls (n=112) abs(%) totally (n=268) abs (%) abs t1 abs (%) t2 abs (%) t3 abs (%) t4 abs (%) n1 abs (%) n2 abs (%) n3 abs (%) age (years) at operation (patients)/sample collection (controls),mean±sd 51.2±9.5* 57.8±9.1 asian 68 10 (15.1) 43 (63.6) 14 (21.2) 1 (1.5) 9 (13.2) 6 (9.0) 72 (64.3) 144 (53.8) caucasian 88 5 <(6.0) 53 (60.0) 25 (28) 5 (6.0) 5 (6.0) 9 (10.0) 5 (6.0) 40 (35.7) 124 (46.2) t – primary tumor: t1 ≤2cm, t2 – >2 to 5cm, t3 >5cm, t4 – tumor of any size with direct extension to chest wall or skin, n – regional lymph nodes, m – distant metastasis *p<0.05 vs controls mutational screening of brca1 and brca2 coding regions was performed for 156 sporadic breast cancer cases and 112 controls. mutation analysis of the brca1 and brca2 genes revealed the presence of 22 distinct variants, including 16 missense mutations and 6 polymorphisms (tables 2 and 3). the sequence variants identified in brca1 gene 9 missense mutations – c.95g>t (g32v), c.254a>g (n85s), c.1067a>g (q356r), c.2612c>t (p871l), c.3113a>g (e1038g), c.3348a>g (k1183r), c.4744c>g (s1542c), c.5397a>g (a1627g) and c.5585t>g (t1862g), three synonymous polymorphisms ser694ser, leu771leu and ser1436ser. most of these polymorphisms were found in exon 11 of brca1, which is 60% of all brca1 coding region. figure 1: detection of the sequence variants in 11 exon of brca1. table 2: details and the frequency of the variants detected in the brca1 in breast cancer and control groups. exon sequence variant amino acid variant frequency in the breast cancer group (n=156), abs (%) frequency in the control group (n=112), abs (%) bic entry total caucasian/asian total caucasian/asian missense mutations 2 c.95(g>t) † (214g>t) ‡ p.gly32val (g32v) 84(54.1)* 51(60.7)/ 33(39.3) # 49(43.7) 17(36.7)/ 32(65.3) # yes 3 c.254(a>g) (373a>g) p.asn85ser (n85s) 83 (53.0)* 48(57.8)/ 35(42.2) # 42(37.5) 15(35.7)/ 27(64.3) # yes 11 c.1067a>g (1186a>g) p.gln356arg (q356r) 11 (7.2) 6(54.5)/ 5(45.4) 10 (8.9) 6(60.0)/ 4(40.0) yes 11 c.2612(c>t) (2731c>t) p.pro871leu (p871l) 87(55.8) 53(60.9)/ 34(39.1) # 54(48.2) 20(37.0)/ 34(63.0) # yes 11 c.3113(a>g) (3232a>g) p.glu1038gly (e1038g) 88(56.6) 55(62.5)/ 33(37.5) # 53(47.3) 18(34.0)/ 35(66.0) # yes 11 c.3348(a>g) (3667a>g) p.lys1183arg (k1183r) 92(59.0)* 58(63.0)/ 34(37.0) # 51(45.5) 17(33.3)/ 34(66.7) # yes 15 c.4744c>g (4863c>g) p.ser1542cys (s1542c) 24(15.5) 14(58.3)/ 10(41.7) 19 (17.0) 10(52.6)/ 9(47.4) yes 20 c.5397a>g (5516a>g) p.ala1627gly (a1627g) 21(13.6) 9(42.8)/ 12(57.1) # 20 (17.8) 10(50.0)/ 10(50.0) yes 20 c.5585t>g (5704t>g) p.thr1684gly (t1862g) 23(14.8) 12(52.2)/ 11(47.8) 17 (15.2) 9(52.9)/ 8(47.1) yes polymorphisms 11 c.2082(c>t) (2201c>t) synonymous ser694ser (s694s) 45(54.2) 28(62.2)/ 17(37.8) # 48(42.8) 17(35.4)/ 31(64.6) # yes 11 c.2311(t>c) (2430t>c) synonymous leu771leu (l771l) 45(54.2) 28(62.2)/ 17(37.8) # 48(42.8) 17(35.4)/ 31(64.6) # yes 13 c.4427(t>c) (4546t>c) synonymous ser1436ser (s1436s) 76(49.0) 35(46.0)/ 41(53.9) # 54(48.2) 25(46.3)/ 29(53.7) yes † numbering according to genbank accession no. nm_007294.1, the a of the atg translation initiation codon is +1,according to approved guidelines (http://www.hgvs.org/mutnomen/) ‡the nomenclature as used in the bic database is given in parentheses. mutation nomenclature is according to refseq accession number u14680 (brca1) with numbering starting at the a of the first atg at the position 120 * p<0.05, ** p<0.001 between cases and controls #p<0.05, ##-p<0.001 between caucasians and asians in group missense mutations c.95g>t (g32v), c.254a>g (n85s), c.3348a>g (k1183r) were detected with frequency in 54.1%, 53.0%, 59.0% of cases and 43.7%, 37.5%, 45.5% of controls, respectively, showing significantly higher prevalence in cases (p<0.05). there was no significant prevalence in frequency of missense mutations c.1067a>g (q356r), c.2612c>t (p871l), c.3113a>g (e1038g), c.4744c>g (s1542c), c.5397a>g (a1627g) in cases comparing to controls. synonymous polymorphisms s694s and l771l were detected in 45 (54.2%) of cases and 48 (42.8%) controls. s1436s was found in 76 (49.0%) cases and 54 (48.2%) controls. in brca2, gene missense mutations c.865a>c (n289h), c.10234a>g (i3412v) were detected with higher frequency in 15.2% and 30.8% of cases compared to controls (10.1%, 18.7%, respectively, p<0.05). table 3: details and the frequency of the variants detected in the brca2 in breast cancer and control groups exon sequence variant amino acid variant frequency in the breast cancer group (n=156), abs (%) frequency in the control group (n=112), abs (%) bic entry total caucasian/asian total caucasian/asian missense mutations 10 c.865(a>c)† (1093a>c) ‡ p.asn289his (n289h) 24(15.2)* 13(54.2)/ 11(45.8) 11(10.1) 7(63.6)/ 4(36.4) yes 10 c.2127(t>c) (2235t>c) p.asn709arg (n709r) 65(41.6)* 36(55.4)/ 29(44.6)# 52(46.4) 29(55.8)/ 23(44.2) yes 11 c.2350(a>g) (2578a>g) p.met784val (m784v) 26(17.0) 16(61.5)/ 10(38.5)# 24(21.4) 13(54.2)/ 11(45.8) yes 11 c.2410(g>a) (2638g>a) p.asp804asn (d804n) 54(34.7) 33(61.1)/ 21(38.9)# 38 (33.9) 16(42.1)/ 22(57.9) yes 11 c.3422(t>c) (3650t>c) p.ile1141thr (i1141t) 39(24.9) 15(38.5)/ 14(35.9) 26 (23.2) 16(61.5)/ 10(38.5)# yes 11 c.3572(c>t) (3800c>t) p.ser1191phe (s1191f) 34(21.8) 15(44.1)/ 19(55.9)# 23 (20.5) 10(43.5)/ 13(56.5) yes 27 c.10234(a>g) (10462a>g) p.ile3412val (i3412v) 48 (30.8)* 29(60.4)/ 19(39.6) # 21 (18.7) 10(47.6)/ 11(52.4) yes polymorphisms 10 c.1365(a>g) (1593a>g) synonymous ser455ser (s455s) 81(52.2*) 48(59.2)/ 33(40.7)# 48(42.8) 19(39.6)/ 29(60.4)# yes 11 c.2229(t>c) (2457t>c) synonymous his473his (h473h) 81(52.2)* 48(59.2)/ 33(40.7)# 48(42.8) 19(39.6)/ 29(60.4)# yes 14 c.7242(a>g) (7470a>g) synonymous ser2414ser (s2414s) 61(39.0)* 35(57.3)/ 26(42.6)# 36(32.1) 16(44.4)/ 20(55.5) yes † numbering according to genbank accession no. nm_000059.1, the a of the atg translation initiation codon is +1, according to approved guidelines (http://www.hgvs.org/mutnomen/). ‡the nomenclature as used in the bic database is given in parentheses. mutation nomenclature is according to genbank accession number u43746 (brca2) with numbering starting at the a of the first atg at the posotion 229. * p<0.05, ** p<0.001 between cases and controls #p<0.05, ##-p<0.001 between caucasians and asians in group there was no significant difference in frequency of missense mutations c.2350a>g (m784v), c.2410g>a (d804n), c.3422t>c (i1141t), c.3572c>t (s1191f) in cases compared to controls. synonymous polymorphisms s455s, h473h, were detected in 81 (52.2%) cases and s2114s was detected in 61 (39.0%) cases, p>0.05 (table 3). all identified polymorphisms were previously reported in the bic database26 (table 2,3). interestingly, frequency of nearly all sequence variants was significantly different in caucasian and asian groups of study participants (table 2,3). there was higher prevalence of observed mutations in caucasian cases comparing to asian breast cancer cases (p<0.05) and higher frequency of sequence variants was observed in the control group in asians. the clinical and pathological characteristics of women with breast cancer are summarized in: table 4: clinical-pathological profile of breast cancer cases with/or without brca1/2 polymorphisms cases (n=156) polymorphism positive (n = 111) 71.2% polymorphism negative (n = 45) 28.8% 1 polymorphism 15(13.6) 2-3 polymorphisms 17(15.2) 4-6 polymorphisms 79(71.2) age 50.6±8.8 52.7±10.7 caucasian 66(59.3) 28(62.5) asian 45(40.7) 17(37.5) tumor histology invasive ductal 68(61.0) 32(70.8) invasive lobular 34(30.5) 13(29.2) medullary 8(6.8) mucinous 2(1.7) tumor size t1 1(1.1) 4(8.4) t2 66(59.3) 30(66.7) 30(27.1) 9(20.8) t4 38(3.4) 2(4.2) lymph node involvement yes 21(18.6) 4(16.7) no 90(81.4) 20(83.3) t – primary tumor: t1 ≤2cm, t2 – >2 to 5cm, t3 >5cm, t4 – tumor of any size with direct extension to chest wall or skin, n – regional lymph nodes, m – distant metastasis there was no significant difference between both groups of cases in mean age at diagnosis (50.6±8.8 years vs. 52.7±10.7 years, respectively, p=0.36). assuming that the absolute numbers of co-existing brca1/2 alterations in each case may also play a relevant biological role, the cases in the mutation-positive group were divided in three subgroups: (a) with 1 alteration; (b) with 2-3 alterations; (c) with 4-6 alterations. we found that 79 of 156 women (71.2%) carried 4-6 alterations. this may be due to polymorphisms located in one haplogroup and inherited together. also amongst controls, in 48 (73.8%) of 65 alteration carriers we detected more than 3 mutations simultaneously (data not shown). invasive ductal carcinoma was the predominant histological subtype in both groups (61.0% and 70.8%, respectively). primary tumors larger than 5.0 cm were more frequently found in women carrying sequence alterations. however, the size of tumor (t stage) and lymph node involvement did not show a statistically significant difference between these two groups (p=0.92 and p=1.0, respectively). discussion 156 kazakhstan patients with sporadic breast cancer were analyzed for mutations throughout the entire coding regions of the brca1 and brca2 genes, using direct sequencing. whereas the majority of studies on brca gene mutations have focused on western populations with a family history of breast or ovarian cancer, only a relatively small number of investigations on the role of the brca genes have been undertaken in asian sporadic breast cancer populations. a large number of distinct mutations in the brca1 and brca2 genes have been reported worldwide, but little is known regarding the role of these inherited susceptibility genes in breast cancer risk among kazakhstan women. so far there was no information about the role of the brca1/2 gene in breast cancer risk among kazakhstan women. the incidence of detectable brca1 sequence alterations was estimated for the first time in females with sporadic breast cancer as well as in healthy women from semipalatinsk (east kazakhstan) region of kazakhstan in our studies for the first time beginning from 2006.46 we showed a higher prevalence of brca1 sequence alterations in exon 11 in 59 (71.1%) from 83 women with breast cancer and in 65 (58.0%) from 112 healthy women (controls). in the present study, the entire coding regions of brca1 and brca2 were analyzed, and patients with sporadic breast cancer were selected by excluding patients at high risk of being mutation-carriers. this included those with a family history of breast or ovarian cancer, those diagnosed at less than 35 years of age, and those with bilateral or multifocal breast cancer. given that the great majority of breast cancer cases are sporadic, further extensive studies are needed to precisely identify the roles of brca genes in sporadic breast cancer. in our present study we sequenced all coding regions of both brca1 and brca2 genes in larger group of cases including an astana cohort, where women gathered from different kazakhstan regions. the sequence variants identified in the brca1/2 genes include 16 missense mutations of unknown clinical significance and 6 synonymous polymorphisms by mutation type (table 2, 3 and figure 1). all cases of the single nucleotide changes in brca1 and brca2 detected in the study were recorded according to the breast cancer information core.26 it seems likely that five mutations in brca1 (c.95g>t, c.254 a>g, c.2612c>t, c.3113a>g, c.3348a>g) and three mutations in brca2 (c.2127t>c, c.2410g>a, c.10234a>g) are neutral polymorphisms, in view of the relatively high allele frequencies (>30%) of these variants. because of the unavailability of a functional brca protein assay system, the disease associations of other mutations remain uncertain. however, the possibility cannot be ruled out that some of these unverified variants are pathogenically relevant. no deleterious mutations were detected in either gene among studied groups. the lack in the germline of clearly deleterious alterations might be unsurprising. in fact, these are extremely rare in patients not selected due to a family history and/or early disease onset.41 however, the true contribution made by the brca genes to sporadic breast cancer remains controversial for a number of reasons. first, missense mutations with an unknown significance could have a pathogenic effect. secondly, in addition to missense mutations, silent polymorphisms may affect the splicing mechanism. however, these variants cannot be classified as disease associated in the absence of a good functional assay system for brca1 and brca2. when a functional assay becomes available, it will be important to elucidate the relevance of such variations with unknown clinical significances. to our knowledge, this report is the first to include information on the prevalence of missense mutations of unknown significance, and to provide information on polymorphisms in the kazakhstan population in both brca1 and brca2 genes. moreover, these kazakhstan population-based polymorphisms could be used as potential markers. missense mutation q356r in brca1 was detected in 11 (7.2%) breast cancer cases and 10 (8.9%) control subjects. a study on the brca1 polymorphisms reported that the arg356 allele had a higher genotype distribution in healthy controls than in breast cancer patients30 and may thus play a protective role against breast cancer. in this study, the polymorphism at codon 356 in the brca1 gene had previously been described as being inversely associated with breast cancer risk (gln356→ arg, or 0.88, 95% confidence interval [ci] 0.63–1.23; arg356→ arg, or 0.00, 95% ci 0.00–0.56).30 another study showed that q356r polymorphism was significantly associated with family history of ovarian cancer, suggesting that this sequence variant may increase ovarian cancer risk.31 in contrast, tommasi et al.47 analyzed brca1 mutational risk using myriad ii software and showed that k1183r, the polymorphism in exon 11 as reported in bic,26 resulted inversely related with brca1 mutation carrier status. also they showed that brca1 sequence alterations such as p871l and e1038g were not significantly related with higher brca1 mutational risk.47 this data leads us to suggest further investigation of the effects of these sequence variants on brca1 activity to understand whether these variations have any pathological role. we found that 79 of 156 women (71.2%) carried 4-6 alterations. this may be due to polymorphisms located in one haplogroup that are inherited together. dunning et al examined the frequency of four polymorphisms: gln356arg, pro871leu, glu1038gly and ser1613gly in large series of breast and ovarian cancer cases and matched controls.30. due to strong linkage disequilibrium, these four sites generate only three haplotypes with a frequency >1.3%. the two most common haplotypes, defined by the alleles gln356pro871glu1038ser1613 and gln356leu871gly1038gly1613, have frequencies of 0.57 and 0.32, respectively, and these frequencies do not differ significantly between patient and control groups, indicating that the most common polymorphisms of the brca1 gene do not make a significant contribution to breast or ovarian cancer risk.30 common polymorphisms in brca1/2 genes appear to be highly prevalent in kazakhstan breast cancer cases and in healthy controls which is in concordance with previously reported findings in some asian and european populations.37-43, 47-49 frequencies of these polymorphisms were higher in breast cancer cases vs controls, particularly in the brca2 gene, p<0.05. to date, there is little evidence that highly penetrant, germline mutations in brca1/2 are observed in sporadic cases, but whether common polymorphisms play a role in disease risk is still controversial. the roles of common missense snps, as well as variation in noncoding regions (that may influence risk through expression levels and alternative splicing), have yet to be thoroughly explored (at single loci as well as throughout the genome) as markers of breast cancer susceptibility. ongoing efforts to systematically characterize genetic polymorphisms, such as the international hapmap project,50 provide the foundation for conducting comprehensive association studies of common variation. in a large study, freedman ml et al tested common variation across the brca1 locus in african american, native hawaiian, japanese, latino, and white women in the multiethnic cohort study.51 28 single nucleotide polymorphisms (snps) spanning the brca1 gene were used to define patterns of common variation in these populations. the majority of snps were in strong linkage disequilibrium with one another. nine tagging snps, including five missense snps, were selected to predict the common brca1 variants and haplotypes among the non–african american groups (five additional snps were required for african americans) and genotyped in a breast cancer case-control study nested in the multiethnic cohort study (cases, n = 1,715; controls, n = 2,502). in their another study52 freedman ml et al observed most of the common brca2 haplotypes to be shared among native hawaiians, japanese, latinos, and whites; four of the eight common haplotypes were found in at least three ethnic populations and six of the eight were found in at least two groups. authors found no evidence for significant associations between common variation in brca1/2 and risk of breast cancer.51,52 in another study, cox dg et al reported a modestly positive association between a brca1 haplotype and breast cancer among white women in the nurses’ health study (or, 1.18, 95% ci, 1.02-1.37).53 interestingly, the frequencies of nearly all sequence variants were significantly different in caucasian and asian groups among study participants (table 2, 3). there was higher prevalence of observed mutations in caucasian cases comparing to asian breast cancer cases, (p<0.05) and higher frequency of sequence variants was observed in control group in asians. further studies of large numbers of cases may give a more accurate estimation of prevalence and variations between asian and caucasian populations in kazakhstan. the vast majority of common variation is shared between populations; however, allele frequencies are known to vary across populations54 and studies conducted in a multiethnic population may lend insight into better understanding ethnic differences in breast cancer risk.55 although the role of common variation in brca1 and sporadic breast cancer risk has been thoroughly addressed, it remains a possibility that this locus may still prove to be involved in breast cancer risk. specifically, rare (<5%) variants may contribute to disease; to address this hypothesis, however, large-scale resequencing efforts (to discover the rare variants) and testing of these variants in larger cohorts, such as the national cancer institute consortium of cohorts,56 will be required. another possibility is that a sporadic breast cancer is actually a collection of genetically distinct subclasses of breast cancer. in this scenario, it would be unlikely that the same set of underlying susceptibility alleles occur in all breast cancer cases (i.e., the genetic architecture of disease is not genetically homogeneous). if these subgroups are not recognized and analyzed separately, then the power to detect them will be diminished. at the histologic and molecular levels, breast tumors have different characteristics; subsets of breast tumors as defined by immunohistochemistry [e.g., estrogen-receptor (+/-) and her2/neu(+/-)] often display different biological behaviors, such as time to disease progression and response to therapy, which may reflect different genetic origins. studies have shown that breast tumors of women with hereditary breast cancer with mutations in brca1 and a subset of women with sporadic disease (f25%) share similar traits, including a basal cell histology, higher grade tumors, cytokeratins 5/6, and estrogen receptor negativity, suggesting they may have a similar etiology.57-59 the ability to stratify breast cancer cases by expression profiling, immunohistochemistry, methylation patterns, and/or clinical variables may facilitate the identification of more genetically homogeneous subsets of cancer cases, and therefore may help to identify causal variants underlying specific breast cancer phenotypes. there are several limitations to this study. we did not include results of screening entire exons of brca1 and brca2 genes in families with breast/ovarian cancer members. this study is still ongoing because family bc cases in kazakhstan are sparse. further evaluation is needed to clarify the relationship between frequency of sequence alterations in brca1/2 genes and breast cancer risks in kazakhstan women in family-based and genetically homogeneous cases. in conclusion, 156 kazakhstan patients with sporadic breast cancer were analyzed for mutations throughout the entire coding regions of the brca1 and brca2 genes, using direct sequencing. the present investigation revealed 22 different sequence variants. although we found none of pathological deleterious mutations in brca1/2 genes, we believe that the present study allows a better evaluation of the need for the genetic screening of brca mutations in sporadic breast cancer patients in kazakhstan. however, large population-based screening studies are needed to establish the frequency, penetrance, and significance of the broad spectrum of variations in the sequence of brca1/2 genes in kazakhstan population. it is hoped that similar mutation surveys in other central asian countries will be completed so that information can be compared and the most common mutations identified. acknowledgements we are thankful to all patients and healthy women who took part in this study and to the staff of semey and astana oncological centers who helped to collect samples. this work was supported by grant-in-aid from the kazakhstan ministry of education and science. references 1. parkin dm, bray f, ferlay j, pisani p. global cancer statistics, 2002. ca cancer j clin. 2005; 55 (2): 74–108. 2. official site of ministry of healthcare, republic of kazakhstan, http://www.minzdrav.kz. 3. martin am, blackwood ma, antin-ozerkis d, et al. germline mutations in brca1 and brca2 in breast-ovarian families from a breast cancer risk evaluation clinic. j clin oncol. 2001; 19:2247–2253. 4. hall jm, lee mk, newman b, morrow je, anderson la, huey b, king mc. linkage of early-onset familial breast cancer to chromosome17q21. science. 1990; 250:1684-1689. 5. wooster r, neuhausen sl, mangion j, quirk y, ford d, collins n, nguyen k, seal s, tran t, averill d. localization of a breast cancer susceptibility gene, brca2, to chromosome 13q12-13. science. 1994; 265:2088-2090. 6. scully r, livingston dm. in search of the tomour-supperssor function of brca1and brca2. nature. 2000; 408:429-432. 7. scully r, puget n, vlasakova k. dna polymerase stalling, sister chromatid recombination and the brca genes. oncogenes. 2000; 19:6176-6183. 8. wang q, zhang h, fishel r, greene mi. brca1 and cell signaling. oncogene. 2000; 19:6152-6158. 9. zhang l, li s, boyer tg, lee wh. lessons learned from brca1 and brca2. oncogene. 2000; 19:6159-6175. 10. zhong q, chen cf, li s, chen y, wang cc, xiao j, chen pl, sharp zd, lee wh. association of brca1 with the hrad50-hmre11-p95 complex and the dna damage response. science. 1999; 285:747-750. 11. welcsh piri l, king mary-claire: brca1 and brca2 and genetics of breast and ovarian cancer. human molecular genetics. 2001; 10:7705-713. 12. deng cx, brodie sg. roles of brca1 and its interacting proteins. bioessays. 2000; 22:728–737. 13. seery lt, knowlden jm, gee jm, et al. brca1 expression levels predict distant metastasis of sporadic breast cancers. int j cancer. 1999; 84:258–262. 14. wilson ca, ramos l, villaseñor mr, et al. localization of human brca1 and its loss in high-grade, non-inherited breast carcinoma. nat genet. 1999; 21:236–240. 15. yoshikawa k, honda k, inamoto t, et al. reduction of brca1 protein expression in japanese sporadic breast carcinomas and its frequent loss in brca1-associated cases. clin cancer res. 1999; 5:1249–1261. 16. albertsen hm, smith sa, mazoyer s, et al. a physical map and candidate genes in the brca1 region on chromosome 17q12-21. nature genet. 1994; 7:472-479. 17. o'connell p, albertsen h, matsunami n, et al. a radiation hybrid map of the brca1 region. am j hum genet. 1994; 54:526-534. 18. matsushima m, kobayashi k, emi m, saito h, saito j, suzumori k, nakamura y. mutation analysis of the brca1 gene in 76 japanese ovarian cancer patients: four germline mutations, but no evidence of somatic mutation. hum mol genet. 1996; 4:1953-1956. 19. de benedetti vm, radice p, mondini p, et al. screening for mutations in exon 11 of the brca1 gene in 70 italian breast and ovarian cancer patients by protein truncation test. oncogene. 1996; 13(6):1353-1357. 20. katagiri t, emi m, ito i, et al. mutations in the brca1 gene in japanese breast cancer patients. hum mutat. 1996; 7:334-339. 21. håkansson s, johannsson o, johansson u, et al. moderate frequency of brca1 and brca2 germ-line mutations in scandinavian familial breast cancer. am j hum genet. 1997; 60:1068–1078. 22. vehmanen p, friedman ls, eerola h, mcclure m, ward b, sarantaus l. low proportion of brca1 and brca2 mutations in finnish breast cancer families: evidence for additional susceptibility genes. hum mol genet. 1997; 6:2309–2315. 23. miki y, swensen j, shattuck-eidens d, futreal pa, harshman k, tavtigian s, liu q, cochran c, bennett lm, ding w. a strong candidate for the breast and ovarian cancer susceptibility gene brca1. science. 1994; 266:66-71. 24. wooster r, bignell g, lancaster j, swift s, seal s, mangion j, collins n, gregory s, gumbs c, micklem g. identification of the breast cancer susceptibility gene brca2. nature. 1995; 378:789-92. 25. tavtigian sv, simard j, rommens j, couch f, shattuck-eidens d, neuhausen s, et al. the complete brca2 gene and mutations in chromosome13q-linked kindreds. nat genet. 1996, 12:333-337. 26. breast cancer information core database (bic). available from: http://research.nhgri.nih.gov/bic. 27. narod sa, goldgar d, cannon-albright l, et al. risk modifiers in carriers of brca1 mutations. int j cancer. 1995; 64: 394–398. 28. ford d, easton df, peto j. estimates of the gene frequency of brca1 and its contribution to breast and ovarian cancer incidence. am j hum genet. 1995; 57:1457–1462. 29. easton df, hopper jl, thomas dc, antoniou a, pharoah pdp, whittemore a, haile rw. breast cancer risks for brca1/2 carriers. science. 2004; 306:2187–2188. 30. dunning am, chiano m, smith nr, et al. common brca1 variants and susceptibility to breast and ovarian cancer in the general population. hum mol genet. 1997; 6:285–289. 31. janezic sa, ziogas a, krumroy lm, et al. germline brca1 alterations in a population based series of ovarian cancer cases. hum mol genet. 1999; 8:889–897. 32. healey cs, dunning am, teare md, et al. a common variant in brca2 is associated with both breast cancer risk and prenatal viability. nat genet. 2000; 26:362–364. 33. szabo ci, king mc. population genetics of brca1 and brca2. am j hum genet. 1997; 60:1013-1012. 34. offit k, gilewski t, mcguire p, et al. germline brca1 185delag mutations in jewish women with breast cancer. lancet. 1996; 347:1643–1645. 35. abeliovich d, kaduri l, lerer i, et al. the founder mutations 185delag and 5382insc in brca1 and 6174delt in brca2 appear in 60% of ovarian cancer and 30% of early-on-set breast cancer patients among ashkenazi women. am j hum genet. 1997; 60:505-514. 36. johannesdottir g, gudmundsson j, bergthorsson jt, et al. high prevalence of the 999del5 mutation in icelandic breast and ovarian cancer patients. cancer res. 1996; 56:3663–3665. 37. de leon matsuda ml, liede a, kwan e, mapua ca, cutiongco em, tan a, borg a, narod sa. brca1 and brca2 mutations among breast cancer patients from the philippines. int j cancer. 2002; 98:387–480. 38. han sh, lee kr, lee dg, kim dy, lee ke, chung ws. mutation analysis of brca1 and brca2 from 793 patients with sporadic breast cancer. clin genet. 2006, 70:496-501. 39. seo jh, cho dy, ahn sh, et al. brca1 and brca2 germline mutations in korean patients with sporadic cancer. hum mutat. 2004; 24:350-356. 40. song cg, hu z, wu j, et al. the prevalence of brca1 and brca2 mutations in eastern chinese women with breast cancer. j cancer res clin oncol. 2006; 132:617–26. 41. anglian breast cancer study group. prevalence and penetrance of brca1 and brca2 mutations in a population-based series of breast cancer cases. br j cancer. 2000; 83:1301-1308. 42. emi m, matsushima m, katagiri t, et al. multiplex mutation screening of the brca1 gene in 1000 japanese breast cancers. jpn j cancer res. 1998; 89(1):12-16. 43. sng jh, chang j, feroze f, et al. the prevalence of brca1 mutations in chinese patients with early onset breast cancer and affected relatives. br j cancer. 2000; 82:538-542. 44. peto j, collins n, barfoot r, seal s, warren w, rahman n. prevalence of brca1 and brca2 gene mutations in patients with early-onset breast cancer. j nat cancer inst. 1999; 91:943-9. 45. stenson pd; mort m, ball ev, howells k, phillips ad, thomas ns, cooper dn. the human gene mutation database: 2008 update. genome medicine. 2009; 1(1):13. 46. akilzhanova a, meirmanov s, zhunussova t, nakashima m, takamura n, akanov zh, et al. mutational screening of the brca1 gene in sporadic breast cancer in the kazakhstan population. the breast journal. 2011; 17(3):328–330. 47. tommasi s, crapolicchio a, lacalamita r, et al. brca1 mutations and polymorphisms in a hospital-based consecutive series of breast cancer patients from apulia, italy. mutation research. 2005; 578:395–405. 48. kim by, lee dg, lee kr, han sh, surendran s, han cw, chung n. identification of brca1 and brca2 mutations from korean breast cancer patients using denaturating hplc. j bioch and bioph res com. 2006; 349:604-610. 49. loizidou m, marcou y, anastasiadou v, newbold r, hadjisavvas a, kyriacou k. contribution of brca1 and brca2 germline mutations to the incidence of early-onset breast cancer in cyprus. clin genet. 2007; 71:165-170. 50. the international hapmap project. nature. 2003; 426:789–796. 51. freedman ml, penney kl, stram do, riley s, mckean-cowdin r, le marchand l, altshuler d, haiman ca. a haplotype-based case-control study of brca1 and sporadic breast cancer risk. cancer res. 2005; 65(16):7516-7522. 52. freedman ml, penney kl, stram do, et al. common variation in brca2 and breast cancer risk: a haplotype based analysis in the multiethnic cohort. hum mol genet. 2004; 13:2431–2441. 53. cox dg, kraft p, hankinson se, hunter dj. haplotype analysis of common variants in the brca1 gene and risk of sporadic breast cancer. breast cancer res. 2005; 7:r171–175. 54. bowcock am, kidd jr, mountain jl, et al. drift, admixture, and selection in human evolution: a study with dna polymorphisms. proc natl acad sci usa. 1991; 88:839–843. 55. pike mc, kolonel ln, henderson be, et al. breast cancer in a multiethnic cohort in hawaii and los angeles: risk factor-adjusted incidence in japanese equals and in hawaiians exceeds that in whites. cancer epidemiol biomarkers prev. 2002; 11:795–800. 56. sachidanandam r, weissman d, schmidt sc, et al. a map of human genome sequence variation containing 1.42 million single nucleotide polymorphisms. nature. 2001; 409:928–933. 57. sorlie t, tibshirani r, parker j, et al. repeated observation of breast tumor subtypes in independent gene expression data sets. proc natl acad sci usa. 2003; 100:8418–8423. 58. foulkes wd, stefansson im, chappuis po, et al. germline brca1 mutations and a basal epithelial phenotype in breast cancer. j natl cancer inst. 2003; 95:1482–1485. 59. turner n, tutt a, ashworth a. hallmarks of ‘‘brcaness’’ in sporadic cancers. nat rev cancer. 2004; 4:814–819. cajgh the central asian journal of global health: a supercourse journal faina linkov and ronald laporte for the central asian supercourse network inaugural editorial the history of science has repeatedly shown that when hypotheses are proposed it is impossible to predict which will turn out to be revolutionary and which will be considered ridiculous (http://medicalhypotheses.blogspot.com/2009/12/david-horrobins-inaugural-editorial.html). also, hypotheses that appear to be ridiculous now or even 50 years from now may turn out to be genius 100 years later. for example, william coley, who pioneered the development of cancer immunotherapy in late part of the 19th century, was not recognized for his discoveries until the end of the 20th century. furthermore, a large number of wonderful hypotheses have been lost due to the inability to record them. most of the works of al-farabi, the 10th century scientist, philosopher, cosmologist, and musician who was born in modern kazakhstan, were not recorded during his lifetime, depriving his followers from effectively using his ideas. with the introduction of internet technologies, we now have the capability to share our most innovative ideas with the rest of the world. to speed up the translation of science from labs to classrooms, researchers from the university of pittsburgh started the global health network supercourse project in the late 1990s (www.pitt.edu/~super1), where lectures are used as “nuggets of knowledge” to be shared with scientists around the world. the new central asian journal of global health will be the first open access scientific journal affiliated with the supercourse network. this journal is a direct outgrowth of the supercourse effort, possible due to the large network that has been developed as a result of the supercourse activities. the central asian journal of global health is a biannual journal aimed at those working in the fields of public health and medicine. specifically, our aim is to focus on a geographic region that is not sufficiently highlighted by existing journals: central asia. however, this journal will not be limited to research from central asia, but will be open to submissions from around the world. in addition to the highest-quality reviews and perspectives covering the field of health in central asia, each issue will include news stories and investigations into the hottest topics and new research practices in the field of public health, helping us fulfill our goal of uniting multiple disciplines and cross-disciplinary research under one roof. the supercourse and the new journal will greatly interface with each other. each will rely on a similar network of over 50,000 scientists from 174 countries that utilize the supercourse library. furthermore, every author of an accepted article will be strongly encouraged to submit a supercourse lecture in powerpoint format to rapidly disseminate the findings. the central asian journal of global health is a fully peer-reviewed online open access journal. it will provide a forum for discussion for all aspects of public health, medicine, and global health in central asia and around the world. the central asian journal of global health is dedicated to publishing material of the highest scholarly interest, and to this end we have assembled a distinguished editorial advisory board. we welcome contributions from established researchers, especially those working on cutting edge questions, but we are also keen to act as a supportive environment for new investigators and for those who have never published in english language journals before. our hope is that this journal will serve as a greenhouse for revolutionary biomedical and public health ideas in central asia and around the world. please send us your papers through the journal’s website at http://cajgh.pitt.edu. estrogen receptor gene (esr1) pvuii and xbai polymorphisms and bone mineral density in kazakh women new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. estrogen receptor gene (esr1) pvuii and xbai polymorphisms and bone mineral density in kazakh women ainur akilzhanova1, zhannur abilova1, akbota aitkulova2, zaida zhumatova3, gulbanu akilzhanova4, elena zholdybayeva2, kuvat momynaliev2 1center for life sciences, nazarbayev university, astana, kazakhstan; 2national center for biotechnology, almaty, kazakhstan; 3city hospital #1, pavlodar, kazakhstan; 4regional perinatal center, pavlodar, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.100 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ akilzhanova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.100 | http://cajgh.pitt.edu abstract introduction: osteoporosis is a common age-related disease that is strongly influenced by genetics. polymorphisms of the estrogen receptor gene alpha (esr1) are consistently been associated with bone mineral density (bmd) and fracture. the purpose of this investigation was to evaluate potential association of single nucleotide polymorphism (snp) variants of the esr1 gene and bone mineral density (bmd) of the lumbar spine in kazakh women. methods: 140 female participants in pavlodar clinics with varying measures of bmd. we are examined the potential association of bmd with 2 snps from the esr1 gene (rs2234693 [pvuii] and rs9340799 [xbai]). genotyping of the pvuii and xbai polymorphisms was performed by direct sequencing of the gene fragments containing restriction sites with the identification of genotypes pp, pp, pp and xx, xx, xx respectively. results: unadjusted mean bmd values ranged from 1.140.14 g/cm2 in caucasian women and 1.030.11 g/cm2 in asian women. the association between pvuii polymorphism and bmd at the lumbar spine (p= 0.04 for pp=pp=pp) was statistically significant in all women. the xbai polymorphism was not associated with bmd at lumbar spine. the relative risk for low bmd was higher for the marker pvuii (rr=1.51) than for the marker xbai (rr=1.35). conclusion: the pvuii polymorphism had a weak association with lumbar spine bmd. xbai polymorphism was unlikely to be a predictor of lumbar spine bmd in kazakh women. these conclusions could help to determine the genetic risk factors for osteoporosis; however, further studies on the association between gene polymorphisms and bmd are needed including larger numbers of participants and genes to clarify genetic risks. keywords: osteoporosis, bone mineral density, genetic risk factors, kazakhstan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. the investigations of nitric oxide influence on lifespan of fruit fly d. melanogaster transgenic strain dnos4 mamura begmanova, nata mit, anara amirgaliyeva, a. tolebayeva, leyla djansugurova institute of general genetics and cytology, almaty, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.153 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ begmanova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.153 | http://cajgh.pitt.edu abstract introduction. aging and longevity control are among the greatest problems in biology and medicine. the fruit fly drosophila melanogaster is a nice model organism for longevity investigations because of its biological features. many d. melanogaster genes have their orthologs, similar in other eukaryotes, including human. the role of nitric oxide (no) in the d. melanogaster lifespan has been analyzed. methods. virgin flies of dnos4 transgenic strain were used for the experiment. this strain contains non-functional additional copies of nitric oxide synthase (nos) gene under heat shock promoter. for promoter activation, transgenic flies on their second day of life were exposed to heat shock (37°c) for an hour. after heat shock, flies were maintained on standard medium temperatures at 25°c, with females separate from males. two types of control were used: oregon r wild-type strain and oregon r strain exposed to heat shock. the average lifespan was evaluated. results. it was revealed that the longevity of females was significantly higher than males in each series of experiments (p < 0.05). the survival rate of females and males was similar in the first month of their life, but in the second month the mortality among males was much higher than among females in all series of experiments. the average lifespan of dnos4 imago was 31 days (34 days for females and 28 days for males), maximum lifespan was 63 days. in controls, the average lifespan of oregon r flies was 54 days (58 days for females and 50 days for males), and the maximum lifespan was 94 days. the average lifespan of oregon r flies exposed to heat shock was 45 days (48 days for females and 41 days for males), and the maximum lifespan was 72 days. the difference between average lifespan in all studied groups is statistically significant (p < 0.05). conclusion. thus, nos-transgene activation results in formation of non-functional dnos4-transcripts and no deficiency. in turn, no deficiency decreases dnos4 imago lifespan. keywords: aging, longevity, nitric oxide synthase transgene, lifespan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx complete genome sequence of the probiotic lactic acid bacterium lactobacillus rhamnosus new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. complete genome sequence of the probiotic lactic acid bacterium lactobacillus rhamnosus samat kozhakhmetov1, almagul kushugulova1, adil supiyev1, indira tynybayeva1, ulykbek kairov1, saule saduakhasova1, gulnara shakhabayeva1, kenzhebulat bapishev2, talgat nurgozhin1, zhaxybay zhumadilov1 1center for life sciences, nazarbaev university, astana, kazakhstan 2medical social institution for older people and invalids, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.113 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kozhakhmetov this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.113 | http://cajgh.pitt.edu abstract introduction: lactobacilli are a bacteria commonly found in the gastrointestinal tract. some species of this genus have probiotic properties. the most common of these is lactobacillus rhamnosus, a microoganism, generally regarded as safe (gras). it is also a homofermentative l-(+)-lactic acid producer. the genus lactobacillus is characterized by an extraordinary degree of the phenotypic and genotypic diversity. however, the studies of the genus were conducted mostly with the unequally distributed, non-random choice of species for sequencing; thus, there is only one representative genome from the lactobacillus rhamnosus clade available to date. the aim of this study was to characterize the genome sequencing of selected strains of lactobacilli. methods: 109 samples were isolated from national domestic dairy products in the laboratory of center for life sciences. after screaning isolates for probiotic properties, a highly active lactobacillus spp strain was chosen. genomic dna was extracted according to the manufacturing protocol (wizard® genomic dna purification kit). the lactobacillus rhamnosus strain was identified as the highly active lactobacillus strain accoridng to its morphological, cultural, physiological, and biochemical properties, and a genotypic analysis. results: the genome of lactobacillus rhamnosus was sequenced using the roche 454 gs flx (454 gs flx) platforms. the initial draft assembly was prepared from 14 large contigs (20 all contigs) by the newbler gsassembler 2.3 (454 life sciences, branford, ct). conclusion: a full genome-sequencing of selected strains of lactic acid bacteria was made during the study. keywords: lactobacilli, lactic acid bacteria, genome sequencing http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx radiation risk factors in incidence and mortality among exposed individuals of east kazakhstan new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. radiation risk factors in incidence and mortality among exposed individuals of east kazakhstan kazbek apsalikov, talgat muldagaliev, rustem apsalikov, shinar serikkankyzy, zaure zholambaeva scientific research institute for radiation medicine and ecology, kurchatov, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.105 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ apsalikov this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.105 | http://cajgh.pitt.edu abstract introduction: lengthy clinical and epidemiological studies at the research institute of radiation medicine and ecology have discovered basic patterns of long-term effects from ionizing radiation in population groups exposed to radiation risk. methodology for calculating injury from radiation risk factors has been developed and implemented to minimize the effects of the semipalatinsk nuclear test site (snts). material and methods: we analyzed materials from the database of the scientific medical register that were exposed to radiation as a result of snts. we analyzed both male and female populations of the abay, beskaragai and zhanasemei, kokpekti (control) areas of east-kazakhstan region (ekr) from 2008-2012. these populations were split into three groups allocated by the generation. the first group represented persons born from the period of 01/01/1930 -08/01/1949 and their children born from the period of 10/09/1949-12/31/1962. the second group were persons born after 01/01/1963. the third group served as the control and were persons who immigrated to these areas after 1990. results: there was an increased incidence of cancer (21.5%, p < 0.000734), cardiovascular diseases (10.2%); respiratory problems (9.6%), gastrointestinal issues (9.1%, p < 0.00371-0.00679) in the first group. the effect of the radiation dose has not been fully stuided among the subjects in the second group. the major causes of excess mortality in the first group were neoplams (30.6%), hypertension (23.8%), and myocardial infarction (22.6%). the effects of radiation influenced mortality in the second group were 2-2.5 times lower than the first group. conclusion: there is a correlation between the size of the radiation dose, the risk profile, and age at the moment of radiation exposure with trends of morbidity and mortality in the radiation exposed areas. keywords: ionizing radiation, radiation risk, kazakhstan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. esophageal cancer in kazakhstan: multi-omic research challenges saule rakhimova1, ainur akilzhanova1, yurii zhukov2, marat omarov2, zhaxybay zhumadilov1 1center for life sciences, nazarbayev university, astana, kazakhstan; 2oncology center, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.170 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ rakhimova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.170 | http://cajgh.pitt.edu abstract introduction. esophageal cancer (ec) is the sixth most common cancer in kazakhstan, fifth leading cause of mortality among men, and ninth leading cause of mortality among women. advances in high-throughput sequencing over the last decade have made mapping the whole genetic variation in genome-wide scale possible. transcriptome sequencing has become a powerful method for detecting driver mutations in cancer, since somatic point mutations as well as aberrant rna variants, such as fusion genes and alternative splicing, can be identified. the aim of the study was to identify the genetic basis of ec by performing whole transcriptome sequencing (rna-seq) study in kazakhstani patients. materials and methods. we included patients with ec who had been admitted to the oncology center in astana, kazakhstan during the 2013-2014 year period. a pair of fresh frozen ec, its adjacent normal tissue specimen, and venous blood were obtained. so far, five pairs of ec samples were subjected to rna-seq. total rna was isolated, and its quality was assessed using agilent bioanalyzer. the cdna library was prepared following the standard mrna protocol by illumina and sequenced using illumina hiseq2000. bionformatic analysis is ongoing. results. during 2013, a total of 74 patients with ec were hospitalized in the oncology center, astana, kazakhstan. radical and palliative surgery was performed on 39 and 34 patients, respectively, and 1 patient refused surgery treatment. the median age of the patients was 66 years (range 49-86 years). 88.4% of the patients were diagnosed with advanced stages t3-t4, and 74.5% from them has dysphagia iii-iv levels. 83% of the cases were squamous cell carcinoma (escc). the major localizations for this type of cancer were the middle section (58.2%), lower section (37.2%), and upper section (4.6%) of the cases. conclusion. escc is the most common histologic subtype of esophageal cancer in our patients and is characterized by a poor prognosis. most patients were diagnosed with late stages t3-t4. using high throughput sequencing approach, we could potentially identify a higher number of crucial molecular pathways involved in esophageal carcinogenesis that could facilitate the development of new diagnostic and treatment strategies. the early detection of ec gives hope of a long-term survival for patients. keywords: esophageal cancer, kazakhstan, rna sequence, squamous cell carcinoma http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. antimutagenic properties of biologically active substances of microalgae associates saule kolumbayeva1, saule dzhokebayeva2, dinara begimbetova3, anna lovinskaya2 1department of biology and biotechnology, al-farabi kazakh national university, almaty, kazakhstan; 2ecology institute, al-farabi kazakh national university, almaty, kazakhstan; 3center for life sciences, nazarbayev university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.162 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kolumbayeva this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.162 | http://cajgh.pitt.edu abstract introduction: there are an increasing number of different xenobiotics negatively influencing population health. therefore, it is important to find effective protectors against mutagenic and toxic effects of environmental pollutants. naturally occurring biologically active substances, the majority of which are antioxidants, are capable of functioning as modifiers of the induced mutation process. the application of various naturally occurring protectors will lower essential risks of congenital malformations, cancer, and hereditary diseases caused by mutational damages. therefore, it is crucial to screen algal flora of kazakhstan for the antimutagenic activity. this study involved the assessment of antimutagenic potential of biologically active polypeptide (bap) produced in mixed microalgae cultures. methods. 70 white outbred male rats (rattus norvegicus) at 6 months of age were used for this study. the dosage of bap produced by microalgae associates anabaena flos-aquae x anabaenopsis sp. comprised 100 mg/kg. cadmium sulfate was used as a mutagen in a concentration of 1 mg/kg. experiments on antimutagenic activity of bap were carried out with the mammalian bone marrow chromosomal aberration test. results. after acute and subacute exposure of bap, the level of chromosomal structural abnormalities in rat bone marrow cells was the same as in control group. therefore, bap showed no mutagenic activity, whereas exposure to cadmium sulfate at used concentration induced chromosomal aberrations with a significantly higher frequency than the spontaneous mutation rate. the exposure combination of bap with cadmium sulfate resulted in a two-fold decrease (р < 0.05) of mutagen-induced chromosomal aberrations. the range of induced chromosomal aberrations included alterations of all types both in control and experimental groups. conclusion. most of the genotoxic effects are mediated through oxidative stress. the repair of dna damage is an enzymatic process, which depends on the cellular metabolic rate. it has previously been shown that many biologically active substances lead to reduction of dna sensitivity to mutagenic damaging factors. based on these facts and obtained results, it can be assumed that bap from mixed microalgae cultures anabaena flos-aquae х anabaenopsis sp. are capable of blocking free radical process reducing the likelihood of genome damage, as well as triggering the cellular repair system. keywords: natural protectors, microalgae, biologically active polypeptide, antimutagenic activity http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx effects of antioxidants and vitamins on the proliferation of human diploid cells new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. effects of antioxidants and vitamins on the proliferation of human diploid cells gaziza dаnlybaeva, assel isabekova, zhansaya akhmadeyeva national center for biotechnology, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.112 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ danlybaeva this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.112 | http://cajgh.pitt.edu abstract introduction: microelements, essential nutrients that are needed in small amounts including minerals such as calcium, zinc, iron and other vitamins (a, b, c, and etc.), are macronutrients necessary for a healthy life. the role of micronutrients in vivo is well known, and there are several publications that have examined the effects of micronutrients on genomic stability. furthermore, a number of vitamins and microelements are substrates and/or cofactors in metabolic pathways, which regulate dna synthesis and/or repair and gene expression. a deficiency in such nutrients may result in disruption of genomic integrity and alterations in dna methylation patterns, linking cellular nutrition with change in gene expression. for example, lack of vitamin c is known to cause increased dna oxidation and chromosomal damage. vitamin a, as well as other micronutrients, have a protective effect, whereas higher concentrations are associated with increased dna damage. ubiquinone (coenzyme q10) and dihydroquercetin are used in therapy as antioxidant compounds and electron carriers, which reduce lipid peroxidation of cell membranes. however, previous studies indicate that various ubiquinone analogs may cause a divergent effect on oxidative stress and oxidative phosphorylation. the aim of our study was to investigate the effect of vitamins a and c, coenzyme q10, and dihydroquercetin on the proliferative potential of cultured human embryonic diploid fibroblasts (m-22). methods: in the first series of experiments, nontoxic concentrations of vitamins for the cells were identified using mtt assay. results: vitamins a and c, dihydroquercetin of 1µm, and coenzyme q10 of 5µm were nontoxic for human skin fibroblasts. in the second series of experiments, cell cultivation was carried out with nontoxic concentrations. a vitamin c concentration of 1µm for 7 consecutive passages increased the proliferation index (pi) compared to the control. thus, the average pi in the experiments was 2.3, whereas in the control, it was 1.7. similar results were obtained when dihydroquercetin was added to the growth medium. however, further cultivation of cells in the presence of vitamin c decreased pi to 1.4, while the control value remained the same. daily examination revealed no morphological changes in the cell culture, but the cell growth had slowed significantly. the use of vitamin a in a nontoxic concentration of 1 µm reduced pi to 0.7 in the first passage, so further culturing of human cells with vitamin a was stopped. conclusion: studies examining the effect of different combinations of microelements on the proliferation of human diploid cells and the expression of specific proteins in them are still being conducted. keywords: vitamins, antioxidants, human diploid cells http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. collagen type i alpha1 (col1a1) gene polymorphism and bone mineral density in postmenopausal kazakh women akbota aitkulova1, ainur akilzhanova2, zhannur abilova2, zaida zhumatova3, gulbanu akilzhanova4, elena zholdybayeva1 1national center for biotechnology, astana, kazakhstan; 2center for life sciences, nazarbayev university, astana, kazakhstan; 3city hospital #1, pavlodar, kazakhstan; 4center for perinatology, pavlodar, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.144 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ aitkulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.144 | http://cajgh.pitt.edu abstract introduction: single nucleotide polymorphism (snp) at the collagen type i alpha 1 gene (col1a1) rs1800012 has been widely studied and has shown an association with bone mineral density (bmd) and fractures. a minor allele tt of this snp was found to be greatly overrepresented in individuals with fractures compared to controls, thus becoming a good predictor of increased fracture risk. the aim of this investigation was to evaluate potential association between col1a1 gene polymorphism and osteoporosis in kazakh postmenopausal women. methods: the study population included 103 postmenopausal women recruited from pavlodar and almaty clinics. bmd was measured using dexa. genomic dna was extracted from peripheral venous blood of study participants with wizard® genomic dna purification kit (promega, usa). detection of col1a1 +1245g/t (sp1) polymorphism was done by the taqman® snp genotyping assay of real-time pcr. results: densitometry results revealed 36 osteoporotic, 42 osteopenic, and 25 normal postmenopausal women. data analysis of 1245g>t polymorphism in col1a1 gene in the group of women with osteopenia and osteoporosis revealed deviation from hardyweinberg equilibrium. the mutant tt genotype was prevalent compared to the heterozygous genotype gt in both groups. distributions were 83% gg, 3% gt, and 14% tt in the group with osteopenia and 80% gg, 6% gt, and 14% tt in the group with osteoporosis. the distribution of genotypes frequency in the group of normal postmenopausal women was 76% gg, 16% gt, and 8% tt. conclusion: these results suggest that tt genotype of col1a1 +1245g/t (sp1) polymorphism is associated with risk of postmenopausal osteoporosis in kazakh women. further studies involving a larger number of women are needed to clarify the relationship of this polymorphism with risk of osteoporosis. keywords: osteoporosis, bone mineral density, gene polymorphism http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.promega.com/resources/protocols/technical-manuals/0/wizard-genomic-dna-purification-kit-protocol/ https://www.promega.com/resources/protocols/technical-manuals/0/wizard-genomic-dna-purification-kit-protocol/ http://www.lifetechnologies.com/kz/en/home/life-science/pcr/real-time-pcr/real-time-pcr-assays/snp-genotyping-taqman-assays/single-tube-snp-genotyping.html?icid=search-product http://www.lifetechnologies.com/kz/en/home/life-science/pcr/real-time-pcr/real-time-pcr-assays/snp-genotyping-taqman-assays/single-tube-snp-genotyping.html?icid=search-product cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. lactobacillus for vaginal microflora correction saule saduakhasova, almagul kushugulova, gulnara shakhabayeva, samat kozhakhmetov, zhanagul khasenbekova, indira tynybayeva, talgat nurgozhin, zhaxybay zhumadilov center for life sciences, nazarbayev university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.171 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ saduakhasova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.171 | http://cajgh.pitt.edu abstract introduction. despite the significant progress made in prevention, diagnosis, and treatment, there is still a high rate of vaginal dysbiosis in kazakh women. the use of antibiotics in the treatment of vaginal dysbiosis contributes to the elimination of pathogens as well as microflora, which can lead to a decrease in local immunity and more favorable conditions for infection spread. the most physiologically safe and promising method for the restoration of vaginal biocenosis is the use of probiotics administered by a vaginal route. methods. we have allocated 64 of cultures of lactobacillus from the vaginal epithelium of healthy women of reproductive age and women with diagnosed bacterial vaginosis (bv). identification of cultures was performed by pcr analysis of 16s ribosomal rna. evaluation of biological significance was determined by the following criteria: high antagonistic activity against candida albicans, escherichia coli, serratia marcescens, proteus mirabilis, klebsiella ozaenae, and staphylococcus aureus; and production of hydrogen peroxide, resistance to antibiotics, adhesive activity. we studied the symbiotic relationship of selected biologically active of cultures to each other and received options for consortiums with properties of probiotics through co-cultivation. results. results of genotyping showed that the isolated lactobacilli belong to the seven species: l. fermentum, l. salivarius, l. gasseri, l. crispatus, l. jensenii, l. plantarum, and l. delbrueskii. l. fermentum, l. salivarius, l. gasseri, and l. jensenii occur in women with suspected bv. the highest percentage of occurrence in the vagina of healthy women was l. fermentum (28%). most strains of lactobacilli possess high inhibitory activity for all test-strains, except candida albicans (37.5%). 56% of studied cultures revealed high adhesion to human erythrocytes. all lactobacillus strains were resistant to metronidazole, 80% to kanamycin, 57% to vancomycin, and sensitivity to roxithromycin, amoxiclav, ampicillin was diagnosed in all strains. 50% of cultures showed a moderate sensitivity to gentamicin and cefazolin. in a study of peroxide-producing activity, 80% of the cultures exhibited peroxideproducing activity. as a result of sсreening, the 7 most active strains of lactobacilli were selected for development of 10 variants of probiotic consortia. also, there was increase of adhesive activity in the consortia compared to other components. these consortia can be used for the treatment of bv in addition to metronidazole. conclusion. the probiotic consortia identified in this study had high antagonistic, adhesive properties, and resistance to metronidazole. these probiotics can potentially be used for the development of biological products for the treatment and prevention of bacterial vaginosis. keywords: vaginal microflora, lactobacillus, bacterial vaginosis, probiotics http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx genotype frequencies of polymorphic mdr1 variants in the kazakhstani population new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. genotype frequencies of polymorphic mdr1 variants in the kazakhstani population samat kozhakhmetov, adil supiyev, almagul kushugulova, indira tynybayeva, alibek kossumov, leila utepova, saule saduakhasova, gulnara shakhabayeva, talgat nurgozhin, zhaxybay zhumadilov center for life sciences, nazarbayev university, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.118 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kozhakhmetov this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.118 | http://cajgh.pitt.edu abstract introduction: statins appear to be handled by an atp-dependent membrane transporter and three snps (c1236t (rs1128503), g2677t (rs2032582), and c3435t (rs1045642), which capture the common genetic variation at this locus. individuals, who carry the t allele at each snp (i.e., the t-t-t haplotype), have higher systemic exposure to simvastatin. a triallelic thymine (t) guanine (g) adenine (a), which is a point mutation at nucleotide 2677 in exon 22, leads to abcb1 in a non-synonymous codons (gct alanine, tct serine, threonine act) at position 893 in a cytoplasmic loop of atp-dependent membrane transporters. methods: blood samples from healthy individuals were collected in the republican diagnostic center, astana, kazakhstan. the research samples included 461 healthy people. genomic dna was extracted from peripheral blood using the ‘salting out’ procedure. for the mdr1 exon 21, 2677g˃t/a (ala893ser/thr) polymorphism was genotyped by pcr sequencing by the use of dye-terminator (abi 3730xl sequencer). results: the gg allele appeared in 23% of samples, the ga in 6.7%, the gt in 44%, the non-g heterozygote in 4.5%, and the non-g homozygote in 18%. these results are consistent with previously published data. importantly, the frequency of 2677t alleles in our group was 15.4%. this represents the lowest frequency of this allele compared to published data in different populations. the frequency of the 2677t allele in asians and caucasians varies from 38 to 62%, and is 15% for african americans. on the other hand, the 2677a allele frequency in the japanese varies from 15 to 22%, and in caucasians from 2% and 4%. the 2677a allele frequency has been found in 4.6% of samples. conclusions: our study further emphasizes differences between various asian populations and the importance of repeating this genetic study in different ethnic groups. keywords: genotype, mdr1, kazakh population http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. features of cytokine profile in different age groups alikhan shortanbayev, beibitgul bizhigitova, anel tarabayeva, aliya nurmuchanbetova department of general immunology, s.d. asfendiyarov kazakh national medical university, almaty, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.173 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ shortanbayev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.173 | http://cajgh.pitt.edu abstract introduction. the study of the cytokine profile during aging is interesting because age-related changes of the immune status are usually correlate with the onset of specific diseases. characteristics of cytokine activity in the elderly can not only detail the pathogenesis of the disease but also help to choose the appropriate therapeutic strategy, which in addition to the therapeutic effect could improve the quality of life of the elderly. the purpose of this study was to examine cytokine levels in older adults. material and methods. we examined 268 people aged 45-80 years and older. all surveyed individuals were divided into 8 different age groups. all participants were tested for concentrations of il-1β, il-2, tnf- and ifn-γ. results. the study found that concentrations of tnf- increased with age. for age group 45-49, the concentration of tnf- was 5.94 pcg/ml. in older age groups, there was a gradual increase in cytokine concentration. in a group of centenarians, concentration of tnf- reached 20.55 pcg/ml, which is 3.4 times higher compared to the middle age group. similar trends were found in the concentration of il-1. for the age group of 45-49, the concentration of il-1  was 3.38 pcg/ml, and in the age group of 80 years and older, levels of this cytokine increased almost 5 times. it was found that with age-related there is a gradual decrease in the level of il-2, and a gradual increase of ifn-γ. the decrease in il-2 is due to the typical aging decrease in the amount of t-lymphocytes. conclusion. thus, our results indicate that there are significant deviations of immune parameters, particularly in cytokine concentrations, in older adults compared to middle aged adults. keywords: aging, cytokines, immunity http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx missing millions and measuring progress towards the millennium development goals with a focus on central asia states missing millions and measuring progress towards the millennium development goals with a focus on central asia states roy carr-hill1 1centre for health economics, university of york abstract background: in developing countries, population estimates and assessments of progress towards the millennium development goals are based increasingly on household surveys. it is not recognised that they are inappropriate for obtaining information about the poorest of the poor. this is because they, typically, omit by design: those not in households because they are homeless; those who are in institutions; and mobile, nomadic or pastoralist populations. in addition, in practice, because they are difficult to reach, household surveys will typically under-represent: those in fragile, disjointed or multiple occupancy households; those in urban slums; and may omit certain areas of a country deemed to pose a security risk. those six sub-groups constitute a pretty comprehensive ostensive definition of the ‘poorest of the poor’. methods: this paper documents these omissions in general, drawing on worldwide literature about the theory and practice of implementing censuses and household surveys; and shows how substantial proportions are missing from both censuses and the sample frames of surveys. results: this paper suggests that between 300 and 350 million will effectively be missed worldwide from the sampling frames of such surveys and from most censuses. the impact on the health mdgs is illustrated for the five republics of the former soviet union making up central asia: kazakhstan, kyrgyzstan, tajikistan, turkmenistan , and uzbekistan. conclusions: it is impossible to assess progress towards or away from the mdgs in both the central asian republics and worldwide. it is urgent to find solutions to the problem of the ‘missing’ poor population sub-groups. introduction for several decades, and in some countries for centuries, populations have been counted through national, usually decennial, censuses in which enumerators go to households. intercensal population estimates have usually depended on reliable birth and death registration systems. in most middle and low income countries, however, vital registration systems have never been fully functioning,1 and there has been a similar decline in donor interest in censuses and vital registration systems.2 but there is an increasing reliance on large scale standardized household surveys for the basic data. many countries run national economic and social surveys to provide detailed information on consumer prices, income and employment, and other relevant data for planning. this move away from censuses to relying on surveys raises the obvious problem that drawing a sample for a survey depends on having a sampling frame in the first place which is frequently based on the census. clearly any problem with the census, if used as the sampling frame for a national survey, will lead to that sampling frame being biased. but there is – rather strangely – little recognition of these problems. censuses population censuses have always faced problems of complete enumeration. groups of adults have been excluded from censuses in some countries for political and/or practical reasons. non-citizens, cultural minorities or marginalised groups, and specific categories of prisoners or rebels who object to government oversight have often been excluded for political reasons3 and although less frequent and certainly more transparent, this still continues.4,5 therefore, the general problem that censuses are not themselves necessarily complete is well understood.6 at the same time, there is an emerging consensus as to what constitutes good census practice,7 and censuses that follow these un guidelines will usually overcome many of the problems that have occurred with earlier censuses. the guidelines are clear but there can still be problems in practice: housekeeping concept: whilst cinderella is a fairy tale, the exclusion of poor servants from the census count in rich households (even though they will usually be sharing some of the household food), especially in asia, is not, and their personal poverty is therefore missed for different reasons. mobile populations: in developed countries, the young highly mobile – usually male population – are also difficult to count, especially when they live in collective households, but they are relatively well-off. in developing countries, they may well be among the poorest. homelessness and counting de facto rather than de jure populations: these are difficult to count, especially where there are disputes over nationality.8 equally there are several millions internally displaced in many countries either as a result of civil war or because environmental change (e.g. floods, nuclear accidents) makes their homes uninhabitable. although there are periodic counts, there is no regular database anywhere. institutional populations: there are several different types of institutions (care homes, (some) factory barracks, hospitals, the military, prisons, refugee camps, religious orders, and school dormitories) and there is still considerable variation over whether or how they should be included in the population count. their characteristics are often not fully reported and they are simply counted as special census blocks. careful census reporting documents how well these groups have been enumerated and most categories are included in estimated census population counts of developed countries but not in those of many developing countries. moreover, in many developing countries, the census enumerators are often police or other government officials who tend to use security based national identity cards or family registration cards to validate the citizenship status of those they are enumerating.9,10 these problems are illustrated in this paper for the central asian states. assessing poverty in assessing the absolute level of poverty or the absolute levels of illness household surveys are an inappropriate instrument for obtaining information about the poorest of the poor, especially in developing countries. this is because household surveys, with rare exceptions, typically omit by design: those not in households because they are homeless; those who are in institutions, including refugee camps; mobile, nomadic, or pastoralist populations. in addition, in practice, because they are difficult to reach, household surveys will typically under-represent: those in fragile, disjointed, or multiple occupancy households (because of the difficulty of identifying them); those in urban slums (because of the difficulty of interviewing); or may omit certain areas of a country deemed to pose a security risk. if one wanted a practical distinct from a theoretical definition of the ‘poorest of the poor’, the above collection of six population sub-groups could hardly be bettered. census officials, because of the difficulty of enumeration, even in developed countries, often only make estimates of their size and location so that the members of those groups are not included in the available sampling frames for household surveys. in developing countries, these marginalised groups may not be included at all, even in the estimated population counts. the lack of recognition of these problems with the design and implementation of household sample surveys, particularly in developing countries, has meant that there has been no systematic attempt to estimate the size and distribution of the population groups ‘missing’ from the sampling frames of national household surveys. central asia: creation of states and mdg indicators for health outcomes the five republics were created by soviet demographers, roughly based on ethnic identity.11 prior to soviet rule, substantial majorities of the population lived as nomads, without ‘states’ in the modern sense.12 under soviet rule, nomads were ‘sedentarised’, although transhumance continued subject to bureaucratic regulation.12 the current populations, poverty rates (mdg 1), and mortality rates for infants, children (mdg 4), and mothers (mdg 5) are given in table 1. there have been only small increases in population, with substantial decreases in the poverty rates in kazakhstan, kyrgzstan, and tajikistan, but a large increase in uzbekistan. in contrast, there have been substantial improvements in respect of infant and child mortality and maternal mortality.   population (millions) poverty (%) infant mortality under 5 mortality maternal mortality   2000 2010 1998 2004 2000 2009 2000 2009 2000 2010 kazakhstan 15.0 16.0 5.0 3.1 38 26 44 29 70 51 kyrgzstan 5.0 5.3 31.8 21.8 44 32 51 37 82 71 tajikistan 6.2 6.9 44.5 36.3 75 52 94 61 120 65 turkmenistan 4.5 5.0 25.8   59 41 71 45 91 67 uzbekistan 24.8 27.4 32.1 46.3 53 32 62 36 33 28 sources: population, poverty rate cia world factbook; infant mortality rate, child mortality rate – world health statistics how many are potentially ‘missing’ from population counts and from sampling frames of household surveys the focus here is on groups for which there are credible sources, and that are normally among the poorest. other groups, not considered below because they are not necessarily the poorest include those caught up in civil wars and economic and environmental migrants,13 which may include the more ambitious and therefore not the poorest, etc. homeless rather obviously, household surveys omit the homeless and street children. estimating numbers is very difficult. over 20 years ago, unicef estimated that there were about 100 million street children.14 the figure is still commonly cited, but has no basis in fact.15,16 but, however many there are, they will not be covered by household surveys. institutionalised populations household surveys, by definition, omit from their sampling frame those in institutions: care homes, (some) factory barracks, hospitals, the military, prisons, refugee camps, religious orders, and school dormitories. care homes and hospitals: those in hospitals and care homes will on average be poorer because morbidity is associated with poverty17 although that is less true for older people. there are estimated to be about 20 million hospital beds worldwide,18 with the number of hospital beds in the central asian countries varying between 40 and 76 per 10,000 (column 1, table 2), with a total of 330,500. military: the cia world factbook19 documents 92 million worldwide (including reservists) and 226,200 in the central asian states (column 2, table 2). prison: those in prisons will usually be poorer and estimates of the total prison population of the world are around 9.8 million.20 none of these 9.8 million will be included in the sampling frame of household survey. the numbers in central asia is 130,800 in central asia (column 3, table 2). refugees: refugees are not considered as part of any nation’s population so they cannot, of course, be included in survey sampling frames nor make any contribution to survey-based estimates. however, the united nations high commissioner for refugees21 publishes figures annually on numbers of officially registered refugees, internally displaced persons, and stateless persons. the total for central asia total is 344,400, and the worldwide total is 36.5 million; these figures do not include the large number of illegal immigrants (and in particular those returning from china into the central asian states), most of whom will not be counted in a national population and, of course, not in the sampling frames of household surveys. table 2: populations vulnerable to undercounting in censuses or surveys, central asian republics (‘000s) around 2010       nomads urban pop. slum (e)   hospital prisoners military refugees 2000 2010(e) % n % n kazakhstan 121.6 56.0 80.5 12.7 4,724 4,874 59 9.44 55 5.19 kyrgzstan 27.0 8.4 20.4 304.2 256 284 35 1.86 75 1.39 tajikistan 35.9 7.4 16.3 7.1 205 240 26 1.79 75 1.35 turkmenistan 20.0 11.0 22.0 20.1 1,532 1,755 50 2.50 55 1.38 uzbekistan 126.0 48.0 87.0 0.3 1.478 1,670 36 9.86 55 5.43 source: hospital beds, prisoners, military, refugees – unhcr; nomads – thornton et al (2002); urban population proportions cia world factbook; slum proportions in urban areas – estimated by author from un habitat nomadic and pastoralist groups by world region the permanently mobile are usually excluded from household surveys. in particular, censuses and surveys in developing countries have difficulty enumerating nomadic/pastoralist populations who have much less access to services. whilst it is difficult to assess their income and wealth, and there clearly are some who are rich-in-kind (or asset rich), the majority are usually poor in all senses. there is no reliable information available on the number of nomadic pastoralists, including sea-faring mobile communities, worldwide. over twenty-five years ago, sandford estimated a total of 22.7 million.22 more recent estimates for most countries are much larger, and when added up the overall total is about triple the earlier estimate at about 66 million. the only internationally comparable source is that compiled by the international livestock research institute,23 based partly on livestock numbers, and these are much larger again. these estimates have been used (column 4, table 2) and although there are some substantial discrepancies, overall, the more recent country-specific estimates are in line with the thornton-based estimates. the worldwide estimate is 217.5 million and the estimate for the central asian countries is 8.823 million; there appears to have been a substantial resurgence in the nomadic lifestyle partly through repatriation. difficult to reach fragile and disjointed households the task of the census enumerator or survey interviewer is made much more difficult when the household structure is ambiguous or undefined so that either identifying the household head and/or counting the numbers in the household is almost impossible. urban slums un habitat24 bases its definition of slums on households lacking one or more of the following four amenities: (1) durable housing, (2) sufficient living area, (3) access to improved water, and (4) access to improved sanitation facilities. the most recent estimates from un habitat24 are that there are more than a billion people living in urban slums in developing countries, but information is rarely disaggregated according to intra-urban location and the poorest urban populations are often simply not included in data gathering. the few surveys that have been conducted in those slums show sharp gradients according to income quintiles within urban populations.25 but given the very high levels of mobility, it would seem reasonable to assume that a substantial minority of those households in the slum areas of developing country cities are uncounted in any census. moreover, even where they are counted in censuses, many would (because of interviewer reluctance) in practice be excluded from sampling frames. for central asia, one might suppose that because most of the cities were built relatively recently during the soviet era, there would have been only a few slums (although see osce report11), but calculations from the unhabitat tables on the percentages in informal employment suggest that large proportions of urban areas are slums. given that some of these calculated figures seem high (93% in tajikistan, 78% in kyrgyzstan, 63% in kazakhstan, 50%+ in uzbekistan), we have used values of 75% for kyrgyzstan and tajikistan and 55% for the other three republics for the proportion of slum populations among urban populations. insecure or isolated areas this will obviously vary according to context and so will be a much larger problem in specific countries. given the security situation – or simply difficulty of transport in many countries, it can often be difficult for the implementing institutions to carry out a fully representative survey or census. overall estimates, discussion and conclusions overall estimates not all those missing populations are poor; in table 3, we give an estimate of the numbers of the poor who are missing. all those hospitalized or in prison are missing. we assume that two-thirds of military are poor and unofficial refugees are assumed to double the official refugees (and that is probably a substantial underestimate). based on informal conversations with census officials in several countries and on the difficulties of using satellite imagery in slum areas26 (because of the need to rely on key informants and the visual obscurity of some structures), the numbers of missing among nomadic and slum populations are estimated as between 10% and 20%. table 3: estimates of poor populations that are missing in central asia 2010       nomads slum   hospital prisoners military refugees 1 in 5 1 in 10 1 in 5 1 in 10 kazakhstan 121.6 56.0 53.6 25.4 974.0 487.0 1,038 519 kyrgzstan 27.0 8.4 13.8 608.4 56.8 28.4 278 139 tajikistan 35.9 7.4 10.8 14.2 48.0 24.0 270 135 turkmenistan 20.0 11.0 14.6 40.2 351.0 175.5 276 138 uzbekistan 126.0 48.0 58.9 0.6 334.0 167.0 1,086 543 worldwide, the totals in the sub-sections above add up to between 171 and 322 million; in central asia it is between 3.31 and 6.01 million (table 4). moreover, the estimates do not include the homeless, those in fragile or disjointed households, or those in areas where there are security risks. most of the homeless are probably from urban slums so there would be double counting, but the other three categories (large, but of unknown size) are definitely additional. estimates of between 300-350 million worldwide and about 7 million for central asia is not unrealistic. table 4: estimates of population groups missing from sampling frames of household surveys worldwide and for central asia     worldwide (millions) central asia (thousands)     minimum maximum minimum maximum pastoralists   21.8 43.5 881.9 1,763.8 institutionalised refugees 36.5 73.0 344.4 688.8   hospitals 20.0 20.0 330.5 330.5   military     150.8 150.8   prisons 10.0 10.0 130.8 130.8 slum populations   82.8 175.6 1,474.0 2.948.0 total   171.1 322.1 3,312.4 6,012.7 as a 4.5-5.0% undercount of the world’s population of c.7 billion, this might be judged acceptable; as a 22.5-25.0% undercount of the poorest wealth quintile, scandalous; and the situation is worse for central asia where the missing constitute about 11.5% of the total population. the undercount in the poorest quintile in central asia means that estimates of the absolute levels of poverty and of the mortality rates are biased upwards; both are probably 10%-15% higher than currently estimated. censuses and sampling frames counting displaced and illegal groups census organisations in developed countries use several procedures for estimating the numbers of illegal immigrants. but those procedures would not work for south-south illegal migration; moreover, there are other omitted sub-groups, often quite large: for example, scheduled castes and tribes in india27 and illegal servants in rich households. counting and sampling nomads and pastoralists these are difficult to count simply because they are moving. reasonable samples have been obtained through combining local level surveys with remote sensing of livestock,28 but documenting change in their human population remains, on the whole, elusive. counting urban slum populations any face-to-face interviewing approach will be very unreliable both because of the lack of a sampling frame and because the respondent will be suspicious of the reason for the questions because they are illegally resident. but even if the census organisation were to make available a listing of ‘houseless’ people, given the high levels of intra-slum mobility, this would be an unreliable sampling frame for surveys. solutions carrying out accurate censuses international organizations should support national census organizations in developing and testing procedures for counting pastoralists and other nomads (gypsies, highly mobile workers, long-distance truck drivers, travelers, etc.) and those in urban slums26, 29 and in adopting best practice from un guidelines. sampling frame problems for surveys the fundamental problem of a household survey is precisely that it will not cover those who are not in households. although there are technical solutions (see above) to the problem of enumerating or at least counting population sub-groups missing from many censuses, the same procedures do not solve the sampling frame problem of household surveys because of the delays between census and survey. special surveys could be and have been carried out of those who are in fixed institutions, however: they tend to be expensive, they often involve proxy respondents,30 and the results are difficult to integrate with those from the main household survey. conclusions population undercounting means that any social programme risks ignoring the poorest of the poor. this blindness is a public scandal affecting at least 300 million of the poorest in developing countries (between 4.5% and 5% of total world population) and 7 million in central asian republics (about 12% of their total population) and should be addressed immediately by international and national organizations, in terms of developing and testing appropriate procedures for counting. this is urgent because these data are used frequently for assessing progress towards the millennium development goals in developing countries. in the absence of any simple solution, this author has shown that, it is possible to make estimates of the missing populations. it is crucial to develop similar methods more systematically, with an agreed theoretical basis. references 1. powell np. major obstacles to achieving satisfactory registration of vital events and the compilation of reliable vital statistics. technical papers of the international institute for vital registration and statistics, no 15. bethesda (md): international institute for vital registration and statistics; 1981. 2. setel p, macfarlane s, szreter s, mikkelsen l, prabhat j, stout s, et al. a scandal of invisibility: making everyone count by counting everyone. the lancet. 2007; 370(9598):1569-1577. doi: 10.1016/s0140-6736(07)61307-5 3.buettner t, garland p. preparing population estimates for all countries of the world: experiences and challenges. rome meeting of committee for the coordination of statistical activities; 2008. 4. coptom [internet]. 2011. available from: http://www.indigenousportal.com/politics/northeast-india-coptam-unpleasant-tidings-greet-census-2011.html. 5. abbasi-shavazi mj, sadeghi r. the adaptation of second-generation afghans in iran: empirical findings and policy implications [internet]. 2011 feb 9. available from: http://www.refugeecooperation.org/publications/afghanistan/05_jalal.php. 6. mid-term evaluation of the efa fast track initiative. working paper 3, issues in data and monitoring and evaluation. 2009 jun 28. 7. un. principles and recommendations for population and housing censuses revision series m no 67/revf 2; st/esa/stat/ser.m/67(rev 2). 2008. 8. refugees international. about being without: stories of stateless in kuwait. 2007. 9. di w. door-to-door census needs more accountability. global times. 2010 sept 10. 10. dwinosumono s. the population census in indonesia. presented at fifth management seminar for the heads of national statistical offices in asia and the pacific, daejon, republic of korea. 2006. 11. usip. us online training course for osce including react, module 6 central asia [internet]. 2011. available from: http://react.usip.org. 12. akiner s. history and politics in central asis: change and continuity. in: mckee m, healey j, falkingham j, editors. health care in central asia. open university press; 2002. 13. myers n. environmental refugees. population and environment. 1997;19(2):167-82 14. unicef. state of the world’s children. new york: unicef; 1989. 15. green d. hidden lives: voices of children in latin america and the caribbean. london: cassell; 1998. 16. hecht t. at home in the street children of north east brazil. cambridge, uk: cambridge university press; 1998 17. lopez a. mortality and morbidity trends and poverty reduction. in: selected papers of the fifth asian and pacific population conference. 2002. 18. world health organisation. world health statistics. 2011. 19. central intelligence agency. the world factbook 2011 [internet]. 2011. available from: https://www.cia.gov/library/publications/the-world-factbook/. 20. walmsley r. world population list home office, research paper findings 188. 2003. 21. united nations high commissioner for refugees (unhcr). unhcr statistical online population database [internet]. [cited 2010 dec 20]. 22. sandford s. management of pastoral development on the third world. chichester, uk: john wiley; 1983. 23. thornton pk, kruska rl, henninger n, kristjanson pm, reid rs, atieno e, et al. mapping poverty and livestock in the developing world. nairobi: international livestock research institute. 2002. 24. un habitat. [cited 2011 oct 21]. available from: http://ww2.unhabitat.org/mdg/. 25. un-habitat. the challenge of slums: global report on human settlements. new york: un; 2003. 26. schurmann a. (2009) bangladesh urban health survey: methods and reproductive health results. in: international conference on urban health; 2009 oct 18-23; nairobi, kenya. 27. government of india, ministry of social justice and empowerment. scheduled caste welfare – list of scheduled castes [internet]. 2012. available from: http://socialjustice.nic.in/sclist.php. 28. galvin ka, boone rb, smith nm, lynn sj. impacts of climate variability on east african pastoralists: linking social science and remote sensing. climate research. 2001;19:161–172. 29. angeles g, lance p, barden-o'fallon j, islam n, mahbub aqm, nazem ni. the 2005 census and mapping of slums in bangladesh: design, select results and application. 2009. available from: http://www.refugeecooperation.org/publications/afghanistan/05_jalal.php. 30. national centre for social research, department of epidemiology and public health at the royal free and university college medical school. health survey for england 2003. department of health; 2004. cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. application of cellular technologies to the experimental treatment of destructive inflammatory arthropathies marzhan kaulambayeva1, galina fedotovskikh2, anara nurmukhambetova1 1rpe antigen ltd, kazakhstan; 2national research medical center, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.161 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kaulambayeva this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.161 | http://cajgh.pitt.edu abstract introduction. the treatment of destructive inflammatory joint diseases (arthropathies) is one of the issues of current interest in modern medicine. in destructive inflammatory diseases, the regenerative ability of cartilaginous tissue proves to be inadequate for neogenesis of joints. the goal of this study is to determine the efficacy of bone marrow-derived mononuclear cell fraction (mnc) and multipotent mesenchymal stromal cells (mmsc) in the treatment of destructive inflammatory joint diseases. materials and methods. the study subjects consisted of 15 male rabbits weighing 3-4 kg with experimental destructive inflammatory knee joint disease. the test animals were divided into 3 groups: reference group without treatment, first test group – introduction of autologous mnc from rabbit bone marrow into the affected joint, and second test group – introduction of cultured mmsc from rabbit bone marrow into the joint. results. a morphological examination of the synovial membranes in the reference group on the 40th day of the experiment revealed chronic synovitis with destruction of synoviocytes, thickening and inflammatory infiltration of the underlying connective tissue (subintima). during examination of synovial membranes in the first test group the patches of thickened regenerating inner layer (intima) made up by large proliferating synoviocytes were observed. the layer of loose connective tissue (subintima) contained a large number of small blood vessels and was only slightly infiltrated by inflammatory cells. the morphological examination of synovial membranes in the second test group discovered thickened regenerating intimal layer sitting on hypertrophied subintima with dense vascular network. elastic collagenous layers of synovial membrane adjoined proliferating elements in cartilage plates. conclusion. both autologous mnc fraction and mmsc from bone marrow proved effectiveness in the treatment of destructive inflammatory joint diseases which stimulate neoangiogenesis. at the same time, it must be noted that the introduction of mmsc diminished destructive changes and accelerated proliferative process. keywords: arthropathies, mononuclear cells, mesenchymal stromal cells, joint diseases http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.multitran.ru/c/m.exe?t=364176_1_2&s1=%f5%f0%ff%f9%e5%e2%e0%ff%20%f2%ea%e0%ed%fc cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. distribution of beijing genotype among clinical isolates of m. tuberculosis circulating in kazakhstan ainur akhmetova1, venera bismilda2, leila chingissova2, ulan kozhamkulov1 1center for life sciences, nazarbayev university, astana, kazakhstan; 2department of bacteriology, national center for tuberculosis problems, almaty, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.145 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ akhmetova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.145 | http://cajgh.pitt.edu abstract introduction. methods of genotyping of m. tuberculosis play an important role in tuberсulosis (tb) infection control. these techniques are used to detect or exclude laboratory errors, control recurrent cases, and determine ways of tb transmission. today, there are more than 10 methods of genotyping; miru-vntr is one of the most widely used methods in the world. in this study we aimed to estimate biological diversity of clinical isolates of m. tuberculosis from different regions of kazakhstan based on miru-vntr analysis. materials and methods. miru-vntr was used to genotype 134 clinical isolates of m. tuberculosis isolated from new cases and recurrent cases of tb from different regions of kazakhstan. amplification was done using 15 miru-vntr loci. determination of the number of tandem repeats in the corresponding locus was performed via quantity one v.4.4.0 (biorad, usa) software. h37rv (nc_000962) reference strain was used as a positive control. results. phylogenic tree was built using www.miru-vntr.org web-resource based on the results of miru-vntr analysis. beijing family strains associated with drug resistance to antituberculosis drugs were prevalent among all isolates of m. tuberculosis circulating in kazakhstan. strains of the beijing genotype were prevalent in both new cases (65%) and recurrent cases (89.4%) of tuberculosis. the second meaningful genotype that is spread in the territory of kazakhstan is lam, the frequency of distribution is 7.3% in new and 4.5% in recurrent cases. other families of m. tuberculosis such as ural, haarlem, cas, new-1, s were found in less than 4% of cases. conclusion. prevalence of beijing family strains among all isolates of m. tuberculosis from different regions of kazakhstan was shown. strains of this family are prevalent among young people. this genotype is responsible for ongoing tb transmission in the present time. this genotype is more virulent; therefore, investigation of the epidemiology of the beijing genotype plays crucial role in the monitoring of tuberculosis. keywords: tuberculosis, mycobacteria, genotyping, kazakhstan, beijing genotype http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.miru-vntr.org/ speman®, a proprietary ayurvedic formulation, reverses cyclophosphamide-induced oligospermia in rats speman®, a proprietary ayurvedic formulation, reverses cyclophosphamide-induced oligospermia in rats mohd. azeemuddin mukram, mohamed rafiq1,suryakant d. anturlikar,pralhad s. patki 1department of pharmacology, r&d center, the himalaya drug company, makali, bangalore, india abstract background: this investigation was aimed to evaluate the effect of speman®, a well known ayurvedic proprietary preparation, in an experimental model of cyclophosphamide-(cp) induced oligospermia in rats. materials and methods: thirty male rats were randomized in to five, equally-sized groups. rats in group 1 served as a normal control; group 2 served as an untreated positive control; groups 3, 4, 5 received speman® granules at doses of 300, 600, and 900mg/kg body weight p.o. respectively, once daily for 13 days. on day four, one hour after the respective treatment, oligospermia was induced by administering a single dose of cp (100mg/kg body weight p.o.) to all the groups except group1. at the end of the study period the rats were euthanised and accessory reproductive organs were weighed and subjected to histopathological examination. the semen samples were subject to enumeration of sperms. weight of the reproductive organs, histopathological examination of the tissues, and sperm count were the parameters studied to understand the effect of speman® on rats with cp-induced oligospermia. results: changes that occurred due to the administration of cp at a dose of 100 mg/kg body weight were dose dependently reversed with speman® at a dose of 300, 600, and 900 mg/kg body weight. there was a statistically significant increase in sperm count and the weight of the seminal vesicle, epididymis, and prostate. conclusion: findings of this investigation indicate that speman® dose dependently reversed the cp-induced derangement of various parameters pertaining to the reproductive system. this could explain the total beneficial actions of speman® reported in several other clinical trials. introduction significant growth of the global human population over the years has been paralleled by a substantial increase in the number of infertile couples, a major reproductive-health concern owing to the fact that it affects quality of human life. in human patients, stresses and strains of modern living may make an individual sexually neurasthenic and functionally impotent. this may lead to a chain of psychological complexes, contributing to sexual inferiority and its allied syndromes. infertility affects both men and women. current epidemiological evidence suggests that 15% of couples in the world experience infertility, half of which remain untreated and/or unresolved. among infertile couples, 40% are primarily due to the infertility of the male partner, while 20% of these cases are a combination of both male and female factors.1 oligospermia, asthenospermia, teratozoospermia, and azoospermia account for 20% to 25% of male infertility cases. clinically, oligospermia (sperm concentrations of < 20 million sperms/ml of semen) is considered to be one of the most prevalent causes of male infertility.2 though the pathophysiology of oligospermia remains unclear, hormones like follicular stimulating hormone (fsh) and luteinizing hormone (lh), which play an important role in spermatogenesis, act as marker components.3 treatment options for oligospermia in modern medicine are still in their infancy given that no specific drug has yet been discovered. in the last few years, extensive research has been carried out in the field of ayurveda for utilizing the natural sources in the treatment of oligospermia. speman®, a polyherbal proprietary formulation developed by the himalaya drug company (makali, bangalore) is approved by the government of india's drug regulatory authority (department of ayush, ministry of health and family welfare). it is used clinically in the management of male sexual disorders like oligospermia, premature ejaculation, senile sex aberrations, and several other related conditions.4-5 several reports are available indicating the beneficial effects of a speman®, on the gametogenic as well as androgenic functions of the testes in humans and animals.6-11 speman® constitutes a mixture of extracts of withania somnifera, asteracantha longifolia, lactuca scariola, mucuna pruriens, parmelia parlata, argyreia speciosa, tribulus terrestris, leptadenia reticulate, and suvarnavang. the formulation has been tested for its quality and consistency at every step of the manufacturing process as per the accepted principles of good manufacturing practice (gmp) and good laboratory practice (glp). its botanical identification, quality parameters, and ayurvedic criteria comply with the international guidelines and pharmacopoeial standards. materials and methods this investigation was discussed and approved by the institutional animal ethics committee (iaec) of the himalaya drug company, bangalore, on 4/01/2008 vide protocol no. 83. its aim was to evaluate the effect of speman® in an experimental model of cp-induced oligospermia in rats. drugs and chemicals: speman® (the himalaya drug company, makali, bangalore), cyclophosphamide (cp) (german remedies limited, mumbai, india), and all the other chemicals used in the experiments were of analytical grade and purchased from reputed suppliers. experimental animals: inbred wistar rats weighing 250–300 g were used for the study; they were housed under standard conditions of temperature (22 ± 3˚c), relative humidity (55 ± 5%), and light (12 h light/dark cycle) before and during the study. they were fed with a standard pellet diet and water ad libitum. all animals received humane care as per the guidelines prescribed by the committee for the purpose of control and supervision of experiments on animals (cpcsea), ministry of environment & forests, government of india. experimental protocol: thirty male rats were randomized into five groups of six rats each. animals from group 1 and 2 received water once a day, orally (p.o.), at a dose of 10 ml/kg body weight; and served as the normal and positive controls, respectively, while those in groups 3 to 5 received speman® granules at a dose of 300, 600, and 900 mg/kg body weight p.o. once daily for 13 days. on day four, one hour after their respective treatments, animals in all groups except group 1 received cp at a single dose of 100 mg/kg body weight p.o. treatment with speman® was continued for 9 days after administration of cp. at the end of treatment period, on day-14, the animals were euthanized and accessory reproductive organs such as the testes, epididymis, and seminal vesicle were collected, weighed, fixed in neutral buffered formalin solution, and sent for routine histopathological examinations. semen samples from unilateral cauda were subjected to enumeration of sperms following dilution with sperm diluting fluid. counting was performed using a haemocytometer and light microscope with 100x magnification.12,13 results this preclinical study was carried out to evaluate the effect of speman® in an experimental model of cp-induced oligospermia in rats. its efficacy was tested at dose levels of 300, 600, and 900 mg/kg body weight p.o., which corresponds to or equivalent to the recommended human dose. dosing volume was decided based on the mean body weight of the animals in each group. administration of cp (100 mg/kg p.o.) to rats induced significant changes, like oligospermia, weight reduction of seminal vesicle, epididymis, and testes. sperm count of the normal control group was 46.3 ± 2.89 million/ml of semen and that of the untreated positive control (cp-induced group) was 30.7 ± 1.13 million/ml of semen. the decrease in sperm count observed after administration of cp was reversed dose-dependently by treating with different doses of speman® (300, 600, and 900 mg/kg). the sperm count was 36.9 ± 1.39, 40.6 ± 0.72, and 42.4 ± 1.07 million/ml in animals from groups 3, 4, and 5, respectively, illustrated in: figure 1: effect of speman® on sperm count in an experimental model of cp-induced oligospermia in rats. increase in sperm count was found to be statistically significant compared to the positive control. decrease in weight of seminal vesicles, unilateral epididymis, prostate, and gonads due to the administration of cp was reversed dose-dependently by treating with different doses of speman®. increase in weight in all tested doses was found to be statistically significant compared to the positive control group (figures 2–5, links below). figure 2: effect of speman® on the absolute weight of seminal vesicle in an experimental model of cp-induced oligospermia in rats. figure 3: effect of speman® on the absolute weight of unilateral epididymis in an experimental model of cp-induced oligospermia in rats. figure 4: effect of speman® on absolute weight of prostate in an experimental model of cp-induced oligospermia in rats. figure 5: effect of speman® on the absolute weight of gonads in an experimental model of cp-induced oligospermia in rats. the histopathological report (see table 1) states that treatment with speman® dose-dependently decreased the mean lesion score of testes, prostate, epdidymis, and seminal vesicles. table 1: results of the histopathological evaluation of the accessory reproductive organs following speman® treatment in rats with cp-induced oligospermia organs lesions normal control positive control speman® (300 mg/kg) speman® (600 mg/kg) speman® (900 mg/kg) testes interstitial oedema 1.67 ± 0.21 2 ± 0.63 2 ± 0 1.5 ± 0.22 2.4 ± 0.24 tubular degeneration 3.17 ± 0.31 3 ± 0 1.6 ± 0.25 2.2 ± 0.66 prostate epithelial thinning 4 ± 0 3 ± 0.52 1.8 ± 0.37 1.25 ± 0.32 epididymis epithelial proliferation 1.83 ± 0.48 1.67 ± 0.21 1.5 ± 0.22 1.0 ± 0 seminal vesicle degeneration 2 ± 0.32 1.5 ± 0.29 2 ± 0.58 2 ± 0.52 severity score: minimal: 1 (very small amount of changes ≤ 10%); mild: 2 (lesion is easily identified with limited severity 11%–25%); moderate: 3 (lesion is predominant 26%–75%); severe: 4 (degree of changes is 76%–100%, that is, great enough in intensity or extent to expect significant tissue or organ dysfunction. discussion in the present study, cp was used to induce oligospermia in rats. cp is a cytotoxic alkylating agent used in the treatment of neoplasia and autoimmune disorders. its cytotoxic effects are the result of chemically-reactive metabolites that alkylate dna and proteins, producing cross-links.14 it affects rapidly-dividing cells and damages the highly proliferative testis. thus, the use of this drug for treatment of neoplasia in male patients increases the incidence of oligospermia and azoospermia resulting in male infertility.15 animal studies have revealed that treatment of rats/mice with cp leads to transitory oligospermia, decreased testicular weight, dna synthesis in spermatogonia, protein synthesis in spermatids, and biochemical and histological alterations in the testis and epididymis.16-18 the precise mechanism by which cp causes testicular toxicity is unknown. however, numerous studies have shown that exposure to cp can disrupt the redox balance of tissues, suggesting that biochemical and physiological disturbances may result from oxidative stress.19-21 the beneficial effects of speman® granules in cp-induced oligospermia are due to the synergistic action of the various herbs used in the formulation of speman®. most of the herbs present in this formulation have been reported to have a beneficial effect on the male reproductive organs—mucuna pruriens reduces stress and improves the quality of semen in infertile men22; argyreia nervosa is known for its aphrodisiac property23; asteracantha longifolia and hygrophila spinosa are reported to improve sexual behavior and reproductive function in male rats24,25; tribulus terrestris ameliorates the testicular development of immature albino rats.26 conclusion from the findings reported here, it can be concluded that speman® is effective in increasing sperm count and weight of sex organs like gonads, seminal vesicles, prostate, and epididymis in rats with cp-induced oligospermia. treatment with speman® showed dose-dependent and significant reversal of the cp-induced changes under the testing conditions and doses employed. acknowledgements the authors are thankful to dr. gopumadhavan, toxicology department, r& d centre, the himalaya drug company for his help in carrying out enumeration of sperms and also acknowledge the work of dr. jayashree b keshav and team (scientific publications division of the himalaya drug company) in terms of editing and proofreading the article. conflict of interest the formulation of speman® was received from formulation research and development (f & d) division, r & d center, the himalaya drug company, bangalore. no formal funding from any agencies was used for this project, however all the experiments were conducted in department of pharmacology, r & d center, the himalaya drug company, bangalore. the authors declare no conflict of interest. references 1. templeton a. infertility-epidemiology, aetiology and effective management. health bull (edinb). 1995;53(5):294–298. http://www.ncbi.nlm.nih.gov/pubmed/7490200 2. haslett c, chilvers er, boon na, colledge na. davidson’s principles and practice of medicine. edinburgh: churchill livingstone, 2002:711. 3. pramanik d. principles of physiology. kolkata: academic publishers; 2007:370–374. 4. agarwal vk, mittal pc. clinical studies with speman in cases of benign enlargement prostate. probe. 1969; 9:153–156. http://indianmedicine.eldoc.ub.rug.nl/root/a/375 5. vyas jn, bhattachariya dd, bhandari jr. sexual potency disorders of the male: a clinical trial. probe. 1970; 9:149–153. 6. bhatnagar vb. therapy of the enlarged prostate with speman. probe. 1973; 6:29. http://himalayahealthcare.com/pdf_files/speman008.pdf 7. khaleeluddin k, suresh r, santpur rajaram p. clinical trials in cases of oligozoospermia with speman. probe. 1973; xii(4):203. http://www.himalayahealthcare.com/pdf_files/speman038.pdf 8. kunaiah pp. role of speman and speman forte in oligozoospermia. probe. 1966; 5:49. http://www.himalayahealthcare.com/pdf_files/confido017.pdf 9. mukherjee m. male sterility. probe. 1973; 4(xii):201–202. http://himalayahealthcare.com/pdf_files/speman037.pdf 10. jadhav ss, bhaga hs. effect of tentex forte and speman individually and in combination on gonadal structure in rats. j indian med prof. 1971; 18:8055. http://himalayahealthcare.com/pdf_files/tforte010.pdf 11. subbarao vv, gupta ml, arora hl. effect of speman on the testes – a histological study. probe. 1973; 6:21. http://www.himalayahealthcare.com/pdf_files/tforte011.pdf 12. das ub, mallick m, debnath jm, ghosh d. protective effect of ascorbic acid on cyclophosphamide-induced testicular gametogenic and androgenic disorders in male rats. asian j androl. 2002; 4:201–7. http://www.ncbi.nlm.nih.gov/pubmed/12364977 13. matsumoto s, hirakawa m, shimomoto t, sato m, kitaura k, minami t. collaborative work to evaluate toxicity on male reproductive organs by repeated dose studies in rats: effects of a single oral dose of cyclophosphamide. j toxicol sci. 2000; 25:139–43. http://www.ncbi.nlm.nih.gov/pubmed/11349437 14. dollery c. therapeutic drugs. edinburgh: churchill livingstone; 1999:349–54. 15. howell s, shalet s. gonadal damage from chemotherapy and radiotherapy. endocrinol metab clin north am. 1998; 27:927–943. http://www.ncbi.nlm.nih.gov/pubmed/9922915 16. meistrich ml, parchuri n, wilson g, kurdoglu b, kangasniemi m. hormonal protection from cyclophosphamide-induced inactivation of rat stem spermatogonia. j androl. 1995; 16:334–341. http://www.ncbi.nlm.nih.gov/pubmed/8537251 17. anderson d, bishop jb, garner rc, ostrosky-wegman p, selby pb. cyclophosphamide: review of its mutagenicity for an assessment of potential germ cell risks. mutat res. 1995; 330:115–181. http://www.ncbi.nlm.nih.gov/pubmed/7623863 18. kaur f, sangha gk, bilaspuri gs. cyclophosphamide-induced structural and biochemical changes in testis and epididymidis of rats. indian j exp biol. 1997; 35:771–775. http://www.ncbi.nlm.nih.gov/pubmed/9418379 19. ghosh d, das ub, ghosh s, mallick m, debnath j. testicular gametogenic and steroidogenic activities in cyclophosphamide treated rat: a correlative study with testicular oxidative stress. drug chem toxicol. 2002; 25:281–292. http://www.ncbi.nlm.nih.gov/pubmed/12173249 20. manda k, bhatia al. prophylactic action of melatonin against cyclophosphamide-induced oxidative stress in mice. cell biol toxicol. 2003; 19:367–372. http://www.ncbi.nlm.nih.gov/pubmed/15015761 21. abraham p, rabi s. protective effect of aminoguanidine against cyclophosphamide-induced oxidative stress and renal damage in rats. redox rep. 2011; 16(1):8–14. http://www.ncbi.nlm.nih.gov/pubmed/21605493 22. shukla kk, mahdi aa, ahmad mk, jaiswar sp, shankwar sn, tiwari sc. mucuna pruriens reduces stress and improves the quality of semen in infertile men. ecam. 2010; 7(1):137–144. http://www.ncbi.nlm.nih.gov/pubmed/18955292 23. subramoniam a, madhavachandran v, ravi k, anuja vs. aphrodisiac property of the elephant creeper argyreia nervosa. j endocrinol reprod. 2007; 2(11):82–85. http://srbce.org/jer2007/subramoniametal.pdf 24. nagendra sc, vikas s, dixit vk. effect of asteracantha longifolia seeds on the sexual behavior of male rats. nat prod res. 2011; 25(15):1423–1431. http://www.tandfonline.com/doi/abs/10.1080/14786410802588493 25. sahoo ak, bhushan g. effect of hygrophila spinosa t. on reproductive function of male albino rats. jcim. 2010; 7(1):1553–3840. http://www.degruyter.com/view/j/jcim.2010.7.1/jcim.2010.7.1.1246/jcim.2010.7.1.1246.xml 26. bashir a, tahir m, samee w, munir b. effects of tribulus terrestris on testicular development of immature albino rats. biomed. 2009; 25:63–68. http://www.thebiomedicapk.com/articles/149.pdf cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. metagenomic analysis of koumiss in kazakhstan samat kozhakhmetov1, indira tynybayeva1, dinara baikhanova2, saule saduakhasova1, gulnar shakhabayeva1, almagul kushugulova1, talgat nurgozhin1, zhaxybay zhumadilov1 1center for life sciences, nazarbayev university, astana, kazakhstan; 2eurasian national university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.163 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kozhakhmetov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.163 | http://cajgh.pitt.edu abstract introduction. koumiss is a low-alcohol product made from fermented mare's milk, which is popular in kazakhstan, russia, and other countries of central asia, china, and mongolia. natural mare's milk is fermented in symbiosis of two types of microorganisms (lactobacteria and yeast). koumiss’s microbial composition varies depending on the geographical, climatic, and cultural conditions. based on a phenotypic characteristic from samples, wu, r. and colleagues identified the following bacteria isolated in inner mongolia, an autonomous region of china: l.casei, l.helveticus, l.plantarum, l.coryniformis subsp. coryniformis, l.paracasei, l.kefiranofaciens, l.curvatus, l.fermentum, and w.kandleri. studies of the yeast composition in koumiss also showed significant variations. thus, there were saccharomyces unisporus related 48.3% of isolates, to kluyveromyces marxianus (27.6%), pichia membranaefaciens (15.0%), and saccharomyces cerevisiae (9.2%) from 87 isolated yeast cultures. the purpose of this study was to examine the bacterial composition in koumiss. methods. to extract dna, 1.8 ml of fermented milk was centrifuged to generate a pellet, which was suspended in 450 µl of lysis buffer p1 from the powerfood microbial dna isolation kit (mobio laboratories inc, usa). amplification of the microflora was used to determine the composition of a fragment of the gene 16s rrna and its1. plasmid library with target insertion was obtained on the basis of height copy plasmid vectors producing high pgem-t. the definition of direct nucleotide sequencing was performed by the method of sanger using a set of "bigdye terminanor v 3.1 cycle sequencing kit with automatic genetic analyzer abi 3730xl (applied biosystems, usa). informax vector nti suite 9, sequence scanner v 1.0 software package used for the analysis. results. our studies showed that in the most samples of koumiss isolated from akmola region (central kazakhstan) prevailed the following bacteria species: lactobacillus diolivorans, lactobacillus acidophilus, l. casei, l. curvatus yeast genus torula (62.4%) and saccharomyces cerevisiae (37.6%). conclusion. thus, the first metagenomic research of koumiss, which was conducted in kazakhstan, showed significant variations in microbial composition. keywords: fermentation, lactobacteria, dna sequencing, kazakhstan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. transplantation of cultivated fibroblasts on a backing of xenogenic tissue in the treatment of wounds kabylbek abugaliyev1, ogay vyacheslav2, danlybayeva gaziza2, miras karzhauov2, akhmadeyeva zhansaya2, anuar zhaikenov1 1republican scientific center for emergency care, astana, kazakhstan; 2national center for biotechnology, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.143 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ abugaliyev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.143 | http://cajgh.pitt.edu abstract introduction. trophic ulcers are a common health problem, and there are numerous treatment methods. irreversible damage in the skin, subcutaneous tissue, and fascia with long-term ulcer existence make standard autotransplantation inneffective. skin grafts are often complicated by partial or complete rejection of skin flaps. the aim of this study was to examine the feasibility of using transplanted cultivated allogenic fibroblasts on the backing of a cellularless xenogenic fabric for wound healing. methods. transplantation of cultured embryonic fibroblasts on a backing of xenogenic tissue was used in the complex treatment of trophic ulcers for stimulation of regenerative processes. decellularization xenogenic film was previously held. then allogenic fibroblasts were cultivated on the surface of collagen-elastin matrix. since 2013, we treated 12 patients with giant ulcers caused by the following: lymphedema (2 patients), vascular disease (3 patients), diabetes (2 patients), after injury (4 patients), and radiation ulcer (1 patient). dimensions of ulcers were from 150 to 600 cm2. duration of the lower limb ulcers ranged from 8 months to 10 years. for a number of years, all patients were on a complex therapy, which had not resulted in healing wounds. during the operation when excision of granulation tissue was performed, plastic wounds perforated with the ratio 1:2 autoskin. xenogenic fabric with cultured fibroblasts was applied on top. in this case, xenogenic film protected the skin from drying, created optimal microclimate, and cultured fibroblasts stimulating regeneration and improving engraftment. results. the first redress was held on the fifth day. in all cases, the results of engraftment skin grafts achieved maximum possible (100%) and optimal (90%). complete epithelialization of the cell perforation was seen in five patients on the fifth day and three on seventh day after skin plastics. average period of inpatient treatment was 20.7 days. all patients were discharged with healed wounds. conclusion. thus, the treatment of trophic ulcers can be successfully solved using advances in biotechnology. transplantation of cultivated allogenic fibroblasts on a backing of cellularless xenogenic fabric shows good clinical results due to the stimulation of regenerative processes and creates the optimum environment for autotransplants. keywords: transplantology, tissue engineering, fibroblasts http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx whole genome sequencing of m.tuberculosis in kazakhstan: preliminary data new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. whole genome sequencing of m.tuberculosis in kazakhstan: preliminary data ulykbek kairov1, ulan kozhamkulov1, saule rakhimova1, ayken askapuli1, maxat zhabagin1, venera bismilda2, leyla chingissova2, zhaxybay zhumadilov1, ainur akilzhanova1 1center for life sciences, nazarbayev university, astana, kazakhstan; 2national center for problems of tuberculosis, almaty, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.121 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kairov this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.121 | http://cajgh.pitt.edu abstract background: tuberculosis is a major public health problem which infects one third of the world’s population, resulting in more than two million deaths every year. the emergence of whole genome sequencing (wgs) technologies as a primary research tool has allowed for the detection of genetic diversity in mycobacterium tuberculosis (mtb) with unprecedented resolution. wgs has been used to address a broad range of topics, including the dynamics of evolution, transmission, and treatment. to our knowledge, studies involving wgs of kazakhstani strains of m. tuberculosis have not yet been performed. aim: to perform whole genome sequencing of m. tuberculosis strains isolated in kazakhstan and analyze sequence data (first experience and preliminary data). results: in the present report, we announce the whole-genome sequences of the two clinical isolates of mycobacterium tuberculosis, mtb-489 and mtb-476, isolated from the almaty region. these strains were part of a repository that was created during our project “creating prerequisites of personalized approach in the diagnosis and treatment of tuberculosis, based on whole genome-sequencing of m. tuberculosis”. two strains were isolated from sputum samples of patients p1 and p2. phenotypically, two isolates were drug-susceptible m. tuberculosis. sequence data was compared with the publicly available data on m. tuberculosis laboratory strain h37rv and others. the sequencing of the strains was performed on a roche 454 gs flx+ next-generation sequencing platform using a standard protocol for a shotgun genome library. the whole genome sequencing was performed for two m.tuberculosis isolates mtb-476 and mtb-489. 96 m bp with an average read length of 520 bp, approximately 21.8x coverage and 104.2 m bp with an average read length of 589 bp and approximately 23.7x coverage were generated for the mtb-476 and mtb-489, respectively. the genome of mtb-476 consists of 257 contigs, 4204 cds, 46 trnas and 3 rrnas. mtb-489 has 187 contigs, 4183 cds, 45 trnas and 3rrnas. conclusion: the results of genome assembling have been submitted into ncbi genbank and are available for public access under the accession numbers azba00000000 and azaz00000000. these genome assemblies can be useful for comparative genome analysis and for identification of novel snps and gene variants in genomes of m.tuberculosis. keywords: tuberculosis, genome sequencing, kazakhstan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx influence of probiotic consortium on th1 and th2 immune response new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. influence of probiotic consortium on th1 and th2 immune response gulnara shakhabayeva, almagul kushugulova, saule saduakhasova, samat kozhakhmetov, zhanagul khasenbekova, indira tynybayeva, talgat nurgozhin, zhaxybay zhumadilov center for life sciences, nazarbayev university, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.122 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ shakhabayeva this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.122 | http://cajgh.pitt.edu abstract introduction: the main role of probiotics is to maintain homeostasis in the intestines and improve bowel protective function. the aim of the present study is to investigate immuno-modulatory effects of a probiotic consortium. methods: observations were carried out in vitro. the presence of il-2, il-4, il-6, il-8, il-10, tnf-α, ifn-γ, iga, igm, and ige was studied using a solid-phase enzyme immunosorbent assay on the vector-best sets (russia). results: immunomodulatory properties of the probiotic consortium were studied, which consisted of the following strains: streptococcus thermophilus, lactococcus lactis, lactobacillus plantarum, lactobacillus fermentum, lactobacillus acidophilus, bifidobacterium longum, and bifidobacterium bifidum. elevated concentrations of infγ in control samples decreased 3.9 times (p < 0.05) after a saturation of blood with the probiotic consortium. significant reduction of cytokine levels after the probiotic effects of the consortium was observed in il-10 by 2.1 times (p < 0.05) and iga by 1.87 times (p < 0.0005). there was a significant increase in the levels of il-4, ige, il-6, and il-8 by 1.3 (p < 0.005), 1.1 (p < 0.5), 18.0 (p < 0.005), and 6 (p < 0.05) times, respectively, in comparison with the control samples. il-4 and infγ have different effects on the synthesis of ige. soluble low affinity receptors fcεrii (cd23) in association with il-4 facilitate a differentiation of the b-lymphocytes in igesynthesizing cells, while γ-inf inhibits this process. it is known that the intracellular expression of γ-inf and il-4 is the most reliable marker for th1 and th2 immune responses, respectively. the conducted studies determined that the ratio of inf-γ/il-4 was 0.9 (control 4.8, p < 0.005) after the saturation of the blood cells with probiotic consortium. nf-γ/il4 ratio decreased by 5.3 times compared with a control value, which indicates a reduction in the functional activity of th1 type lymphocytes in comparison with the function of th2 cells. conclusion: the application of the probiotic consortium results in the maintenance of homeostasis by the stimulation of immune function through the activation of humoral immunity. moreover, the probiotic application changes the orientation of the immunological memory causing the cancellation of the recruitment of th1 cells in the response. keywords: probiotics, immune response, immunity http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx why does kazakhstan need new scientific journals? why does kazakhstan need new scientific journals? shalkar adambekov1, galiya dosmukhambetova2, gani nygymetov2, ronald laporte3, faina linkov4 1center for life sciences, nazarbayev university, astana, kazakhstan; 2center for international programs, astana, kazakhstan; 3department of epidemiology, university of pittsburgh, pittsburgh, pa; 4magee-womens research institute, university of pittsburgh, pittsburgh, pa editorial kazakhstan is young country located in the heart of the eurasian continent. it was an integral part of the soviet union until 1991 and was primarily known for oil, mining, agriculture, as well as nuclear bomb testing. during the soviet era, kazakhstan underwent industrialization and the country's economy shifted from purely agricultural to partially industrial. to provide cadre for the new industries, a large number of educational and scientific institutions were established; however, most of the scientific research was concentrated in the european part of the soviet union and was heavily government controlled.1 scientific developments were moscow-oriented. kazakhstani scientists published almost exclusively in russian language journals and periodicals. as a result of this scientific isolation, kazakhstani scientists were not known outside of the former ussr region, which became evident after kazakhstan gained its independence. currently, kazakhstan is seeking integration into the international scientific arena, which is one of the goals of the 2050 development strategy. as part of this strategy, kazakhstan is aiming to develop a knowledge and innovation-based economy in addition to harnessing its rich mineral and oil resources. governmental attention is focused on the modernization of kazakhstani research, pushing scientific innovation and producing competition by establishing new universities, schools, and research centers. in addition, a governmental scholarship program is established in kazakhstan, which is responsible for training young specialists in the world's leading universities. the financing of the science sector is constantly increasing, albeit the portion of gdp spent on r&d is less than 0.25%, compared with an average 1.7% in developed countries.2 the transition from a resource-based economy to a science-oriented state is slow, and requires passing many important milestones. one of the most important benchmarks in establishing a knowledge based economy is achieving competitive scientific productivity. the currency of scientific productivity is articles published in internationally recognized, english-language journals, which are available to a wide readership. in the past 25 years, kazakhstan transitioned from being part of an industrialized country in the soviet era to a developing country in 1990s, and is now a developed country in the 2010s. this creates an unique public health environment with an ongoing epidemiologic transition,3 coupled with the double burden of chronic and infectious diseases. excess morbidity and mortality associated with tuberculosis4 and increasing life expectancy take place in parallel. it makes kazakhstan an interesting model for public health and medical research. there are a number of prominent medical research centers in almaty, astana, and karaganda that are equipped to address these problems; we can hypothesize that kazakhstan can potentially produce interesting and relevant research. however, according to the bibliographic database scopus, only around 7% of articles published by kazakhstani scientists were in the areas of medicine and public health. it does not mean that kazakhstani specialists produce less research in this area, but they evidently publish less in international journals. the exact reasons for this discrepancy are not known, but one might hypothesize that major reasons include a lack of english language skills, training in research methodology, and the aforementioned scientific isolation, which is especially relevant for conservative medical workers. this trend is not unique for kazakhstan, but for all of central asian countries. whereas most post-soviet countries are spread between 50th and 100th place in the list of countries according to the number published documents, central asian countries such as uzbekistan, kazakhstan, kyrgyzstan, tajikistan and turkmenistan are in 82nd, 94th, 143rd, 148th, and 183rd places, respectively. despite a large number of general and specialized journals kazakhstan and central asia represent a blank spot on the scientific publishing map. figure 1: the total number of publications for 13 former soviet union countries for 1996-2012 the situation with english language and research methodology can be solved by modern education, workshops, and training courses. however the problem of scientific isolation is not that easily fixed. in the absence of recognized authors and institutions, the question of research credibility is crucially important. it is usually difficult to publish research if one does not have an established name supporting one's manuscript, which is a problem for kazakhstan authors. to solve this situation, two major approaches can be applied. the first is to establish international collaboration and hire foreign professors; such is the case, for example, of nazarbayev university a newly established kazakhstani university based on the western standards of education and research. the second approach is to train the next generation of researchers in countries that have high publication rates, which is the primary mission of the "bolashak" scholarship. the third approach is to establish a platform for publishing research from kazakhstan and central asia, such as the establishment of a new scientific journal. if one examines the statistics, countries such as the us and the uk own the top 20 highest h index ranking journals. overall, among 20,544 journals referenced in scopus, 5,605 are of us origin and 5,036 are published in uk. thus, 50% of all scientific documents indexed in scopus are published in these countries. to be successful, the new journal must follow a simple rulebe an english language, peer-reviewed journal, but be primarily focused on the central asian research community to avoid the "credibility" problem. the central asian journal of global health (cajgh.pitt.edu) has been developed in collaboration between experts at nazarbayev university and the university of pittsburgh with the goal of ending scientific isolation and allowing kazakhstan scientists to publish their research discoveries in an english language medium. in conclusion, kazakhstan is a progressively developing country aimed to become a regional power through the establishment of a diversified economy based on knowledge and innovation. however, to achieve this, kazakhstan needs to overcome several barriers, one of which is the scientific isolation that resulted from being part of the russian oriented science system. establishing english language peer-reviewed journals is a one way of tackling this problem and could help emerging kazakhstani scientists make significant contributions to the international scientific arena. references graham lr. science in russia and the soviet union: a short history. cambridge: cambridge university press; 1993. unesco science report 2010. 2010. accessed november 26, 2013. omran ar. the epidemiologic transition: a theory of the epidemiology of population change. 1971. the milbank quarterly. 2005;83(4):731-757. terlikbayeva a, hermosilla s, galea s, et al. tuberculosis in kazakhstan: analysis of risk determinants in national surveillance data. bmc infect dis. 2012;12:262. prevalence of obesity among bangladeshi pregnant women at their first trimester of pregnancy new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. prevalence of obesity among bangladeshi pregnant women at their first trimester of pregnancy shatabdi goon nutrition and food engineering department, daffodil international university, dhanmondi, dhaka, bangladesh vol. 2, no. 2 (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu abstract background: paradoxically, the escalating global epidemic of maternal obesity coexists with malnutrion in many areas of bangladesh. this proves a major challenge to obstetric practice from preconception to postpartum due to related comorbid conditions including: maternal death or severe morbidity, gestational diabetes and hypertension, increased risk of early and recurrent miscarriage, pre-eclampsia, thromboembolism, post-caesarean wound infection, postpartum haemorrhage, and low breastfeeding rates. a dramatic increase in birth defects and other pregnancy-induced disorders related to maternal obesity has added millions of dollars to health care costs leading great economical loss to the country. objective: the study was designed to determine the prevalence of obesity among bangladeshi pregnant women in their 1st trimester of pregnancy. study design: 426 pregnant women presenting to the antenatal care until of azimpur maternity hospital of dhaka, bangladesh were randomly selected for this cross sectional study to determine their weight status using body mass index (bmi, kg/m2). result: 90 (21.2%) pregnant women were reported as obese with pregnancy bmi of >30 kg/m2. 171 (40.1%) and 140 (32.8%) pregnant women were reported as overweight and healthy with pregnancy bmi of 25-29.9 kg/m2 and 18.5-24.9 kg/ m2, respectively. statistical analysis revealed obesity and overweight status were found to be significantly associated with age; women aged 31 or above were more likely to be obese (or=2.5; 95% ci 1.53–3.96) and overweight (or=3.3; 95% ci 2.15– 4.99). conclusion: this study provides evidence of increasing trends in obesity among bangladeshi pregnant women, which poses possible health risks both for mother and child. the findings of this study may act as baseline data for monitoring the effectiveness of national programs for the prevention and control of maternal obesity. keywords: obese pregnant, first trimester, adverse pregnancy outcome, body mass index, neonatal health, maternal health prevalence of obesity among bangladeshi pregnant women at their first trimester of pregnancy shatabdi goon nutrition and food engineering department, daffodil international university, dhanmondi, dhaka, bangladesh research maternal obesity and related comorbid conditions have serious impact on the health and development of obese women's offspring. the incidence of maternal obesity at the start of pregnancy is increasing worldwide. 1 international studies show a prevalence of maternal obesity ranging from 1.8% to 25.3% across countries. 2 approximately 50% of pregnant women have a body mass index (bmi) >25 kg/m. 2,3 nearly two-thirds of reproductive-age women in the united states (u.s.) are currently overweight or obese, placing them at elevated risk for adverse health outcomes. 4 the recent national health and nutrition examination survey (nhanes) found that in the united states, more than 50% of pregnant women are overweight or obese and 8% of reproductive-aged women are extremely obese. 5 in 2009, 26% of adult, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu reproductive-age, u.s. women were classified with a bmi ≥30 kg/m 2 . 6 compared to developed countries, maternal obesity is less of an epidemic in developing ones; however, bangladeshi women of reproductive age have shown a trend of increasing bmi. 7 a survey conducted among this subpopulation found obesity prevalence increased from 2.7% to 8.9% between 1996 and 2006. 7 in comparison, the prevalence of maternal obesity in the united states ranged from 13.9% to 25.1% between 2004 and 2005. 8 current institute of medicine guidelines, published in 1990, recommend that all women can expect to gain one or two kilograms in their first trimester of pregnancy, but additional weight gain above is considered excessive. 9 in recent years, excessive weight gain has led to increased obesity prevalence among pregnant women, resulting in maternal and fetal health complications. maternal obesity carries significant risks for the mother and fetus with increased health risks to the mother during the antenatal, intrapartum, and postnatal periods. 10-13 excess accumulation of adipose tissue within the abdominal cavity, or visceral obesity, among obese, pregnant women has been associated with a cluster of metabolic alterations, which includes: insulin resistance, hyperinsulinemia, elevated triglyceride levels, low hdl cholesterol, and hypertension. 14,15 evidence from both animal and human studies indicates that maternal obesity 1) increases the risk for offspring to develop obesity, 2) alters body composition in childand adulthood, and 3) impacts the offspring's cardiometabolic health with dysregulation of metabolism, including: insulin homoeostasis, development of hypertension, and vascular dysfunction. 16 maternal obesity is associated with increased odds of neural tube defects, 17-22 spina bifida, 17 cardiovascular anomalies, 23 and high mortality rate. reynolds et al. found that offspring of obese mothers have an increased risk of hospital admission for a cardiovascular event (or=1.29; 95% ci 1.06-1.57) compared with offspring of mothers with normal bmi. 24 first trimester maternal obesity has significantly increased over time, having more than doubled from 7.6% to 15.6% since 1994, 25 resulting in lost pregancies and birth defects 26 that occur during embryogenesis. overweight and obese women have larger anatomic depots of adipose tissue in all compartments, resulting in different metabolic adaptations. 27 obese women are more likely to develop gestational diabetes, 28,29 high blood pressure, 30-33 and proteinuria 34-37 after 20 weeks of pregnancy, which promote preeclampsia. 38,39 compared with normal weight women (bmi < 25 kg/m 2 ), a recent meta-analysis of 20 studies demonstrated that the or of developing gestational diabetes was 2.14 (95% ci 1.82– 2.53), 3.56 (95% ci 3.05–4.21), and 8.56 (95% ci 5.07–16.04) among overweight (bmi: 25-30 kg/m 2 ), obese (bmi > 30 kg/m 2 ), and severely obese women (bmi > 40 kg/m 2 ), respectively. 29 obesity among pregnant women has also been linked to poorer cognitive performance, higher incidence of autism spectrum disorders, and more attention deficithyperactivity disorder (adhd) in their children. increased bmi is associated with increased rates of midline vertical incision, longer operative time, urinary tract infections, 40 stillbirths and fetal death, 41-44 lower rates of subcuticular skin closure, 45 and caesarean delivery. 46 a meta-analysis of 33 studies showed that the odd ratio (or) of cesarean delivery were 1.46 (95% ci 1.34–1.60), 2.05 (95% ci 1.86–2.27), and 2.89 (95% ci 2.28–3.79) among overweight, obese, and severely obese women, respectively, compared with normal weight pregnant women. 10,11,47,48 also in a recent metaanalysis, a bmi ≥ 25 was found to be associated with miscarriage, regardless of mode of conception (or=1.67; 95% ci 1.25–2.25). 49 obesity increases the risk of preterm delivery, 50 (a leading cause of infant mortality, morbidity, and long-term disability). 51 these risks increase with decreasing gestational age. 52 obese women are at increased risk of thrombosis as well as delivering an infant significantly larger than average (macrosomia). 46,53,54 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu evidence shows that a child of an obese mother may suffer from exposure to a suboptimal in utero environment and that early life adversities may extend into adulthood. 55 being obese during pregnancy might increase the risk that the baby will develop heart disease or diabetes as an adult. research suggests that obesity during pregnancy slightly increases the risk of having a baby who's born with a birth defect, 3 such as heart problems or conditions affecting the brain or spinal cord. 19 higher maternal bmi at first prenatal hospital visit is associated with increased risk of prolonged pregnancy and increased rate of induction of labor. 56 maternal obesity offers an altered genetic, hormonal, and biochemical environment for the developing fetus/embryo and influences fetal growth and organ development. 57 compared with neonates born to women of normal weight, neonates born to women with bmis ≥40 (severely obese) were at increased risk of birth injury to the peripheral nervous system, birth injury to the skeleton, respiratory distress syndrome, bacterial sepsis, convulsions, and hypoglycemia. 58 increased maternal bmi is associated with categorical and continuous reductions in the proliferative index and a continuous reduction in the apoptotic index. 59 obese women are also less likely to initiate and sustain breastfeeding. 60 women who are obese during pregnancy might be at increased risk of a potentially serious sleep disorder in which breathing repeatedly stops and starts. sleep apnea occurring in this group of women may further complicate anesthetic management and postoperative care. 61 helping women understand the risks associated with obesity and working with them to develop strategies to decrease their risk is a challenge for both the patient and the healthcare provider. the objective of this study was to evaluate the prevalence of maternal obesity among bangladeshi pregnant women. methods study design this cross-sectional study was carried out at azimpur maternity hospital, dhaka, bangladesh between may and june 2013. a total of 450 urban, pregnant women in their first trimester of pregnancy were selected by systemic random process by approaching every 2 nd woman attending to prenatal care clinic. after approaching potential participants, 426 pregnant women (94.6%) agreed to participate. 24 pregnant women refused consent. verbal, informed consent was obtained from all study subjects per the bangladesh medical research council. inclusion/ exclusion criteria women were approached to participate in this investigation if they were currently in their first trimester of pregnancy and attending the prenatal care clinic of azimpur maternity hospital. women were exluded from analysis if they had a history of hypertension, diabetes, or spontaneous abortions. thus, 426 pregnant women were enrolled and included in analysis. data collection participants completed questionnaires providing information about age, month of pregnancy, and education status. age was stratified into 4-year categories: <20 years, 21-25 years, 26–30 years, and >30 years. all demographic information was collected via face-to-face interview. body mass index (bmi) (kg/m 2 ) was calculated based on clinically assessed weight (kg) and height (m) at baseline. the current analysis considered only the baseline measurements, as there was no notable change with regard to bmi during the follow up across the trials. who definitions were used to categorize women as normal weight (bmi: 18.5– 24.9), overweight (bmi: 25–29.9), and obese (bmi: 30+). substantial weight gain typically does not occur http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu during the first trimester of pregnancy, therefore anthropometric measurements taken at baseline were compared to prepregnancy measurements found in the patients’ medical records. no significant differences were found between the two measurements therefore no patients were excluded. weight and height were measured by pre-defined procedure using a standard weight scale and measuring tape. statistical analysis considering an expected obesity prevalence of 50% and using a confidence level of 95% the sample size of the cross-sectional study was calculated as 450 using the following formula: n = t² * p(1-p) m² data were analyzed using ibm spss ® statistics version 15.0. 62 descriptive statistics were used for demographic information and chi-squared tests were used to test significance of associations between age and bmi. results this paper presents the weight status (determined by bmi) in a sample of bangladeshi pregnant women at their first trimester of pregnancy. 426 women were interviewed and examined. the mean age of the selected pregnant women was 27.13 ± 5.38(mean ± sd). 66 (15.5%) pregnant women were <20 years of age, 114 (26.8%) 21-25 years of age. 108 (25.4%), 26-30 years of age, and 138 (32.3%) were >30 years. 90 (21.2%) and 171 (40.1%) pregnant women were classified as obese or overweight with pregnancy. 140 (32.8%) pregnant women were normal weight. table 1 shows the distribution of this sample by age and bmi level. table 1. distribution of respondents by age and bmi level. figure one illustrates the prevalence of overweight (40.1%) and obese (21.2%) participants in this sample. figure 1: distribution of respondents by bmi level. among obese women, 48.9% were aged 31 or above. additionally, approximately 48% of overweight women were aged of 31 or above. women aged 31 years or above were more likely to be obese (or=2.5; 95% ci 1.53–3.96) and overweight (or=3.3; 95% ci 2.15–4.99). the correlation between age and bmi level was found to be significant, as shown in table 2 (p=0.01). table 2: unadjusted or for selected age (30 or above) by bmi category. obesity was detected among 21.2% of participants. those aged 31 years or above showed significantly higher prevalence (x 2 =14.18, p<0.05). overweight was detected among 40.1% of participants and those aged 31 years or above showed significantly higher prevalence (x 2 =31.58, p<0.05). table 3 illustrates the distribution of respondents according to weight status. table 3: distribution of respondents according to the presence or absence of specific weight status. discussion http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu we determined the prevalence of obesity among a sample of 426 pregnant, bangladeshi women who visited azimpur maternity hospital in dhaka, bangladesh between may and june 2013. approximately 40% of pregnant women were identified as overweight in their first trimester of pregnancy, whereas 21.2% were identified as obese. these findings mirror those of other literature. for example, fattah et al. showed an obesity prevalence of 19% in a study of 1,000 caucasian pregnant women. 63 another study, conducted on pregnant women receiving maternal care in bangladesh, showed an obesity prevalence of 23%. 64 furthermore, a retrospective cohort study including 8,176 pregnant women showed an obesity prevalence of 17.7%, 35 lastly, a cohort study of 4,830 patients with gestational diabetes (gdm) showed an obesity prevalence of 15.7%, 65 flegal et al. showed the prevalence of obesity among us women of 35.8% in 2009-2010. 5 while the centre for maternal and child enquiries published that more than 1 in 20 pregnant women in us are severely obese, 66 this is one of the first studies that has been conducted in bangladesh to evaluate the current data on maternal obesity. in most cases, bangladeshi women are considered malnourished during their gestational period, but this study has revealed pregnant, bangladeshi women have relatively high prevalence of overweightness and obesity. though this study was conducted only among bangladeshi urban women, weight status of rural pregnant women could be different considering socio-demographical condition. as a developing country, bangladesh has struggled with the burden of malnutrition; however, these new findings of obesity prevalence among pregnant bangladesh women point to the possibility that obesity point to the possibility of obesity becoming an increasing problem to the bangladeshi healthcare system. previously, pregnant, bangladeshi women typically participated in moderate household work, but with the extension of civilization, women are becoming dependent on modern technologies to cope with their daily work needs, decreasing their amount of daily, physical activity. as a result, obesity has more prevalent among this group. economic, technologic, and lifestyle changes have created an abundance of cheap, high-calorie food coupled with a decrease in required physical activity, promoting excessive weight gain among this group. research suggests that as age increases, hormonal changes and decreased physical activity increases the risk of obesity. in this study, obesity was more prevalent among women aged 31 or more. approximately 48.9% of obesity cases were found in women aged 31 years or higher. overweightness was also higher among women aged 31 years or higher (48% of the sample). other investigators showed that bmi increases with increasing maternal age. 50 our study corroborates these findings, with a positive correlation between maternal age and bmi status (p=0.01). the risks of obesity in the first trimester are primarly pregnancy loss and birthday defects that occur during embryogenesis. studies show that the risks of early miscarriage, and recurrent early miscarriage were significantly higher among obese patients. 67 the evidence is fairly clear that obesity is significantly associated with increased risk of pregnancy complications, ranging from miscarriage to problems later in pregnancy. studies in genetically identical rodents convincingly show that maternal obesity, as well as elements of a hypercaloric diet, can permanently influence offspring risk of obesity, and these findings are also supported by studies in larger mammals. 68 our findings highlight overweight and obesity as an important public health issue. this study had several limitations. first, we only evaluated the weight status of bangladeshi pregnant women corresponding to find out the prevalence of maternal obesity, not the maternal and fetal outcome associated with the prevalence of obesity among those pregnant women. unless evaluating the pregnancy outcome, it will not be able to determine the overall risk associated with maternal obesity. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu considering this issue, the next step of this study will be to follow up respondents up to their delivery, and further research should evaluate the adverse pregnancy outcome associated with the maternal obesity. second, data other than anthropometric measurements were selfreported, and the study is cross-sectional, which does not infer causal relationships. lastly, we examined only one maternity hospital located in dhaka, bangladesh, so caution should be taken to generalize the data for other maternity hospitals and locations. conclusion the current study presented evidence for high rates of obesity among pregnant, bangladeshi women in their first trimester of pregnancy. babies born to obese mothers are more likely to be obese, develop diabetes, and have high blood pressure later in life, indicating that this issue not only affects the current generation, but may have long term implications in terms of quality of life and healthcare costs, among others. new strategies are needed to re-formulate existing obesity prevention and treatment programs by incorporating information on a healthy diet and lifestyle to produce holistic health and wellness interventions. considering the high prevalence of obesity in females of reproductive age group in bangladesh, this study emphasizes a strong need for pre-pregnancy advice about weight loss in these women before conception as even minimal weight loss can lead to better perinatal outcomes. references 1. heslehurst n, ells l, simpson h, batterham a, wilkinson j, summerbell c. trends in maternal obesity incidence rates, demographic predictors, and health inequalities in 36,821 women over a 15-year period. bjog. 2007;114(2):187-194. 2. guelinckx i, devlieger r, beckers k, vansant g. maternal obesity: pregnancy complications, gestational weight gain and nutrition. obes rev. 2008;9(2):140-150. 3. callaway l, prins j, chang a, mcintyre h. the prevalence and impact of overweight and obesity in an australian obstetric population. med j aust. 2006;184(2):56-59. 4. hillemeier m, weisman c, chuang c, downs d, mccall-hosenfeld j, camacho f. transition to overweight or obesity among women of reproductive age. j womens health (larchmt). 2011;20(5):703-710. 5. flegal k, carroll m, kit b, ogden c. prevalence of obesity and trends in the distribution of body mass index among us adults, 1999-2010. jama. 2012;307(491-497). 6. centers for disease control and prevention. state-specific prevalence of obesity among adults — united states, 20092010. 7. balarajan y, villamor e. nationally representative surveys show recent increases in the prevalence of overweight and obesity among women of reproductive age in bangladesh, nepal, and india. j nutr. 2009;139(11):2139-2144. 8. chu s, kim s, bish c. prepregnancy obesity prevalence in the united states, 2004-2005. matern child health j. 2009;13(5):614-620. 9. institute of medicine. nutrition during pregnancy. part i, weight gain. washington, dc, 1990. 10. sebire n, jolly m, harris j, et al. maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in london. int j obes relat metab disord. 2001;25(8):1175-1182. 11. cedergren m. maternal morbid obesity and the risk of adverse pregnancy outcome. obstetrics and gynecology. 2004;103(2):219-224. 12. aimukhametova g, ukybasova t, hamidullina z, et al. the impact of maternal obesity on mother and neonatal health: a study in a tertiary hospital of astana, kazakhstan. nagoya j med sci. 2012;74(1-2):83-92. 13. voigt m, straube s, zygmunt m, krafczyk b, schneider k, briese v. obesity and pregnancy-a risk profile. z geburtshilfe neonatol. 2008;212(6):201-205. 14. adult treatment panel iii. third report of the national cholesterol education program http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu (ncep) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel iii) final report2002. 15. arner p. differences in lipolysis between human subcutaneous and omental adipose tissues. ann med. 1995;27:435-438. 16. drake a, reynolds r. impact of maternal obesity on offspring obesity and cardiometabolic disease risk. reproduction. 2010;140(3):387-398. 17. watkins m, rasmussen s, honein m, botto l, moore c. maternal obesity and risk for birth defects. pediatrics. 2003;111(5 pt 2):11521158. 18. blomberg m, kallen b. maternal obesity and morbid obesity: the risk for birth defects in the offspring. birth defects res a clin mol teratol. 2009;88(1):35-40. 19. shaw g, velie e, schaffer d. risk of neural tube defect-affected pregnancies among obese women. jama. 1996;275(14):1093-1096. 20. werler m, louik c, shapiro s, mitchell a. prepregnant weight in relation to risk of neural tube defects. jama. 1996;275(14):1089-1092. 21. rasmussen s, chu s, kim s, schmid c, lau j. maternal obesity and risk of neural tube defects: a metaanalysis. am j obstet gynecol. 2008;198(6):611-619. 22. watkins m, scanlon k, mulinare j, khoury m. is maternal obesity a risk factor for anencephaly and spina bifida? epidemiology. 1996;7(5):507-512. 23. fraser a, tilling k, macdonald-wallis c, et al. association of maternal weight gain in pregnancy with offspring obesity and metabolic and vascular traits in childhood. circulation. 2010;121(23):2557-2564. 24. reynolds r, allan k, raja e, et al. maternal obesity during pregnancy and premature mortality from cardiovascular event in adult offspring: follow-up of 1,323,275 person years. bmj. 2013;347:f4539. 25. straughen j, trudeau s, misra v. changes in adipose tissue distribution during pregnancy in overweight and obese compared with normal weight women. nutr diabetes. 2013;3:e84. 26. roman h, robillard p, hulsey t, et al. obstetrical and neonatal outcomes in obese women. west indian med j. 2007;56(5):421426. 27. heslehurst n, rankin j, wilkinson j, summerbell c. a nationally representative study of maternal obesity in england, uk: trends in incidence and demographic inequalities in 619 323 births, 1989-2007. int j obes (lond). 2010;34(3):420-428. 28. hedderson m, williams m, holt v, weiss n, ferrara a. body mass index and weight gain prior to pregnancy and risk of gestational diabetes mellitus. am j obstet gynecol. 2008;198(4):409. 29. chu s, callaghan w, kim s, et al. maternal obesity and risk of gestational diabetes mellitus. diabetes care. 2007;30(8):20702076. 30. alanis m. maternal super-obesity (body mass index > or = 50) and adverse pregnancy outcomes. acta obstet gynecol scand. 2010;89(7):924-930. 31. cedergren m. effects of gestational weight gain and body mass index on obstetric outcome in sweden. int j gynaecol obstet. 2006;93(3):269-274. 32. athukorala c, rumbold a, willson k, crowther c. the risk of adverse pregnancy outcomes in women who are overweight or obese. bmc pregnancy childbirth. 2010;10:56. 33. mandal d, manda s, rakshi a, dey r, biswas s, banerjee a. maternal obesity and pregnancy outcome: a prospective analysis. j assoc physicians india. 2011;59:486-489. 34. mcintyre h, gibbons k, flenady v, callaway l. overweight and obesity in australian mothers: epidemic or endemic? med j aust. 2012;196(3):184-188. 35. kerrigan a, kingdon c. maternal obesity and pregnancy: a retrospective study. midwifery. 2010;26(1):139-146. 36. nucci l, schmidt m, duncan b, fuchs s, fleck e, santos britto m. nutritional status of pregnant women: prevalence and associated pregnancy outcomes. rev saude publica. 2001;35(6):502-507. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu 37. abrams b, parker j. overweight and pregnancy complications. int j obes. 1988;12(4):293-303. 38. kumari a. pregnancy outcome in women with morbid obesity. int j gynaecol obstet. 2001;73(2):101-107. 39. o'brien t, ray j, chan w. maternal body mass index and the risk of preeclampsia: a systematic overview. epidemiology. 2003;14(3):368-374. 40. usha kiran t, hemmadi s, bethel j, evans j. outcome of pregnancy in a woman with an increased body mass index. bjog. 2005;112(6):768-772. 41. kristensen j, vestergaard m, wisborg k, kesmodel u, secher n. pre-pregnancy weight and the risk of stillbirth and neonatal death. bjog. 2005;112(4):403-408. 42. nohr e, bech b, davies m, frydenberg m, henriksen t, olsen j. prepregnancy obesity and fetal death: a study within the danish national birth cohort. obstetrics and gynecology. 2005;106(2):250-259. 43. tennant p, rankin j, bell r. maternal body mass index and the risk of fetal and infant death: a cohort study from the north of england. hum reprod. 2011;26(6):1501-1511. 44. conner s, verticchio j, tuuli m, odibo a, macones g, cahill a. maternal obesity and risk of postcesarean wound complications. am j perinatol. 2013. 45. sheiner e, levy a, menes t, silverberg d, katz m, mazor m. maternal obesity as an independent risk factor for caesarean delivery. paediatr perinat epidemiol. 2004;18(3):196201. 46. ehrenberg h, mercer b, catalano p. the influence of obesity and diabetes on the prevalence of macrosomia. am j obstet gynecol. 2004;191(3):964-968. 47. smith g, shah i, pell j, crossley j, dobbie r. maternal obesity in early pregnancy and risk of spontaneous and elective preterm deliveries: a retrospective cohort study. am j public health. 2007;97(1):157-162. 48. weiss j, malone f, emig d, et al. obesity, obstetric complications and cesarean delivery rate--a population-based screening study. am j obstet gynecol. 2004;190(4):1091-1097. 49. metwally m, ong k, ledger w, li t. does high body mass index increase the risk of miscarriage after spontaneous and assisted conception? a meta-analysis of the evidence. fertil steril. 2008;90(3):714-726. 50. leung t, leung t, sahota d, et al. trends in maternal obesity and associated risks of adverse pregnancy outcomes in a population of chinese women. bjog. 2008;115(12):15291537. 51. nohr e, vaeth m, bech b, henriksen t, cnattingius s, olsen j. maternal obesity and neonatal mortality according to subtypes of preterm birth. obstetrics and gynecology. 2007;110(5):1083-1090. 52. cnattingius s, villamor e, johansson s, et al. maternal obesity and risk of preterm delivery. jama. 2013;309(22):2362-2370. 53. kamanu c, onwere s, chigbu b, aluka c, okoro o, obasi m. fetal macrosomia in african women: a study of 249 cases. arch gynecol obstet. 2009;279(6):857-861. 54. bowers d, cohen w. obesity and related pregnancy complications in an inner-city clinic. j perinatol. 1999;19(3):216-219. 55. poston l, harthoorn l, van der beek e, contributors to the ilsi europe workshop. obesity in pregnancy: implications for the mother and lifelong health of the child. a consensus statement. pediatr res. 2011;69(2):175-180. 56. arrowsmith s, wray s, quenby s. maternal obesity and labour complications following induction of labour in prolonged pregnancy. bjog. 2011;118(5):578-588. 57. tenenbaum-gavish k, hod m. impact of maternal obesity on fetal health. fetal diagn ther. 2013. 58. koch l. obesity: effect of maternal obesity on neonatal outcomes. nat rev endocrinol. 2013. 59. higgins l, mills t, greenwood s, cowley e, sibley c, jones r. maternal obesity and its effect on placental cell turnover. j matern fetal neonatal med. 2013;26(8):783-788. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu 60. li r, jewell s, grummer-strawn l. maternal obesity and breast-feeding practices. am j clin nutr. 2003;77:931-936. 61. maasilta p, bachour a, teramo k, polo o, laitinen l. sleep-related disordered breathing during pregnancy in obese women. chest. 2001;120:1448-1454. 62. spss for windows [computer program]. version 15.0. chicago: spss inc.; released 2006. 63. fattah c, farah n, barry s, o'connor n, stuart b, turner m. maternal weight and body composition in the first trimester of pregnancy. acta obstet gynecol scand. 2010;89(7):952955. 64. akter j, shahjahan m, hossain s, chowdhury h, ali l. prevalence and determinants of overweight and obesity among diabetic women of reproductive age attending a tertiary care hospital in bangladesh. 65. yogev y, langer o. pregnancy outcome in obese and morbidly obese gestational diabetic women. eur j obstet gynecol reprod biol. 2008;137(1):21-26. 66. boseley s. more than one in 20 pregnant women severely obese. the guardian. december 7, 2010, 2010. 67. lashen h, fear k, sturdee dw. obesity is associated with increased risk of first trimester and recurrent miscarriage: matched casecontrol study. human reproduction (oxford, england). jul 2004;19(7):1644-1646. 68. poston l. maternal obesity, gestational weight gain and diet as determinants of offspring long term health. best pract res clin endocrinol metab. 2012;26(5):627-639. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu table 1: distribution of respondents by age and bmi level. age total under weight normal (healthy weight) overweight obesity 426 25(5.9%) 140(32.8%) 171(40.1%) 90(21.2%) <20 66(15.5%) 25(100%) 24(17.1%) 10(5.8%) 7(7.8%) 21-25 114(26.8%) 0 79(56.4%) 23(13.5%) 12(13.3%) 26-30 108(25.4%) 0 25(17.8%) 56(32.7%) 27(30%) ≥31 138(32.3%) 0 12(8.7%) 82(48%) 44(48.9%) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu table 2: unadjusted or for selected age (≥30) by bmi category. total overweight (bmi 25-29.9 kg/m 2 ) obese (bmi >30 kg/m 2 ) or(95% ci) or(95% ci) 261 n=171 3.3; 2.15-4.99 n=90 2.5 ;1.53-3.96 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu table 3: distribution of respondents according to the presence or absence of specific weight status. character present/ absent <20 years 21-25 26-30 ≥31 statistical values obesity present 7 (7.8%) 12 (13.3%) 27 (30%) 44 (48.9%) x 2 =14.18, p<0.05 absent 59 (17.5%) 102 (30.4%) 81 (24.1%) 94 (28%) overweight present 10 (5.8%) 23 (13.5%) 56 (32.7%) 82 (48%) x 2 =31.58, p<0.05 absent 56 (21.9%) 91 (35.7%) 52 (20.4%) 56 (22%) normal weight present 24 (17.1%) 79 (56.4%) 25 (17.9%) 12 (8.6%) x 2 =54.03, p<0.05 absent 42 (14.7%) 35 (12.2%) 83 (29.0%) 126 (44.1%) underweight present 25 (100%) 0 0 0 x 2 =12.73, p<0.05 absent 0 117 (29.2%) 108 (26.9%) 138 (43.9%) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goon this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, no. 2 (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.70 | http://cajgh.pitt.edu figure 1: distribution of respondents by bmi level. 0 20 40 60 80 100 underweight normal overweight obesity 5.9 32.8 40.1 21.2 underweight normal overweight obesity http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx current impact, future prospects and implications of mobile healthcare in india new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. current impact, future prospects and implications of mobile healthcare in india rishi kappal1,2, amit mehndiratta3,4, prabu anandaraj5, athanasios tsanas4 1mindactiv consulting, pune, india; 2mit school of telecom management, pune, india; 3center for biomedical engineering, indian institute of technology, delhi, india; 4institute of biomedical engineering and keble college, university of oxford, united kingdom; 5school of medical science and technology, indian institute of technology, kharagpur, india vol. 3, no. 1 (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kappal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu abstract india has a diverse geographical landscape and predominately rural population. telemedicine is identified as one of the technological pillars to support healthcare services in this region, but is associated with high cost and complex infrastructure, thus restricting its wider use. mobile-based healthcare (m-health) services may provide a practical, promising alternative approach to support healthcare facilities. india has a high mobile user base, both in cities and in rural regions. the appropriate identification of mobile data transmission technology for healthcare services is vital to optimally use the available technology. in this article, we review current telecommunication systemsin india, specifically the evolving consensus on the need for cdma (code division multiple access a wireless technology used by leading international and national operators. this technology is deployed in 800mhz band making it economically viable and far reaching with high quality of services) to continue its operations in india along with mobile healthcare services. we also discuss how healthcare services may be extended using mhealth technologies, given the availability of telecommunications and related services. keywords: telemedicine, m-health, telecommunication, mobile healthcare current impact, future prospects and implications of mobile healthcare in india rishi kappal1,2, amit mehndiratta3,4, prabu anandaraj5, athanasios tsanas4 1mindactiv consulting, pune, india; 2mit school of telecom management, pune, india; 3center for biomedical engineering, indian institute of technology, delhi, india; 4institute of biomedical engineering and keble college, university of oxford, united kingdom; 5school of medical science and technology, indian institute of technology, kharagpur, india perspective introduction india is the home to 1.24 billon people with a predominantely rural population. 1 geographically, india’s landscape is diverse, with both mountainous and seafront regions. furthermore, a large percentage of the population resides in villages who often have limited access to direct provision of primary healthcare services. due to these challenges, the healthcare system is primarily managed by the government and complemented by various private healthcare institutes. delivering medical services to remote areas is extremely intensive and often not viable for private healthcare providers. while the government is primarily responsible for general healthcare, approximately 69% of the population has inadequate access to most health resources. 2 the number of public health facilities is also insufficient. for instance, india needs over 74,000 community health centers (chc) per one million people, but it currently has approximately half that http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu number. 3 approximately 80% of total healthcare expenditure in the country is accounted for by those who see private healthcare providers; however, 70% of the healthcare infrastructure focuses almost exclusively on metropolitan cities. there is an impending need for innovation to maximize outreach and provide healthcare services to a wider population, primarily those in rural areas. the indian government has launched multiple projects to facilitate healthcare services in rural regions. 4 telemedicine, one such project, may be able to facilitate the providing of vital healthcare services, even to the most remote parts of india. telemedicine, by use of wireless technologies, will ensure that medical facilities are available to people in locations where physical healthcare facilities may be difficult to contruct, even in the most remote parts of india. over the last ten years, the indian government, along with private healthcare providers, has invested considerable research efforts and resources exploring the possibility of providing medical services and healthcare education to rural areas using telemedicine technology. 4,5 this article has three main foci of discussion. first, we address the current telecommunication environment in india, mobile technology, and services enabling m-health. second, we review published manuscripts, government reports, mobile healthcare provider’s web links, and publicly available articles on telecommunication and healthcare. the impact of telecommunication technology while considering the fate of m-health in india is also highlighted. third, we detail recommendations on which m-health services can empower india at large. telecommunication services in india in india, m-health services are subject to regulators’approval based on governmental guidelines. these services are not owned by any particular industry, so the first step in setting standard operating procedures is done by the government. 6 the telecommunication industry (mobile and internet services) has grown exponentially in the last ten years, from under 37 million users in 2001 to over 846 million users in 2011. 7 india also has the world's second-largest wireless phone user base, of which 37% are rural subscribers. 8 the urban states are hyper-dense with a tele-density (defined as the number of telecommunication facilities per one hundred individuals) of 154%, while rural india has a tele-density of only 40%. 8 table 1 shows the rural and urban distribution of telecommunication services in india in 2012. 8 table 1. total wireless users and tele-density in india with urban and rural distribution as of september 2012. as of september 2012, approximately 50% of total wireless users have access to data services and the internet. 9 however, of the 446 million data enabled users that can potentially access the internet on their phone, only 79 million actually use the function. 9 there are many services available on mobile phones; however, not every mobile phone operator is informed of these services. while some operators activate data services by default with each connection, the gap between data ready phones and actively used data connections is wide due to the lack of education on the utility of such devices. this provides a sizeable window of opportunity to educate and connect rural india to receive m-health services. figure 1 depicts the status of wireless data technologies deployed in india, which gives the breadth of state-of-the-art telecommunications led data technology available for use. wireless data technology deployment has lagged in india compared to global figures, but has succeeded by providing readily available, well-tested devices and services. in addition to existing broadand narrow-band data technologies, facilitated by robust devices and services ecosystem, mhttp://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kappal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu health and telemedicine initiatives need only faster, economic services deployment and ownership by telecom ecosystem contributors in order to succeed. figure 1. the trend of wireless technology (data speed) deployment in india and worldwide from 1996 to 2012. table 2 reflects the time lag of technology deployment and also maps the coverage of various wireless data technologies launched in india. general packet radio service (gprs) and enhanced data for global evolution (edge) are narrowband technologies only available pan india. the available wireless technology across the nation is code division multiple access (cdma), enhanced by voice-data optimized (evdo) reva and revb. this ecosystem of evdo can be further enhanced to deliver last mile broadband connectivity, especially since the technology is deployed in the 850mhz spectrum. this provides the possibility of low capex (capital expenditure) technology deployment and unmatched in-building coverage and penetration, making it viable for semiurban and rural m-health/telemedicine applications. although these wireless technologies could help mhealth services deploy in a more efficient manner, cdma and evdo technology subscribers have declined in india. the cost of acquiring patients and services for deployment can be adequately managed with cdma/evdo services and devices. since multiple operators already have a passive infrastructure in each semi-urban town/village, the deployment of telecommunication is viable. this could save almost 30% capex for operators and make m-health services deployment more cost effective. 10 table 2. technological details of current telecommunication services and its launch in india. why should technology matter for m-health? stable and cost-effective technology for mhealth: cdma, evdo, gsm (gprs and edge), and high speed packet access (hspa) are very stable technologies that are proven globally for various data transmission processes using mobile phones and other data access devices, like usb dongles. cdma, evdo, and gsm (gprs and edge) could be the most cost effective wireless technologies to be used in healthcare deprived areas of india. these technologies are more available, have the ability to connect most of the states, and incur very low cost to the end user (<$2 per month). hspa technology could provide a higher bandwidth for large data transmission by facilitating advanced healthcare services; however, it is not available in all areas of india and is expensive. the spectrum band of 2100mhz, in which hspa is deployed in india, is a viable constraint, and available in only the 5mhz spectrum in 3g, a further bottleneck. lte td (long-term evolution, timedivision duplex) technology is still not deployed in india, particularly because most mobile devices are not equipped to support it. lte td rollout obligations are long standing and are offered in 2300mhz, making it capex intensive (e.g., rollout of this technology is much more expensive as compared to rollout of wireless technology in lower frequency spectrums such as 700mhz and 800mhz frequency bands) and too far from reaching rural areas, leading to a low return on deployment. choosing the appropriate technology is an integral part for m-health services to reach the wider population in india. it is clear from the speeds and distances supported by these technologies that sms based mhealth applications can be supported in all wireless frameworks. the choice of technology depends on the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu amount of data one needs to share between patient and doctor. radiological images, vital statistics analyses, and single or multi-dimension data may require high data transmission protocols like evdo and hspa. m-healthservices available in india in india, some of the mobile services providers have already initiated m-heath consultations. for example, airtel (a leading mobile service provider in india) has formed a collaboration with healthfore (a division of religare technologies) and fortis healthcare (a religare group company) to offer mediphone services to its mobile users. 11 by using this service, users are able to access basic medical guidance regarding non-emergency health problems over the phone. the service is available 24hrs a day for < $1 per consultation. 11 other telecommunication service providers launched similar services in 2011 in collaboration with healthnet global, a hyderabadbased emergency and healthcare management services firm. 12 paramedical staff equipped with laptops, with high speed wireless technology, and medical diagnostic equipment consult with remotely located physicians using video conferencing and offer guidance to mobile phone users calling for healthcare advice. 12 in december 2011, equitas micro finance also launched a tele-healthcare delivery center in association with healthnet global. 13 equitas provides services such as “consult 4 health and call 4 health,” allowing its members to consult with apollo hospital physicians over video for approximately $1 per consultation. 13,14 the subject's data may be stored for further assessment, treatment, and subsequent follow-ups. other new models in m-health are also emerging, like a mumbaibased service called meradoctor (my doctor) founded in 2010. 15 this service provides healthcare consultation over the phone to its members. the basic package of meradoctor costs approximately $17 per month per user (rs 1000 pm). another example is “3nethra” from a bangalore-based forus health. 16,17 “3nethra” is a portable, non-invasive device, which could help in the early diagnosis of eye diseases such as cataract, diabetic retina, glaucoma and cornea related issues. 16,17 the digital information captured by “3nethra” can be easily transmitted electronically for analysis and consultation from experts at tertiary center hospitals located far from the screening center. india landscape: basic m-health using wireless technology the most prolific and efficient technologies are between the spectrum band of 850mhz (cdma) and 900mhz (gsm) for india. some healthcare services that can be provided using this platform include: 1. sms consulting: increased access to mobile phones has led to the development of sms services that connect users, allowing exchange of vital information and expert opinions in near real-time. this simple format allows users to ask time-sensitive questions anonymously to gain insight on potentially sensitive subjects. concise information is easily spread, while being timely and conserving mobile battery. 2. e-education on healthcare matters: mobile services can be used to broadcast useful healthcare-related information to a wide population. the development of faster mobile networks and improved device technology allows for an unprecedented level of quality content to be streamed and viewed. this enables access to the web’s entire library of video tutorials, how-to program, virtual classrooms, peer-to-peer chat on health tips, etc. users can learn appropriateand home care techniques like first aid and up-to-date medical information. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kappal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu 3. do it yourself (diy) check-ups: it provides self screening tutorials like oral hygiene, insulin syringe injections, preparation of ors (oral rehydration solutions) for dehydration treatment, breast feeding techniques, or even self breast examinations for mass or tumours. 4. improve drug compliance by mobile alert system: this program improves patient monitoring and drug compliance. one of the successful examples is multi drug therapy (mdt) for tuberculosis. this therapy must be administrated for 6 to 8 months and the failure rate for mdt is considerably high due to poor patient compliance. 18,19 recent studies by barcaly 18 and kunawararak 19 et al. have shown that the treatment success rate could improved to over 90% by setting up an automated reminder to patients for drug either by sms or a call. india landscape: advanced m-health using wireless narrowband and broadband technology the evdo rev a and rev b networks deployed by cdma operators are the most efficient alternative for data intensive healthcare applications like real time patient consulting or tele-radiology. due to the lack of device ecosystem of cdma in india, hspa+ might be the next best alternative available. the potential use of evdo and hspa technology in facilitating healthcare services are elaborated in table 3. table 3. the potential use of evdo and hspa technology in facilitating healthcare services. it is unclear as to which entities within the telecom ecosystem will take the lead in facilitating an m-health solutionon the telecom network, encompassing medical experts for service delivery and making services reach the wider population in india, as well as determining billing mechanisms. advanced m-health solutions for chronic diseases in addition to tele-consultation, m-health might be useful in providing more advanced services to patient in the form of diagnosis and monitoring of diseases. research has demonstrated that mobile technology can provide the means for accurately monitoring symptom and severity for diverse pathologies, including diabetes, coronary artery disease, and parkinson’s disease. diabetic monitoring according to the international diabetes federation, india has the largest patient burden for diabetes mellitus, with approximately 50.8 million nationwide cases. 20 the prevalence of diabetes varies between 6 to 8% in the urban population and 2 to 3% in the rural population. 20 mobile phone-based diabetic monitoring is currently in research and development. many mobile applications have been developed to regularly record blood glucose in order to achieve a healthy lifestyle. 21,22 patients can keep a record of their blood glucose on a mobile phone, and their levels can be sent to a physician through data protected mobile services. this simple, self-collected process may alleviate individuals from frequent physical visits to the clinic for glucose testing. the mobile application might also provide useful analysis tools based on previous blood glucose measures of the patient. thus, a patient can now self-monitor his or her diabetes and plan an appointment with a physician only when required. this could be a very cost effective example of personalized mobile-based healthcare facility. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu coronary artery disease and remote ecg monitoring there are around 45 million patients in india with coronary artery disease (cad); one-fifth of all deaths are caused by cad. 20 at the current rate, it is expected that cad will account for almost one-third of the total deaths by 2020. 20 in cad management, it is important to regularly monitor the patient’s cardiac function, which involves regular visits with medical experts to perform an electrocardiography (ecg) examination. regular ecgs can be a lifesaving procedure since it can indicate when patient might be at risk for myocardial infarction. smartheart devices are designed to record the 12-lead ecg and can transmit securely encrypted data to a mobile phone. 23 the ecg signal may then be transmitted to a central processing unit at the patient’s hospital, where the medical team can assess and advise appropriate further action. telemonitoring of parkinson’s disease using speech signals parkinson’s disease (pd) is a neurodegenerative disorder affecting the central nervous system. current prevalence of pd in india is approximately 3 million (diagnosed cases) and could be an additional 11 million undiagnosed cases according to a pd statistics report. 24 it is possible to record various trademark pd characteristics (such as limb tremor) via dedicated devices to remotely assess symptom severity. 25 however, many of these devices (e.g. accelerometers) are expensive and require careful placement to obtain reliable data. recent research has shown the potential of using speech signals both to differentiate pd subjects from healthy controls 26 and also for telemonitoring pd symptom severity. 27 this aspect does not involve the use of specialized equipment, and the data is very easy to self-collect. hence, someone using a mobile phone and a simple voice recording system could have direct access to an objective assessment of pd symptom severity. 28 then, medical experts might provide guidance on optimizing pharmacological treatment. potential for growth a recent report entitled "global telemedicine market analysis" by rncos industry research solutions, 30 an india-based market research and information analysis company, projects that the global telemedicine market will grow at a compound annual growth rate (cagr) of around 19% from 2010 to 2015. an earlier report in 2009, titled “global telemedicine market: 2008-2012” published by infiniti research, 31 a london-based market intelligence firm, estimated the size of the global telemedicine market in 2008 at $9 billion. according to another report by the university of pennsylvania, asia is the fastest growing region for the telemedicine market, with india and china leading the growth. 29 the current size of the telemedicine market in india is difficult to be accurately estimated. murali rao, associate vice president for healthcare at the new delhi–based research and consultancy firm technopak advisors, estimates the current size of the indian telemedicine market to be around $7.5 million, 29 suggesting “this is expected to grow at a [compound annual growth rate] of 20% over the next five years”, or approximately $18.7 million by 2017. mehta of pwc on the other hand notes: “studies indicate that the size of india's telemedicine market is expected to be $500 million us by 2015.” 29 challenges remain and options available various challenges still remain in the telemedicine market in india, despite the fact that telemedicine is gaining popularity around india. choice of wireless technology: cdma evdo is a technology well-positioned to leverage m-health http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kappal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu and telemedicine solutions. however, with availability of other technologies, cdma operators are returning precious spectrum back to government 32 and not contesting for more cdma spectrum. this, in effect, will make cdma dormant, and m-health solutions on hspa will not be as cost effective. secondly, for wireless led healthcare, data networks should be stable and promise a ubiquitous experience across geographies. this, again, is compromised due to the overpriced and patchy hspa spectrum presently and lack of investment continuity on hspa from operators, since the existing investment awaits returns. moreover, no operator has a pan india hspa presence. the available 2.3ghz lte spectrum in india is a very capex intensive setup to deploy. the lte spectrum is on lte tdd, which is less popular globally. lte network owners restrict themselves to only the top 10 to 20 cities. in this scenario, it is important that a more cost effective wireless technology be launched in rural india. if the government allowed more cdma/evdo spectrum to be available to operators at an affordable price (in india, spectrum price is decided by the government), this would encourage operators to deploy a more affordable wireless technology to reach rural areas in india. doctor-patient relationship: mutual trust between patient and their doctor is important and is benefitted by the physical presence of both. in telemedicine or m-health services, a virtual world might assist establishing a doctor-patient relationship. the potential of m-health in india is still under-realized because the lack of awareness among the population and lack of an appropriate service providing model. this would require an initiative from government agencies and private healthcare providers. in effect, m-health services will not be successful until doctors are more enthusiastic and market m-health as the most cost effective mode for providing quality healthcare in india. well-recognized leaders in semi-urban and rural indian states need to use telemedicine solutions. this will reduce perceived risk of relationships with other populations in the near vicinity. also, projects like gramjyoti 33 (launched by ericsson india in collaboration with a large medical institute to demonstrate the benefits and use of 3g based telemedicine services in rural india) should be encouraged, in which the larger community sees delivery of a physical service through the virtual world. strengthening of ecosystem and its awareness: the indian telecom and medical ecosystem has limitations dependent on regulators, technology providers, technology deployment agencies, content providers, device developers, sales, and marketing companies. with so many factors, lack of ownership is imminent since each ecosystem partner will have to make sizeable investments. the telecomservice providers and patients need to be defined, facilitated, and executed. this, combined with technology and affordable devices, will be the tipping point. all parts of the telecom ecosystem must coexist to make a deployment solution mechanism. standardization of solutions: in m-health, the accountability of error needs to be examined when more service providers enter the domain. standardization will lead to seamless adoption by relevant agencies and ensure timely upgrades so as to avoid redundant services. india’s partnering with global telecom standardization agencies like itu-t and 3gpp/3gpp2 should develop telemedicine and healthcare service standardization authorities to lend a common approach to the partners at large. reducing cost: the cost of m-health delivery still remains a challenge; however, it is expected that initiation of pan india government funded projects might reduce the cost and increase the benefit of the technology. also, by using cdma as technology of choice, capital expenditure and operational expenditure optimization will lead to lesser cost of service delivery. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu acknowledgement authors would like to thank the keble college at university of oxford, united kingdom for its support. references 1. india: world development indicators. 2012. http://data.worldbank.org/country/india. accessed october 27, 2014. 2. chandramouli c. census of india 2011: rural urban distribution of population (provisional population totals). 2011. http://censusindia.gov.in/2011-provresults/paper2/data_files/india/rural_urban_2011.pdf. accessed october 27, 2014. 3. park k. park's textbook of preventive and social medicine. 20 ed: banarsidas bhanot publishers; 2009. 4. mishra sk, kapoor l, singh ip. telemedicine in india: current scenario and the future. telemed j e health. 2009;15(6):568-575. 5. ganapathy k. telemedicine and neurosciences in developing countries. surg neurol. 2002;58(6):388-394. 6. bedi bs. telemedicine standards: need and indian initiatives. telemed j e health. 2009;15(6):597-599. 7. telecom india. http://www.imaginmor.com/telecomindia. accessed october 27, 2014. 8. telecom regulatory authority of india. performance indicators report september 2012. 2012; http://www.trai.gov.in/content/performanceindicatorsreports. aspx?id=1&qid=1. accessed october 27, 2014. 9. internet & mobile association of india. mobile internet in india. http://www.iamai.in/. accessed october 27, 2014. 10. gsm association. mobile infrastructure sharing. 2012; http://www.gsma.com/publicpolicy/wpcontent/uploads/2012/09/mobile-infrastructure-sharing.pdf. accessed october 27, 2014. 11. airtel. mediphone. http://www.airtel.in/mediphone/. accessed october 27, 2014. 12. healthnet global. healthnet global. http://www.healthnetglobal.webs.com/aboutus.htm. accessed october 27, 2014. 13. microfinance. equitas microfinance clients to get tele healthcare. 2011; http://www.aboutmicrofinance.com/microfinance-newsupdates/equitas-microfinance-clients-to-get-tele-healthcare. accessed october 27, 2014. 14. india infoline. apollo introduces tele medicine centers in association with healthnet global. http://www.indiainfoline.com/markets/news/apollo-introducestele-medicine-centers-in-association-with-healthnetglobal/5320976738. accessed october 27, 2014. 15. meradoctor. http://www.meradoctor.com/. accessed october 27, 2014. 16. forus. 3nethra. http://forushealth.com/forus/3nethraclassic.html. accessed october 27, 2014. 17. global commercialization group. 3nethra ophthalmology device. http://www.ic2.utexas.edu/global/techbriefs/opthalmology-device/. accessed october 27, 2014. 18. barclay e. text messages could hasten tuberculosis drug compliance. the lancet. 2009;373(9657):15-16. 19. kunawararak p, pongpanich s, chantawong s, et al. tuberculosis treatment with mobile-phone medication reminders in northern thailand. southeast asian j trop med public health. 2011;42(6):1444-1451. 20. new cardiabcare. http://neocardiabcare.com/alarmingstatistics-india.htm. accessed october 27, 2014. 21. university of florida health. top-rated diabetes apps. http://diabetes.ufl.edu/my-diabetes/diabetesresources/diabetes-apps/. accessed october 27, 2014. 22. webicina. diabetes in social media. http://www.webicina.com/diabetes/diabetes-on-mobile/. accessed october 27, 2014. 23. shl telemedicine. smartheart. 2014; http://www.shltelemedicine.co.uk/portfolio/smartheart/. accessed october 27, 2014. 24. healthgrades. statistics by country for parkinson's disease. http://www.rightdiagnosis.com/p/parkinsons_disease/statscountry.htm#extrapwarning. accessed october 27, 2014. 25. patel s, lorincz k, hughes r, et al. monitoring motor fluctuations in patients with parkinson’s disease using wearable sensors. ieee trans inf technol biomed. 2009;13(6):864-873. 26. tsanas a, little ma, mcsharry pe, spielman j, ramig lo. novel speech signal processing algorithms for high-accuracy classification of parkinson’s disease. ieee trans inf technol biomed. 2012;59(5):1264-1271. 27. tsanas a, little ma, mcsharry pe, ramig lo. nonlinear speech analysis algorithms mapped to a standard metric http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kappal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu achieve clinically useful quantification of average parkinson’s disease symptom severity. j r soc interface. 2011;8(59):842855. 28. tsanas a. acoustic analysis toolkit for biomedical speech signal processing: concepts and algorithms. 8th international workshop on models and analysis of vocal emissions for biomedical applications (maveba); 2013. 29. knowledge @ wharton university of pennsylvania. can telemedicine alleviate india's healthcare problems? 2012; http://knowledge.wharton.upenn.edu/india/article.cfm?articleid =4675. accessed october 27, 2014. 30. market research.com. rncos. http://www.marketresearch.com/rncos-v3175/. accessed october 27, 2014. 31. infiniti research limited. global telemedicine market 2008-2012. 2008; http://www.researchandmarkets.com/reports/888692/global_te lemedicine_market_20082012. accessed october 27, 2014. 32. the economic times. tata teleservices to surrender excess spectrum in all circles barring delhi, mumbai 2013. 2013; http://articles.economictimes.indiatimes.com/2013-0417/news/38616482_1_2-5-mhz-one-time-spectrum-feeadditional-spectrum. 33. gram jyoti. http://gramjyoti.org. accessed september 22, 2013. 34. gsm association. gprs (general packet radio service). http://www.gsma.com/aboutus/gsm-technology/gprs. accessed june 17, 2013. 35. cellular news. http://www.india-cellular.com/news-janmar-2002.html. accessed june 17, 2013. 36. gsm association. edge. http://www.gsma.com/aboutus/gsm-technology/edge. accessed june 17, 2013. 37. aditya birla group. idea. http://www.ideacellular.com/wps/wcm/connect/aboutus/idea/in fo/history. accessed june 17, 2013. 38. prashant p. cellular service: edge it's got a long way to go. 2004; http://www.voicendata.com/voicedata/news/162697/cellular-service-edge-its-got-a-long-way-togo. accessed june 17, 2013. 39. cdg. cdma history. http://www.cdg.org/resources/cdma_history.asp. accessed june 17, 2013. 40. tata photon. tata teleservices ltd. http://www.tataphoton.com/about-us.aspx. accessed june 17, 2013. 41. tata teleservices. tata group in communications. http://www.tatateleservices.com/t-aboutus-ttslorganization.aspx. accessed june 17, 2013. 42. tata photon. tata photon plus towns. http://www.tataphotonplans.com/tata-photon-coverage. accessed june 17, 2013. 43. reliance. coverage. http://www.rcom.co.in/rcom/personal/internet/wireless_intern et_coverage.html. accessed june 17, 2013. 44. tarun. ttsl launches photon max rev b evdo services on tata docomo. 2011; http://telecomtalk.info/ttsl-launchesphoton-max-rev-b-evdo-services-on-tata-docomo/80075/. accessed june 17, 2013. 45. bafna s. mts intros mblaze ultra world's first evdo rev b phase 2 network. 2011; http://telecomtalk.info/mts-mblazeultra-evdo-revb-phase-2network/75834/. accessed june 17, 2013. 46. gsm association. hspa. http://www.gsma.com/aboutus/gsm-technology/hspa. accessed june 17, 2013. 47. cellular news. bsnl launches 3g services in 11 cities. http://www.cellular-news.com/story/36268.php. accessed june 17, 2013. 48. light reading. india's tata ready for 3g launch. http://www.lightreading.com/hsdpa-hsupa/indias-tata-readyfor-3g-launch/240115918. accessed june 17, 2013. 49. broadband india forum. all india 3g network status + coverage. 2011; http://www.broadbandindia.com/forum/showthread.php/298all-india-3g-network-status-coverage. accessed june 17, 2013. 50. gsm association. lte. http://www.gsma.com/aboutus/gsm-technology/lte. accessed june 17, 2013. 51. lteworld. lte operators. http://lteworld.org/operator. accessed june 17, 2013. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kappal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu table 1: total wireless users and tele-density in india with urban and rural distribution as of september 2012. total wireless users 906.62 million urban wireless users 571.70 million (63.06%) rural wireless users 33.49 million (36.94%) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kappal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu table 2: technological details of current telecommunication services and its launch in india. data technology data speed global launch year india launch year india coverage gprs 34 40 kbps 2000 jan. 16, 2002 by bpl mobile 35 pan india by all gsm wireless operators in 900 mhz and 1800 mhz spectrum band edge 36 120 384 kbps 2003 july 28, 2004 37,38 pan india by all gsm wireless operators in 900 mhz and 1800 mhz spectrum band 1x cdma2000 39 154 kbps 2002 may 2003 39 first launch by reliance, followed by tata indicom, bsnl and mts. reliance and tata provide pan india 1x cdma 2000 network, launched in 850 mhz spectrum band evdo rev a 39 2.1 mbps upload and 1.8 mbps download 2006 2008 40,41 launched by tata under brand name of tata photon, followed by reliance, bsnl and mts in 850 mhz spectrum band. tata 42 and reliance 43 provide evdo rev a coverage pan india evdo rev b 39 9.3 mbps upload and 5.4 mbps download with 3 carriers 2010 sept. 2011 44,45 available in top 16 cities across india, by tata, reliance and mts, in 850 mhz spectrum band hspa/hspa+ 46 up to 14.4 mbps/42 mbps with mimo 2005/2009 feb. 2009 limited launch by bsnl; 47 first private no operator has pan india 3g coverage on 2100 mhz spectrum band; 49 limited 3g coverage and http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu operator hspa launch in india on nov. 5, 2010, tata teleservices 48 mobile broadband experience on hspa+ yet to stabilize. only 5 mhz of 3g spectrum allocated by government. lte 50 up to 100 mbps 2009 april 2012 51 lte-tdd in 2.3 ghz spectrum band, launched by airtel and recently by aircel. no further launches to date. expensive technology with limitedlte tdd handsets available. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kappal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu table 3: the potential use of evdo and hspa technology in facilitating healthcare services. distance learning and diagnosis a) mobile led video assisted healthcare awareness [20,21] b) connecting to hospitals at a distance: in late 2009, hospitals in sierra leone launched a satellite link-up to connect doctors in the country to doctors in india where there is better equipment for data analysis. this facilitates real-time consultations between doctors in the field and specialists in hospitals c) remote patient monitoring d) web tutorials based healthcare [22] e) web based anatomical display of symptoms and diagnosis [23] f) self-help groups [24] handheld hospital a) mobile phone based ophthalmic test equipment [25] b) mobile phone enabled biometric and vital signs tester [26] tracking services a) tracking medicines delivery [27] b) smart labels for medicine time reminders [28] c) mobile rfid based patients records tracking in hospitals [29] http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kappal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.116 | http://cajgh.pitt.edu figure 1: the trend of wireless technology (data speed) deployment in india and worldwide from 1996 to 2012. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. sequence alterations of i(ks) potassium channel genes in kazakhstani patients with atrial fibrillation ainur akilzhanova1, saule rakhimova1, zhannur abilova1, omirbek nuralinov2, gulzhaina rashbayeva2, ayan abdrakhmanov2, mahabbat bekbosynova2 1center for life sciences, nazarbayev university, astana, kazakhstan; 2national scientific cardiac surgery center, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.147 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ akilzhanova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.147 | http://cajgh.pitt.edu abstract introduction. atrial fibrillation (af) is the most common sustained arrhythmia, and it results in significant morbidity and mortality. however, the pathogenesis of af remains unclear to date. recently, more pieces of evidence indicated that af is a multifactorial disease resulting from the interaction between environmental factors and genetics. recent studies suggest that genetic mutation of the slow delayed rectifier potassium channel (i(ks)) may underlie af. objective. to investigate sequence alterations of i(ks) potassium channel genes kcnq1, kcne1 and kcne2 in kazakhstani patients with atrial fibrillation. methods. genomic dna of 69 cases with atrial fibrillation and 27 relatives were analyzed for mutations in all protein-coding exons and their flanking splice site regions of the genes kcnq1 (nm_000218.2 and nm_181798.1), kcne1 (nm_000219.2), and kcne2 (nm_172201.1) using bidirectional sequencing on the abi 3730xl dna analyzer (applied biosystems, foster city, ca, usa). results. in total, a disease-causing mutation was identified in 39 of the 69 (56.5%) index cases. of these, altered sequence variants in the kcnq1 gene accounted for 14.5% of the mutations, whereas a kcne1 mutation accounted for 43.5% of the mutations and kcne2 mutation accounted for 1.4% of the mutations. the majority of the distinct mutations were found in a single case (80%), whereas 20% of the mutations were observed more than once. we found two sequence variants in kcnq1 exon 13 (s546s g1638a) and exon 16 (y662y, c1986t) in ten patients (14.5%). in kcne1 gene in exon 3 mutation, s59g a280g was observed in 30 of 69 patients (43.5%) and kcne2 exon 2 t10k c29a in 1 patient (1.4%). genetic cascade screening of 27 relatives to the 69 index cases with an identified mutation revealed 26.9% mutation carriers who were at risk of cardiac events such as syncope or sudden unexpected death. conclusion. in this cohort of kazakhstani index cases with af, a disease-causing mutation was identified in 56.5 % of the referred patients. further screening of mutations in other genes encoding cardiac ion channels is needed to clarify possible disease causing and founder mutations in kazakhstani atrial fibrillation patients. keywords: atrial fibrillation, delayed rectifier potassium channel, genetic analysis http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx immunocytochemical characterization of alzheimer’s disease hallmarks in app/ps1 transgenic mice treated with a new anti-amyloid-𝛽 vaccine new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. immunocytochemical characterization of alzheimer’s disease hallmarks in app/ps1 transgenic mice treated with a new anti-amyloid-𝛽 vaccine ivan carrera1, ignacio etcheverria1, yi li2, lucia fernandez-novoa1, valter lombardi1, carmen vigo3, hector h. palacios4, valery v. benberin5, ramon cacabelos6, gjumrakch aliev7,8 1department of neurosciences, euroespes biotechnology, la coruna, spain; 2yale university school of medicine, new haven, ct; 3atlas pharmaceuticals, sunnyvale, ca; 4national institute on aging, national institutes of health, baltimore, md; 5medical center of the administration of the president of the republic of kazakhstan, astana, kazakhstan; 6euroespes biomedical research center, institute for cns disorders and genomic medicine, la coruna, spain; 7gally international biomedical research consulting llc, san antonio, tx; 8department of health science and healthcare administration, university of atlanta, atlanta, ga vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.119 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ carrera this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.119 | http://cajgh.pitt.edu abstract introduction: app/ps1 double-transgenic mouse models of alzheimer’s disease (ad), which overexpress mutated forms of the gene for the human amyloid precursor protein (app) and presenilin 1 (ps1), have provided robust neuropathological hallmarks of an ad-like pattern at early ages. this study aimed to characterize immunocytochemical patterns of the ad mouse brain, which is treated with the eb101 vaccine, as a model for human ad. material and methods: in this novel vaccine, a new approach has been taken to circumvent past failures with a𝛽 vaccines by judiciously selecting an adjuvant consisting of a physiological matrix embedded in liposomes, composed of naturally occurring phospholipids (phosphatidylcholine, phosphatidylglycerol, and cholesterol). results: our findings showed that the administration of amyloid-𝛽1−42 (a𝛽) and sphingosine-1-phosphate emulsified in liposome complex (eb101) to app/ps1 mice before the onset of a𝛽 brain deposition (at 7 weeks of age) and/or at an older age (35 weeks of age) can be effective in both halting the progression and clearing the ad-like neuropathological hallmarks. in addition, passive immunization with eb101 did not activate inflammatory responses from the immune system and astrocytes. consistent with a decreased inflammatory background, the basal immunological interaction between the t cells and the affected areas (hippocampus) in the brain of treated mice was notably reduced. conclusion: these results provide strong evidence that immunization with the eb101 vaccine prevents and attenuates ad neuropathology in this type of double-transgenic mice. keywords: alzheimer’s disease, anti-amyloid-𝛽 vaccine http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx health benefits of new symbiotic “nar” new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. health benefits of new symbiotic “nar” saule saduakhasova, almagul kushugulova, samat kozhakhmetov, gulnara shakhabayeva, adil supiyev, zhanagul khasenbekova, indira tynybayeva, talgat nurgozhin, zhaxybay zhumadilov center for life sciences, nazarbayev university, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.114 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ saduakhasova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.114 | http://cajgh.pitt.edu abstract introduction: the immune-modulatory effects of synbiotics and their ability to reduce free radical levels may be useful for functional food that is able to be active throughout whole period of colonization of the gastrointestinal tract. the aim of the present study was to investigate the immune-modulatory and antioxidant effects of the synbiotic product "nаr," a probiotic beverage. methods: the presence of il-2, il-4, il-6, il-8, il-10, αtnf, γifn, ig a, ig m, and ig e was studied in vitro using a solid immunosorbent analysis. the total antioxidant activities of superoxide dismutase and glutathione reductase were determined by a spectrophotometry using the sigma-aldrich sets. results: studies of the immune-modulatory properties of the synbiotic product nar showed 1.7 fold increase of γinf levels (p<0.01) in blood after consumption of the synbiotic product “nar” in comparison to control values, whereas the concentrations of il-4 and ig e decreased 2.0 times (treatment: 9.3; control: 18.7; p<0.01) and 1.3 times (p<0.1), respectively. the consumption of the synbiotic product “nar” caused an increase in the proportion of γinf/il 4 (treatment: 15.4; control: 4.4; p<0.01), which indicates a reduction in functional activity of th2-type lymphocytes in comparison with the function of th1 cells. our study showed a high level of the total antioxidant activity of the synbiotic product (67.4 mmol/ml). the antioxidant activity of the intact cells of consortium (15.3 mm/ml), which was the basis for the preparation of the symbiotic product, is several times lower than the activity observed in the symbiotic samples. expression of sod is one of the mechanisms of antioxidant stress radicals inactivation by bacteria. the analysis identified a superoxide dismutase activity of synbiotic product (1.42 u/mg protein). a glutathione reductase activity of the synbiotic product was elevated (0.06 u/ml). conclusion: the majority of the inflammatory mediators found in the blood after the consumption of symbiotic product nar were inflammatory mediators that activate a cellular component of the resistance. moreover, the symbiotic product has a high antioxidant activity. keywords: synbiotics, immune modulation, antioxidant activity http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. studies of health effects from nuclear testing near the semipalatinsk nuclear test site, kazakhstan bernd grosche1, tamara zhunussova2, kazbek apsalikov3, ausrele kesminiene4 1federal office for radiation protection, department of radiation protection and health, oberschleissheim, germany; 2norwegian radiation protection authority, department of monitoring and research, osteras, norway; 3scientific research institute for radiation medicine and ecology, semey, kazakhstan; 4international agency for research on cancer, lyon, france vol. 4, no. 1 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.127 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ grosche this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.127 | http://cajgh.pitt.edu abstract the nuclear bomb testing conducted at the semipalatinsk nuclear test site in kazakhstan is of great importance for today’s radiation protection research, particularly in the area of low dose exposures. this type of radiation is of particular interest due to the lack of research in this field and how it impacts population health. in order to understand the possible health effects of nuclear bomb testing, it is important to determine what studies have been conducted on the effects of low dose exposure and dosimetry, and evaluate new epidemiologic data and biological material collected from populations living in proximity to the test site. with time, new epidemiological data has been made available, and it is possible that these data may be linked to biological samples. next to linking existing and newly available data to examine health effects, the existing dosimetry system needs to be expanded and further developed to include residential areas, which have not yet been taken into account. the aim of this paper is to provide an overview of previous studies evaluating the health effects of nuclear testing, including some information on dosimetry efforts, and pointing out directions for future epidemiologic studies. keywords: semipalantinsk nuclear test site, kazakhstan, radiation health, environmental health studies of health effects from nuclear testing near the semipalatinsk nuclear test site, kazakhstan bernd grosche1, tamara zhunussova2, kazbek apsalikov3, ausrele kesminiene4 1federal office for radiation protection, department of radiation protection and health, oberschleissheim, germany; 2norwegian radiation protection authority, department of monitoring and research, osteras, norway; 3scientific research institute for radiation medicine and ecology, semey, kazakhstan; 4international agency for research on cancer, lyon, france review the semipalatinsk nuclear test site (sts) is located in the present east-kazakhstan oblast (or administrative division) of kazakhstan, a country that was previously a part of the soviet union. the test site is named after the city of semipalatinsk (in kazakh: semey) and is located approximately 150 km west of the city. the test site covers an area of 18,500 km², or 7,143 square-miles. the sts was a major site for nuclear weapons testing by the former soviet union, and it was where the former soviet union conducted their first nuclear test on august 29, 1949. afterwards, 456 nuclear explosions were carried out between 1949 and 1989, including 111 atmospheric events (86 air events and 25 surface events) between 1949 and 1962.1,2 after the limited test ban treaty was signed in 1963, the tests at sts were restricted to underground shafts and tunnels so that little or no offsite environmental contamination was caused; except for four events that occured between 1965 and 1968, within the framework of peaceful uses of nuclear energy program, which was designed for earthhttp://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.127 | http://cajgh.pitt.edu moving purposes (e.g. the construction of artificial lakes, canals, and harbors). the last event conducted at the sts was on october 19, 1989. the total yield of atmospheric events conducted at the sts is reported to be 6.58 megatons of tnt equivalent, which corresponds to approximately 66% of the total estimated soviet bomb yield.3 the test site had three major testing areas. atmospheric bomb tests were performed at ground zero. over 200 underground nuclear tests were performed in the degelen mountains. 123 underground nuclear tests were conducted in the balapan area, one of which led to the formation of lake chagan (or lake balapan), which is sometimes called ‘atomic lake’ due to the current radioactive environment.2 during the tests, access to the site was strictly controlled by the soviet armed forces, and no civilian use of the area was permitted. previous analyses made by several institutes from different countries might provide insight into the health effects from low dose radiation exposure, as defined by the european low-dose initiative melodi.4,5 there have also been numerous biological studies published on radiation effects.6-11 the european commission has funded a new project to assess whether it is possible to create a unified cohort of individuals affected by the atomic bomb testing,12 which, if successful, could provide numerous insights into the health effects of radiation exposure. beyond giving an overview on already published evidence, this paper provides recommendations about future research directions on radiation health effects. in particular, the authors would like to argue that it is necessary to better link future epidemiological cohort studies with biological research either based on already collected, existing biomaterial or on biomaterial that will be sampled in the frame of the future investigations. this manuscript aims to provide an overview on previous studies focused on the health effects of the nuclear testing by evaluating information on dosimetry efforts and insights on the direction of future epidemiological studies. environmental health exposures the 111 atmospheric events conducted between 1949 and 1962 caused the primary source of radioactive contamination of the environment and the majority of the radiation exposure of the public. the most damaging tests, in terms of exposure, were those conducted on august 29, 1949 (with a yield of 22 kilotons (kt) tnt equivalent), september 24, 1951 (38 kt), august 12, 1953 (400 kt), and august 24, 1956 (27 kt). most of the other explosions led to exposures that affected only the test ground, not the vicinity of the test site. the population living closest to the test site was exposed to relatively high levels of radiation. settlements affected by the 1949 test were located north-east of the test site (e.g. dolon and cheremushka), but traces from this test have also been documented in residents living further away in the altai region in russia.13 the tests of 1951, 1953, and 1956 affected settlements south and south-east of the test site (e.g. kainar, karaul, kaskabulak, sarzhal, and znamenka). both, external and internal exposures need to be considered when estimating the individual doses to which residents have been exposed. external exposure was caused by the radioactive clouds and submersion, whereas internal exposure is caused by the consumption of contaminated foods. food consumption varied between the different ethnic groups living in the contaminated areas, such as kazakhs, russians, and germans. the first effort to evaluate both external and internal exposure was attempted in kazakhstan and published in 2000.14 the extensive work of different international groups has found that the calculated doses tended to overestimate the actual exposures,15-18 where the village of dolon was used as the primary location for comparing different methods for dose estimates. during a research meeting held at the university of hiroshima in 2005, researchers with different approaches to retrospective dosimetry compared and discussed their results, paying close attention to reasons for large variation among estimates. the results from this http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx grosche this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.127 | http://cajgh.pitt.edu workshop were published in a special issue of the japanese journal for radiation research in 2006, with agreement achieved about exposure doses for dolon.19 today, the previously published u.s./russian joint methodology is considered as being the most appropriate.18 previous studies on health effects the first studies on health effects associated with nuclear bomb testing were of a descriptive nature. one of the first published reports focused on the increased age-specific incidence rates of malignant tumors in the semipalatinsk oblast compared to the general population of the soviet union and kazakhstan populations.20 based on the survey data that was collected in five year intervals from 1949 onwards, increased cancer incidence rates were reported in highly exposed villages compared to the villages of the kokpektinskii district (control area).21 in an ecological study of childhood cancer incidence in four administrative divisions adjacent to the sts spanning from 1981 to 1990, an increase in relative risks for all cancers, including leukemia and brain tumors, were reported in children living less than 200 km from the test epicenter compared to children residing more than 400 km from the test site.22 in 2000, a comprehensive book was published, which included information on the incidence and mortality of a few selected diseases such as cancer, cardiovascular disease, and mental retardation, as well as the prevalence of congenital malformations.2 overall, there was clear evidence of unfavorable health outcomes in the population living around the test site. based on data that were collected from 1960 to 1991 by the national research institute of radiation medicine and ecology of kazakhstan, a cohort was established which became known as the “historical” cohort. this cohort was comprised of approximately 20,000 individuals. half of these individuals came from exposed villages and the other half came from a comparison (unexposed) area. the first analyses were based on the dosimetry system developed by kurakina et al.14 and focused on cancer mortality with follow-ups until 1999.23,24 a more recent analysis employed a dosimetry system, which was developed by the u.s. national cancer institute for the purpose of studying thyroid diseases, amongst the population living near the semipalatinsk nuclear test site (see figure 1). figure 1: the 18,000 km2 area of the semipalantinsk test site (indicated in red attached to kurchatov (along the irtysh river), and near semey, as well as karaganda and astana the dosimetry system was based on a joint u.s./russian dose reconstruction methodology that combined the experience of dose-reconstruction scientists in russia and the u.s.16,18 another study looked at mortality associated with cardiovascular disease.25 while given doses, around 90 milligray (mgy) on average, with a maximum of 630 mgy, had no effect on cardiovascular disease, the analyses of mortality due to solid tumors had to be revised to incorporate the updated dosimetry system. the dosimetry system developed by kurakina et al.14 generally gave higher dose estimates in comparison to more recent systems,16,18 including the university of hiroshima consensus meeting. a cross-sectional study of the prevalence of thyroid diseases was conducted using 2,994 residents from eight villages. the study involved ultrasound screening, and malignancy status was confirmed by cytopathology evaluation. in terms of excess relative risk per unit dose, the dose-response findings for nodule prevalence were compatible with those from populations exposed to medical x-rays and atomic bomb survivors.26 another study looking at the differences between birth cohorts of those in east kazakhstan found that those born closest to the dates during the nuclear tests had an http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.127 | http://cajgh.pitt.edu increased risk of numerous health problems, including cardiocascular disease and cancer.27 two studies looked into possible radiation effects in the offspring of exposed individuals. the first study focused on investigating whether the exposures led to a significant change in the sex ratio of newborns. based on 11,464 single births from 3,992 mothers exposed to radiation during 1949–1956, the overall sex ratio was 1.07 (e.g. 107 boys per 100 girls), which was comparable to the sex ratio in kazakhstan in the mid2000s (1.06).28 using a subset of 141 twin deliveries from 3,992 mothers, further analyses were conducted on the effects of radiation exposure on same sex and different sex twin delivery. there was an increase in the odds of having different sex twins for births occurring within 5 years after exposure compared with more than 20 years after exposure [or = 4.08 (95% ci: 1.11, 15.07)] in all villages, regardless of exposure level.29 another study focused on the frequency of mini-satellite mutations in exposed offspring and unexposed (control) offspring, and found a negative correlation between mutation rate and the parental year of birth in the exposed f1 generation, with the highest mutation rate in the most exposed cohort of parents born before 1960.8 to our knowledge, no additional studies have been conducted on mental disability or congenital malformation. data bases several databases and registries have been developed over the past few decades, which need to be further explored for risk analyses. one of these resources is the previously mentioned historical cohort.23 another database is the registry of the population of the former semipalatinsk oblast. initiated in 1949, this registry is a valuable source of health data, including information on residential histories, vital statistics, and causes of death for over 100,000 individuals.30 this database includes the participants of the historical cohort. more recently, a joint japanese-kazakh effort was initiated by a group headed by the late dr. ogiu from japan, focusing on creating a database of exposed residents and those from a comparison area – which is different from the one used for the historical cohort. this database was designed to include residential history and causes of death.31 as mentioned earlier, one of the tasks of the semi-nuc project12 is to test how the two databases may be linked. a respective report is under development, which will define how to best use available data from both databases for future epidemiological research. biological material biological samples from individuals living in the affected areas have been collected in numerous studies;6-11 however, to our knowledge, not all were stored. in recent years, the national research institute of radiation medicine and ecology in semey started collecting blood samples and teeth from the persons still residing in the villages close to the former sts and stored them in a biobank.32 discussion this review demonstrates that different datasets are available for investigating health effects of radiation among the population living in proximity to the semipalatinsk nuclear testing site. the eu-funded project semi-nuc aims to evaluate to what extent the different data sets can be linked and whether there is a possibility to use this data for a future prospective cohort study. to that end, possible follow-up mechanisms are going to be tested, including monitoring of incidence and mortality data, where the outcomes of interest are cancer and non-cancerous diseases. avenues of ascertainment of vital statistics and cause of death have yet to be identified and validated. thus, available sources of information must be defined (e.g. death certificates, hospital records, etc.). methodologies that were used to calculate doses for http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx grosche this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.127 | http://cajgh.pitt.edu existing cohorts have to be reviewed and compared, including identifying potential discrepancies and reasons for the discrepancies. furthermore, it will be important to evaluate the quality and the content of existing biomaterials. such evaluations will need to look at how samples were processed and stored, which types of equipment was used for dna extraction, methods of evaluation of previous cytogentic analyses, and the condition of stored tissue samples. in addition, there will be evaluations of the possible use for modern technology analysis. for the latter, validated sops have already been developed and are available on the internet.33 newly collected biomaterial will mainly come from elderly participants since the last bomb testing that led to significant exposures to the public was conducted in 1954. however, there are other interesting options for future research on the effects of low to intermediate doses. the large data sets independently developed by katayama et al.30 and researchers from the radiation effects association31 give rise to the possibility of investigating transgenerational effects. further, there is a three-generation data set available at niirme, which includes limited results from previously conducted chromosomal aberration analyses. the collection of the relevant information for this dataset is currently underway. although research on the health effects of low to medium exposures from the nuclear testing is of high public health relevance, a major limitation is that studies mentioned in this paper are not well connected with each other. this makes an overall joint evaluation difficult. additionally, epidemiological research in the area close to the test site faces a number of difficulties. one of the problems is that exposures are dominated by the radioactive plumes (external), but for some health endpoints, internal exposures are of a higher relevance. since exposure estimates have been carried out many years after actual events, this introduces another source of bias. another limitation is that biological materials from the affected population were not always properly stored and labeled. it is difficult to link available biological material to individuals included in the epidemiological studies and their demographic data. despite the fact that difficulties exist, studies of individuals affected by atomic bomb testing have the potential to contribute to a better understanding of radiation exposure risk, particularly because the population is not a randomly selected one (e.g. nuclear workers have much fewer and lower exposures in comparison to atomic bomb survivors).34,35 however, calculating internal exposures is still a challenge. for a complete coverage of the area affected by the nuclear bomb testing at the semipalatinsk test site, dose estimates have to be developed for settlements that have not yet been included in the existing dosimetry systems. accordingly, one of the tasks of the semi-nuc project is to test the feasibility of dose reconstruction. in summary, data are available for more than 100,000 persons forming a large cohort which needs to be further investigated.30 furthermore, the range of external doses as described in the study of cardiovascular diseases (i.e. 0-630 mgy) is wide enough to conduct meaningful health studies.25 lastly, the data from the 3generation studies are of high interest to study transgenerational effects. overall, this line of research has great relevance not only for the region of central asia but also to countries around the world affected by nuclear testing. references 1. mikhailov vn. nuclear weapon tests and nuclear explosions for peaceful purposes in the ussr 1949-1990. 1996; http://docs.nrdc.org/nuclear/files/nuc_10009601a_173.pdf. accessed may 6, 2015. 2. nugent rw, zhumadilov zs, gusev bi, hoshi m. health effects of radiation associated with nuclear weapons testing at the semipalatinsk test site. hiroshima, japan: nakamoto sogo printing; 2000. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://docs.nrdc.org/nuclear/files/nuc_10009601a_173.pdf central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.127 | http://cajgh.pitt.edu 3. matuschenko am, tsyrkov ga, chernyshov ak, et al. chronological list of nuclear tests at the semipalatinsk test site and their radiation effects. in: shapiro cs, kiselev vi, zaitsev ev, eds. nuclear tests. vol 36: springer berlin heidelberg; 1998:89-97. 4. melodi. multidisciplinary european low dose initiative. 2012; http://melodi-online.eu/. accessed may 6, 2015. 5. salomaa s, prise km, atkinson mj, et al. state of the art in research into the risk of low dose radiation exposure--findings of the fourth melodi workshop. j radiol prot. 2013;33(3):589603. 6. gusev bi, abylkassimova zn, apsalikov kn. the semipalatinsk nuclear test site: a first assessment of the radiological situation and the test-related radiation doses in the surrounding territories. radiat environ biophys. 1997;36(3):201-204. 7. stephan g, pressl s, koshpessova g, gusev bi. analysis of fish-painted chromosomes in individuals living near the semipalatinsk nuclear test site. radiat res. 2001;155(6):796800. 8. dubrova ye, bersimbaev ri, djansugurova lb, et al. nuclear weapons tests and human germline mutation rate. science. 2002;295(5557):1037. 9. salomaa s, lindholm c, tankimanova mk, et al. stable chromosome aberrations in the lymphocytes of a population living in the vicinity of the semipalatinsk nuclear test site. radiat res. 2002;158(5):591-596. 10. lindholm c, murphy bp, bigbee wl, et al. glycophorin a somatic cell mutations in a population living in the proximity of the semipalatinsk nuclear test site. radiat res. 2004;162(2):164-170. 11. tanaka k, iida s, takeichi n, et al. unstable-type chromosome aberrations in lymphocytes from individuals living near semipalatinsk nuclear test site. j radiat res. 2006;47(suppl a):a159-a164. 12. world health organization (who), international agency for research on cancer. semi-nuc: prospective cohort study of residents near the semipalantinsk nuclear test site feasibility assessment. 2015; http://semi-nuc.iarc.fr/. accessed may 6, 2015. 13. shoikhet y, loborev v, sudakov v, kiselev vi, zelenov v, azarov l. fallout from nuclear tests: dosimetry in the altai region. radiat environ biophys. 2002;41(1):57-60. 14. kurakina nn, sekerbaev ak, gusev bi, ospanov ek. assessment of absorbed and effective radiation doses in the population living on the radioactive traces of nuclear tests. methodological guidelines for experts in radiation medicine and ecology. paper presented at: semipalatinsk 2000; almaty. 15. gordeev k, vasilenko i, lebedev a, et al. fallout from nuclear tests: dosimetry in kazakhstan. radiat environ biophys. 2002;41(1):61-67. 16. gordeev k, shinkarev s, ilyin l, et al. retrospective dose assessment for the population living in areas of local fallout from the semipalatinsk nuclear test site part i: external exposure. j radiat res. 2006;47(suppl a):a129-a136. 17. simon sl, baverstock kf, lindholm c, world health organization, radiation and nuclear safety authority in finland, national cancer institute. a summary of evidence on radiation exposures received near to the semipalatinsk nuclear weapons test site in kazakhstan. health phys. 2003;84(6):718-725. 18. simon sl, beck hl, gordeev k, et al. external dose estimates for dolon village: application of the u.s./russian joint methodology. j radiat res. 2006;47(suppl a):a143-a147. 19. stepanenko vf, hoshi m, bailiff ik, et al. around semipalatinsk nuclear test site: progress of dose estimations relevant to the consequences of nuclear tests (a summary of 3rd dosimetry workshop on the semipalatinsk nuclear test site area, rirbm, hiroshima university, hiroshima, 9-11 of march, 2005). j radiat res. 2006;47(suppl a):a1-a13. 20. bul'bulian ma, tokareva gd. descriptive epidemiological study of malignant neoplasms in the semipalatinsk district of the kazakh s. s. r. vestn akad med nauk sssr. 1991(7):59-63. 21. gusev bi, rosenson ri, abylkassimova zn. the semipalatinsk nuclear test site: a first analysis of solid cancer incidence (selected sites) due to test-related radiation. radiat environ biophys. 1998;37(3):209-214. 22. zaridze dg, li n, men t, duffy sw. childhood cancer incidence in relation to distance from the former nuclear testing site in semipalatinsk, kazakhstan. int j cancer. 1994;59(4):471-475. 23. bauer s, gusev bi, pivina lm, apsalikov kn, grosche b. radiation exposure due to local fallout from soviet atmospheric nuclear weapons testing in kazakhstan: solid cancer mortality in the semipalatinsk historical cohort, 1960-1999. radiat res. 2005;164(4 pt 1):409-419. 24. bauer s, gusev bi, pivina lm, apsalikov kn, grosche b. esophagus cancer and radiation exposure due to nuclear test fallout: an analysis based on the data of the semipalatinsk historical cohort, 1960-1999. radiat biol radioecol. 2006;46(5):611-618. 25. grosche b, lackland dt, land ce, et al. mortality from cardiovascular diseases in the semipalatinsk historical cohort, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://melodi-online.eu/ http://semi-nuc.iarc.fr/ grosche this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.127 | http://cajgh.pitt.edu 1960-1999, and its relationship to radiation exposure. radiat res. 2011;176(5):660-669. 26. land ce, zhumadilov z, gusev bi, et al. ultrasounddetected thyroid nodule prevalence and radiation dose from fallout. radiat res. 2008;169(4):373-383. 27. apsalikov k, muldagaliev t, apsalikov r, serikkankyzy s, zholambaeva z. radiation risk factors in incidence and mortality among exposed individuals of east kazakhstan. cajgh. 2013;2(suppl). 28. mudie ny, gusev bi, pivina lm, et al. sex ratio in the offspring of parents with chronic radiation exposure from nuclear testing in kazakhstan. radiat res. 2007;168(5):600-607. 29. mudie ny, swerdlow aj, gusev bi, et al. twinning in the offspring of parents with chronic radiation exposure from nuclear testing in kazakhstan. radiat res. 2010;173(6):829-836. 30. katayama h, apsalikov kn, gusev bi, et al. an attempt to develop a database for epidemiological research in semipalatinsk. j radiat res. 2006;47(suppl a):a189-a197. 31. kyo ̄kai he. study on health effects of radiation on residents near the former semipalatinsk nuclear test site: the final report of the 2001-2009 study. tokyo, japan: radiation effects association; 2010. 32. the ministry of public health of the republic of kazakhstan. the research institute for radiation medicine and ecology. 2013; http://de.slideshare.net/irpslideshare/instradiology-med. accessed may 6, 2015. 33. store database. store database. 2014; http://www.rbstore.eu/. accessed may 6, 2015. 34. akleyev av, grosche b, gusev bi, et al. developing additional resources. radiat environ biophys. 2002;41(1):13-18. 35. gilbert es, land ce, simon sl. health effects from fallout. health phys. 2002;82(5):726-735. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://de.slideshare.net/irpslideshare/inst-radiology-med http://de.slideshare.net/irpslideshare/inst-radiology-med http://www.rbstore.eu/ grosche this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.127 | http://cajgh.pitt.edu figure 1: the 18,000 km2 area of the semipalantinsk test site (indicated in red attached to kurchatov (along the irtysh river), and near semey, as well as karaganda and astana http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. proximity utilizing biotinylation of nuclear proteins in vivo arman kulyyassov1, gulsamal zhubanova1, erlan ramanculov1, vasily ogryzko2 1national center for biotechnology, astana, kazakhstan; 2institut gustave roussy, villejuif, france vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.165 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kulyyassov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.165|http://cajgh.pitt.edu abstract introduction. the human genome consists of roughly 30,000 genes coding for over 500,000 different proteins, of which more than 10,000 proteins can be produced by the cell at any given time (the cellular “proteome”). it has been estimated that over 80% of proteins do not operate alone, but in complexes. these protein-protein interactions (ppi) are regulated by several mechanisms. for example, post-translational modifications (methylation, acetylation, phosphorylation, or ubiquitination) or metal-binding can lead to conformational changes that alter the affinity and kinetic parameters of the interaction. many ppis are part of larger cellular networks of interactions or interactomes. indeed, these interactions are at the core of the entire interactomics system of any living cell, and so, aberrant ppis are the basis of multiple diseases, such as neurodegenerative diseases and cancer. the objective of this study was to develop a method of monitoring protein-protein interactions and proximity dependence in vivo. methods. the biotin ligase bira was fused to the protein of interest, and the biotin acceptor peptide (bap) was fused to an interacting partner to make the detection of its biotinylation possible by western blot or mass spectrometry. results. using several experimental systems (bira.a + bap.b), we showed that the biotinylation is interaction/proximity dependent. here, a and b are the next nuclear proteins used in the experiments – 3 paralogues of heterochromatin protein hp1 (cbx5), hp1 (cbx1), hp1 (cbx3), wild type and transcription mutant factor kap1, translesion dna polymerase polh and e3, ubiquitin ligase rad18, proliferative cell nuclear antigen (pcna), ubiquitin ub, sumo-2/3, different types and isoforms of histones h2a, h2az, h3.1, h3.3, cenpa, h2a.bbd, and macroh2a. the variant of this approach is termed pub-nchip (proximity utilizing biotinylation with native chromatin immuno-precipitation) and is designed to purify and study the protein composition of chromatin in proximity to the nuclear protein of interest. using the rad18 protein as a model, we demonstrated that the rad18-proximal chromatin is enriched in some h4 acetylated species. moreover, the rad18-proximal chromatin containing a replacement histone h2az has a different pattern of h4 acetylation. conclusion. progress in the last decade in cancer drug therapy has led us to the conclusion that the nucleus of eukaryotic cells is an active site for many cellular processes important to the development of cancer. these processes include changes in genetic and epigenetic landscape (e. g. methylation of dna, modification of histones) and the expression levels of transcription factors, which regulates gene products (e.g. hypoxia-inducible factor 1α (hif-1α) in chronic anemia, etc.) where protein-protein interactions play important role. understanding the nature of protein-protein interactions may improve design strategies for small-molecule ppi modulators. ppi assay technologies that closely reflect physiological conditions hold the key to developing specific anti-cancer drugs. keywords: protein-protein interaction, proximity, biotinylation http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://en.wikipedia.org/wiki/interactomics http://en.wikipedia.org/wiki/alzheimer%e2%80%99s_disease http://en.wikipedia.org/wiki/cancer study of the erythropoiesis activity of nano-encapsulated forms of erythropoietin new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. study of the erythropoiesis activity of nano-encapsulated forms of erythropoietin zhanagul khasenbekova1, alexandr gulayev1, elena nechayeva2, talgat nurgozhin1, zhaxybay zhumadilov1 1center for life sciences, nazarbayev university 2the state research center of virology and biotechnology vector, novosibirsk, russia vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.110 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ khasenbekova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.110 | http://cajgh.pitt.edu abstract introduction: the recombinant human erythropoietin (rhepo) is used in the treatment of anemia. in order to improve its pharmacokinetic properties, nanoparticles of biodegradable polymers of natural or synthetic origin were used. the aim of this study was to investigate the effect of new nano-encapsulated forms of recombinant human erythropoietin for oral use on the erythropoiesis in the cyclophosphamide immunosuppression model. material and methods: the chope immortalized cells culture (a primary producer of rhepo "vector" in russia) was used. the following biodegradable polymers were chosen: 0.05% and 0.005% carbopol, 0.05% and 0.005% kollidon, and 0.05% and 0.005% pectin. immunosuppression was obtained by a single dose of i.p. injection of cyclophosphamide (250 mg/kg) in white mice (18-20 g). during the next 5 days, the nano-encapsulated erythropoietin (100 ed/mouse) was administered orally to each mouse. after 5 and 10 days, the cell count of the number of blood reticulocytes and the myelogram of bone marrow were performed. the control group of mice received injections of eprex. results: on the 5th day of the experiment, the highest level of reticulocyte was observed in the samples of erythropoietin with kollidon (0.05%) and pectin (0.005%) nanoparticles. on the 10th day, the highest activity was observed in the samples of erythropoietin substance with pectin at 0.05% and 0.005% concentrations. the levels of reticulocytes in these groups reached 13.53% and 14.55%, respectively. the results of the myelogram during immunosuppression showed some activity of erythropoietin in conjunction with both concentrations of pectin when a two-fold increase in the number of erythroblasts was observed on the 5th day. high degrees of erythrokaryocytes in the state of mitosis were observed in the 0.05% pectin samples. similar results were observed in equivalent groups of control animals on the 10th day of the experiment, which is compatible with the data on eprex action. conclusion: the erythropoietic activity of nano-encapsulated forms of erythropoietin was observed in the 0.05% and 0.005% pectin samples in the cyclophosphamide immunosuppression model setting. keywords: erythropoiesis, nanobiotechnology, recombinant human erythropoietin http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. the results of fetal chondrocytes transplantation in patients with rheumatoid arthritis natalya krivoruchko, saltanat tuganbekova, gulnar rakhimbekova, karlygash kuzembaeva, lina zaripova national research medical center, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.164 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ krivoruchko this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.164 | http://cajgh.pitt.edu abstract introduction. nowadays anti-inflammatory and immunosuppressive therapy has significantly improved the quality of life and prognosis of rheumatoid arthritis (ra). nevertheless, there are still many patients with progressive rheumatoid inflammation, resulting in the destruction of joints. cell therapy seems like a promising direction in rheumatology. the aim of our research was to evaluate the efficacy of fetal chondrocyte transplantation in patients with ra. methods. we examined 60 patients with rheumatoid arthritis (i iii stages) between 20 and 63 years of age. they were divided into 2 groups: the first group underwent the fetal chondrocytes transplantation (n = 40), and the second was a control group who got conservative therapy (n = 20). donor cells were taken from the chondrogenic layer of the humerus or femur heads and hip condyles of human embryos in gestation for 17-20 weeks. a suspension of fetal chondrocytes injected into affected areas of the articular surfaces under x-ray control. cell viability was determined before the injection. efficacy of the therapy was assessed by clinical, instrumental, and laboratory tests. this clinical trial was allowed by the ministry of public health and ethics committee. all of our patients gave informed consent for the fetal chondrocytes transplantation. results. evaluation of the clinical manifestations of ra in the first group of patients showed 3.7 times decrease in pain and 1.6 times relief of synovitis. complete reduction of contracture was observed in 82% of patients in the first group. morphometric changes in x-ray demonstrated inhibition of the destruction in articular cartilage and surfaces of bones after transplantation of fetal chondrocytes. the dynamics of morphological changes in synovium showed 2.5 times reduction of the inflammatory reaction. transplantation of fetal chondrocytes led to a significant reduction in esr, crp, fibrinogen , γ-globulin after a period of 12 months (p < 0.03). furthermore, patients in the second group had 2.7 times higher risk of ankylosis compared to the first group. we did not observe any complications of fetal chondrocytes transplantation. conclusions. application of fetal chondrocytes therapy had the desired clinical effect, which was confirmed by reduction of the ra activity and decrease of cartilage and bone destruction. keywords: rheumatoid arthritis, fetal chondrocyte transplantation, chondrocytes http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. molecular and genetic research in tuberculosis clinical practice and epidemiology bahytkul zhakipbayeva, sholpan beisembayeva, talgat muminov department of epidemiology, asfendiyarov kazakh national medical university, almaty, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.182 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ zhakipbayeva this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.182 | http://cajgh.pitt.edu abstract introduction. tuberculosis (tb) remains a global public health problem. in order for multi-drug resistant tuberculosis (mdr-tb) to be more effectively managed, there is a need for better tools for diagnosis, treatment, and prevention. the decline of tb incidence and mortality in kazakhstan during last decade was accompanied with consistent growth of mdr-tb. this study aimed to investigate genotype characteristics of mycobacterium tuberculosis (mt) isolated from tb patients from different regions of the country and its clinical and epidemiological significance. methods. over 500 clinical mt isolates from pulmonary tb patients between 2003-2008 were genotyped using spoligotyping, miru-vntr, is6110 rflp, and hybridization on an oligonucleotide biochip “tb–biochip.” results. out of 250 isolates with interpretable results, 31 different spoligopatterns were detected. the beijing genotype was the most predominant lineage detected (71.6%), characterized by heterogenicity on etr a, b, c, d, and e markers, and 56.6% of them had an allelic profile 42435. the beijing genotype and dominating variant strains have a high transmission rate, a high rate of primary mdr (associated with infiltrating lung tb and complications), and a high level resistance to rifampicin and izoniazid due to mutation of rpob531ttg and katg315acc. miru-vntr–typing by 15 loci of 33 isolates from 13 family tb foci revealed that strains from supposed sources and contact persons completely coincide in only 5 foci in the genomic structure. conclusion. there is a heterogeneous pool of genotypes that circulate in kazakhstan, with the beijing lineage being the most predominant. it appears that at the present stage of circulation , mt beijing genotype has an endemic character. however, clonal spreading of epidemiologically and clinically significant mdr strains of this genotype is also a serious threat to the population. to increase tb control efficiency and prevent further transmission, it is necessary to compile a modern countrywide system of microbiological monitoring for the agent by use of a computer bank of spoligotyping and miru-vntr-typing profiles of circulating strains. keywords: tuberculosis, drug resistance, genotype http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. therapeutic potential of noble nanoparticles for wound repair timur saliyev1, gulsim kulsharova2, alma akhmetova1, talgat nurgozhin1, sergey mikhalovsky2,3 1center for life sciences, nazarbayev university, kazakhstan; 2school of engineering, nazarbayev university, kazakhstan; 3school of pharmacy and biomedical sciences, university of brighton, uk vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.172 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ saliev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.172 | http://cajgh.pitt.edu abstract introduction. nanoparticles made of noble metals, such as gold and silver, have a great potential to be effectively employed for wound management. the nano-size of such particles provides an opportunity to enlarge the contacting area, which results in more effective anti-bacterial action and faster wound repair. it must be noted that the shape of noble nanoparticles might play a crucial role in the manifestation of their anti-microbial properties. the modern state of technology allows fabrication of the nanoparticles with the desired shape and physical properties. in order to provide efficacy and close contact with the wound, the noble nanoparticles can be incorporated into a special matrix made of a cryogel (based on polymethyl methacrylate). this combination might serve as a foundation for developing completely new types of wound dressing. materials and methods. we have developed a few methods for synthesizing gold and silver nanoparticles of different shapes and sizes. after fabrication of metallic nanoparticles, they were characterized by using tunneling electron microscopy (tem) and malvern zetasizer system in order to determine the average population size and consistency. the silver nanoparticles was synthesized using sodium borohydride reduction of silver nitrate. the synthesis of gold nanoparticles was conducted by using the turkevich method. results. we have developed a synthetic cryogel based on polyacrylamide (by cryogelation reaction) at several temperatures. at the second step, we developed a method for conjugating fabricated gold and silver nanoparticles to the surface (or pores) of cryogel through covalent bonds so they can provide antibacterial action within the wound. by following the developed protocol, we were able to obtain an approximate cryogel layer (1 cm thickness) with embedded gold and silver nanoparticles. this conjugate was analyzed and confirmed using scanning electron microscopy (sem) and tem. discussion. the obtained results indicate the feasibility of the fabrication of a novel type of wound dressing. at the next step, we are planning to elucidate the bio-compatibility of the combination of cryogel and nanoparticles. moreover, anti-bacterial properties of this new type of wound dressing will be analyzed. keywords: wound management, cryogel, nanoparticles, silver, gold http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx effect of probiotic consortium on the local inflammatory process in chronic periodontitis new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. effect of probiotic consortium on the local inflammatory process in chronic periodontitis zhanagul khasenbekova, saule saduakhasova, alexandr gulayev, almagul kushugulova, samat kozhakhmetov, gulnara shakhabayeva, indira tynybayeva, talgat nurgozhin, zhaxybay zhumadilov center for life sciences, nazarbayev university, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.109 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ khasenbekova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.109 | http://cajgh.pitt.edu abstract introduction: inflammatory periodontal disease is one of the major concerns of researchers and clinicians, because it can lead to tooth loss and an increased risk of systemic pathologies, even at the age of 35. the purpose of this study was to determine the effects of gelatin-based probiotic consortium on the local and general factors of inflammation in rats with chronic periodontitis. methods: the study object was a complex of probiotic bacteria based in an odourless 6% gelatin plate with neutral flavour. a cellular biomass of the consortium consists of following lactobacilli: lactobacillus casei subsp. pseudoplantarum, lactobacillus caseisubsp.casei, l.fermentum, and l. helveticus. the viable cell number was 2.5 x 109 cfu/ml. the model of chronic periodontitis was reproduced in the white random-bred rats that weighed 160-220g, by keeping them on a low-protein diet. after three months, symptoms associated with medium and severe chronic periodontitis were observed in the rats. application was carried out on the oral mucosa of rats 1 time per day for 14 days. the stickers lacking consortium of microorganisms were used as the placebo. the "solcoseril" gel was chosen as a comparator. the hematologic, biochemical, and morphological characteristics were investigated. results: a complete clearance of periodontal pockets was observed during an objective examination of the experimental group rats on the 14th day of the experiment. moreover, a gingival mucous turned pink, and there were no cyanosis tissues. the local changes were accompanied by improvement in hematological parameters, such as a reduction of blood eosinophilia and neutrophilia, and a recovery of the white blood cells number to the normal degree within the group that received the probiotic complex. a decrease of the acute plethora of microvasculature was observed morphologically as a result of the treatment. there were signs of basal layer activation of the stratified squamous epithelium with a merger of the acanthosis outgrowths and a formation of the fibrotic nodules. biochemical investigations did not show significant changes in the indicators. conclusions: in the settings of the chronic periodontitis model, the use of gelatin-based probiotic consortium consisting of lactobacillus casei subsp. pseudoplantarum, lactobacillus caseisubsp.casei, l.fermentum, l. helveticus. at 2.5 x 109 cfu/ml viable cell numbers lead to the reduction of the local inflammatory manifestations of the periodontitis in 14 days of treatment. keywords: probiotics, chronic periodontitis, lactobacilli http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. screening of gestational diabetes and hypertension among antenatal women in rural west india viral r. dave1, bhavik m. rana1, kantibhai n. sonaliya1, suraj j. chandwani2, samkit v. sharma2, swati o. khatri2, khalid m. shaikh2, farida m. hathiari2 1community medicine department, gujarat cancer society (gcs) medical college, ahmedabad, gujarat, india; 2gujarat cancer society (gcs) medical college hospital & research centre, ahmedabad, gujarat, india vol. 3, no. 1 (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.140 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ dave this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu abstract background: hypertension and gestational diabetes are among the leading causes of maternal and perinatal mortality, especially in rural areas of developing countries with meager health facilities. with early diagnosis and timely treatment, these adverse events can be decreased. the primary aim of this study was to implement a screening program for gestational diabetes and hypertension, and to assess risk factors associated with these conditions among antenatal women in the rural area of the gujarat province in india. methods: a cross–sectional study was conducted at one of the rural areas of gujarat province in india. following a random cluster sampling procedure, the village of davas was selected. a multistage random sampling method was utilized, resulting in a sample of 346 antenatal women. screening guidelines from the american diabetes association were followed for gestational diabetes screening. results: the majority of antenatal mothers (55.50%) were between 21-25 years of age. 242 antenatal women were multigravida, and among them, 85.96% had institutional delivery at their last pregnancy. of the total 346 women, 17.60% were prehypertensive. the prevalence of systolic hypertension was 1.40%, diastolic hypertension was 0.90%, and gestational diabetes was 1.73%. conclusion: socioeconomically upper class, a family history of hypertension, and bmi ≥ 25 were strong risk factors for hypertension during pregnancy and gestational diabetes. health education should be made readily available to antenatal mothers by paramedical workers regarding symptoms of hypertension and gestational diabetes mellitus for early self identification. keywords: gestational diabetes, hypertension, screening, maternal mortality, perinatal mortality screening of gestational diabetes and hypertension among antenatal women in rural west india viral r. dave1, bhavik m. rana1, kantibhai n. sonaliya1, suraj j. chandwani2, samkit v. sharma2, swati o. khatri2, khalid m. shaikh2, farida m. hathiari2 1community medicine department, gujarat cancer society (gcs) medical college, ahmedabad, gujarat, india; 2gujarat cancer society (gcs) medical college hospital & research centre, ahmedabad, gujarat, india research maternal mortality and perinatal mortality are two very important indicators of the developmental index of a country and have a significant impact on the population’s life expectancy. hypertension (htn) during pregnancy/pre-eclampsia and gestational diabetes are among the leading causes of maternal and perinatal morbidity and mortality, especially in rural areas of developing countries.1,2 the literature suggests that 10-15% of maternal mortality in developing countries is due to hypertensive disorders of pregnancy.3,4 various adverse effects of htn in pregnancy include preterm delivery, intrauterine growth retardation, reduced birth weight, still birth, and perinatal mortality.5,6 early detection and prompt care are required to prevent adverse outcomes of pregnancy with htn. for this reason, it is recommended to evaluate a http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu woman’s risk for htn at their first prenatal visit. in india, the national health programme of reproductive and child health has stipulated routine screening of blood pressure (bp) for antenatal mothers at each visit, which should be implemented in conjunction with the assessment of maternal history of htn symptoms. prevalence of gestational diabetes mellitus (gdm) in some ethnic groups ranges from 1 to 14% depending on screening method selection, diagnostic criteria, and population screened. gdm can negatively affect pregnancy and result in adverse perinatal outcomes such as macrosomia, birth trauma, shoulder dystocia, and higher rates of cesarean section.7 in india, screening is essential in all pregnant women, as indian women have an eleven-fold increased risk8 of developing glucose intolerance during pregnancy compared to caucasian women,9 which can be decreased with early screening, diagnosis, and treatment. it is generally accepted that women of asian origin, especially ethnic indians, are at a higher risk of developing gdm and subsequently type 2 diabetes.10,11 the so-called asian-indian phenotype refers to certain unique clinical and biochemical abnormalities in indians, which includes, but is not limited to, increased insulin resistance and greater abdominal adiposity. this phenotype makes indians more prone to diabetes.12 the objective of this study was to implement screening for gestational diabetes and htn and to investigate risk factors associated with the development of these conditions among women in gujarat province in india. the ultimate goal of this work was to minimize complications and reduce morbidity and mortality associated with gestational diabetes and htn in highrisk groups. methodology after obtaining permission from the institutional ethical committee at gujarat cancer society (gcs) medical college, hospital & research centre, ahmedabad, india, the present study was conducted at one of the rural areas of the gujarat province in india. the study was conducted between march 2013 and june 2013 and utilized cross-sectional assessments. a multistage random cluster sampling method was utilized to obtain a sample of 346 antenatal women. after preparing a list of districts of gujarat state in their ascending order as per their population, the banaskantha district was randomly selected. following random selection procedure, the taluka “deesa” (administrative subunit of district) and the village of “davas” were selected. the primary health centre (phc) is a very basic medical setting, which provides health care services to rural populations. the phc of davas was contacted to ascertain a list of “anganwadi” discovered in the field practice area of phc. anganwadi is a part of the indian public health-care system where basic health-care activities are carried out for antenatal and postnatal women, adolescent girls, and children less than 6 years of age. phc in davas covers a total population of 39,001 people and 15 other villages around davas, as per the 2011 census. anganwadi centers are a basic unit of the integrated child development scheme run by the government of india and provide health care services to antenatal and postnatal women, adolescent girls, and children less than 6 years of age. monthly prenatal check ups is one of the key health services provided by these centers. a total of 346 antenatal women were registered with all anganwadis covered by davas phc. all were interviewed and after informed consent was taken from each participant, they were included in the study. a pretested and structured questionnaire on sociodemographic information, obstetric details, and outcome of screening tests was used for data collection. various risk factors generally associated with gestational diabetes and htn such as age, bmi (body mass index), education, occupation, socioeconomic class, and family history were also assessed using questionnaires. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx dave this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu the modified prasad classification13 was used for socioeconomic stratification, which is commonly used on the indian subcontinent. this classification system divides the community into five different classes based on per capita income of family and taking into consideration all india consumer price index declared by the labour bureau, government of india at the time of study.14 for screening of gestational diabetes, guidelines of american diabetes association15 were followed, which state that: a fasting plasma glucose level > 126 mg/dl (7.0 mmol/l) or casual plasma glucose > 200 mg/dl (11.1 mmol/l) meets the threshold for diagnosis of diabetes, if confirmed on a subsequent day and precludes need for any glucose challenge. following the abovementioned guidelines, random blood sugar levels (rbs) were measured using a standard glucometer (glucosign @ accubiotech). participants with rbs > 200 mg/day were re-screened on the following day with a fasting blood sugar. blood pressure was classified per the following criteria:16 normal if < 120 systolic bp and < 80 diastolic bp, prehypertension if 120-139 systolic bp or 80-89 diastolic bp, stage i htn if 140-159 systolic bp or 9099 diastolic bp, and stage ii htn if systolic bp ≥ 160 or diastolic bp ≥ 100. a standard sphygmomanometer was used to measure bp. all bp measurements were taken in sitting position, and on finding bp higher than normal, a recording was repeated immediately and also on the next day to ensure that measurements were accurate. conservative recording of the lowest reading was evaluated in the data analysis. data entry and data analysis were performed using spss software. risk factors for htn and diabetes were analysed by bi-variate analysis along with the use of odds ratios. results table 1 presents sociodemographic data of study participants at baseline. the majority of antenatal mothers (55.50%) were 21-25 years of age. it is noteworthy that 21.10% of pregnant women were ≤ 20 years of age while 2.89% of participants were > 30 years aged. 60.98% of expectant mothers were illiterate, and only 0.87% had education at secondary school level, while none of them had completed any secondary education. most of participant females were housewives (63.58%), while 34.97% of mothers were engaged in strenuous labor activities such as farming, construction, etc. based on modified prasad classification for socioeconomic class, the majority of women belonged to lower socioeconomic classes. 39.60% of women were from class iv and 42.77% belonged to socioeconomic class v. 7.23% of antenatal women had a bmi ≥ 25. table 1: baseline characteristics of study participants table 2 describes obstetric profiles of study participants. 69.94% of antenatal women were multigravida, while 30.06% were primigravida. in multigravida participants, most deliveries were institutional (85.96%) while 14.04% of mothers had their last delivery without medical supervision. of this 14.04% of mothers, the majority had home delivery; however, some delivered at their work place, including farms. 11.57% had their deliveries conducted by traditional birth attendants (tba) known as “dai” in india, while 2.47% of deliveries were conducted by other attendants (including relatives, neighbors, and quacks). table 2: obstetric profile of study participants figure 1 shows the distribution of bp among antenatal women in the study at screening. it suggests that 80.90% of study participants had systolic bp within normal range, while 17.60% were prehypertensive. 1.20% and 0.20% had stage i and stage ii systolic bp htn, respectively. diastolic bp distribution was http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu somewhat different. 90.80% had normal diastolic bp. 8.40% were prehypertensive, while 0.60% and 0.30% had stage i and ii diastolic bp htn, respectively. figure 1: distribution of stages of hypertension among antenatal women at screening table 3 suggests the role of various risk factors associated with htn, using odds ratio based on bivariate analysis. the risk factors evaluated were age, bmi ≥ 25, lower socioeconomic class, occupation, education and family history positive for htn. upper socioeconomic class and positive family history of htn were significantly (p < 0.05) associated with htn among study participants. table 3: odds ratio for risk factors found to be associated with systolic hypertention random blood sugar levels were checked for screening of gdm as per guidelines mentioned in methodology. the screening yielded 1.73% antenatal mothers had their rbs levels more than 200 mg/dl on two occasions. none of them were known cases of diabetes, while 98.27% had their rbs within normal range. the role of various risk factors associated with gestational diabetes, using odds ratio based on bi-variate analysis is described in table 4. it shows that among various risk factors such as age, bmi ≥ 25, upper socioeconomic class, occupation, education, and family history of htn, only a bmi of ≥ 25 was significantly (p < 0.05) associated with gdm among study participants. table 4: odds ratio for risk factors found to be associated with gestational diabetes discussion the present study found the prevalence of systolic htn was 1.40%, diastolic htn was 0.90%, and gdm was 1.73%. upper socioeconomic class and positive family history of htn were significantly associated with htn. while analyzing other risk factors, only bmi ≥ 25 was significantly associated with gdm among study participants. a study conducted by yadav et al.17 found a prevalence of htn as high as 8.70% among females of less than 40 years of age. however, the sample included females from an urban colony of high-income residents among the general population, which could be responsible for the high prevalence. while the government is expending a considerable amount of funds as well as manpower to decrease maternal and perinatal mortality, it appears that residents of remote rural and tribal areas may not be taking advantage of some of the screening and early diagnosis practices. the overall prevalence of diabetes in the western region of india was found to be 3.70%;18 however, in this study, all age groups as well as all genders were included in this study. a previous study19 conducted in punjab region of india showed a prevalence of systolic htn at 4.45% and diastolic htn at 4.20% in a sample of 1,000 pregnant females, while the present study found a prevalence of systolic htn was only 1.40% and diastolic htn was 0.90%. the differences between this study and the above mentioned study could be attributed to a larger sample size from both rural and urban areas of the punjab state used in the previous study. sayeed et al.20 found in their study at bangladesh a crude prevalence of systolic and diastolic htn was 6.80% and 5.40%, respectively, possibly due to the inclusion of a higher aged sample. bener and saleh21 in their study at qatar found maternal age > 30, increased bmi, previous abortion, lack of antenatal care, and physical activity were significantly associated with an increased risk of pregnacy induced hypertension http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx dave this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu (pih). in the current study, upper socioeconomic class and positive family history of htn were found to be associated with htn, which is comparable to other similar studies.20,21 in the present study, the prevalence of gdm was found to be 1.73%. kalra et al.22 found a prevalence of gdm among the study population was 6.60%, while gupta et.al.23 in the jammu region of india found a prevalence of gdm was 3.05%. these data reveal a wide variation in the prevalence of gestational diabetes in india. a previous study24 conducted in haryana, north india, showed 7.10% prevalence, while another study25 conducted in south india revealed prevalence of 17.80% women in urban, 13.80% in semi urban, and 9.90% in rural population of gestational diabetes. sayeed et al.20 in bangladesh found the prevalence of diabetes was 6.80% according to fasting blood glucose (fbg) guideline values. in the present study, we found that only bmi ≥ 25 was significantly associated with gdm, while sheshiah et al.25 found that age ≥ 25 years, bmi ≥ 25 kg/m2, and positive family history of diabetes were significantly associated with gdm. rajput et al.24 found that socioeconomic status above upper middle class and kalra et al.22 found that family history of diabetes mellitus, age ≥ 25 years, past history of gdm, and bmi ≥ 25 kg/m2 were significantly associated with gdm group. rajput et al.24 found that socioeconomic status above upper middle class was associated significantly with gdm in their findings. kalra et al.22 found that a family history of diabetes mellitus, age ≥ 25 years, past history of gdm, and bmi ≥ 25 kg/m2 were significantly associated with gdm group in their study. 55.49% of participants in the present study were 21-25 years of age, and 60.98% were illiterate. in a similar study by rajput et al.24 58.20% were 21-25 years of age, while only 4.90% were illiterate. literacy rate in the present study was low as compared to national average (65.46%) and gujarat state average (70.73%) for females.26 the reason may be due to the fact that the selected district was in a remote area with tribal vicinity. in the same study, rajput et al.24 found that 8.20% of participants had a bmi ≥ 25 while in current study it was 7.20%. limitations of the study this investigation had one main limitation. though most research recommends oral glucose tolerance test (ogtt) as a method of choice for screening of diabetes, this method was not possible to implement in the context in this study. ogtt is supposed to be performed under clinical observation with laboratory set up. it also requires multiple blood draws for which the subject needs to be contacted more than 2 times and requires longer time duration (3-4 hours). as the current study is a cross sectional study with limited resources at remote rural area, the necessary time, human resource and financial resources were limiting factors for conducting gtt. strengths of the study as there are very limited number of studies conducted in the past involving pregnant women of rural india, this study can contribute significantly and provide a glimpse about health conditions of antenatal women in rural population of india. the current study also provided an opportunity to contact study subjects and identify some previously undetected at risk women who were referred for further evaluation and management. conclusion & recommendations the present study found prevalence of systolic htn was 1.40%, diastolic htn was 0.90%, and gdm was 1.73% among study population in the rural area of gujarat province, india. overall, the prevalence of gestational diabetes and htn in the gujarat state should be evaluated in the future with a multicenter study and larger sample size. incidence and prevalence rate of any specific disease is the basis for making prevention http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu strategies at national level of health planning. a proper disease registry should be created for monitoring gestational diabetes and pregnancy induced htn. public health education should be made readily available to antenatal mothers by paramedical workers regarding alarming symptoms of htn and gdm for early self identification. adopting a healthy life style and monitoring blood pessure and sugar levels are keys for prevention of htn and diabetes in india and globally. conflict of interest the authors report no conflict of interest. references 1. world health organization (who). maternal mortality. 2014; http://www.who.int/mediacentre/factsheets/fs348/en/. accessed june 25, 2012. 2. otolorin eo, famuyiwa oo, bella af, dawodu ah, adelusi b. reproductive performance following active management of diabetic pregnancies at the university college hospital, ibadan, nigeria. afr j med med sci. 1985;14(3-4):155-160. 3. al-ghamdi sm, al-harbi as, khalil a, el-yahyia ar. hypertensive disorders of pregnancy: prevalence, classification and adverse outcomes in northwestern saudi arabia. ann saudi med. 1999;19(6):557-560. 4. mounier-vehier c, delsart p. pregnancy-related hypertension: a cardiovascular risk situation. presse med. 2009;38(4):600-608. 5. yadav s, saxena u, yadav r, gupta s. hypertensive disorders of pregnancy and maternal and foetal outcome: a case controlled study. j indian med assoc. 1997;95(10):548-551. 6. jain l. effect of pregnancy-induced and chronic hypertension on pregnancy outcome. j perinatol. 1997;17(6):425-427. 7. gasim t. gestational diabetes mellitus: maternal and perinatal outcomes in 220 saudi women. oman med j. 2012;27(2):140-144. 8. neelakandan r, sethu ps. early universal screening for gestational diabetes mellitus. j clin diagn res. 2014;8(4):oc12oc14. 9. wahi p, dogra v, jandial k, et al. prevalence of gestational diabetes mellitus (gdm) and its outcomes in jammu region. j assoc physicians india. 2011;59:227-230. 10. dornhorst a, paterson cm, nicholls js, et al. high prevalence of gestational diabetes in women from ethnic minority groups. diabet med. 1992;9(9):820-825. 11. seshiah v, sahay bk, das ak, et al. diagnosis and management of gestational diabetes mellitus: indian guidelines. 2013; http://www.apiindia.org/medicine_update_2013/chap44.pdf. accessed october 4, 2014. 12. magon n. gestational diabetes mellitus: get, set, go from diabetes capital of the world to diabetes care capital of the world. indian j endocrinol metab. 2011;15(3):161-169. 13. agarwal a. social classification: the need to update in the present scenario. indian j community med. 2008;33(1):50-51. 14. labour bureau, government of india. statistics. 2014; http://labourbureau.nic.in/indtab.html. accessed october 4, 2014. 15. american diabetes association. position statement, gestational diabetes mellitus: diabetes care. 2004. 16. kotchen ta. hypertensive vascular disease. harrison’s principals of internal medicine. 17th ed. united states: the mcgraw-hill companies; 2008. 17. yadav s, boddula r, genitta g, et al. prevalence & risk factors of pre-hypertension & hypertension in an affluent north indian population. indian j med res. 2008;128(6):712-720. 18. mohan v, pradeepa r. epidemiology of diabetes in different regions of india. health administrator. 2009;22:1-18. 19. gupta s, gupta v, bakshi d, madaan u, meshwari r, yashpal j. to study the prevalence of hypertension and prehypertension and their correlation with age, number of pregnancies, duration of pregnancy, body mass index, fasting blood sugar and hemoglobin in pregnant females in punjab. 2008; http://www.japi.org/april2008/oral_hypertension.htm accessed august 12, 2013. 20. sayeed ma, mahtab h, khanam pa, begum r, banu a, azad khan ak. diabetes and hypertension in pregancy in a rural community of bangladesh: a population-based study. diabet med. 2005;22(9):1267-1271. 21. bener a, saleh nm. the impact of socio-economic, lifestyle habits, and obesity in developing of pregnancy-induced hypertension in fast-growing country: global comparisons. clin exp obstet gynecol. 2013;40(1):52-57. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/mediacentre/factsheets/fs348/en/ http://www.apiindia.org/medicine_update_2013/chap44.pdf http://labourbureau.nic.in/indtab.html http://www.japi.org/april2008/oral_hypertension.htm dave this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu 22. kalra p, kachhwaha cp, singh hv. prevalence of gestational diabetes mellitus and its outcome in western rajasthan. indian j endocrinol metab. 2013;17(4):677-680. 23. gupta a, gupta yv, kumar s, kotwal r. screening of gestational diabetes mellitus with glucose challenge test in high risk group. journal of medical education and research. 2006;8(2). 24. rajput r, yadav y, nanda s, rajput m. prevalence of gestational diabetes mellitus & associated risk factors at a tertiary care hospital in haryana. indian j med res. 2013;137(4):728-733. 25. seshiah v, balaji v, balaji ms, et al. prevalence of gestational diabetes mellitus in south india (tamil nadu)--a community based study. j assoc physicians india. 2008;56:329333. 26. state of literacy. http://censusindia.gov.in/2011-provresults/data_files/india/final_ppt_2011_chapter6.pdf. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://censusindia.gov.in/2011-prov-results/data_files/india/final_ppt_2011_chapter6.pdf http://censusindia.gov.in/2011-prov-results/data_files/india/final_ppt_2011_chapter6.pdf central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu table 1: baseline characteristics of study participants from the davas village characteristics number of participants (%) age (years) ≤ 20 73 (21.10) 21 – 25 192 (55.49) 26 – 30 71 (20.52) 31 – 35 9 (2.60) ≥ 36 1 (0.29) education illiterate 211 (60.98) primary 132 (38.15) secondary and above 3 (0.87) occupation housewife 220 (63.58) laborer 121 (34.97) other 5 (1.45) socioeconomic class i 3 (0.87) ii 18 (5.20) iii 40 (11.56) iv 137 (39.60) v 148 (42.77) bmi (kg/m2) < 18.5 68 (19.65) 18.5 – 25 253 (73.12) ≥ 25 25 (7.23) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx dave this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu table 2: obstetric profile of study participants characteristics number of participants (%) gravida primigravida 104 (30.06) multigravida 242 (69.94) last delivery conducted (n = 242) institutional deliveries 208 (85.96) traditional birth attendants 28 (11.57) other 6 (2.47) mode of last delivery (n = 242) full term normal delivery 202 (83.47) premature delivery 7 (2.89) miscarriage 2 (0.83) abortion 27 (11.16) cesarian section 4 (1.65) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu table 3: odds ratio for risk factors found to be associated with systolic hypertension risk factors odds ratio 95% confidence interval p-value lower upper age > 25 years 0.81 0.08 7.37 0.60 bmi ≥ 25 3.29 0.35 30.62 1.25 se upper class (i + ii)* 7.77 1.27 47.60 0.03 housewife 0.14 0.01 1.26 0.13 education (illiterate) 0.15 0.01 1.41 0.08 family history* 2.89 0.32 25.83 0.02 note. * denotes significance with a p < 0.05. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx dave this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu table 4: odds ratio for risk factors found to be associated with gestational diabetes risk factors odds ratio 95% confidence interval p-value lower upper age > 25 years 1.66 0.30 9.26 0.38 bmi ≥ 25* 5.36 0.53 53.94 0.01 se upper class (i + ii) 1.53 0.73 3.21 0.46 housewife 1.14 0.20 6.35 0.28 education (illiterate) 1.29 0.23 7.14 0.81 family history 1.78 0.27 8.13 0.09 note. * denotes significance with a p < 0.05. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.140|http://cajgh.pitt.edu figure 1: distribution of stages of hypertension among antenatal women at screening 80.9 17.6 1.2 0.2 90.8 8.4 0.6 0.3 0 10 20 30 40 50 60 70 80 90 100 normal prehypertensive stage i stage ii p er ca n ta g e d is tr ib u ti o n o f st u d y p a rt ic ip a n ts systolic diastolic http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx examination of lactic acid bacteria to secretion of bacteriocins new articles in this journal are licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. examination of lactic acid bacteria to secretion of bacteriocins maira urazova, asel moldagulova, sandugash anuarbekova, altynay tuyakova, gulyaim abitaeva, elvira nagyzbekkyzy, eleonora bekenova, serik shaikhin, kairtai almagambetov republican collection of microorganisms, astana, kazakhstan vol. 2, suppl. (2013) | issn 2166-7403 (online) doi 10.5195/cajgh.2013.106 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ urazova this work is licensed under a creative commons attribution 3.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 2, suppl. (2013) | issn 2166-7403 (online) | doi 10.5195/cajgh.2013.106 | http://cajgh.pitt.edu abstract introduction: bacteriocins produced by lactic acid bacteria (lab) have the potential to cover a very broad field of applications, including the food industry and the medical sector. in the food industry, bacteriocinogenic lab strains can be used as starter cultures, co-cultures, and bioprotective cultures, which would be used to improve food quality and safety. in the medical sector, bacteriocins of probiotic lab might play a role in interactions, which take place in human gastrointestinal tract, and contribute to gut health. the aim of this study was the examine the effect of lab antimicrobial activity. methods: lab were isolated from different commercial and home made products, such as kazy and sour cream. to screen for bacteriocin producing lab, we used an agar diffusion bioassay, described in a previous study by dr. yang, with three modifications in cell-free supernatant (cfs). first we had a clear supernatant, second we adjusted the cfs to ph 6.0 to eliminate acids antimicrobial effects, and third the cfs ph 6.0 was treated with catalase to exclude the action of h2o2 and confirm action of bacteriocin-like substances. pathogenic s.marcescens, e. coli, s.aureus cultures were used as indicators. results: screening of 95 strains of lab through deferred antagonism to six indicator cultures showed that all of the selected strains had a high value of antibacterial activity. however, cfs of only 50 strains retained their antimicrobial activity, and 10 of them lost this activity in the second modification of cfs with ph 6.0 to test culture s.marcescens, which confirmed the acidic nature of antimicrobial activity of cfs. lb.rhamnosus (p-1), lb.fermentum (n-6), and lc.lactis (7m) lost antibacterial activity in the presence of the catalase. all modifications of cfs of three strains: lb.pentosus (16al), lb.pentosus (p-2), and pediococcusacidilactici (8) retained inhibitory activity to e.coli and s. aureus. supernatants of only lactococcusgarvieae (10a) and pediococcusacidilactici (25) extracted from homemade meat food kazy (karaganda) and sour cream (astana), respectively retained antibacterial activity to all three indicator cultures. conclusion: the antibacterial activity (ph 6.0, added catalase) of lactococcusgarvieae (10a) and pediococcusacidilactici (25) to s. marcescens, e. coli, and s.aureus indicates these strains as promising strains for further use in the preparation of bacteriocins. keywords: lactic acid bacteria, antibacterial activity, bioassay, food products, kazy http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. prevalence of psychiatric disorders among the rural geriatric population: a pilot study in karnataka, india sreejith s. nair1, pooja raghunath2, sreekanth s. nair3 1department of community medicine, navodaya medical college, raichur, karnataka, india; 2department of microbiology, pushpagiri institute of medical sciences and research center, tiruvalla, kottayam, kerala, india; 3department of forensic medicine, academy of medical sciences, pariyaram, kannur, kerala, india vol. 4, no. 1 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.138 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ nair this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.138|http://cajgh.pitt.edu abstract background: increasing life expectancy around the world, an outstanding achievement of our century, has brought with it new public health challenges. india is the second most populous country in the world, with over 72 million inhabitants above 60 years of age as of 2001. the life expectancy in india increased from 32 years in 1947 to over 66 years in 2010, with 8.0% of the population now reaching over 60 years of age. few studies in india target the health, especially mental health, of this geriatric population. this study aims to estimate the current prevalence of psychiatric disorders in the geriatric population of the rural area of singanodi,karnataka, india. methods: this cross sectional, epidemiological, community-based study was conducted in a rural health training area of singanodi, raichur district, karnataka, india.the general health questionnaire-12, mini mental state examination, and geriatric depression scale were administered to 366 participants. chi square tests with yates correction were utilized for statistical analysis using spss 19.0 software. results:we found that 33.9% of the geriatric population in the selected province were above the threshold for mental illness based on the ghq-12 questionnaire. females had a higher prevalence of mental disorder at 77.6% (152 out of 196) as compared to males who had a prevalence of 42.4% (72 out of 170). the most common psychiatric disorder was depression (21.9%), and generalized anxiety was present in 10.7% of the study population. prevalence of cognitive impairment was 16.3%, with a significantly higher percentage of affected individuals in 80+ age group. conclusion: mental disorders are common among elderly people, but they are not well documented in rural india. the assessment of psychiatric disorder prevalence will help strengthen psycho-geriatric services and thus improve the quality of life of the elderly. a system that ensures comprehensive health care will have to be developed for this purpose as part of our future efforts. keywords: psychiatric disorder, depression, anxiety, geriatric, aging, india prevalence of psychiatric disorders among the rural geriatric population: a pilot study in karnataka, india sreejith s. nair1, pooja raghunath2, sreekanth s. nair3 1department of community medicine, navodaya medical college, raichur, karnataka, india; 2department of microbiology, pushpagiri institute of medical sciences and research center, tiruvalla, kottayam, kerala, india; 3department of forensic medicine, academy of medical sciences, pariyaram, kannur, kerala, india research aging refers to the multidimensional process of physical, psychological, and social change.1 recent advances in health sciences and improvement in social conditions have led to an increase in life expectancy in most countries of the world.2 however, increased life expectancy around the world also brought new public health challenges, such as increasing incidence and prevalence of chronic, age-related disorders.3 in india, the second most populous country in the world, the proportion of those 60 years and older was 5.4% in 1951, and it increased to 8.0% in 2010.4 life expectancy at birth for males increased from 42 years (1951-1960) to 58 years (1986-1990).4 life expectancy is projected to increase to 67 years for males and 69 years for females by the year 2016.5 furthermore, the united http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.138|http://cajgh.pitt.edu nations indicated that 21.0% of the indian population will be aged 60+ years by 2050.5 mental disorders in the elderly often go untreated due to the misperceptions that these disorders are a normal part of aging and a natural reaction to chronic illness, loss of family members, and social transition occurring with age.6 the burden of late-life psychiatric disorder on physical health, social support systems, and overall functioning is considerable, making mental disorders a leading cause of burden in elderly adults.7 additionally, mental disorder is a preventable risk factor for mortality, particularly suicide attempts.8 western countries have conducted numerous studies on the resources, needs, and outcomes on the community-based care of the elderly, which helped in the estimation of public health burden of the geropsychiatric population.9-14 few studies have been conducted in india on the extent of mental disorder burden in these geriatric age groups. pathak14 noted that there have been few publications on the health problems of those aged 60 years and above in india,15 while even fewer have examined the mental health of the elderly in india.16 the purpose of this article is to highlight the psychiatric problems faced by the elderly indian population as well as develop strategies to improve the quality of life for the elderly.17 methods this cross-sectional, observational, communitybased study was conducted in the rural health training area of singanodi, raichur district, karnataka, india.the navodaya medical college and research centre institutional ethical review board approval was obtained before commencing the study. informed consent was obtained prior to study participation. study population we used the united nations (un) guideline of 60+ years to refer to the elderly population.18 the area of singanodi has a population of 25,486 with a geriatric population of approximately 2,500 residents. a sample size of 383 was estimated using the formula 4pq/l2 (prevalence of 42%,19 allowable error 12% and 95% confidence). of the 383 elderly participants, 17 persons could not be included in the study due to the individuals or their family members’ refusal to participate. thus, a total of 366 were included in the final sample. procedures the team made twenty visits between january 15 and april 15, 2014. a community medicine postgraduate physician and 3 social workers visited the study area once or twice a week. prior to the start of the study, the team members underwent training in the use of the screening devices and a degree of standardization was achieved. all interviewers were trained in the standard operating procedure of survey administration to avoid any information bias. commencing from the eastern end of the town, a door-to-door survey was implemented. residents of the houses were querried for the presence of any resident aged 60 years and above in the house. if due to some reason the potential participant was not available during first visit, he/she was contacted during the subsequent visit. inclusion criteria for the study were: aged 60 years or above at the time of survey, a resident of the study area (singanodi) for at least one year prior to the start of the study or those staying for less than a year but intended to stay permanently. individuals were excluded if they were guests or lived in the area for less than one year and did not intend to stay permanently. measures four survey instruments were utilized. first, the general health questionnaire-12 (ghq-12)20,21 is a selfadministered screening test, which is the most commonly used screening instrument for detecting psychiatric disorders in community settings and non-psychiatric http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx nair this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.138|http://cajgh.pitt.edu clinical settings. a score of ≥2 is the cut-off score for possible psychiatric disorder for this screening instrument.20 second, the mini-mental state examination (mmse) is the most widely used cognitive screening instrument worldwide.22 it is commonly used to screen for dementia. any score ≥27 points indicates a normal cognition. below this, scores can indicate severe (<9 points), moderate (10-18 points) or mild (19-26 points) cognitive impairment. the hindi translation of mmse that was suitably modified was used in this study, which has been validated in various studies.16-18 third, the geriatric depression scale-15, short version (gds) is a 15 item self-report scale for assessing depression.23 in this scale, scores of 0-9 are considered normal, 10-19 indicated mild depression, and 20-30 indicated severe depression. fourth, the generalized anxiety (ga) scale was adapted from the care24 schedule as a subscale. scores of 5-9 points is indicative of mild anxiety, and a score of 10 points or higher is indicative of major anxiety.19-21 data analysis descriptive statistics were used to gather basic participant characteristics as well as the prevalence of psychiatric disorders. chi square analyses with a yates correction were used to analyze age group differences for psychiatric disorder prevalence and to analyze gender differences for psychiatric disorder prevalence. all analyses were conducted using spss 19.0 software. results there were 366 persons from 205 households aged 60 years and above in the surveyed population who agreed to participate in the study, with women comprising 53.6% of the sample. the distribution of participants in each age group was similar for both the sexes. table 1 shows the distribution of the sample population according to age and gender. table 1: distribution of study population stratified by sex and age group the majority of participants were in 60-64 age group (42%). table 2 shows the distribution of psychiatric disorder prevalence stratified by age, sex, and marital status. table 2: distribution of psychiatric disorder prevalence stratified by age, sex, and marital status presence of psychiatric morbidity was defined as having screened positive for at least one of the following: cognitive decline, dementia, depression, or generalized anxiety. participants in the age group 80+ screened positive for more psychiatric disorders as compared to younger age groups (x2 = 10.25, p < 0.05). similarly, significantly more females were mentally ill as compared to males (x2 = 23.75, p < 0.001). further, we observed that significantly more widowed participants have been affected by mental disorders compared to married participants (x2 = 25.17, p < 0.001). prevalence of psychiatric disorders 33.9% had scores ≥2 in ghq-12, i.e. above the cut-off score for possible psychiatric disorder for this screening instrument and requiring further mental health evaluation (table 3). table 3: participants who screened positive for psychiatric disorders stratified by age group of these subjects, cognitive impairment was present in 60 participants (16.3%). depression was present in 80 (21.9%) of the study participants. generalized anxiety was present in 39 (10.66%) study participants. there was a significant effect of age on http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.138|http://cajgh.pitt.edu having a diagnosable disorder based on the ghq-12 (p=0.03) and cognitive impairment based on he mmse (p=0.03). however, there was no statistically significant effect of age on depression (p=0.82) and anxiety (p=0.87). discussion this study demonstrated that the prevalence of mental disorder was 33.9% of the elderly population (60 years and older). one previous study estimated that he prevalence of mental disorder in those 50 years and older was 34.9% in the area of madras, india.25 another study conducted in the uk estimated that the prevalence of mental disorder in those 65 years and older was 46.0%.13,26 in our sample, the burden of mental disorder was higher in females, corroborating the findings of many studies conducted in india25,27-29 and western countries.30,31 the most prevalent disorder amongst the elderly population, as reported by many field-surveys conducted in india and abroad, was depression. depression was found in 16.4% of the population, which is similar to a 13.3–18.3% prevalence reported in the literature.32,33 the prevalence rates in indian studies have been widely varied, ranging from 6.0%to 55.2%.34 banerjee and macdonald13found that depression was prevalent in 26.0% of their sample comprising persons aged 65 years and above. a significant finding of this study, which may have important implications for both social and psychological perspectives, is the high prevalence of psychiatric disorder amongst widowed people. stressful factors such as isolation and low socioeconomic status are closely associated with widowhood. in the present study, 10.66 % of the persons had gad, which is similar to the 4.6% prevalence rate reported by ritchie et al.35 most indian researchers reported a low prevalence of anxiety disorders in the elderly population.25,34 it is therefore evident that the mental health care needs of the elderly are multifaceted. a system that ensures a comprehensive health care needs to be developed for this purpose. we should not, however, lose sight of the fact that provision of health facilities does not necessarily ensure its adequate utilization.36,37 strengths and limitations one limitation of this study is that all of the study participants were from one rural location instead of multiple sites. future studies wanting to understand the impact of psychological disorders among the elderly in rural populations could focus on a multi-centric approach, using cohorts from multiple rural populations. another limitation is that the data was gathered by selfreport methods, which might cause bias due to the fact that the study population is relatively small. major strengths of this study are the inclusion of reliable screening questionnaires and standardization of interviewers to reduce bias. conclusion there are many barriers to the utilization of health facilities by the community, with more barriers experienced by the elderly. apart from their limited mobility, limited information access, and inadequate awareness of treatability of mental disorders, the elderly are likely to experience a lack of family support and social isolation. the basic philosophy of geriatric research is neither the prevention of old age nor a mere addition of years, but to “add life to years.” by assessing the social and familial risk factors of mental disorder among elderly persons residing in a rural community, community-based rehabilitation and suicide prevention programs could be developed. raising awareness about mental disorders and its association with the geriatric age group may be an effective measure for the early detection and treatment of such disorders. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx nair this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.138|http://cajgh.pitt.edu references 1. morley je. successful aging or aging successfully. jamda. 2008;10(2):85-86. 2. palacios r. the future of global ageing. int j epidemiol. 2002;31(4):786-791. 3. cassel ck. successful aging. how increased life expectancy and medical advances are changing geriatric care. geriatrics. 2001;56(1):35-39. 4. population reference bureau. today's research on aging: issue archive. 2012; http://www.prb.org/about/programsprojects/aging/todaysrese archaging/issuearchive.aspx. 5. madhu t, sreedevi a. a study of socio demographic profile of geriatric population in the field practice area of kurnool medical college. ijrdh. 2013;1(2):69-76. 6. nair ss, hiremath sg, ramesh, pooja, nair ss. depression among geriatrics: prevalence and associated factors. ijcrr. 2013;5(8):110-112. 7. world health organization (who). depression. 2012; http://www.who.int/mediacentre/factsheets/fs369/en/. 8. motohashi y, kaneko y, sasaki h, yamaji m. a decrease in suicide rates in japanese rural towns after community-based intervention by the health promotion approach. community ment health j. 2007;37(5):593-599. 9. walston j, hadley ec, ferrucci l, et al. research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the american geriatrics society/national institute on aging research conference on frailty in older adults. j am geriatr soc. 2006;54(6):991-1001. 10. houttekier d, cohen j, bilsen j, addington-hall j, onwuteaka-philipsen bd, deliens l. place of death of older persons with dementia. a study in five european countries. j am geriatr soc. 2010;58(4):751-756. 11. mills tl, cody-rydzewski s. psychology of older adults: exploring the effects of class and culture on the mental health of african americans. in: chang ec, downey ca, eds. handbook of race and development in mental health. new york: springer; 2012:67-85. 12. lawson r, davies bp, bebbington a. the uk home help service in england and wales. in: jamieson a, ed. home care for older people in europe: a comparison of policies and practices. oxford: oxford university press; 1991:63-98. 13. banerjee s, macdonald a. mental disorder in an elderly home care population: associations with health and social service use. br j psychiatry. 1996;168(6):750-756. 14. pathak jd. our elderly: some effects of aging in indian subjects. 1978; medical research centre of the bombay hospital trust, bombay. 15. nair tk. older people in rural tamil nadu. paper presented at: madras school of social work1980; madras. 16. venkoba rao a. national task force study on problems of the aged seeking psychiatric help. i. c. m. r. 1987. mental health status of the elderly. vol 26: icmr bulletin; 1996:5. 17. ingle gk, nath a. geriatric health in india: concerns and soluations. indian j community med. 2008;33(4):214-218. 18. world health organization (who). definition of an older or elderly person. health statistics and information systems 2014; www.who.int/healthinfo/survey/ageingdefnolder/en/. 19. tiwari sc, srivastava s. geropsyciatric morbidity in rural uttar pradesh. indian j psychiatry. 1998;40(3):266-273. 20. goldberg dp. a user's guide to the general health questionnaire. windsor, berks: nfer-nelson; 1988. 21. burns a, lawlor b, craig s. rating scales in old age psychiatry. br j psychiatry. 2002;180:161-167. 22. f. fm, folstein se, mchugh pr. "mini-mental state". a practical method for grading the cognitive state of patients for the clinician. j psychiatr res. 1975;12(3):189-198. 23. yesavage ja, brink tl, rose tl, et al. development and validation of a geriatric depression screening scale: a preliminary report. j psychiatr res. 1982-1983;17(1):37-49. 24. blacker d. psychiatric rating scales. in: sadock bj, sadock v, eds. comprehensive textbook of psychiatry. 8th ed. philadelphia: lippincott williams & wilkins; 2005:929-955. 25. ramachandran v, menon sm, ramamurti p. psychiatric disorders in subjects aged over fifty. indian j psychiatry. 1979;22:193-198. 26. copeland jr, dewey me, griffiths-jones hm. a computerized psychiatric diagnostic system and case nomenclature for elderly subjects: gms and agecat. psychol med. 1986;16(1):89-99. 27. patel v, kirkwood br, pednekar s, et al. gender disadvantage and reproductive health risk factors for common mental disorders in women: a community survey in india. arch gen psychiatry. 2006;63(4):404-413. 28. sood a, singh p, gargi pd. psychiatric morbidity in nonpsychiatric geriatric inpatients. indian j psychiatry. 2006;48(1):56-61. 29. pereira b, andrew g, pednekar s, pai r, pelto p, patel v. the explanatory models of depression in low income countries: http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.prb.org/about/programsprojects/aging/todaysresearchaging/issuearchive.aspx http://www.prb.org/about/programsprojects/aging/todaysresearchaging/issuearchive.aspx http://www.who.int/mediacentre/factsheets/fs369/en/ http://www.who.int/healthinfo/survey/ageingdefnolder/en/ central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.138|http://cajgh.pitt.edu listening to women in india. j affect disord. 2007;102(1-3):209218. 30. ramsay r, welch s, youard e. needs of women patients with mental illness. bjpsych advances. 2001;7(2):85-92. 31. steadman hj, osher fc, robbins pc, case b, samuels s. prevalence of serious mental illness among jail inmates. psychiatr serv. 2009;60(6):761-765. 32. lindesay j, briggs k, murphy e. the guy's/age concern survey. prevalence rates of cognitive impairment, depression and anxiety in an urban elderly community. br j psychiatry. 1989;155:317-329. 33. beekman at, copeland jr, prince mj. review of community prevalence of depression in later life. br j psychiatry. 1999;174:307-311. 34. rao av, madhavan t. gerospsychiatric morbidity survey in a semi-urban area near madurai. indian j psychiatry. 1982;24(3):258-267. 35. ritchie k, artero s, beluche i, et al. prevalence of dsm-iv psychiatric disorder in the french elderly population. br j psychiatry. 2004;184(147-152). 36. lorig kr, ritter p, stewart al, et al. chronic disease selfmanagement program: 2-year health status and health care utilization outcomes. med care. 2001;39(11):1217-1223. 37. gill tm, desai mm, gahbauer ea, holford tr, williams cs. restricted activity among community-living older persons: incidence, precipitants, and health care utilization. ann intern med. 2001;135(5):313-321. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx nair this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.138|http://cajgh.pitt.edu table 1: distribution of study population age and sex age group n (%) male female 60 – 64 80 (47.0) 74 (37.7) 65 – 69 52 (30.6) 58 (29.6) 70 – 74 16 (9.4) 28 (14.3) 75 – 79 10 (5.9) 18 (9.2) 80+ 12 (7.1) 18 (9.2) total 170 (100.0) 196 (100.0) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.138|http://cajgh.pitt.edu table 2: distribution of psychiatric disorder prevalence stratified by age, sex, and marital status variable n (%) normal screen positive screen age group* 60 – 64 62 (44.9) 92 (40.4) 65 – 69 50 (36.2) 60 (26.3) 70 – 74 8 (5.8) 36 (15.8) 75 – 79 14 (10.2) 14 (6.1) 80+ 4 (2.9) 26 (11.4) gender** male 98 (69.0) 72 (32.1) female 44 (31.0) 152 (67.9) marital status** married 106 (74.6) 82 (36.6) widowed 36 (25.4) 142 (63.4) note. *indicates p < 0.05; ** indicates p < 0.001. participants who scored above the threshold in at least one psychiatric disorder screening tool were counted as a “positive screen.” participants who did not score above the threshold were counted as “normal.” http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx nair this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.138|http://cajgh.pitt.edu table 3: participants who screened positive for psychiatric disorders stratified by age group age group n (%) 60 – 64 65 – 69 70 – 74 75 – 79 80+ total ghq-12 32 31 35 4 22 124 mmse 15 7 5 15 18 60 gds 27 15 11 13 14 80 ga 18 7 4 3 7 39 note. ghq-12 is the general health questionnaire-12. mmse is the mini-mental status examination. gds is the geriatric depression scale. ga is the generalized anxiety scale. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. the first kazakh whole genomes: the first report of ngs data ainur akilzhanova1, ulykbek kairov1, saule rakhimova1, askhat molkenov1, arang rhie2, jong-il kim2, jeong-sun seo2, zhaxybay zhumadilov1 1center for life sciences, nazarbayev university, astana, kazakhstan; 2department of biochemistry and molecular biology, genomic medicine institute, seoul national university college of medicine, south korea vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.146 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ akilzhanova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.146 | http://cajgh.pitt.edu abstract introduction: the human genome sequence will underpin human biology and medicine in the next century, providing a single, essential reference to all genetic information. extraordinary technological advances and decreases in the cost of dna sequencing have made the possibility of whole genome sequencing (wgs) feasible as a highly accessible test for numerous indications. the international project “genetic architecture of kazakh population” is well underway to determine the complete dna. next generation sequencing is a powerful tool for genetic analysis, which will enable us to uncover the association of loci at specific sites in the genome associated with disease. the aim of this study was to introduce first data on wgs of 6 kazakh individuals. methods: this pilot study is among the first wgs performed on 6 healthy kazakh individuals, using next generation sequencing platform hiseq2000, illumina by manufacturer’s protocols. all generated *.bcl files were simultaneously converted and demultiplexed using bcl2fasta application. alignment of sequence reads performed using bwa-mem against human b19 reference genome. sorting, removing of intermediate files, *.bam files assembling, and marking duplicates were performed using picardtools package. gatk haplotype caller tool was used for variant calling. clinvar, snpedia, and cosmic databases were processed to identify clinical genomic variants in 6 kazakh whole genomes. java runtime environment and r. bioconductor packages were installed to perform raw data processing and run program scripts. results: the sequence alignment and mapping procedures on reference genome hg19 of each 6 healthy kazakh individual were completed. between 87,308,581,400 and 107,526,741,301 total base pairs were sequenced with average coverage x29.85. between 98.85% and 99.58% base pairs were totally mapped and on average 96.07% were properly paired. het/hom and ti/tv ratios for each whole genome ranged from 1.35 to 1.52 and from 2.07 to 2.08, respectively. we compared and analyzed each genome with on existing clinical databases clinvar, snpedia, cosmic and found from 20 to 25, from 269 to 288, from 7 to 12 snp records, respectively. the availability of a reference kazakh genome sequences provides the basis for studying the nature of sequence variation, particularly single nucleotide polymorphisms. conclusion: the first whole genome sequencing of kazakhs were performed. in this pilot study, we identified snps associated with different conditions. further studies of wgs on kazakh population are needed to identify possible unique genetic variants in kazakhs. keywords: whole genome sequencing, kazakh population http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. diagnostics of cognitive function in women of menopausal period at level of primary health care n. zhilgeldina & t. ulykbassova department of ob/gyn, national research center for maternal and child health, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.183 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ zhilgeldina this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.183 | http://cajgh.pitt.edu abstract introduction. in the medical community, there is no consensus on whether or not climacteric changes are pathologic and require treatment. one of the main problems related to menopause is misperception of menopause; consequently, there is no consensus on treatments for psychological dysfunction and cognitive deficits in menopausal women. timely diagnosis and adequate treatment of psychological disorders and cognitive dysfunction are imperative and complicated. the purpose of this study was to evaluate physician perceptions of cognitive and psychological deficits in menopausal women in outpatient settings. methods. 215 obstetricians-gynecologists working in out-patient services were surveyed using a multiple choice questionnaire assessing perceptions and knowledge of menopausal transition. results. of total respondents, 42.0% ± 2.5 of physicians found it hard to define menopausal period, and 67.5% ± 3.2 could not give a clear definition of hormone replacement therapy. on the question “cognitive function includes…,” 62.5% ± 2.1 of physicians selected “memory,” 32.3% ± 1.8 selected attention, 77.5% ± 3.2 selected mood and/or imagination, 37.4% selected intellect, 36.3% ± 3.1 of respondents selected character traits, and 6.2% ± 1.7 selected speech. regarding the question “how do you study memory status function?” it was estimated that 71.2% ± 2.5 of study participants have studied the memory only on the basis of subjective complaints, and none of the respondents (100%) have ever used neuropsychological tests. conclusion. the survey allows us to ascertain that primary medical care services lack the ability to appropriately recognize and diagnose cognitive deficits in women of menopausal age. based on these data, we can assume that proper mental care is not provided. thus, the study indicates a need to create training programs for general practitioners and other specialists (cardiologists, neurologists, and endocrinologists) to fulfill this need. implementation of a standard of care, testing, and treatment of cognitive and psychological function, such as the use of neuropsychological tests and questionnaires, in an out-patient setting for menopausal women would improve the quality of life during a woman’s transition period. keywords: menopause, cognitive function, psychological function, women’s health http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. clinical experience with chitosan matrix and cultured fibroblasts for burns gaziza danlybayeva1, assylbek zhylkibayev1, zhansaya akhmadeyeva1, elena belan2, zhanatay ramazanov2 1laboratory of stem cells, national center for biotechnology, astana, kazakhstan; 2scientific research institute of traumatology and orthopedics, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.157 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ danlybayeva this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.157 | http://cajgh.pitt.edu abstract introduction. burns are an important public health challenge due to the frequency of getting burns in day-to-day life, occupational hazards, and catastrophes. treatment of burns is complex and is associated with high morbidity and mortality. duration and complexity of burn treatment require finding new ways of curing and rehabilitating burns. the result of burn treatment plays a significant role in post-traumatic status of a patient and his or her consequent adaptation in society. chitosan is a natural safe nontoxic product compatible with human tissues, characterized by hydrosorbid, anticoagulant, antibacterial, and wound healing features. the study aims to show a clinical application of chitosan-pectin scaffold with cultured human skin fibroblasts in the treatment of deep burns. methods. the substrate was prepared by dissolving 3% chitosan in 0.5n acetic acid, which was then mixed with 3% solution of pectin dissolved in distillated water. chitosan film was formed in a petri dish for 20-24 hours at 20-25 °c. after drying the film, cultured allogeneic fibroblasts (patent number rk-25091) were seeded on its surface. results. the results from an in vitro culture study showed that human allogeneic fibroblasts could adhere well and grow on the selected scaffold with a typical morphology. during autodermoplasty surgery, cultured allogeneic fibroblasts were applied on granulating wounds of 9 patients with iiia to ivb degree burns and limited donor resources. wounds treated with the fibroblastseeded scaffold among all patients provided the highest level of re-epithelialization (day 5), in comparison to cell-free scaffold (day 7) and untreated surface of wounds (day 10). conclusion. our results indicate the potential use of chitosan for wound healing due to its allogenic fibroblast adherence to scaffolding as well as high epithelization. this warrants further studies on chitosan for use in wounds resulting from third and fourth degree burns. keywords: burns, chitosan-pectin scaffold, fibroblast, epithelialization http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. pre-clinical evaluation of an adult extracoproreal carbon dioxide removal system for pediatric application yerbol mussin1, richard jeffries2, denis bulanin1, zhaksybay zhumadilov1, farkhad olzhayev1, william federspiel2 1center for life sciences, nazarbayev university, astana, kazakhstan; 2mcgowan insitute for regenerative medicine, pittsburgh, usa vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.167 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ mussin this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.167 | http://cajgh.pitt.edu abstract introduction. adult extracorporeal carbon dioxide removal (ecco2r) systems and pediatric ecmo share the common objectives of having a low blood flow rate and low priming volume while safely maintaining sufficient respiratory support. the hemolung is a highly simplified adult ecco2r system intended for partial respiratory support in adult patients with acute hypercapnic respiratory failure. the objective of this work was to conduct pre-clinical feasibility studies to determine if a highly efficient, activemixing, adult ecco2r system can safely be translated to the pediatric population. methods. 14 healthy nonsedated juvenile sheep were used for acute (2 animals) and 7-day chronic (12 animals) in-vivo studies to evaluate treatment safety independently of respiratory related injuries. in all evaluations, we hypothesized that gas exchange capabilities of the hemolung ras in this model would be equivalent to the adult configuration performance at similar blood flows minimum co2 removal of 50 ml/min at a venous partial pressure of co2 equal to 45 mmhg. target blood flow rates were set to a minimum of 280 ml/min. swan ganz catheters were used under general anesthesia in the two acute subjects to evaluate blood gas status in the pulmonary artery. results. the hemolung ras was found to have adequate gas exchange and pumping capabilities for full respiratory support for subjects weighing 3 – 25 kg. the hemolung device was estimated to provide a partial respiratory support for subjects weighing 27 – 34 kg. the seven-day studies in juvenile sheep demonstrated that veno-venous extracorporeal support could be provided safely at low flows with no significant adverse reactions related to device operation. conclusion. the study outcomes suggest the potential use of the hemolung ras in a veno-venous pediatric configuration to safely provide respiratory support utilizing a significantly less complex system than traditional pediatric ecmo. keywords: hemolung, extracorporeal carbon dioxide removal, pediatric ecmo, respiratory support http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. ectopic liver tissue formation in rats with induced liver fibrosis bauyrzhan umbayev1, andrey tsoy1, tamara shalakhmetova2, sholpan askarova1 1center for life sciences, nazarbayev university, astana, kazakhstan; 2department of biology and biotechnology, al-farabi kazakh national university, almaty, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.180 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ umbayev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.180 | http://cajgh.pitt.edu abstract introduction: the possible alternative approach to whole-organ transplantation is a cell-based therapy, which can also be used as a "bridge" to liver transplantation. however, morphological and functional changes in the liver of patients suffering from chronic liver fibrosis and cirrhosis restrict the effectiveness of direct cell transplantation. therefore, extra hepatic sites for cell transplantation, including the spleen, pancreas, peritoneal cavity, and subrenal capsule, could be a useful therapeutic approach for compensation of liver functions. however, a method of transplantation of hepatocytes into ectopic sites is needed to improve hepatocyte engraftment. previously published data has demonstrated that mouse lymph nodes can support the engraftment and proliferation of hepatocytes as es and rescue fah mice from lethal liver failure. thus, the aim of the study was to evaluate the engraftment of i.p. injected allogeneic hepatocytes into extra hepatic sites in albino rats with chemically induced liver fibrosis (lf). materials and methods: albino rats were randomly divided into 4 groups: (1) intact group (n = 18); (2) rats with induced lf (n = 18); (3) rats with induced lf and transplanted with hepatocytes (n = 18); (4) as a control, rats were treated with cyclosporine a only (n = 18). in order to prevent an immune response, groups 2 and 3 were subjected to immunosuppression by cyclosporine a (25 mg/kg per day). lf was induced using n-nitrosodimethylamine (ndma), i.p., 10 mg/kg, three times a week for 4 weeks and confirmed by histological analysis of the liver samples. hepatocytes transplantation (ht) was performed two days after ndma exposure cessation by i.p. injection of 5×106 freshly isolated allogeneic hepatocytes. liver function was assessed by quantifying blood biochemical parameters (alt, ast, ggt, total protein, bilirubin, and albumin) at 1 week, 1 month, and 2 months after hepatocytes transplantation (ht). to confirm a hepatocytes’ engraftment, we conducted immunohistochemical staining against heppar1. results: we observed a 30% mortality rate among rats with lf within 1 week after ndma exposure cessation, while 100% of animals with ht survived. alt, ast, and ggt activities and bilirubin levels were markedly elevated in blood samples of lf rats compared to the control animals. however, ht significantly improved alt, ast, and ggt activity as well as bilirubin levels. we also observed decreased levels of total protein and albumin in the blood serum of rats with lf, while ht normalized these parameters. at the same time, we have not detected any statistical differences of the studied parameters in the group 4, which was treated with cyclosporine a only, compared with the intact animals. heppar1 immunohistochemical staining of the different tissue sections demonstrated the presence of engrafted hepatocytes, mainly within enlarged peyer's patches (aggregated lymphoid nodules in the lowest portion of the small intestine). conclusion: the results of our study provide evidence that ht improves animal survival and liver functions. one potential reason for these results is that ectopic hepatic mass inside the peyer's patches can rescue rats from liver failure. keywords: ectopic liver tissue, chronic liver fibrosis, transplantation http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. association between the p2ry12 receptor gene polymorphism and aspirin resistance in patients with coronary artery disease ludmila karazhanova1, sholpan zhukusheva1, ainur akilzhanova2 1department of internal medicine, semey state medical university, astana, kazakhstan; 2center for life sciences, nazarbayev university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.160 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ karazhanova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.160 | http://cajgh.pitt.edu abstract introduction. platelet activation and aggregation are key elements in the development of coronary atherosclerosis. recent studies have shown that the two polymorphisms of platelet adp receptor p2ry12 (haplotypes h2 and 34t) are associated with increased platelet aggregation and atherothrombotic risk. it was shown that these polymorphisms promote reduced body response to antiplatelet therapy. aim. we investigated the association of p2ry12 gene polymorphisms with aspirin resistance in patients with coronary artery disease (cad). methods. this case-control study included 100 cases with cad (mean age 57.6 ± 2.8 years) treated in the cardiology department of the city hospital semey, kazakhstan, 90 of whom suffered from myocardial infarction. the control group (n = 100) were healthy people without a history of cad, matched on sex and age. genotyping of polymorphisms h1/h2 in p2ry12 gene was performed by pcr. statistical analysis was performed using spss v.19.0. results. the distribution of h1/h2 genotypes p2ry12 was 42%, 34%, and 24%, respectively, in cases and 42%, 58%, and 0%, respectively, in controls. all allele frequencies were consistent with the hardy weinberg equilibrium (p = 0.0036 and p = 0.0001 in cases and controls, respectively). genotype h2 was associated with risk of cad with aspirin resistance (co-dominant model: or = 3.75, 95% ci 0.14 99.88, p = 0.05 and dominant model: or = 2.78, 95% ci 0.11 70.93, p = 0.05). we found significant differences in the distribution of the mutant genotype h2 between cad patients with aspirin resistance and healthy controls (χ2 = 30.3, p < 0.05). conclusion. we found an association of h2 haplotype in p2ry12 gene with aspirin resistance in patients with cad. however, in order to obtain definitive conclusions about the role of genetic variants with the development of aspirin resistance in patients with cad, there is a need for further research with a larger sample size as well as the use of selective thromboxane receptor antagonists for studying functional effects of genetic variants. keywords: coronary artery disease, aspirin resistance, gene polymorphism http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. application of clinical aging indicators for the assessment of neurological health via screening among residents of the almaty region erkin nurguzhayev, renat iliyev, dmitriy mitrokhin, altynay karimova department of neurological diseases, asfendiyarov national medical university, almaty, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.168 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ nurguzhayev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.168 | http://cajgh.pitt.edu abstract introduction. life expectancy at birth is considered to be a primary indicator of public health success. however, an increase in life expectancy is meaningless if it is not accompanied by an equivalent increase in the number of life years without disability such as physical, cognitive, and psychological abilities. the main consequences of disease leading to neurological dysfunction are directly related to issues such as the inability to walk, talk, learn, live in society, or take care of oneself. the objective of the study was to conduct a medical examination of elderly people as a part of the scientific program "development of a model (program) of anti-aging to provide active longevity of elderly people of kazakhstan.” methods. as part of a pilot study, we assessed the presence of the following clinical indicators of aging: cognitive impairment (mmse test), pyramidal symptoms,and ataxia. we conducted medical examination (screening) among 150 elderly persons in almaty city polyclinic #8 and 287 elderly persons in central regional clinic of rayimbek area, almaty region aged 45 and above. results. the results show that the intensity of changes is directly dependent on the age of the study groups. the cognitive function is the most affected and depends on the age of examinees. the changes are more expressed among residents of almaty region. the average mmse score in almaty was 28.2 (age group of 45-49 years) and 25.8 (age group of 80 and above), and 27.3 and 24.0 respectively in almaty region. the various symptoms among residents of almaty tend to stabilize after 65 years, however, the frequency of ataxia continues to grow and increases significantly after 75 years. conclusions. considering that important risk factors of neurological disorders are cerebrovascular diseases of various origins (primarily hypertension, atherosclerosis, and diabetes), an adequate treatment of these diseases will increase a healthy lifespan. furthermore, it is necessary to conduct additional research for possible methods of reducing existing morbidities so that healthy aging can be achieved. keywords: aging, cognitive impairment, screening http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx a new paradigm of primary health care: personal, community-based, standardized, and technology-driven new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. a new paradigm of primary health care in kazakhstan: personalized, community-based, standardized, and technology-driven almaz sharman co-founder and ceo, healthcity llp, almaty, kazakhstan; president, academy of preventive medicine of kazakhstan vol. 3, no. 1 (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.186 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ sharman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.186 | http://cajgh.pitt.edu abstract this paper discusses the need for change from kazakhstan’s current disease-centric healthcare paradigm to a new primary health and wellness-centric health care paradigm, technology-driven and based on personal relationships within a social context. while many different papers have been published about the importance of prevention and primary health care, few have focused on healthcare transition in kazakhstan or other countries in central asia. the who’s historic 1978 alma-ata declaration signed in kazakhstan promoted the centrality of primary care to the provision of effective, efficient, and equitable health services. modern technologies such as the internet, social media, and portable medical devices democratize medicine, providing great opportunities to rethink the alma-ata declaration and reinvent primary health care on an entirely new platform that is knowledge-based and technology-assisted. the new paradigm suggested for the future development of health in central asian region emphasizes personal relationships and encourages sustainable solutions created by communities. this paper also introduces healthcity, a new project in kazakhstan aiming at introducing private, community-based and standardized primary healthcare that is driven by smarthealth innovative technology. keywords: healthcity, smarthealth, health and wellness, healthcare a new paradigm of primary health care in kazakhstan: personalized, community-based, standardized, and technology-driven almaz sharman co-founder and ceo, healthcity llp, almaty, kazakhstan; president, academy of preventive medicine of kazakhstan perspective current healthcare paradigm is disease-centric because of vast hydrocarbon resources available in kazakhstan, this central asian country experienced tremendous growth and rapid economic expansion in recent years. over the 20 years of independence, transformation of kazakhstan’s economy, lifestyle, and social system have influenced the burden of both infectious and chronic disease and increased demand for health services. 1 following the break-up of the soviet union, kazakhstan experienced a dramatic increase in tuberculosis and other infectious diseases. 2 on the other hand, the health of population in kazakhstan is characterized by high prevalence of cardiovascular disorders, cancer, diabetes, and other non-communicable diseases. combined with a rapidly aging population and an outdated healthcare infrastructure, kazakhstan’s healthcare provider network is facing challenges associated with country’s healthcare transition. significant changes will be required, at both the national and regional levels, to meet the current and future health needs of its population. in kazakhstan, the government owns or has control over approximately 80% of medical institutions, which include more than 1,000 hospitals and 3,400 ambulatory care clinics. although public healthcare spending was forecasted to reach $6 billion in 2014 and expected to grow at a 4-year compund annual growth rate (cagr) of 13.4% to $9.1 billion in 2017, it may prove difficult to absorb and efficiently allocate the government’s increased levels of investment given constraints such as shortfalls of skilled healthcare professionals. 3 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.186 | http://cajgh.pitt.edu public and private health expenditures in kazakhstan exceed 4% gdp, of which 2.6% from public sources. 4 despite such investments, kazakhstan’s healthcare is characterized by insufficient access to the latest technology and slow integration of evidencebased clinical care practices. addressing the need for raising additional healthcare funds, the government of kazakhstan has made a decision to introduce national mandatory health insurance system starting 2017. based on previous personal communications with ms. tamara duisenova, the minister of health and social services, funding for insurance will be generated from three sources: (1) government guaranteed healthcare benefits package; (2) individual co-payment, and (3) additional payroll taxes. while the government plays a dominating role in healthcare, the private sector (households and private health insurance) contributes around 34 percent of total health expenditures. households contribute most private funds on an out-of-pocket basis. 5 inability of the state-run health care system to meet the growing healthcare demands of kazakhstan population has forced people of kazakhstan to turn to a growing array of private health services that operate based on fee for service system. as a result, a dual health care picture has emerged in kazakhstan: an inefficient old state run system; and a second, loosely regulated market–based private system that offers competitive solutions to deficiencies of the government system. extensive hospital infrastructure in most countries, the current healthcare paradigm can be described as disease-centric. medical establishment and the general public often believe that hospitals and efforts to treat diseases lead to better healthcare and more active and productive lives. investing in hospitals and in-patient care still dominates the healthcare of kazakhstan. an extensive hospital infrastructure and a neglect of primary health care is one of the legacies of the soviet health system. even though kazakhstan has undertaken many health related reforms over the last 20 years, the inherited public health and medical infrastructure still determines provision of care. current public allocations for in-patient services in kazakhstan have doubled within the past 5 years. according to a report by oxford policy management (opm), a large number of hospitals in kazakhstan still treat patients on an in-patient basis, despite the fact that many of them could be effectively treated on an outpatient basis. few years ago, such cases collectively amounted to around 15% of hospital discharges. consequently, a significant portion of healthcare resources were spent on in-patient services instead of funding the primary health care. overall, less than 5% of the national health expenditures are allocated to support primary healthcare and disease prevention. 6 this is especially true in the city of astana, the capital of kazakhstan, where a dozen of new inpatient facilities (tertiary care hospitals) were built during the last 10 years. not only are too many hospitals being built, they are also becoming fancier and much more expensive to build, equip, and maintain. if in the ancient world marble was used to build temples and pyramids and in medieval times marble was used to build castles and churches, the 20th century used it to outfit banks and offices. where does the marble go now? …to build hospitals. equipping the tertiary care facilities introduces extra costs that burden the healthcare system in kazakhtan. while most consumer technologies such as smartphones and tablet pcs are becoming more sophisticated but cheaper and easier to use, medical technologies are moving in the opposite direction. they have become more expensive, complicated, and often very intimidating to patients. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx sharman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.186 | http://cajgh.pitt.edu permanent battle against diseases we are in a state of permanent battle with our eternal enemy – diseases and maladies. the enemy gains more power by engaging weapons of mass destruction debilitating chronic illnesses such as heart disease, dementia, diabetes and cancer, as well as emerging and re-emerging infections. inventing new drugs and medical technologies has become increasingly difficult and resource-intensive. the fruits of medical knowledge that grew at the bottom of the tree of knowledge have already been picked all that are left are the ones on top, demanding more efforts and resources. 7 modern medicine deals with almost 14,000 diseases and operates with about 6,000 different types of medications and 4,000 types of medical procedures. 8 despite having this rich arsenal of treatments, we are consistently losing our battles against disease because our curative strategies are often inefficient and costly. medical mistakes, that are especially common in tertiary care facilities kill enough people around the world each day to fill many jumbo jets. 9 250 years ago, french enlightenment writer françois voltaire wrote, “doctors prescribe medicine of which they know little, to cure diseases of which they know less, in human beings of which they know nothing.” 10 we are still focusing on inventing new drugs and medical technologies, but what we really do is fighting diseases at the point where the body has almost been conquered by the disease. is this really the right direction that is being taken by our healthcare systems? an alternative to this is a change from the current paradigm that is diseases-centric to a new paradigm, the one that is health and prevention-centric, technology-driven and is based on personal relationships within a social context. primary care is a backbone of healthcare system in 1946, the world health organization defined health as: “… a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” 11 despite tremendous gains in life expectancy achieved in the 20 th century, poor physical, mental and social well-being continues to burdensome and costly issue throughout the world in the 21 st century. one of the key contributing factors to this paradox is that we keep forgetting the key role of disease prevention and early detection, which is an essence of primary health care. the who’s historic alma-ata declaration of 1978 promoted the centrality of primary care to the operation of effective, efficient, and equitable health services. 12 while many countries adopted the declaration, primary health care has been neglected and remains underfunded in many countries around the world including kazakhstan. a significant portion of national healthcare resources go towards in-patient services instead of funding primary health care and shifting the balance in favor of the latter. 13 an inevitable result of such policies is an increase in healthcare utilization, increasing burden of chronic disease care, and subsequently, rising healthcare costs. aging populations, environmental issues, as well as emerging and re-emerging infections make it even more difficult to contain healthcare costs. focusing on primary care and disease prevention is one of the key strategies that can be effectively implemented to contain increasing healthcare costs. primary health care is not just the first line of defense, but an effective gateway that facilitates communication with the various components of healthcare system. if country's primary health care system is strong, hospital admissions are typically reduced by 40% and health care costs are reducted by 30%. previous research demonstrated that around 70% to 80% of health-related episodes in an individual's life http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.186 | http://cajgh.pitt.edu can be identified by general practitioners at a primary care level outside hospitals. 14 primary care doctors are not superstar surgeons, but their role is crucial. they are the ones who protect consumers of healthcare from getting ill and help them navigate in the ocean of medical knowledge and healthcare institutions. their mission is to organize the full range of healthcare services: from individual to household to hospitals and from disease prevention to treatment and rehabilitation. in many countries around the world primary care doctors that are considered to be “cinderellas” of healthcare. they don't share the glory of sophisticated medical technologies, their salaries are fractions of what surgeons get, and their role is not recognized. we need to empower them with knowledge and technology, while motivating and properly compensating them for their hard work. community-based and technology-driven healthcare one of the key ways to bridge multiple disciplines, professions, and approaches to healthcare is to work towards developing patient centered personalized medicine. this can be achieved through practicing primary health care that is community-based, utilizes technology, and incorporates patient wishes and values. the seventh tenet of the alma-ata declaration says that, “the people have the right and duty to participate individually and collectively in the planning and implementation of their health care.” the declaration also implies that “primary health care …requires and promotes maximum community and individual self-reliance and participation…” 12 primary health care emphasizes local ownership and encourages sustainable solutions created by communities. 15 the team-based approach that is essential in addressing the healthcare needs of a person and community. 16 the key question is how to engage all the players – consumers of healthcare, primary care doctors and nurses – not just the specialty doctors and hospitals. modern technologies provide great opportunities to reinvent primary health care on an entirely new platform. internet and social media as well as portable ekg and ultrasound machines, iphone medical apps and devices democratize medicine making knowledge and technology available to the doctors and consumers. 7,17 dr. eric topol described this trend as, “creative destruction of medicine.” 10 technology creates a new primary health care environment that is more efficient and knowledgebased. in average, every day we spend 5 hours on internet, and 77% of internet users rely on this technology to search for medical information. in 2013, google registered 30 billion searches for medical information associated terms. when analyzed historical query-based flu estimates for different countries and regions compared against official influenza surveillance data, it was determined that estimates based on google search queries about flu are very closely matched to traditional flu activity indicators. 18 electronic patient records help to reduce unnecessary human intervention and free time for costeffective and high quality services. specialized social networks for healthcare professionals such as doximity, enable primary care doctors to easily get on the same page with specialists and more effectively collaborate by sharing notes, records and other information. technology-driven primary health care is an effective way to build collaborations among different healthcare sectors. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx sharman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.186 | http://cajgh.pitt.edu the need for patient-centered and personalized care according to a population-based representative household health survey conducted in 2012 by the academy of preventive medicine of kazakhstan, more than 30% residents of almaty, kazakhstan aged 25-44 prefer seeking medical care in private healthcare facility. more than 40% among them believe that they can be harmed when treated in the government ambulatory and in-patient medical facilities. 19 disadvantages of government based medical system in kazakhstan include long waiting lines, need to rely on friends and family to know which doctor is good, inability to get consistent diagnosis if you go to more than one doctor, poor medical record retrieval system, and many others. these challenges translated into unsatisfied consumers, both on individual and community levels. dissatisfied with poor quality of medical services, many kazakh citizens turn to medical tourism to solve their healthcare issues. a study conducted a few years ago by harvard medical international reported $200-250 million that channeled annually from kazakhstan to overseas to cover the costs of medical care. 20 there is an opportunity to capture those who travel abroad for medical care by providing high quality medical services at home. with the emerging middle class in kazakhstan, we are witnessing the evolvement of healthcare market, with consumers becoming interested in better healthcare. these consumers will ultimately want to be empowered to make their own health decisions and be in the center of their care, with access to high quality services. in the opinion of the author, personalized medicine is when doctors practice with the consumer at heart, with personal relationships that revolves entirely around their needs, time and convenience. with such attitudes, doctors will likely be able to actively engage consumers in managing their own health. healthcity and smarthealth technology in forefront of the new paradigm of healthcare in order to address the health-centric paradigm, a new initiative called healthcity has recently been implemented in kazakhstan. 21 it aims to create an integrated network of private technology-driven and patient-centered primary care clinics and diagnostic center to serve communities’ healthcare needs at highest international standards. to ensure quality in its infrastructure, the healthcity project established partnerships with such global technology companies as philips and medtronic. healthcity facilities will have online medical records and telemedicine activities, home health, community systems, among other which allow supporting a growing community of 50,000 to 100,000 people in key cities of kazakhstan where healthcity will operate. overall, activities of healthcity lead to transformation of kazakhstan’s healthcare system. in order to empower primary care physicians and customers of its clinics, the healthcity project will employ a proprietary application called smarthealth comprising of three main components: 1) diagnostic algorithms «symptoms online», designed for web and mobile platforms in three languages: kazakh, russian, and english; 2) web resources of zdrav.kz web-portal with many years of successful track record of providing internet users with widely available information as how to maintain health and treat illnesses; and, 3) electronic search system helping to locate specialized doctors and healthcare organizations. at the heart of smarthealth there are more than 70 algorithms integrated together as the "symptoms online” product. they represent a logical http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.186 | http://cajgh.pitt.edu process as how to interpret symptoms of many diseases allowing users to make informed decisions. these algorithms are presented in the form of web and mobile applications for android and ios integrated with zdrav.kz portal containing a wealth of information about thousands of diseases and conditions, as well as about methods for their prevention, early detection and treatment. because of availability of such resources, smarthealth users will be able to solve many common medical problems that do not require the participation of the medical professional or visit a medical institution. in more complex cases smarthealth provides opportunities for informed and targeted search for assistance of a general practitioner or a specialist. in such efforts the users may be able to utilize smarthealth resources allowing them to find needed healthcare organizations and medical professionals. this healthcity project will significantly reduce the burden on the health care system, promoting active participation of citizens and empowering them to make decisions about their own health. smarthealth is a technology solution that aims at providing accessibility and convenience in obtaining knowledge about medicine. summary in summary, the current healthcare paradigm in kazakhstan and many countries around the world is centered around hospitals and highly specialized medical doctors. it can be described as disease-centric medicine, dominated by technology and aggressive treatments. an alternative to this is an alliance of primary care doctors with consumers, empowered and engaged to be active participants in healthcare decisions on both sides. only by building such an effective and fully potential ecosystemic healthcare system will we be able to successfully prevent diseases and achieve higher quality and quantity of life for our citizens. by building a healthier and brighter healthcare ecosystem, we have a great opportunity to improve quality of life locally and globally. references 1. devi s. reforming health care in kazakhstan. lancet. 2014;383(9936):2197-2198. 2. terlikbayeva a, hermosilla s, galea s, et al. tuberculosis in kazakhstan: analysis of risk determinants in national surveillance data. bmc infect dis. 2012;12:262. 3. world health organization (who). bmi kazakhstan pharmaceuticals and healthcare report q2. 2013. 4. agency of statistics of the republic of kazakhstan. quarterly household budget survey produced together with gdp estimates. www.stat.kz. 5. who euro. 10 health questions about the caucasus and central asia. 2009; www.ho.int/nha. 6. oxford policy management. report on current funds flow and current pattern of health care expenditure by economic and functional categories in public and private sectors and on the impact of the new budget re-allocation model in kazakhstan. 2011. 7. sharman a. modernization and growth in kazakhstan. cajgh. 2012;1(1). 8. gawande a. the velluvial matrix. 2010. 9. makary m. how to stop hospitals from killing us. the wall street journal2012. 10. topol e. the creative destruction of medicine: how the digital revolution will create better health care. basic books; 2012. 11. world health organization (who). constitution of the world health organization. 2013; http://www.who.int/governance/eb/who_constitution_en.pdf. 12. world health organization (who). declaration of almaata: international conference on primary health care. 1978; http://www.who.int/publications/almaata_declaration_en.pdf. 13. sharmanov t, mcalister a, sharman a. health care in kazakhstan. world health forum. 1996;17(2):197-199. 14. knowledge @ warton. family physicians make a comeback in india. 2013; http://knowledge.wharton.upenn.edu/india/article.cfm?articleid =4719. accessed august 7, 2014. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.stat.kz/ http://www.ho.int/nha http://www.who.int/governance/eb/who_constitution_en.pdf http://www.who.int/publications/almaata_declaration_en.pdf http://knowledge.wharton.upenn.edu/india/article.cfm?articleid=4719 http://knowledge.wharton.upenn.edu/india/article.cfm?articleid=4719 sharman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program, and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, no. 1 (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.186 | http://cajgh.pitt.edu 15. chan m. return to alma-ata. lancet. 2008;372(9642):865-866. 16. lubell j. economists outline strategy to counter primary care shortage. 2013; http://www.amaassn.org/amednews/2013/01/14/gvsd0118.htm. accessed august 7, 2014. 17. painter k. 35% of americans ask dr. google for medical diagnoses. usa today2013. 18. google.org. explore flu trends united states. 2011; http://www.google.org/flutrends/us/#us. 19. academy of preventive medicine of kazakhstan. final report on 2012 national household health survey. almatyastana2013. 20. harvard medical international, the chartis group. bringing world-class healthcare to almaty. 2007. 21. healthcity. healthcity. www.healthcity.kz. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.ama-assn.org/amednews/2013/01/14/gvsd0118.htm http://www.ama-assn.org/amednews/2013/01/14/gvsd0118.htm http://www.google.org/flutrends/us/#us http://www.healthcity.kz/ cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. role of ros in aβ42 mediated activation of cerebral endothelial cells andrey tsoy1, bauyrzhan umbayev1, tamara shalakhmetova2, sholpan askarova1 1center for life science, nazarbayev university, astana, kazakhstan; 2department of biodiversity and bioresources, al-farabi kazakh national university, almaty, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.179 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ tsoy this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.179 | http://cajgh.pitt.edu abstract introduction. there is substantial evidence that the deposition of aggregated amyloid-beta peptide (aβ) in brain parenchyma and brain vessels is the main cause of neuronal dysfunction and death in alzheimer’s disease (ad). aβ exhibits multiple cytotoxic effects on neurons and glial cells and causes dysfunction of the blood brain barrier (bbb). in ad brains, an increased deposition of aβ in the cerebral vasculature has been found to be correlated with increased transmigration of blood-borne inflammatory cells and neurovascular inflammation. however, regulatory mediators of these processes remain to be elucidated. in this study, we examined the role of ros in actin polymerization and expression of adhesion molecules (p-selectin) on the surface of the cerebral endothelial cells (cecs) that are activated by aβ42. materials and methods. mouse bend3 line (atcc) was used in this research. bend3 cells respond to aβ treatment similarly to human primary cecs and are a common model to investigate cecs’ function. we used immortalized bend3 cells as the following: controls; cells incubated with aβ42 for 10, 30, and 60 minutes; cells incubated with 30 mm of antioxidant n-acetylcysteine (nac) for 1 hr; and, cells pre-treated with nac followed by aβ42 exposure. we measured dhe fluorescence to investigate intracellular ros production. immunofluorescent microscopy of anti-p-selectin and oregon green phalloidin was used to quantify the surface p-selectin expression and actin polymerization, and western blot analysis was used to analyze total p-selectin expression. results. the results of this study have demonstrated a significant time-dependent ros accumulation after 10 minutes, 30 minutes, and 60 minutes of aβ42 treatment, while aβ42 stimulated ros production in cecs was attenuated by pre-treatment with the nac antioxidant. we also found that aβ42 increased p-selectin fluorescence at the surface of bend3 cells in a time dependent manner in parallel to ros elevation. however, total expression levels of p-selectin were not changed following exposure to aβ42. pretreatment with nac attenuated aβ42 induced p-selectin localization, while nac alone did not significantly affect p selectin localization. as a positive control, h2o2 also increased p-selectin expression on the cell surface, which peaked after 30 minutes of h2o2 treatment. exposure of cecs with aβ42 promoted actin polymerization, which peaked after 10 minutes of aβ42 treatment, while no significant increase of f-actin intensity was observed when cells were pre-treated with nac. h2o2 was able to mimic aβ42 induced oxidative stress, causing increased actin polymerization with similar timing. conclusions. the results of our study have indicated that aβ42 induced accumulation of p-selectin on the surface of bend3 cells and promoted actin polymerization, and all these events were correlated with ros generation. the rapid post-translational cell signaling response mediated by ros may well represent an important physiological trigger of the microvascular inflammatory responses in ad and requires further investigations. keywords: alzheimer’s disease, cerebral endothelial cells, ros, aβ4, p-selectin http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. new approaches to treatment of severe intrauterine growth restriction zhanar kurmangali1,2 1national research center for maternal and child health, astana, kazakhstan; 2center for life sciences, nazarbayev university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.166 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kurmangali this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.166 | http://cajgh.pitt.edu abstract introduction. intrauterine growth restriction (iugr) is a leading cause of perinatal morbidity and mortality due to placental insufficiency. currently, one of the new approaches to treating this disease is the injection of nutrients to the fetus through intravascular port-systems (catheters). objective. to assess the impact of nutrient injections as treatment to fetuses with severe growth retardation. materials and methods. pregnant women with iugr (abdominal circumference (ac) < 5th percentile) with the absence of diastolic flow in the umbilical artery and a fetal gestational age of less than 30 weeks were randomly divided into two groups. the treatment group included six pregnant women who had an intravascular port-system for the infusion of nutrients (amino acids and glucose) in the umbilical vein of the fetus for 14 ± 3 days. the control group consisted of eight patients who received only traditional dynamic monitoring and delivery at the optimum time of pregnancy. fetal status was assessed using ultrasound equipment accuvix v20 (medison, south korea) by examining indicators of biometry and doppler study of blood flow in utero, umbilical arteries, middle cerebral artery, and ductus venosus with fetal vascular resistance index calculation pulsatility index (pi). criteria for blood flow disturbances in the vessels were considered pi values above normal values for their gestational age, which were defined as absence or reverse blood flow in a diastole in the umbilical artery. results. in a comparative analysis of the two groups, the treatment led to a 44.7% increase in ac of the fetus (121.0 ± 11.5 mm and 219.3 ± 18.3 mm, respectively, p ˂ 0.001). in all cases, the profile of blood flow in the umbilical artery had a positive diastolic component. as a result, there was a 45.3% decrease in pi in the umbilical artery (2.14 ± 0.54 and 1.17 ± 0.15, respectively, p < 0.05). average fetal weight in the study group was not significantly higher than the control group (1,120.3 ± 213.6 g and 909.6 ± 131.4 g, p > 0.05). conclusion. thus, injection of nutrients to the fetuses through intravascular port-system improved placental perfusion and metabolism, which has the potential for improved fetal growth. this, in turn, promoted full-term pregnancy and improved perinatal outcomes in fetal pathology. keywords: intrauterine growth restriction, pregnancy, fetal growth http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. cost-effectiveness analysis of denosumab in the prevention of skeletal-related events in patients with prostate cancer in kazakhstan carina bektur & talgat nurgozhin center for life sciences, nazarbayev university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.154 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ bektur this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.154 | http://cajgh.pitt.edu abstract introduction. bone mass loss (bml) is one of the adverse effects of oncological chemotherapy, especially in cases of hormonal types of cancer, such as a prostate cancer (pc). bml is strongly associated with skeletal-related events (sres), therefore decreasing the quality of patient’s life. denosumab shows an advantage over zoledronic acid (za) in delaying the first onset of sres and subsequent sres in adults with pc in several phase iii clinical trials. since generic za recently became available, the purpose of the present study was to assess the cost-effectiveness of denosumab vs. brand or generic za in the prevention of sres in kazakhstani patients with pc. methods. a markov model was constructed in tree-age pro 2013 software program with 4-week model cycles to analyze the cost-effectiveness of the treatments from the perspective of ministry of health (moh) over a 10-year pc cohort. direct costs (in kazakhstani monetary units “tenge” in 2014) included costs of drug, sre (pathologic fracture, surgery to bone, radiation to bone, spinal cord compression), and adverse events treatment. all costs were discounted for 3% per year. effectiveness was appraised based on the number of sres. health states were defined according to sre occurrence, sre history, and death. the model assumed that a maximum of 1 sre could occur in each cycle. transition probabilities were derived from the relevant phase iii trials. results were present in the incremental total cost per sre avoided. one-way sensitivity analyses were performed to examine the robustness of the model. results. over the 10-year period, denosumab incurred 103,091 tenge higher costs than brand za, 677,133 tenge higher costs than generic za, and 0.58 fewer sres per patient with pc. the estimated incremental total direct costs per sre avoided with the use of denosumab were 177,743 tenge (instead of brand za) and 1,167,470 tenge (instead of generic za). results were robust to oneway sensitivity analyses. conclusions.with the assumption that brand and generic zas are equally effective in the prevention of sres in pc patients, denosumab seems to be a cost-effective alternative for brand za (insignificant difference in costs – less than 5%) and a costly alternative for generic za from the perspective of moh of kazakhstan. keywords: prostate cancer, bone mass loss, denosumab, zoledronic, cost-effectiveness http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. risk for disability and poverty among central asians in the united states carlos siordia1 & athena k. ramos2 1center for aging and population studies, graduate school of public health, university of pittsburgh, pa; 2center for reducing health disparities, college of public health, university of nebraska, ne vol. 4, no. 2 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.220 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/4.0/ siordia this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn | doi 10.5195/cajgh.2015.220 | http://cajgh.pitt.edu abstract understanding the disability-poverty relationship among minority groups within the united states (us) populations may help inform interventions aimed at reducing health disparities. limited information exists on risk factors for disability and poverty among “central asians” (immigrants born in kazakhstan, uzbekistan, and other central asian regions of the former soviet union) in the us. the current cross-sectional analysis used information on 6,820 central asians to identify risk factors for disability and poverty. data from the 2009-2013 public use microdata sample (pums) file from the american community survey (acs) indicate that being married, non-latino-white, and having higher levels of educational attainment are protective against disability and poverty. in contrast, older age, residing in the middle atlantic geographic division, and having limited english language ability are risk factors for both disability and poverty. research should continue to develop risk profiles for understudied immigrant populations. expanding knowledge on the well-being of central asians in the us may help impact public health interventions and inform health policies. keywords: disability, poverty, american community survey, public use microdata sample, former ussr, central asia risk for disability and poverty among central asians in the united states carlos siordia1 & athena k. ramos2 1center for aging and population studies, graduate school of public health, university of pittsburgh, pa; 2center for reducing health disparities, college of public health, university of nebraska, ne research in the united states (us) and across the world, having the ability to overcome psycho-social and physical barriers for independent living can influence quality of life.1 the differently abled (i.e., disabled) and economically deprived (i.e., poor) are at greater risk for adverse health.2 although low-income minorities should not be defined as being “trapped in an inescapable cycle of poverty,”3 it should be noted that both the physically and economically disadvantaged individuals do face unique challenges for resisting exposures that may lead to disability.4 unfortunately, the relationship between disability and poverty (i.e., the disability-poverty nexus) remains under-researched among smaller immigrant groups.5-7 this investigation fills a gap in the disabilitypoverty nexus literature by focusing on the central asian population of the us. although research on the disability-poverty nexus on minorities has been conducted,8-11 it is difficult to find peer-reviewed publications in scientific journals that focus on the group that may be called the central asian population of the us. although explained more technically below, “central asians” in this investigation were selected based on place of birth. the us census bureau only defines “south central asians.”12 this is the first publication to define central asians as immigrants who report being born in kazakhstan, uzbekistan, former ussr, or other south central asia, not specified. the specific aim of this investigation was to identify risk factors for disability and poverty in the central asian immigrant population in the us. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.220 | http://cajgh.pitt.edu methods data this cross-sectional analysis used data from the american community survey (acs), 5-year (20092013) public use microdata sample (pums) file. data from the acs is important for public health research because it may be used to influence policy aimed at providing services for disabled individuals. for example, acs data influenced the distribution of us federal dollars to local governments in 2008 by affecting the distribution of $562.2 billion in grant funds.13 the use of publicly available acs data does not require institutional review board approval. the same data source has been used before to delineate the prevalence of disability and poverty in other minority and immigrant populations in the us.14-16 acs pums data may be one of the few data sources that has the capacity to provide information on the demographic, geographic, and health profiles of the central asian population in the us. central asians the sample of 6,820 central asians was selected using place of birth (pob). the us census bureau only provides an official definition of south central asia which includes places like india and iran.12 the analysis labeled us immigrants born in kazakhstan, former ussr, uzbekistan, and other south central asia, not specified as “central asians.” although this data source does not allow researchers to identify immigrants who report being born in places like kyrgyzstan, tajikistan, and turkmenistan, immigrants who were coded under the “other south central asia, not specified” category where included as central asians in the analysis. after extensive research, this appears to be the first analysis defining central asians as individuals born in kazakhstan, former ussr, uzbekistan, and other south central asia, not specified while using acs data. while this grouping scheme is imperfect, limitations of the data source do not allow analysis by specific country of origin.17 as with people born in kazakhstan, uzbekistan, kyrgyzstan, tajikistan, and turkmenistan, identifying immigrants in the us from recently transformed regions of the world is difficult.18 for simplicity, the selected sample is referred to as central asians. in addition to pob, individuals were only included in the sample if they resided within the contiguous us. disability central asians were labeled as “disabled” if they reported a ‘yes’ to one or more of the following questions: is this person deaf or does he/she have serious difficulty hearing?; is this person blind or does he/she have serious difficulty seeing even when wearing glasses?; because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions?; does this person have serious difficulty walking or climbing stairs?; does this person have difficulty dressing or bathing?; because of a physical, mental, or emotional condition, does this person have difficulty doing errands alone such as visiting a doctor’s office or shopping? limitations and benefits of using these questions have been discussed in detail previously;2,8 however, responses to these questions may be utilized to identify perceived ability to perform physical functional tasks in daily living.9 it is important to note subjectively assessed physical function faces measurement bias because study participants are asked to self-evaluate their health and rely on their memory for reporting the data. in addition, in the acs, the majority of individuals are assigned their disability status through a proxy-report.16 despite these limitations, the acs is the most reliable and largest data source for delineating the disability of hard-to-reach populations in the us. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx siordia this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn | doi 10.5195/cajgh.2015.220 | http://cajgh.pitt.edu poverty the acs pums file contains the “income-topoverty ratio” (ipr) measure. the ipr shows at what ‘level of poverty’ an individual is—e.g., being at or below a 100 ipr indicates that this person is in-poverty status. for example, in fiscal year 2013, the poverty threshold for a family of four was $23,550. thus, all members of a family with a total household income of $23,550 would be assigned an ipr of 100 and be coded as being “in-poverty.” if the family reports a total household income of $11,775, each family member would be assigned an ipr of 50 and be coded as being in “deep-poverty.” if a family reports a total household income of $35,325, then each family member would be assigned an ipr of 150 and be coded as being “nearpoverty.” in this analysis, a person is classified to be inpoverty if they have an ipr of 150 or below—an approach used to account for the fact that federal poverty thresholds do not account for geographical heterogeneity in cost-of-living. statistical approach all data management and analysis was conducted using sas® 9.3 software. although population-weights are provided in the data, they were not used because generalizing information from 6,820 individuals to about 149,473 central asian immigrants would result in population estimates with very large standard errors. that is, the 95% confidence limits around the population estimates would be large enough to render population-weighted estimates uninformative. descriptive statistics for the analytic sample are presented. non-population-weighted multivariable logistic regressions were used to model the likelihood of being disabled or in-poverty while adjusting for age, sex, marital status, race, ethnicity, naturalization status, ability to speak english, educational attainment, and geographic division of residence. variables were coded using common approaches in socio-epidemiological research on poverty and disability. results participant characteristics our sample was 54% female, 59% married, 83% non-latino-white, 60% us citizens (95.6% by naturalization, 4.4% by being born to parents with us citizenship), 18% lacked health insurance coverage, and 24% were unable to speak english ‘well’ or ‘at all’ (table 1). participants in this sample were aged 40.6±19.9, 36% reported high school education or below, and the majority (36%) of participants resided in the middle atlantic geographic division of the us. about 13% of the sample reported a disability and about 30% may be classified as being in-poverty (i.e., ipr < 150). the low level of disability in the sample may be partially explained by the plausibility that the selection process influences who emigrates from central asia table 1. demographics of 6,820 central asians living within the us risk factors for disability several factors were identified as risk factors for disability. for example, naturalized citizens were twice as likely to be disabled compared to those who report not being a citizen or naturalized (table 2). those who spoke english not well or not at all were over three times as likely to be disabled as those who spoke english very well or well. each increase in age (by year) was associated with a 7% increase in the likelihood of being disabled. in addition, residing in the middle atlantic geographic division was associated with a 20% greater likelihood of being disabled than residing in other divisions. education and marital status were associated http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.220 | http://cajgh.pitt.edu with lower odds of being disabled. for example, married central asians were 64% less likely to be disabled than non-married people. each increase in educational attainment category was associated with a 7% decrease in the likelihood of being disabled. table 2. multivariable logistic regression predicting the likelihood of being disabled risk factors for poverty the regression (table 3) indicates that being married, non-latino-white, and a naturalized citizen was associated with a 52%, 33%, and 56%, respectively, lower odds of being in-poverty. each additional increase in educational attainment category was associated with a 4% reduction in the likelihood of being in-poverty. in contrast, residing in the middle atlantic division reduced the odds of poverty by 16% while speaking english not well or not at all significantly increased the odds of poverty almost three-fold. table 3. multivariable logistic regression predicting likelihood of being in poverty discussion high levels of educational attainment and being married were found to be consistently protective against disability and poverty. in contrast, older ages, residing in the middle atlantic geographic division, and speaking english not well or not at all were consistently found to be risk factors for disability and poverty. more complex is the fact that being a naturalized citizen is simultaneously a risk factor for disability and protective against being in-poverty. it may be said that a “central asian immigrant paradox” is found, where those at greater risk for economic disadvantage are also at lower risk for disability. this is paradoxical because for most non-immigrant groups, greater risk for poverty is frequently accompanied by greater risk for disability.19,20 future research should seek to disentangle plausible explanations for the central asian immigrant paradox. this study has some limitations including the inability to obtain and/or identify data from individuals from some of the countries within the region such as kyrgyzstan, tajikistan, and turkmenistan as previously described. there is an inherent selection bias in participation in government administered surveys which may partially be affected by legal status. furthermore, subjectively assessing disability through recall and selfreport may affect the validity of the results. it is possible that individuals born in central asia and who have the ability and the means to immigrate to the us come from family units with social and economic resources. the low prevalence of disability in the analytic sample may be partially explained by the fact that about two-thirds of the sample is below age 47 or due to ‘healthy immigrant selectivity.’9 objective measurements for disability are needed to supplement these results. poverty is assessed using only economic measures. additional measures for both poverty and health status are also needed to be able to assess the impact of disability on poverty and health status. the cross-sectional analysis provides empirical evidence on the understudied central asian population in the us. findings from this analysis should be generalized with caution to the community-dwelling immigrants born in kazakhstan, former ussr, uzbekistan, other south central asia, not specified and who resided within the us mainland during the survey period. a multitude of challenges remain for intervening on the relationship between poverty and disability.21 future research should be sensitive to poverty indicators focusing on practical http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx siordia this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn | doi 10.5195/cajgh.2015.220 | http://cajgh.pitt.edu matters such as quantifying the risk for poverty among individuals related to someone with a disability.22 for immigrants residing in the us, like central asians, disability and poverty have the potential to become entangled with other forms of oppressions.23 research should continue to explore if and how immigrants from central asia residing in the us retain their language, identity, health, family structures, and economic wellbeing. acknowledgement supported by nih grant number t32 ag000181 and u01 ag023744 (ab newman). references 1. dalal ak. disability–poverty nexus psycho-social impediments to participatory development. psychol dev soc. 2010;22(2):409-437. 2. siordia c. disability prevalence according to a class, race, and sex (csr) hypothesis. j racial ethn health disparities. 2015;2(3):303-310. 3. block p, balcazar f, keys c. from pathology to power rethinking race, poverty, and disability. j disabil policy stud. 2001;12(1):18-27. 4. braithwaite j, mont d. disability and poverty: a survey of world bank poverty assessments and implications. alter. 2009;3(3):219-232. 5. groce n, kett m, lang r, trani jf. disability and poverty: the need for a more nuanced understanding of implications for development policy and practice. third world quarterly. 2011;32(8):1493-1513. 6. loeb m, eide ah, jelsma j, toni mk, maart s. poverty and disability in eastern and western cape provinces, south africa. disabil soc. 2008;23(4):311-321. 7. lamichhane k, okubo t. the nexus between disability, education, and employment: evidence from nepal. oxford development studies. 2014;42(3):439-453. 8. siordia c. rates of allocation for disability items by mode in the american community survey. issues in social science. 2015;3(1):62-82. 9. siordia c. sex-specific disability prevalence in immigrants from china, india, and mexico and their us-born counterparts. ijhsr. 2015;5(4):267-279. 10. curtis kj, voss pr, long dd. spatial variation in povertygenerating processes: child poverty in the united states. soc sci res. 2012;41(1):146-159. 11. siordia c. disability estimates between same-sex and different-sex couples: data from the 2009-2011 american community survey. sex disabil. 2015;33(1):107-121. 12. gryn t, gambino c. the foreign born from asia: 2011. american community survey briefs. 2012. 13. reamer ad. surveying for dollars: the role of the american community survey in the geographic distribution of federal funds. washington d. c.: metropolitan policy program at brookings;2010. 14. siordia c, le vd. precision of disability estimates for southeast asians in american community survey 2008-2010 microdata. cajgh. 2013;1(2). 15. siordia c. a multilevel analysis of mobility disability in the united states population: educational advantage diminishes as race-ethnicity poverty gap increases. journal of studies in social science. 2015;12(2):198-219. 16. siordia c. proxy-reports in the ascertainment of disability prevalence with american community survey data. j frailty aging. 2014;3(4):238-246. 17. batalova j. asian immigrants in the united states. washington d. c.: migration policy institute;2011. 18. mason pl, matella a. stigmatization and racial selection after september 11, 2001: self-identity among arab and islamic americans. iza journal of migration. 2014;3:1-21. 19. palmer m. disability and poverty: a conceptual review. j disabil policy stud. 2011;21(4):210-218. 20. lustig dc, strauser dr. causal relationships between poverty and disability. rehabilitation counseling bulletin. 2007;50(4):194-202. 21. hansen h, bourgois p, drucker e. pathologizing poverty: new forms of diagnosis, disability, and structural stigma under welfare reform. soc sci med. 2014;103:76-83. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.220 | http://cajgh.pitt.edu 22. fujiura gt. the political arithmetic of disability and the american family: a demographic perspective. family relations. 2014;63(1):7-19. 23. goodley d. dis/entangling critical disability studies. disabil soc. 2013;28(5):631-644. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx siordia this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn | doi 10.5195/cajgh.2015.220 | http://cajgh.pitt.edu table 1. demographics of 6,820 central asians living within the us characteristic n (%) disabled 884 (13) female 3,667 (54) married 3,990 (59) non-latino-white 5,630 (83) us citizen 4,089 (60) has no health insurance coverage 1,204 (18) speaks english not well/at all5 1,658 (24) age group age < 17 839 (12) age 18-27 1,171 (17) age 28-37 1,216 (18) age 38-47 1,123 (16) age 48-57 957 (14) age > 58 1,514 (22) education < 8th grade 1,026 (15) 9th – 12th grade* 499 (7) high school 968 (14) some college 1,319 (19) > bachelor’s degree 3,008 (44) poverty level deep poverty (<50) 542 (8) in-poverty (51-100) 798 (12) near poverty (101-150) 697 (10) above near-poverty (151-200) 581 (9) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.220 | http://cajgh.pitt.edu out of poverty (>200) 4,202 (62) location new england 448 (7) middle atlantic 2,453 (36) east north central 571 (8) west north central 203 (3) south atlantic 950 (14) east south central 97 (1) west south central 295 (4) mountain 431 (6) pacific 1,372 (20) *note. participants in the 9th-12th grade education group did not complete high school. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx siordia this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn | doi 10.5195/cajgh.2015.220 | http://cajgh.pitt.edu table 2. multivariable logistic regression predicting the likelihood of being disabled or 95% ci female 0.99 0.83, 1.18 married 0.37 0.30, 0.44 *** non-latino-white 0.84 0.62, 1.13 citizen or naturalized 2.01 1.60, 2.52 *** speaks english not well/at all 3.25 2.67, 3.97 *** age 1.07 1.07, 1.08 *** education 0.93 0.92, 0.95 *** resides in middle atlantic division 1.20 1.00, 1.43 * *p<0.05, **p<0.01, ***p<0.001 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.220 | http://cajgh.pitt.edu table 3. multivariable logistic regression predicting likelihood of being in poverty or 95% ci female 1.00 0.89, 1.12 married 0.48 0.42, 0.54 *** non-latino-white 0.67 0.57, 0.78 *** citizen or naturalized 0.44 0.39, 0.50 *** speaks english not well/at all 2.86 2.47, 3.30 *** age 1.01 1.01, 1.02 *** education 0.96 0.95, 0.97 *** resides in middle atlantic division 1.16 1.03, 1.31 ** *p<0.05, **p<0.01, ***p<0.001 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. genetic diversity of ifγ, il1β, tlr2, and tlr8 loci in pulmonary tuberculosis in kazakhstan dauren yerezhepov, axat zhabagin, ayken askapuli, saule rakhimova, zhannur nurkina, aliya abilmazhinova, alma akhmetova, askhat molkenov, ulykbek kairov, ainur akilzhanova center for life sciences, nazarbayev university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.181 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ yerezhepov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.181 | http://cajgh.pitt.edu abstract introduction. tuberculosis (tb) is caused by bacterium mycobacterium tuberculosis (mtb), and according to the who, up to 30% of world population is infected with latent tb. pathogenesis of tb is multifactorial, and its development depends on environmental, social, microbial, and genetic factors of both the bacterium and the host. the number of tb cases in kazakhstan has decreased in the past decade, but multidrug-resistant (mdr) tb cases are dramatically increasing. polymorphisms in genes responsible for immune response have been associated with tb susceptibility. the objective of this study was to investigate the risk of developing pulmonary tb (ptb) associated with polymorphisms in several inflammatory pathway genes among kazakhstani population. methods. 703 participants from 3 regions of kazakhstan were recruited for a case-control study. 251 participants had pulmonary tb (ptb), and 452 were healthy controls (hc). males and females represented 42.39% and 57.61%, respectively. of all participants, 67.4% were kazakhs, 22.8% russians, 3.4% ukrainians, and 6.4% were of other origins. clinical and epidemiological data were collected from medical records, interviews, and questionnaires. dna samples were genotyped using taqman assay on 4 polymorphisms: ifnγ (rs2430561) and il1β (rs16944), tlr2 (rs5743708) and tlr8 (rs3764880). statistical data was analyzed using spss 19. results. genotyping by ifγ, il1β, tlr2 showed no significant association with ptb susceptibility (p > 0.05). tlr8 genotype a/g was significantly higher in females (f/m – 41.5%/1.3%) and g/g in males (m/f – 49%/20.7%) (χ2=161.43, p < 0.001). a significantly increased risk of ptb development was observed for tlr a/g with an adjusted or of 1.48 (95%, ci: 0.96 2.28), and a protective feature was revealed for tlr8 g/g genotype (or: 0.81, 95%, ci: 0.56 1.16, p = 0.024). additional grouping by gender revealed that tlr8 g/g contributes as protective genotype (or: 1.83, 95%, ci: 1.18 2.83, p = 0.036) in males of the control group. conclusion. results indicate that heterozygous genotype a/g of tlr8 increases the risk of ptb development, while g/g genotype may serve as protection mechanism. a/a genotype is strongly associated with susceptibility to ptb. to clarify the role of other polymorphisms in susceptibility to ptb in kazakhstani population, further investigations are needed. keywords: tuberculosis, inflammation polymorphism, kazakhstan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. pharmacokinetic properties of cytokines in their targeted delivery based on autologous erythrocyte pharmacocytes zhaxybay zhumadilov, kulzhan berikkhanova, alexander gulyayev, zarina shulgau, dilbar ibrasheva, zhanybek bokebaev, nadiar mussin, talgat nurgozhin center for life sciences, nazarbayev university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.184 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ zhumadilov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.184 | http://cajgh.pitt.edu abstract introduction. using autologous erythrocytes as drug carriers for targeted delivery of cytokines to the sites of inflammation could potentially provide new opportunities for treatment of patients with purulent diseases. the targeted characteristic of erythrocytes is associated with the nature of purulent inflammation, where a large amount of erythrocytes is phagocytized and drugs encapsulated into the erythrocytes could be easily released. on the other hand, autologous erythrocytes meet all the criteria for the ideal drug carrier. they are nontoxic, not immunogenic, and able to bear a large number of drug molecules while preserving an original conformation of the drugs. thus, in this study, we aimed to analyze pharmacokinetic profiles of il-1β encapsulated into erythrocytes’ ghosts (pharmacocytes) in comparison to intravenously injected free il-1β. material and methods. albino rats were randomly divided into two groups, each group receiving a different kind of iv injection via the tail vein. group a (control) received 500 µg of free il-1β, and group b received an injection of 1 ml of pharmacocytes loaded with 500 µg of test substance. at fixed time points after injection (15, 30, 60, 180, 540, 720, and 1,440 minutes) serum samples were collected. homogenates of liver, spleen, lung, heart, kidney, and adipose tissue were obtained 24 hours after injections. concentration of the tested substance in the collected organs and blood plasma were measured by elisa. results. we have observed an increased half-life period (t1/2) for encapsulated il-1β compared to the control. t1/2 for free il1β was one hour, while administration of loaded pharmacocytes allowed the half-life period to increase by more than 15 fold (1,043.40 ± 137.92 min) preserving high level of il-1β activity in the blood samples up to 24 hours. the increased time of il-1β presence in the body when administered in the form of pharmacocytes could be explained by reduction of elimination constant (cel) by 1.6 fold, and clearance (clel) by more than 100 fold. we also observed an increased concentration of il-1β in liver, spleen, and lung over at least 24 hours. when administered in free form, il-1β disappeared from these organs within 6 hours. conclusions. pharmacocytes have shown to improve pharmacokinetic profiles of il-1β by increasing the half-life period of the cytokine, reducing its clearance and elimination as well as increasing the deposition of the drug in liver, spleen and lungs. these data suggest that pharmacocytes be effective drug carriers for targeted delivery of cytokines to the sites of inflammation and have a potential for improving the treatment outcomes of purulent diseases. keywords: cytokine delivery, autologous erythrocytes, pharmacocytes http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. quantifying socioeconomic and lifestyle related health risks: burden of cardiovascular disease among indian males neetu purohit1, divya k. bhati1, shiv d. gupta1, azad s. kundu2 1indian institute of health management research university; 2indian council of medical research vol. 4, no. 2 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.218 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ purohit this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu abstract background: non-communicable diseases account for a significant disease burden in the south east asia region. india is facing an increased incidence of lifestyle-related diseases, such as cardiovascular disease. socioeconomic and lifestyle risk factors for cardiovascular disease (cvd) have been under investigated in india. this study was designed to explore risk factors contributing to the development of cardiovascular disease among indian males. methods: a population-based cross-sectional study was conducted among 2,235 males in the age group of 18-60 years across three states of india. a household survey was used to collect demographic and socioeconomic status information in addition to lifestylerelated attributes such as smoking, alcohol consumption, diet, and physical activity. descriptive statistics and logistic regression were performed to identify the role of various factors that may be associated with the development of cardiovascular disease in this population. results: the prevalence of cardiovascular disease among the male respondents contacted through a household survey was reported to be 9.8%. logistic regression revealed that males with higher education and higher income were more likely to report cvd. with age as a strong predictor of cvd, the risk of cvd was found to be five times higher in the older age group. current smokers were 1.3 times more likely to have cvd compared to those who never smoked. those who were engaged in physical activity were less likely to have cvd; however, the adverse effects of smoking and excessive consumption of red meat showed a stronger association with cvd than the protective effects of physical activity. conclusion: in developing countries, where the increase in earning capacity and change in lifestyle has been found to be accompanied by substantial risk of heart disease for males, public health measures like health promotion programs need to be implemented to decrease cvd burden. keywords: cardiovascular diseases, risk factors, lifestyle, behavior, smoking, physical activity quantifying socioeconomic and lifestyle related health risks: burden of cardiovascular disease among indian males neetu purohit1, divya k. bhati1, shiv d.gupta1, azad s.kundu2 1indian institute of health management research university; 2indian council of medical research research non-communicable diseases (ncds) account for an increasing share of disease burden. in 1998, 43% (36 million) of global mortalities were due to ncds and are expected to increase to 73% by 2020.1 among ncds, cancer, cardiovascular disease (cvd), and diabetes are of serious concern, accounting for 52% of all deaths and 38% of disease burden in the world health organization south east asia region (who-sear). in the industrialized world and developing nations such as india,2 cvds are the primary causes of death and disability.3 according to who, an estimated 17 million people died from cvd in 2005, comprising 80% of the deaths in low and middle income countries. in a developing country like india, 35% of all cvd deaths occur in working age adults (aged 35-64 years) which makes prevention of these deaths crucial for society.4 unlike other non-communicable diseases, cvd is one of the most preventable causes of death in the world, as a majority of its risk factors are controllable. worldwide, approximately 31% of heart disease is believed to be attributable to poor diet and 22% to physical inactivity, and a further 22% is estimated to be attributable to smoking in industrialized countries.5 until the 1990s, cvd was regarded as a disease of the affluent class in india.6 however, studies conducted in 1996, 2004, and 2006 showed a higher incidence of cvd http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu events among lower socioeconomic groups, reflecting a reversal of the social gradient of cvd within socially disadvantaged groups in india.7-10 there are significant gaps in the knowledge of cvd associated risk factors in countries of the south asian region. in india, there has been no national study that has used a uniform methodology to assess prevalence of multiple cardiovascular risk factors. existing studies in india were done at different geographic locations and in different time periods.11 a recently published report indicated that new and more rigorous research and surveillance studies are needed in india to assess the extent of ncd burden.12 due to scarce national level data, there is a lack of effort to initiate policy changes for controlling the cvd epidemic.13 however, a few public health sentinel surveys have found that a cluster of major risk factors (tobacco, alcohol, inappropriate diet, and physical inactivity) govern the occurrence of cvds in india.14 studies have also found that rapid dietary changes associated with a decrease in levels of physical activity also play a particularly important role in the increasing incidence of cardiovascular diseases.15 the purpose of this multi-site study was to determine the contribution of several socioeconomic and lifestyle factors to cardiovascular diseases among the adult male population of india. it was hypothesized that lifestyle factors, such as socioeconomic characteristics (e.g. age, education, place of residence, income, occupation) and lifestyle factors (e.g. smoking, alcohol consumption, red meat consumption, physical activity) are predictors of cvd in indian population. methods sample size calculation, site, and study tools a population-based, multi-centric, crosssectional survey was conducted in three major states in india, including rajasthan, maharashtra, and west bengal, which represent the northern, western, and eastern regions of india, respectively (figure 1). the appropriate sample size needed was determined using the standard formula as described in world health organization sample size determination manual.16 figure 1. study locations in india: rajasthan, maharashtra and west bengal the sample size of 1,480 adults per state was calculated using 10% precision and took into account a non-response rate of 15%. thus, the total study sample included 4,460 adults in the age group of 18-60 years (2,225 females and 2,235 males). this paper presents the sub-study focusing on data collected from 2,235 male participants (figure 2). in 2001-2003, a large scale study was conducted by the registrar general of india, which reported that cardiovascular disease (cvd) was the major cause of deaths in males (20.3%) as compared to females (16.9%);17 hence, the authors decided to report results on the male population first. further, the data from females was not considered for this particular paper as the risk factors for females are not necessarily identical to males and a separate analysis quantifying risk factors among females is proposed in a separate follow up publication. figure 2. sample selection flow-chart the multilingual household survey questionnaire was prepared by the indian council of medical research (icmr, delhi). the structured survey questionnaire and its contents were validated with the help of literature review and face validity was conducted with experts working in the area of ncds / cvds. the questionnaire was translated into hindi / relevant regional languages and subjected to forward and backward translation. the structured questionnaire was pre-tested with respondents with similar characteristics http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx purohit this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu who reside in a different geographical area (other than the study area) to ensure the sequencing and understanding of the questions. suggestions from the study team and experts were incorporated into the questionnaire before its administration within the study area. ethical clearance for the study was obtained from the ethical review board of indian council of medical research (icmr), which was the funding agency for this multi-centric study. verbal consent (due to concern about literacy level) was obtained from study respondents prior to survey administration. the study team was comprised of a principal coordinator and research officers. the study team provided uniform study procedure-related training to the field investigators of the respective states. the field investigators administered the structured questionnaire through face-to-face interviews. the responses were recorded by the field investigators in a standardized format. definitions and measurement the outcome variable was the presence or absence of selfreported cardiovascular disease, which was defined as per world health organization.17 for the purpose of this study, cardiovascular disease has been defined as coronary heart disease (heart attacks), cerebrovascular disease (stroke), high blood pressure (hypertension), peripheral artery disease, rheumatic heart disease, congenital heart disease, and congestive heart failure.18 information on demographic, socioeconomic and lifestyle risk factors was ascertained through the questionnaire developed by the study team. study population was divided into two age categories (18 to 40 years) and (41 to 60 years). current place of residence was classified as rural or urban. self-reported educational attainment levels were grouped in five categories (i.e. illiterate/no-schooling, primary [≤5thgrade], secondary [≤12th grade], graduate [including post-graduate], and professional degree). occupation was divided into 8 categories: skilled or unskilled labor, agriculture, military/police, office job, business/shop, managerial position, unemployed, and teachers/small traders. per capita monthly family income from all sources was grouped into three categories: low income group (lig): < 5,326 inr (< $83.75), middle income group (mig): 5,327 inr – 21,067 inr ($83.76 $331.25), and high income group (hig): > 21,068 inr (>$331.26).19 as per the global adult tobacco survey report in 2009,20 current smoker has been defined as a person who had smoked over their lifetime, and continued to smoke every day or some days. ever smoker was defined as a person who had smoked sometime in their lifetime, but does not smoke currently. a never smoker was defined as a person who never smoked over their lifetime.20 current alcohol user was defined as a person who consumes alcohol every day or some days. ever alcohol user was defined as a person who was consuming alcohol in the past and stopped consuming alcohol. a never alcohol user was defined as person who never consumed alcohol over their lifetime.21 diet was categorized in terms of consumption of non-vegetarian food (i.e.consumption of red meat daily or 3 to 5 times a week, and no consumption of red meat). physical activity time was defined based on the who global recommendation on involvement in any physical activity for 30 minutes or more per day.22 statistical analysis descriptive statistics were used to describe the sample characteristics. bivariate regression model estimates the contribution of indicators of socioeconomic status and lifestyle factors to self reported cvd. the dependent variable was presence or absence of selfreported cvds. statistical assessments were carried out using statistical package for social sciences (spss) version 20.0 (chicago il). all statistical analyses were considered significant when the p-value was < 0.05 at 95% confidence interval. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu results population characteristic: socioeconomic and lifestyle attributesof respondents a total of 2,235 males from three states were included in the present subanalysis. their socioeconomic status and lifestyle factors are presented in table 2 by geographical region. of the total interviewed males, the prevalence of self-reported cardiovascular disease was found to be around 9.8%. the age of interviewed respondents ranged from 18 to 60 years with a mean age 37.51+12.16 (table 2). the majority (61.0%) of respondents were in the 18 to 40 years age group. table 1. percent distribution of respondents by socioeconomic characteristics and lifestyle factors table 1 also shows that approximately 45% of the respondents were residing in rural areas. nearly 37.5% of the respondents completed elementary education. education beyond grade school was reported by 31.3% males and 10.9% reported having a professional degree. occupation of the interviewed respondents shows that around 40.6% were engaged in professions involving physical activity, such as skilled /unskilled labor, agriculture, and police or military service. about 21% and 12.9 % of the respondents were from high and middle income categories, respectively. the proportion of smokers, alcohol consumers, those who consumed red meat daily (or 3 to 5 times a week), and those engaged in regular physical activity was also assessed. results showed that never smokers and those who never consumed alcohol constituted 50.0% and 64.1% of the sample, respectively. about 18.1% of the respondents consumed red meat daily or 3 to 5 times a week. results also showed that involvement in regular physical activity was as high as 76.0%. predictors of cvd based on bivariate logistic regression analysis, table 2 illustrates the estimated odds ratios for association between cvd and socioeconomic and lifestyle related attributes. age was a strong predictor of cvd; males who were 41-60 years old had a 5-fold increased risk of having cvd compared to those in the age group of 18-40 years. compared to males who were illiterate or have received only non-formal education (i.e. able to write their names and read and write on rudimentary level), those with a professional degree were 2.1 times more likely to have cvd. further, males who were living in urban areas were 1.5 times more likely to have cvd as compared to those living in rural areas. table 2. bivariate logistic regression analysis of predictors of cardiovascular diseases for occupation, compared to those engaged in skilled/unskilled labor, males in teaching and trading jobs were 1.8 times more likely to get cvd. the odds for other occupation categories did not show a significant relationship with cvd. income level has also been associated with cvd level. compared to those in a low income category, participants with a high income had a marginally significant increased odds of having cvd (or=1.39, p=0.09). with respect to lifestyle related attributes, smoking and consumption of red meat daily or 3-5 times a week showed a significant positive relationship with cvd. males who consumed red meat were 1.6 times more likely to have cvd than those who did not consume red meat at all. smoking was found to be adversely affecting cardiovascular health. compared to those who did not smoke, smokers were 1.3 times more likely to get cvd. engagement in physical activity showed a negative significant relationship with cvd, which indicated that compared to those who did not engage in physical activity, those who engaged in http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx purohit this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu physical activity had 0.7 times less likelihood of reporting cvd. encouraged by the findings on the protective role of physical activity for cvd, we attempted to investigate the interaction effect of physical activity with red meat consumption and physical activity with smoking. these lifestyle variables were univariably marginally or significantly associated with cvd. we then tested whether or not there was an interaction between the lifestyle factors; however, all interactions tests were non-significant (table 3). table 3. logistic regression of predictors of cardiovascular diseases: examining interactions the first interaction examined was the interaction between red meat consumption and physical activity. red meat consumption increased the odds of having cvd, although not significant, while physical activity significantly reduced the odds of reporting cvd. the interaction effect suggested that there may be an interaction between these two factors, as the significance of red meat consumption was attenuated when adjusting for this interaction. however, this interaction effect was not found to be statistically significant (p=0.40). our results suggest that the risks of cvd associated with excessive consumption of red meat cannot be ruled out, even in presence of engaging in physical activity. the second interaction examined was the one between smoking and physical activity. simlarly with the previous interaction test, physical activity was still significantly associated with lower odds of having cvd, while smoking increased the odds of reporting cvd. this interaction effect also suggests that there may have been an interaction between smoking and physical activity due to the attenuated significance of the effects of smoking. however, this interaction was not found to be statistically significant (p=0.33). discussion this study examined the association between lifestyle and cvd among indian males. physical activity was found to reduce the odds of having cvd by 28%, while red meat consumption and smoking increased the odds of having cvd by 62% and 38%, respectively. major causes of morbidity and mortality have undergone an epidemiologic transition from predominantly nutritional deficiencies and infectious diseases in developing nations to chronic diseases such as cardiovascular disease.23 with the epidemiological transition and increased urbanization associated with the increase in cvd risk factors (behavioral, social, and lifestyle patterns), the cvd burden is increasing in developing countries including india.24 previous literature provides evidence that while the prevalence and mortality rate of cvd has decreased in developed nations, it has substantially increased in india, which has been undergoing rapid demographic, social, and economic change.25 studies have shown a major income decline due to cvd-related losses in productive labor.3 understanding the health characteristics of young and middle aged males (18–60 years) will allow public health experts and policy makers to adopt focused interventions for prevention of disease and promoting lifestyle modifications. age, as a risk factor for cvd, is well established26 and was confirmed in the current study. prevalence of cardiovascular disease was found to be higher in the age group of 41-60 years. additionally, males with higher education were found to be more vulnerable to the risk of reporting cardiovascular disease, which could be due to bias, as more educated adults may be more likely to report a disease. an earlier study carried out in the capital city of india also demonstrated that prevalence of heart disease was higher among literate as compared to illiterate participants.26 thus, populationspecific interventions need to be designed for various educational groups to promote a healthy lifestyle. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu the study findings provided further evidence suggesting that males in the high income group had an increased likelihood of reporting cvd. a study from southern india also reported a higher prevalence of coronary heart disease in high socioeconomic groups.27 occupation is also used as a marker in epidemiological studies of cardiovascular disease. a systematic review carried out in 2010 demonstrated an increased risk of cardiovascular disease in occupations involving prolonged sitting.28 however, the current study did not find any significant association of cvd with office jobs. we found that teachers and small traders are more vulnerable to cvd, but this finding was only marginally significant. the current study also found that urban males were at significantly greater risk compared to their rural counterparts. this is consistent with other published studies.29,30 corroborating earlier studies, this study reported that smoking adversely affects cardiovascular health. smoking has been shown to be a major risk factor for chronic illnesses in males below 65 years of age in developing countries.31 in long-term smokers, smoking is responsible for more than 50% of avoidable deaths, and one half of these are due to cvd.31 our study did not establish any significant association of alcohol consumption with cvd. however, the results of current study support the findings of 2010, who-global status report on non-communicable diseases, which states that there is a direct relationship between higher levels of alcohol consumption and the rise in risk of cardiovascular disease, which is dependent on the amount and pattern of alcohol consumption.32 a systematic review carried out between 1992 and 2009, which included 17 cohort and 3 case-control studies, showed that processed red meat was associated with a higher incidence of coronary heart disease (chd) when compared with unprocessed red meat.33 a previously published study failed to establish a significant link between meat consumption with chronic diseases like coronary heart disease (chd), stroke, and type 2 diabetes mellitus.34 thus, this study provides interesting new information. the benefits of physical activity on cardiovascular health were well established in the past review of key issues in public health.35 people who are insufficiently physically active have a 20–30% increased risk of all-cause mortality compared to those who engage in at least 30 minutes of moderate intensity physical activity on most days of the week. previous studies also suggest that physical activity lowers the risk of stroke and hypertension.36 consistent with previously published research, this study also reported the importance of regular physical activity in reducing the risk of cvd. this study reinforces the need to consider current prevention and treatment strategies at the national level to include behavior change,37 early diagnosis, screening, and early detection. cardiovascular health awareness programs including but not limited to those focusing on obesity and smoking need to be continued and expanded to better educate populations about healthy lifestyles. however, awareness is only the first step towards behavior change and other factors, like developing public health infrastructure (i.e. parks, cycling tracks, public sport centers, primary care clinics, obesity prevention programs, addiction treatment centers), that could facilitate healthy lifestyle choices to be promoted. the results from this study add to the existing knowledge on the associated risk factors and their role in causing cardiovascular diseases among males in india. the primary limitation of this study was that no medical examination was conducted to assess the presence of cardiovascular diseases, and only self-reported cardiovascular diseases were taken into consideration. however, the findings of this study are relevant for other developing countries undergoing the edpidemiologic transition. public health programs need to focus on building awaremenss about healthy lifestyles and changing public health infrastructure to promote healthier lifestyles, which could benefit all segments of society. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx purohit this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu competing interests the author declares that they have no competing interests. acknowledgements the study was supported by the indian council of medical research, new delhi for a grant-in-aid under extramural research projects to indian institute of health management research, jaipur, india. references 1. world health organization. preventing chronic diseases: a vital investment. 2005; http://www.who.int/chp/chronic_disease_report/en/. accessed sept. 9, 2015. 2. anand ss, yusuf s. stemming the global tsunami of cardiovascular disease. lancet. 2011;377(9765):529-532. 3. murray cjl, lopez ad. global comparative assessments in the health sector. 1994; http://www.nap.edu/openbook.php?record_id=5513&page=44. accessed sept. 10, 2015. 4. leeder s, raymond s, greenberg h, liu h, esson k. a race against time: the challenge of cardiovascular disease in developing economies. new york: columbia university press; 2004. 5. awad a, al-nafisi h. public knowledge of cardiovascular disease and its risk factors in kuwait: a cross-sectional survey. bmc public health. 2014;14:1131. 6. world health organization. the world health report 2002 reducing risks, promoting healthy life. 2002; http://www.who.int/whr/2002/en/. accessed sept. 9, 2015. 7. chadha sl, radhakrishnan s, ramachandran k, kaul u, gopinath n. epidemiological study of coronary heart disease in urban population of delhi. indian j med res. 1990;92:424-430. 8. rastogi t, reddy ks, vaz m, et al. diet and risk of ischemic heart disease in india. am j clin nutr. 2004;79(4):582-592. 9. pais p, pogue j, gerstein h, et al. risk factors for acute myocardial infarction in indians: a case-control study. lancet. 1996;348(9024):358-363. 10. xavier d, pais p, devereaux pj, et al. treatment and outcomes of acute coronary syndromes in india (create): a prospective analysis of registry data. lancet. 2008;371(9622):1435-1442. 11. gupta r. epidemiology and regional variations in cardiovascular disease and risk factors in india. j preventive cardiology. 2011;1(1):7-15. 12. anjana rm, ali mk, pradeepa r, et al. the need for obtaining accurate nationwide estimates of diabetes prevalence in india rationale for a national study on diabetes. indian j med res. 2011;133(369-380). 13. gupta r, joshi p, mohan v, reddy ks, yusuf s. epidemiology and causation of coronary heart disease and stroke in india. heart. 2008;94(1):16-26. 14. shah b, mathur p. surveillance of cardiovascular disease risk-factors in india: the need and scope. indian j med res. 2010;132(634-642). 15. stein ad, thompson am, waters a. childhood growth and chronic disease: evidence from countries undergoing the nutrition transition. matern child nurs. 2005;1(3):177-184. 16. lwanga sk, lemeshow s. sample size determination in health studies: a practical manual. 1991; http://apps.who.int/iris/bitstream/10665/40062/1/9241544058 _(p1-p22).pdf. accessed sept. 11, 2015. 17. world health organization. a global brief on hypertension: silent killer, global public health crisis. 2013; http://apps.who.int/iris/bitstream/10665/79059/1/who_dco_ whd_2013.2_eng.pdf. accessed sept. 10, 2015. 18. registrar general of india. report on causes of deaths in india 2001-2003. 2009; http://www.cghr.org/wordpress/wpcontent/uploads/causes_of_death_2001-03.pdf. accessed sept. 10, 2015. 19. mukherjee a, satija d. the consumption pattern of the rising middle class in india. 2012; http://www.boaoreview.com/plus/view.php?aid=38. accessed sept. 10, 2015. 20. global tobacco surveillance system. global adult tobacco survey (gats) indicator guidelines: definition and syntax. 2009; http://www.who.int/tobacco/surveillance/en_tfi_gats_indicator _guidelines.pdf. accessed sept. 11, 2015. 21. us department of health and human services. the health consequences of smoking 50 years of progress. a report of the surgeon general. 2014. accessed sept. 10, 2015. 22. world health organization. global recommendations on physical activity for health 2010; http://apps.who.int/iris/bitstream/10665/44399/1/9789241599 979_eng.pdf. accessed sept. 10, 2015. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/chp/chronic_disease_report/en/ http://www.nap.edu/openbook.php?record_id=5513&page=44 http://www.who.int/whr/2002/en/ http://apps.who.int/iris/bitstream/10665/40062/1/9241544058_(p1-p22).pdf http://apps.who.int/iris/bitstream/10665/40062/1/9241544058_(p1-p22).pdf http://apps.who.int/iris/bitstream/10665/79059/1/who_dco_whd_2013.2_eng.pdf http://apps.who.int/iris/bitstream/10665/79059/1/who_dco_whd_2013.2_eng.pdf http://www.cghr.org/wordpress/wp-content/uploads/causes_of_death_2001-03.pdf http://www.cghr.org/wordpress/wp-content/uploads/causes_of_death_2001-03.pdf http://www.boaoreview.com/plus/view.php?aid=38 http://www.who.int/tobacco/surveillance/en_tfi_gats_indicator_guidelines.pdf http://www.who.int/tobacco/surveillance/en_tfi_gats_indicator_guidelines.pdf http://apps.who.int/iris/bitstream/10665/44399/1/9789241599979_eng.pdf http://apps.who.int/iris/bitstream/10665/44399/1/9789241599979_eng.pdf central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu 23. yusuf s, reddy s, ounpuu s, anand s. global burden of cardiovascular diseases: part i: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. circulation. 2001;104(22):2746-2753. 24. gupta r, guptha s, sharma kk, gupta a, deedwania p. regional variations in cardiovascular risk factors in india: india heart watch. world j cardiol. 2012;4(4):112-120. 25. sanderson je, mayosi b, yusuf s, et al. global burden of cardiovascular diseases. heart. 2007;93(10):1175. 26. van uffelen jg, wong j, chau jy, et al. occupational sitting and health risks: a systematic review. am j prev med. 2010;39(4):379-388. 27. kutty vr, balakrishnan kg, jayasree ak, thomas j. prevalence of coronary heart disease in the rural population of thiruvananthapuram district, kerala, india. int j cardiol. 1993;39(1):59-70. 28. national institutes of health. institute of medicine (us) committee on preventing the global epidemic of cardiovascular disease: meeting the challenges in developing countries. washinton, dc: national academies press; 2010. 29. stuckler d. population causes and consequences of leading chronic diseases: a comparative analysis of prevailing explanations. milbank q. 2008;86(2):273-326. 30. nissinen ak. the increasing importance of chronic diseases. in: karis l, staffan, b., & hellena, m. p., ed. health and diseases in developing countries. new york: macmillan press; 1994:317-322. 31. bartecchi ce, mackenzie td, schrier rw. the costs of tobacco use (1). n engl j med. 1994;330(13):907-912. 32. world health organization. global status report on noncommunicable diseases 2010. 2010; http://www.who.int/nmh/publications/ncd_report_full_en.pdf. accessed sept. 10, 2015. 33. micha r, wallace sk, mozaffarian d. red and processed meat consumption and risk of incident coronary heart disease, stroke and diabetes mellitus: a systematic review and metaanalysis. circulation. 2010;121(21):2271-2283. 34. bernstein am, pan a, rexrode km, et al. dietary protein sources and the risk of stroke in men and women. stroke. 2012;43(3):637-644. 35. capizzi s, de waure c, boccia s. global burden and health trends of non-communicable diseases. a systematic review of key issues in public health. switzerland: springer; 2015:19-32. 36. reynolds k, lewis b, nolen jd, kinney gl, sathya b, he j. alcohol consumption and risk of stroke: a meta-analysis. jama. 2003;289(5):579-588. 37. directorate general of health services ministry of health & family welfare, government of india. national programme for prevention and control of cancer, diabetes, cardiovascular diseases and stroke (npcdcs): operational guidelines. 2011; http://health.bih.nic.in/docs/guidelines/guidelinesnpcdcs.pdf. accessed sept. 10, 2015. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/nmh/publications/ncd_report_full_en.pdf http://health.bih.nic.in/docs/guidelines/guidelines-npcdcs.pdf http://health.bih.nic.in/docs/guidelines/guidelines-npcdcs.pdf purohit this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu table 1. percent distribution of respondents by socioeconomic characteristics and lifestyle factors variables northern region m±sd or % western region m±sd or % eastern region m±sd or % total m±sd or % n 740 755 740 2235 age 38.45±11.75 36.64±12.93 37.46±11.69 37.51±12.16 age group in years 18-40 59.9 62.6 60.4 61.0 41-60 40.1 37.4 39.6 39.0 cardiovascular disease status no 91.2 93.5 85.9 90.2 yes 8.8 6.5 14.1 9.8 area of residence rural 40.5 53.4 40.4 44.8 urban 59.5 46.6 59.6 55.2 education level primary 35.9 29.3 47.6 37.5 secondary 33.9 37.0 23.0 31.3 graduate 16.5 24.8 19.5 20.3 professional 13.6 9.0 10.0 10.9 occupation skilled/unskilled labour 26.1 20.5 31.8 26.1 agriculture 14.3 17.1 9.1 13.5 official/job-clerical 8.2 20.8 15.1 14.8 military/police 0.7 1.3 0.4 0.8 business/shops 26.2 15.2 24.7 22.0 manager/professional 8.5 10.3 6.2 8.4 unemployed 4.5 8.2 3.8 5.5 teacher/small traders 11.5 6.5 8.9 8.9 income http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu note: m: mean, sd: standard deviation low income 100.0 44.6 53.9 66.0 middle income 0 22.8 15.8 12.9 high income 0 32.6 30.3 21.0 smoking status current/ever smoked 51.2 36.8 62.2 50.0 never smoked 48.8 63.2 37.8 50.0 alcohol consumption current/ever use 33.0 30.9 43.9 35.9 never use 67.0 69.1 56.1 64.1 red-meat consumption no consumption 94.2 89.9 61.5 81.9 ≥3 times/week 5.8 10.1 38.5 18.1 engagement in physical activity 0 to 30 minutes 24.5 15.8 32.3 24.0 >30 minutes 75.6 84.2 67.7 76.0 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx purohit this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu table 2.bivariate logistic regression analysis of predictors of cardiovascular diseases risk factors odds ratio 95% ci p-value age in years 18-40 41-60 4.57 3.29 – 6.34 <0.001** area of residence rural urban 1.59 1.09 2.29 0.014* education primary secondary 1.25 0.78 – 1.98 0.354 graduate 1.66 0.97 – 2.82 0.064† professional 2.11 1.03 – 4.33 0.041* occupation skilled/unskilled labour agriculture 1.03 0.54 – 1.95 0.924 official/job-clerical 1.56 0.85 – 2.82 0.146 military/police 1.36 0.26 – 6.90 0.712 business/shops 1.37 0.80 – 2.33 0.249 manager/professional 1.24 0.62 – 2.47 0.542 unemployed 1.38 0.58 – 3.22 0.463 teachers/small traders 1.85 0.98 – 3.46 0.054† income low income middle income 0.76 0.44 – 1.29 0.310 high income 1.39 0.94 – 2.02 0.092† smoking status never smoked current/ever smoked 1.383 0.99 – 1.91 0.052† alcohol consumption never use http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu note: †p< 0.1, *p< 0.05, **p< 0.001 current/ever use 1.17 0.84 – 1.61 0.333 red meat consumption no consumption ≥3 times/week 1.615 1.125 – 2.31 0.009** engagement in physical activity 0 to 30 minutes 30 minutes or more 0.719 0.51 – 1.00 0.052† http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx purohit this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu table 3.logistic regression of predictors of cardiovascular diseases: examining interactions odds ratio 95% ci p-value physical activity (≥30 minutes) 0.39 0.25 – 0.62 <0.001** red meat consumption (≥3 times/week) 1.43 0.89 – 2.29 0.138 physical activity x red meat consumption 1.32 0.68 – 2.56 0.409 physical activity (≥30 minutes) 0.39 0.25 – 0.62 <0.001** smoking status (current/ever) 1.37 0.94 – 1.99 0.103 physical activity x smoking status 1.33 0.74 – 2.39 0.335 note: †p< 0.1, *p< 0.05, **p< 0.001 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu figure 1. study locations in india: rajasthan, maharashtra and west bengal x` http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx purohit this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.218|http://cajgh.pitt.edu figure 2. sample selection flow-chart http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. one health and zoonoses: the evolution of one health and incorporation of zoonoses govindaraj v. asokan public health program, college of health sciences, university of bahrain, manama, bahrain vol. 4, no. 1 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ asokan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu abstract introduction: zoonotic disease outbreaks have surged in the last two decades. these include severe acute respiratory syndrome (sars), hendra virus, nipah virus, influenza viruses, middle east respiratory syndrome (mers) coronavirus, and ebola. one health is the initiative of an inclusive collaboration linking human, animal, and environmental health. one health is advocated through an intersectoral coordination to combat zoonoses, and the term has evolved over centuries. the primary aim of this literature review was to examine the change in the definition of the term one health over time, particuarly following the the introduction of the latest definition in 2007 by the american medical association and the american veterinary medical association. methods: this review was conducted in four phases. the first phase consisted of a general pubmed search for the phrase “one health” for every literature published up to december 2014. then an advanced search was carried out using “one health” in conjunction with the terms “zoonosis” and “zoonoses” in pubmed for the time period between january 2007 and december 2014. the articles found were then categorized based on the type of journals in which the articles were published. for the second phase, “one health” was searched as a medical subject heading (mesh) term, which is the national library of medicine controlled vocabulary thesaurus used for indexing articles. in the third phase, one health advocate organizations were found using google search engine. during the final phase, one health was searched in google scholar, examined by google trends, and analyzed by google ngram. results: before 2007, one health had many connotations to health in the medical literature with an incomplete adherence to the usage of one health linking zoonoses. the google trends analysis shows an overal steady increase of the search of one health from 2007 to 2014, which is consistent with the findings of articles from pubmed. discussion: our results indicate that the linkage between the terms one health and zoonoses started in 2007, which correlates with the joint declaration made by the american medical association and the american veterinary medical association in 2007. we suggest creating a mesh term for one health in the pubmed database to support more specific research on zoonoses, and exploring the possibility of a patent of the term one health to support global health and evidence based public health. keywords: one health, zoonoses, global health, public health, mesh one health and zoonoses: the evolution of one health and incorporation of zoonoses govindaraj v. asokan public health program, college of health sciences, university of bahrain, manama, bahrain research an estimated two-thirds of all known infectious diseases and 75% of emerging diseases are zoonoses.1 zoonotic disease outbreaks, often viral, have surged in the last two decades,2 highlighting the necessity for a one health approach. most emerging viruses were often from the south east asian region, such as the severe acute respiratory syndrome (sars),3 nipah virus,4 and the highly pathogenic influenza viruses,5 with the exceptions being the middle east respiratory syndrome (mers)6 coronavirus in the gulf, and the ebola virus in west http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu africa.7 outbreaks of these diseases have augmented public awareness of the links between wild animals, livestock production, and global public health.8 the one health concept, which originates from ancient civilizations, gained substantial acceptance in the 19th century through infectious disease research9 and comparative medicine.10 evolution of the terms related to one health is summarized in table 1. in the 19th century, robert virchow coined the term “zoonosis” to describe pathogens that are naturally transmitted between vertebrate animals and humans.11 virchow’s contemporary, sir william osler, was the first to use the term “one medicine.”9 later, during the 20th century, calvin schwabe revived the concept of “one medicine.”10 a few years ago, the term “one health” emerged from the joint efforts of american veterinary medical association (avma) and american medical association (ama). by definition, one health is based on a systems approach, which includes disciplines of human medicine, veterinary medicine, and other related scientific health disciplines, working locally, nationally, and globally, to attain optimal health for people, animals, and our environment.12 currently, one health aims to develop the capacity and infrastructure to prevent and respond to the rapidly expanding zoonoses through research that is not only focused on the disease but also on the promotion of health at the individual, population, and ecosystem levels.13 table 1: evolution of the term one health the concept of one health strongly emerged in 2007, and has gained acceptance worldwide. to combat the threats of zoonoses, one health is advocated through intersectoral coordination.14-16 in 2008, the united nations established a framework for approaching emerging diseases by establishing intersectoral coordination and communication strategies, which, in turn, enhances surveillance and emergency response of systems at the national, regional, and international levels.14 this new approach minimizes the risk and global impact of epidemics and pandemics due to emerging infectious diseases. the office international des epizooties (oie) – world organization for animal health endorsed the one health approach in 2008, as a collaborative and all-encompassing way to address animal and public health globally.15 the centers for disease control and prevention (cdc) established a one health office in 2009, and in 2010, the european union reaffirmed its commitment to operate under one health umbrella.16 one health also gained international prominence through the coordinated efforts of multidisciplinary professionals, such as physicians, veterinarians, ecologists, etc. the purposes of this literature review are:  to identify how one health has been used recently in the medical literature;  to identify one health advocates, such as national and international organizations, and academia, as promoters of one health research;  to explore the usage of the term one health though google trends and ngram. methods this literature review was conducted in four phases. the first phase consisted of a general search in pubmed for the term “one health” for any literature published up to december 2014. this search returned 1,682 articles, with the oldest article from january 1953. the articles found by the general search term “one health” were not necessarily linked to zoonoses but had a multitude of meanings, such as one health district, region authority, system, care, resource, sciences, etc. literature published beginning in november 2006 was more associated to zoonoses. in order to examine the effect of the 2007 definition of one health, we excluded articles prior to 2007 with no link to zoonosis. after http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx asokan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu exclusion of such articles, an advanced search using the term “zoonosis” and “one health” returned 193 articles published from january 2007 to december 2014. similarly, an advanced search for the term “zoonoses” and “one health” identified 188 articles from january 2007 to december 2014. through an advanced search, “zoonosis and one health” and “zoonoses and one health” terms were searched for the period between january 2007 and december 2014. the articles found were then categorized based on the type of journals in which the articles were published. for the second phase, “one health” was searched as a medical subject heading (mesh)17 term, which is the national library of medicine controlled vocabulary thesaurus used for indexing articles. in the third phase, one health advocate organizations were found using google search engine. during the final phase, “one health” was searched in google scholar and examined by google trends, which analyzes the number of searches for terms in google.18 google ngram was then used to to analyze the use of the terms in google books.19 results the search results indicate that, in general, there was a gradual increase in the usage of one health from the year 2007 onwards, with an accelerated usage of the term in 2013 and 2014. the only exceptions were 2010 and 2012, in which there were slight decreases in the usage of one health (table 2). table 2: frequency of articles from january 2007 to december 2014 for advanced search terms in pubmed a discipline based journal categorization was almost the same between the two advanced search terms (table 3). for the search term “zoonosis” and “one health,” 71 articles were from veterinary medical journals, out of which 30 articles were listed from scientific and technical review of the oie alone; 53 articles were listed by public health journals, 34 articles from medical journals, and 33 articles in the others category, which included basic science journals such as ecology, environmental, and wildlife journals. table 3: stratification of articles by discipline for advanced search terms in pubmed from january 2007 to december 2014 the most common keywords associated with “one health” were “zoonosis” and “zoonoses,” and our search strategy was confirmed by the returned results. our search in the mesh browser for indexing of the term “one health” found no results. one health advocates google searches identified many prominent organizations that support one health, including: who, fao, oie, cdc, avma, ama, one health initiative movement, one health sweden, world veterinary association, one health global network, one health commission, one health alliance of south asia, one world–one health effort, ecological society of america, and the world bank. the oie, as a one health advocate, is the largetst contributor, with 30 articles in scientific and technical review of the journal oie. some universities which support or offer programs in the area of one health include: university of edinburgh, one health institute of university of california at davis, uppsala university, swedish national veterinary institute , swedish university of agricultural sciences, linnaeus university, one health/one medicine initiative at university of missouri, university of minnesota, university of pennsylvania, oregon state university, massey university, university of guelph, center for one health at university of illinois, north carolina one health collaborative, and university of florida. a few more nongovernmental http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu organizations, namely bill and melinda gates foundation, are allied to one health. google trends and ngram analysis the google trends analysis used data from 2004 to 2014 in order to detect any changes in searches of one health and zoonoses preand post-introduction of the new one health definition. the google trends analysis shows a slight decline in searches of one health from 2004 to 2007 and then an overall steady increase in searches for the term one health from 2007 to 2014, which is consistent with the findings of articles from pubmed and the introduction of the new one health definition (figure 1). there was no noticeable change in the trend of zoonosis or zoonoses. a historical ngram analysis of the terms one health and zoonosis/zoonoses shows an overall increase in the use of one health and zoonosis/zoonoses, with the greatest increase occurring in the 1940s while tapering off slightly in 2010 (figure 2). figure 1: google trends analysis of advanced search terms18 figure 2: ngram analysis of advanced search terms19 discussion the prevention of zoonoses that impact public health and animal health requires a sustained collaboration among the stakeholders to promote the one health approach. even though one health has multiple definitions accorded to it by its various advocates, the common theme that has emerged is collaboration across sectors.20 the development of rift valley fever vaccine by the cdc is one of the noteworthy successes of one health’s collaborative action.21 such collaboration needs to expand to developing countries at all levels of health care delivery, risk communication, and research. uninterrupted, accessible, and indispensable information from a reliable source is central to achieving the one health goals. the most popular, peer reviewed, reliable, and freely available medical and veterinary literature database is pubmed. physicians, veterinarians, basic science researchers, and eco-health professionals often rely on pubmed for their basic scientific information searchers. the ngram analysis of the use of one health over time showed a marked increase roughly around 1945. the 1960s to 1980s mark a particular turn of events in infectious disease epidemiology with the eradication of smallpox, and the decrease of incidence and prevalence of many other diseases, such as measles.22 with new research on understanding the etiology of the most recent emerging diseases (e.g. swine flu, sars, etc.), it has been estimated that roughly 75% of emerging diseases are zoonotic in origin,22 which would explain the increase in the study of zoonosis/zoonoses and one health in the past few decades. the purpose of this literature review was to identify how the term one health is used in the medical literature and to identify one health advocates. we were able to identify and list the major one health advocates through a google search, where oie emerges as the most prominent advocate. however, a pubmed search for one health has shown the zoonoses linkage to the term from the year 2007 only, and this correlates with the joint declaration made on one health by avma and ama in 2007. prior to 2007, one health had many connotations to health in the medical literature. our results have shown that there is a sustained use of the term one health from 2007 onwards, with an accelerated use in 2013 and 2014. however, an incomplete adherence to the usage of one health linking zoonoses in the medical literature is evident, and this practice of poor adherence will potentially impede the implementation of the goals of one health initiatives. the systems approach of one health is practical, cost effective, and involves the sustainable, multidisciplinary support of academia and http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx asokan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu various organizations to undertake more rigorous scientific research for countering the accelerated rise of zoonoses. such research inquiry on zoonoses compels the correct use of terminologies that are acceptable and comprehensible, without any misuse and misunderstanding in the medical literature. the term one health suits the current demand of multidisciplinary scientists involved in the development of this term, which evolved with consensus and feedback from multiple disciplines over time. therefore, we suggest creating a mesh term for one health in the pubmed database that could be under the mesh tree structures of health [n01. 400] similar to family health, public health, rural health, occupational health, and veteran’s health to support more specific research on zoonoses. furthermore, exploring the possibility of a comprehensive, definitive definition for the term one health is a necessity to promote one health, global health, and evidence based public health. competing interests the author declares that they have no competing interests. acknowledgements the author would like to thank the central asian journal of global health team, particularly sharon welburn and faina linkov, for their assistance with utilizing google trends and ngram analysis and for their suggestions on improving our original manuscript. references 1. taylor lh, latham sm, woolhouse me. risk factors for human disease emergence. philos trans r soc lond b biol sci. 2001;356(1411):983-989. 2. wang lf, crameri g. emerging zoonotic viral diseases. rev sci tech off int epiz. 2014;33(2):569-581. 3. li w, wong sk, fang l, et al. animal origins of the severe acute respiratory syndrome coronavirus: insight from ace2-sprotein interactions. j virol. 2006;80(9):4211-4219. 4. epstein jh, field he, luby s, pulliam jr, daszak p. nipah virus: impact, origins, and causes of emergence. curr infect dis rep. 2006;8(1):59-65. 5. world health organization. avian influenza. 2014; http://www.who.int/mediacentre/factsheets/avian_influenza/en /. accessed june 25, 2015. 6. centers for disease control and prevention (cdc). middle east respiratory syndrome (mers). 2015; http://www.cdc.gov/coronavirus/mers/faq.html. accessed june 25, 2015. 7. centers for disease control and prevention (cdc). ebola (ebola virus disease). 2015; http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.ht ml. accessed june 25, 2015. 8. food and agriculture organization, united nations. thoughts of fao on 'one health'. 2012; http://www.fao.org/ag/againfo/home/en/news_archive/2010_o ne-health.html. accessed june 9, 2015. 9. cardiff rd, ward jm, barthold sw. 'one medicine---one pathology': are veterinary and human pathology prepared? lab invest. 2008;88(1):18-26. 10. schwabe cw. veterinary medicine and human health. 3rd ed. baltimore: williams & wilkins; 1984. 11. saunders lz. virchow’s contributions to veterinary medicine: celebrated then, forgotten now. vet pathol. 2000;37(3):199-207. 12. american veterinary medical association. one health what is one health? https://www.avma.org/kb/resources/reference/pages/onehealth94.aspx. accessed june 9, 2015. 13. conrad pa, mazet ja, clifford d, scott c, wilkes m. evolution of a transdisciplinary "one medicine-one health" approach to global health education at the university of california, davis. prev vet med. 2009;92(4):268-274. 14. food and agriculture organization, office of international education, world health organization, un system influenza coordination, unicef, world bank. contributing to one world, one health: a strategic framework for reducing risks of infectious diseases at the animal-human-ecosystems interface. 2008; http://www.fao.org/docrep/011/aj137e/aj137e00.htm. accessed june 9, 2015. 15. world organisation for animal health. one health one health at at glance. 2015; http://www.oie.int/for-themedia/onehealth/. accessed june 9, 2015. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/mediacentre/factsheets/avian_influenza/en/ http://www.who.int/mediacentre/factsheets/avian_influenza/en/ http://www.cdc.gov/coronavirus/mers/faq.html http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html http://www.fao.org/ag/againfo/home/en/news_archive/2010_one-health.html http://www.fao.org/ag/againfo/home/en/news_archive/2010_one-health.html https://www.avma.org/kb/resources/reference/pages/one-health94.aspx https://www.avma.org/kb/resources/reference/pages/one-health94.aspx http://www.fao.org/docrep/011/aj137e/aj137e00.htm http://www.oie.int/for-the-media/onehealth/ http://www.oie.int/for-the-media/onehealth/ central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu 16. centers for disease control and prevention (cdc). history of one health. 2015; http://www.cdc.gov/onehealth/peopleevents.html. accessed june 9, 2015. 17. national library of medicine. medical subject headings. 2014; http://www.nlm.nih.gov/mesh/mbrowser.html. accessed may 14, 2014. 18. google. data source: google trends. 2015; www.google.com/trends. accessed june 10, 2015. 19. schmidt d, heckendorf c. ngram: an n-gram babbler. 2014; http://cran.r-project.org/web/packages/ngram/. accessed june 10, 2015. 20. one health global network. what is one health? 2015; http://www.onehealthglobal.net/what-is-one-health/. accessed june 10, 2015. 21. centers for disease control and prevention (cdc). one health in action. 2013; http://www.cdc.gov/onehealth/inaction/index.html. accessed june 10, 2015. 22. gibbs ep. emerging zoonotic epidemics in the interconnected global community. vet rec. 2005;157(22):673679. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.cdc.gov/onehealth/people-events.html http://www.cdc.gov/onehealth/people-events.html http://www.nlm.nih.gov/mesh/mbrowser.html http://www.google.com/trends http://cran.r-project.org/web/packages/ngram/ http://www.onehealthglobal.net/what-is-one-health/ http://www.cdc.gov/onehealth/in-action/index.html http://www.cdc.gov/onehealth/in-action/index.html asokan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu table 1: evolution of the term one health individual/organization experimental basis evolution of the term 19th century robert virchow experimental studies on trichinella spiralis, bovine cysticercosis, and bovine tuberculosis zoonoses9 19th century sir william osler comparative pathology between human and animal diseases one medicine9 20th century dr. calvin w. schwabe comparative and collaborative medicine to combat diseases and to ensure food and environment quality reintroduced one medicine10 2007 american medical association (ama) and american veterinary medical association (avma) integrated research, education, and public health prevention, preparedness, and response for achieving improved animal and human health one health10 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu table 2: frequency of articles from january 2007 to december 2014 for advanced search terms in pubmed search terms year “zoonosis” and “one health” “zoonoses” and “one health” 2007 3 3 2008 5 5 2009 12 12 2010 11 11 2011 21 21 2012 13 13 2013 60 56 2014 68 67 total 193 188 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx asokan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu table 3: stratification of articles by discipline for advanced search terms in pubmed from january 2007 to december 2014 search terms “zoonosis” and “one health” “zoonoses” and “one health” veterinary medicine 71 71 public health 53 52 medical 34 32 health policy 2 2 other 33 31 total 193 188 note. other disciplines include: ecology health, wildlife diseases, nursing, environmental health, etc. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu figure 1: google trends analysis of zoonosis/zoonoses and one health18 one health zoonosis zoonoses one health http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx asokan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.139 | http://cajgh.pitt.edu figure 2: ngram analysis of zoonosis/zoonoses and one health19 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. oligomeric amyloid-β peptide on sialylic lewisx–selectin bonding at cerebral endothelial surface sholpan askarova1, grace y. sun2, gerald a. meininger3, james lee4 1center for life sciences, nazarbayev university, astana, kazakhstan; 2department of biochemistry, university of missouri, usa; 3dalton cardiovascular research center, university of missouri, usa; 4department of biological engineeering, university of missouri, usa vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.150 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ askarova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.150 | http://cajgh.pitt.edu abstract introduction: alzheimer’s disease (ad) is a chronic neurodegenerative disorder, which affects approximately 10% of the population aged 65 and 40% of people over the age 80. currently, ad is on the list of diseases with no effective treatment. thus, the study of molecular and cellular mechanisms of ad progression is of high scientific and practical importance. in fact, dysfunction of the blood-brain barrier (bbb) plays an important role in the onset and progression of the disease. increased deposition of amyloid b peptide (aβ) in cerebral vasculature and enhanced transmigration of monocytes across the bbb are frequently observed in ad brains and are some of the pathological hallmarks of the diseases. since the transmigration of monocytes across the bbb is both a mechanical and a biochemical process, the expression of adhesion molecules and mechanical properties of endothelial cells are the critical factors that require investigation. methods: because of recent advances in the biological applications of atomic force microscopy (afm), we applied afm with cantilever tips bio-functionalized by slex in combination with the advanced immunofluorescent microscopy (qim) to study the direct effects of aβ42 oligomers on the selectins expression, actin polymerization, and cellular mechanical and adhesion properties in cerebral endothelial cells (mouse bend3 line and primary human cecs) and find a possible way to attenuate these effects. results: qim results showed that aβ42 increased the expressions of p-selectin on the cell surface and enhanced actin polymerization. consistent with our qim results, afm data showed that aβ42 increased the probability of cell adhesion with slexcoated cantilever and cell stiffness. these effects were counteracted by lovstatin, a cholesterol-lowering drug. surprisingly, the apparent rupture force of slex-selectin bonding was significantly lower after treatment with aβ42, as compared with the control (i.e. no treatment). similar results were also obtained when cells were treated with latruculin a (f-actin-disrupting drug). these results suggest that the decrease in the apparent rupture force of slex-selectin bonding is the consequence of the dissociation of adhesion between the cytoskeleton and the bilayer membrane induced by aβ42. the major causes of excess mortality in the first group were neoplams (30.6%), hypertension (23.8%), and myocardial infarction (22.6%). the effects of radiation influenced mortality in the second group were 2-2.5 times lower than the first group. conclusion: the studies of the effects of aβ42 on the adhesion properties of cerebral endothelial cells and how pharmacological agents (e.g. statin) counteract these effects should prove to provide insights into the mechanism of inflammation in alzheimer’s brains and the design of therapeutic treatments of the disease. keywords: alzheimer’s disease, statins, brain inflamation, treatment http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. polyphenol concentrate from kazakhstan cabernet sauvignon collection of grapes zarina shulgau, vladislav tritek, alexander gulyaev, gulsim adilgozhina, talgat nurgozhin center for life sciences, nazarbayev university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.174 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ shulgau this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.174 | http://cajgh.pitt.edu abstract introduction. nowadays, most of the research in the field of gerontology is focused on the effects of the grape polyphenols. in particular, resveratrol has been shown to increase life expectancy of various living organisms, including mammals. resveratrol also plays an important role in cancer prevention and decreases the risk of developing cardiovascular disease. in our research, we proposed the development of the therapeutic product from cabernet sauvignon grapes that would exhibit the beneficial properties of polyphenols. standard operating procedures were developed in our laboratories to collect alcohol free concentrate of polyphenols from the kazakhstan cabernet sauvignon collection of grapes. the purpose of the study was to investigate the composition, biological safety, and potential therapeutic effects of the polyphenol concentrate. methods. the total polyphenol amount was determined using the enology analyzer y15 (biosystems, spain). hplc analysis of the polyphenol composition was performed using agilent 1290 chromatograph. the polyphenol concentrate was analyzed for the microbiological purity and the presence of the toxic elements. the cytoprotective effect of the polyphenol concentrate was studied in experimental models of diabetes, toxic hepatitis, doxorubicin cardiomyopathy, and acute radiation sickness. results. the total polyphenol amount in one sample was 12,819 mg/l. polyphenol composition analysis showed presence of the following polyphenols: catechin, epicatechin, gallic acid, quercetin, miricetin, 3-glucosylkaempferol, epicatechin gallate, 3-(3,4dihydroxyphenyl)-2-propenoic acid, catechin gallate, pitseid, kaempferol, n-hydroxy-cinnamic acid, resveratrol and chlorogenic acid. the concentrate was proven to be biologically safe and acceptable for use as a dietary supplement. the polyphenol concentrate demonstrated high antioxidant activity against abts and dpph radicals in vitro. it also showed the following impacts on the various experimental models in vivo: reduction of sugar levels in diabetes; regeneration of the structure and function of the heart tissue in cardiomyopathy; regeneration of the nephron structure and function in nephropathy; regeneration of liver in toxic hepatitis; recovery of the antioxidant status in oxidative stress; and recovery of the hematopoiesis in acute radiation sickness. conclusion. the polyphenol concentrate from kazakhstan cabernet sauvignon collection of grapes was proved to be biologically safe and acceptable for use as a dietary supplement. the concentrate showed high antioxidant, antiradiation activity, and regenerative effect in diabetes, cardiomyopathy, nephropathy, and hepatitis in the corresponding organs. keywords: gerontology, polyphenol, longevity, antioxidants http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. a comparison of comprehensive hiv/aids knowledge among women across seven post-soviet countries hakim zainiddinov1, nazim habibov2 1rutgers university, united states; 2university of windsor, canada vol. 7, no. 1 (2018) | issn 2166-7403 (online) doi 10.5195/cajgh.2018.295 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.295|http://cajgh.pitt.edu abstract introduction: post-soviet countries of eastern europe and central asia have witnessed a recent growth of hiv infection through heterosexual transmission. women’s low levels of knowledge about hiv prevention and transmission methods have been found to account for the higher female-to-male ratio among cases infected through the heterosexual route. this cross national comparison study assessed comprehensive hiv/aids knowledge and its key determinants among women of seven post-soviet countries and identified which countries face the highest levels of risk due to the low levels of hiv/aids awareness. methods: study data were obtained from the third wave of the multiple indicator cluster surveys (mics3) (conducted in 2005 and 2006), nationally representative samples of women aged 15-49 years. data on hiv/aids knowledge were analyzed for women in kazakhstan (n=14,310), kyrgyzstan (n=6,493), tajikistan (n=4,676), uzbekistan (n=13,376), belarus (n=5,884), ukraine (n=6,066), and georgia (n=7,727) using descriptive statistics and ordinary least squares (ols) regressions. results: we found that the percentage of women who could correctly identify all five modes of hiv/aids transmission and prevention was highest in eastern european countries of belarus (34.98%) and ukraine (31.67%). across all countries, the strongest predictors of comprehensive hiv/aids knowledge were age, education, and region of residence. marital status, area of residence (urban vs. rural), and household wealth were significant predictors for several countries. conclusion: high rates of comprehensive hiv/aids knowledge were found among women of belarus and ukraine. to reduce the spread of hiv in the region, programs promoting comprehensive hiv/aids knowledge for women of younger ages and with lower education are recommended. keywords: hiv infection; comprehensive hiv/aids knowledge; women; heterosexual transmission; post-soviet countries a comparison of comprehensive hiv/aids knowledge among women across seven post-soviet countries hakim zainiddinov1, nazim habibov2 1rutgers university, united states; 2university of windsor, canada research in the past fifteen years many countries around the world witnessed dramatic decline in hiv incidence and mortality.1 between 2001 and 2011, the number of people acquiring hiv declined by 50% in 25 low and middle-income countries.1 nepal was at the top of the list with a drop of 91%, followed by ethiopia at 90%, cambodia at 88%, suriname at 86%, myanmar at 74%, dominican republic at 73%, malawi at 72%, and botswana at 71%.1 yet, these encouraging national trends in a dramatic reduction in the rate of new hiv infections in many parts of the world were not observed in eastern europe and central asia.1,2 for example, georgia, kazakhstan, and kyrgyzstan reported a 25% increase in the rate of new hiv infections between 2001 and 2011.1 according to recent who report, between 2006 and 2012, rates of hiv diagnoses per 100 000 population increased more than threefold in tajikistan, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.295|http://cajgh.pitt.edu twofold in kyrgyzstan, and by 72% and 92% in belarus and georgia, respectively.3 among 52 countries of the who european region, ukraine reported the highest rate (37.1%) of newly diagnosed hiv infections in 2012.3 several other countries of eastern europe and central asia, including belarus (13.1%), kyrgyzstan (12.8%), and kazakhstan (12.4%) were among the countries with the highest rates of newly diagnosed hiv infections.3 political and economic instability, as well as the collapse of highly structured public health system contribute to growing rates of hiv/aids epidemic throughout central asia and eastern europe.2,4 other factors leading to the high hiv prevalence rates in post-soviet countries include low levels of preventive practices and punitive measures taken against hiv infected people.5 among low and middle-income countries, the treatment gap remains one of the highest for countries of eastern europe and central asia. in 2011, there was a 75% gap between the number of people receiving antiretroviral therapy (130,000) and the number of people eligible for treatment (510,000).1 in the past decades, the leading mode of hiv transmission in eastern europe and central asia changed from injection drug route to heterosexual transmission.2,3 between 2006 and 2012, the number of hiv infections acquired through heterosexual transmission increased more than three times in kazakhstan and kyrgyzstan, and around six times in tajikistan.3 in 2012, the majority (60%) of new hiv infections were acquired through heterosexual contact in 13 of the 15 countries in the eastern part of the who european region.3 heterosexual mode of transmission affects women more than men.3 one of the main factors contributing to the higher female-to-male ratio among cases infected through heterosexual transmission is a low level of knowledge on hiv prevention and transmission methods among women. recent nationally representative surveys conducted in 26 of 31 countries with generalized epidemics revealed that less than 50% of women have comprehensive hiv knowledge.1 similarly, empirical studies demonstrate that although women’s awareness about hiv/aids has increased, their levels of comprehensive knowledge, as defined by unicef, either remain low,6,7 or have not reached the 90% targeted threshold set by the united nations general assembly special session (ungass).8 since injection drug use was the primary method of hiv transmission in the early days of the epidemic, it is not surprising that most published studies of hiv infections in eastern europe and central asia were focused on injection drug users.9,20,11,12 given the recent rise of new hiv infections acquired through heterosexual contact, this study examined women’s comprehensive hiv knowledge in post-soviet countries to determine regional differences and identify key determinants that could serve in guiding future policies aimed at reducing discrepancies across countries and regions. we focused this investigation on seven postsoviet countries, including four central asian (kazakhstan, kyrgyzstan, tajikistan, and uzbekistan), two eastern european (belarus and ukraine), and one caucasian (georgia). the selection of these countries was determined by 1) data availability; and 2) representativeness of the former soviet union. the hiv/aids trends vary in each of these countries. in 2012 the percentage of newly diagnosed hiv infections ranged from the lowest 10.2% in tajikistan to the highest 37.1% in ukraine.3 the levels of public health expenditure differ substantially across these countries. in 2006, the levels of public health expenditure were lower in the countries of the caucasus and central asia (less than 3% of gdp and even below 1% in georgia and tajikistan) and higher in the western commonwealth of independent countries (cis) countries (4% and 5% of gdp), which includes belarus and ukraine.13 given the level of socio-economic development of central asian countries (except for kazakhstan, the other three countries are low middle income countries13) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.295|http://cajgh.pitt.edu and their low levels of public health expenditure, it is expected that women of this region will report lower levels of comprehensive hiv knowledge compared to women from eastern europe. methods data sources study data were obtained from the third wave of the multiple indicator cluster surveys (mics3) (conducted in 2005 and 2006), nationally representative samples of women aged 15-49 years. eligible women were interviewed from the list of households chosen for participation in the surveys.14,15,16,17,18,19 the survey samples were selected using a multi-stage stratified cluster sampling approach.14,15,16,17,18,19 the data were collected in more than 50 countries around the world.14,15,16,17,18,19 mics3 datasets provide information about basic household socio-demographic characteristics, nutrition, and health indicators for women and children, and women’s general knowledge about hiv/aids, as well as its prevention and transmission methods. the data are publicly available and can be accessed at mics website.20 mics3 surveys included a large number of post-soviet countries: four central asian countries (kazakhstan, kyrgyzstan, tajikistan, and uzbekistan), two eastern european countries (belarus and ukraine), and one country from the caucasus region (georgia). the data for other mics waves were available for a limited number of post-soviet countries, thus our study focused on the wave with the most complete data available. the total sample for all seven countries is 58,532, out of which 4,676 come from tajikistan, 5,884 from belarus, 6,066 from ukraine, 6,493 from kyrgyzstan, 7,727 from georgia, 13,376 from uzbekistan, and 14,310 from kazakhstan. women’s response rates in the surveys were very high, with 90.3% for georgia, 96% for tajikistan, 98% for uzbekistan, 99% for kazakhstan and kyrgyzstan, and 99.8% for belarus and ukraine. statistical agencies of the analyzed countries conducted mics3 with the financial and technical support of the united nations children’s fund (unicef). measures using the unicef definition of comprehensive knowledge of hiv/aids that includes an accurate identification of two primary methods of hiv prevention (using condoms and having one uninfected partner) and rejection of three common misconceptions about hiv transmission (hiv can be transmitted by sharing food and by mosquito bites, and a healthy-looking person cannot be infected),14,15,16,17,18,19 we created a scale, labeled “comprehensive hiv/aids knowledge.” the scale ranged from 0 to 5, with higher scores indicating high comprehensive hiv/aids knowledge, and lower scores indicating low comprehensive knowledge about the disease. we estimated cronbach’s alphas to show the degree of consistency in our scale. cronbach’s alphas ranging from the lowest to highest were as follows: 0.34 for belarus, 0.43 for ukraine, 0.48 for kyrgyzstan and kazakhstan, 0.50 for georgia, 0.52 for uzbekistan, and 0.56 for tajikistan. except for belarus, alpha coefficients for other countries were within the range of previous studies.21,22 independent variables included several sociodemographic measures that were potentially correlated with aids knowledge.23 demographic measures include: age (between 15-49), marital status (currently married vs. not married), region of residence (capital city vs. other), and area of residence (rural vs. urban). education was classified as (higher degree (university graduate) vs. other), and level household income (recoded as tertiles: lower income, middle income, upper income). statistical analysis univariate analyses were used to identify associations between the variables across seven postsoviet countries. to evaluate comprehensive hiv/aids knowledge and its key determinants among women, we http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.295|http://cajgh.pitt.edu figure 1. distribution of scores for hiv/aids knowledge across seven compared countries. ran ordinary least squares (ols) regression on the weighted data. to accurately assess the effect of age, which might not have a linear relationship with the outcome measure, we also included the age squared variable into our models. data analyses were conducted using stata 14 statistical software. results respondents’ average comprehensive knowledge of hiv ranged from the lowest 2.60 (sd = 1.49) in tajikistan to the highest 3.86 (sd = 1.08) in belarus (table 1). average age ranged from 29.45 (sd = 9.97) in uzbekistan to 32.31 (sd = 9.89) in georgia. the majority of participants, ranging from 57.88% in kazakhstan to 70.87% in belarus, were currently married. a small percentage of respondents, ranging from 5.29% in kazakhstan to 24.21% in tajikistan, resided in the capital city. 2. 97 3. 36 9. 9 1. 68 0. 15 1. 14 3. 86 8. 88 6. 55 15 .4 6. 56 2. 58 3. 69 7 16 .7 9 15 .2 9 21 .4 9 14 .5 3 8. 48 10 .4 4 14 .9 7 25 .1 4 26 .4 9 23 .5 9 21 .7 23 .5 4 23 .2 4 25 .2 5 24 .1 6 27 .0 8 17 .1 9 24 .6 7 30 .2 7 29 .8 2 27 .2 8 22 .0 7 21 .2 4 12 .4 3 30 .8 7 34 .9 8 31 .6 7 21 .6 4 0 5 10 15 20 25 30 35 40 kazakhstan kyrgyzstan tajikistan uzbekistan belarus ukraine georgia pr op or tio n of h iv /a id s tra ns m is si on a nd p re ve nt io n k no w le dg e sc or es notes: source: mics 2005-2006 proportions (%) are presented for correctly identified modes of hiv/aids transmission and prevention 0 1 2 3 4 5 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.295|http://cajgh.pitt.edu kazakhstan (n=14,310) mean (sd) or % kyrgyzstan (n=6,493) mean (sd) or % tajikistan (n=4,676) mean (sd) or % uzbekistan (n=13,376) mean (sd) or % belarus (n=5,884) mean (sd) or % ukraine (n=6,066) mean (sd) or % georgia (n=7,727) mean (sd) or % comprehensive hiv/aids knowledge age (range: 15-49) marital status currently married not married region of residence capital other area urban rural education higher other household wealth lower income middle income upper income 3.25 (1.36) 31.36 (10.32) 57.88 42.12 5.29 94.71 52.65 47.35 25.60 74.40 33.11 32.82 34.07 3.31 (1.32) 29.56 (10.08) 60.88 39.12 14.60 85.40 58.91 41.09 23.78 76.22 32.51 32.62 34.87 2.60 (1.49) 30.47 (9.48) 65.44 34.56 24.21 75.79 43.69 56.31 17.39 82.61 25.58 30.33 44.10 3.54 (1.32) 29.45 (9.97) 64.27 35.73 14.66 85.34 41.61 58.39 10.05 89.95 33.63 33.27 33.10 3.86 (1.08) 31.49 (9.35) 70.87 29.13 16.04 83.96 68.13 31.87 25.19 74.81 33.21 33.38 33.41 3.72 (1.18) 30.65 (9.53) 68.08 31.92 5.87 94.13 63.57 36.43 43.54 56.46 33.84 33.55 32.61 3.30 (1.35) 32.31 (9.89) 63.50 36.50 18.18 81.82 59.60 40.40 39.11 60.89 30.93 26.08 42.99 notes: means and standard deviations are presented for continuous variables; proportions (%) are presented for categorical variables. due to differences in the number of regions across countries, only capital city is shown. table 1. descriptive statistics for the sample except for uzbekistan (41.61%) and tajikistan (43.69%), the majority of respondents in other countries resided in urban areas. women in uzbekistan (10.05%) and tajikistan (17.39%) comprised the lowest percentage of respondents with higher (university/institute graduate) levels of education, whereas women in georgia (39.11%) and ukraine (43.54%) had the highest percentage. the percentage of household wealth was evenly distributed among three categories across all countries, except for tajikistan and georgia. the proportion of women who could not correctly identify a single mode of hiv/aids transmission and prevention was found to be the highest http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.295|http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.295|http://cajgh.pitt.edu among women in tajikistan (9.9%) and lowest among women in belarus (0.15%) (figure 1). one third of the respondents in uzbekistan (30.87%), ukraine (31.67%), and belarus (34.98%), every fifth respondent in kazakhstan (22.07%), kyrgyzstan (21.24%), and georgia (21.64%), and only 12.43% of respondents in tajikistan could correctly identify all five modes of hiv/aids transmission and prevention. similarly across the countries of interest, over 20% of women could correctly identify three modes of transmission and prevention. across all of the analyzed countries, younger women’s comprehensive hiv knowledge was higher compared to older women (table 2). currently married women in uzbekistan reported comprehensive hiv knowledge scores that were 0.03 points higher than nonmarried women (p ≤ 0.01), whereas married women in kyrgyzstan and ukraine reported scores that were 0.04 points lower than non-married women (p ≤ 0.05). region of residence was inversely related to women’s comprehensive hiv knowledge in uzbekistan, belarus, ukraine, and georgia, whereas women residing in the capital cities of kazakhstan, kyrgyzstan, and tajikistan reported scores that were respectively 0.04, 0.38, and 0.15 points higher than those residing in one of the regions outside of the capital cities. women from rural areas in kazakhstan and georgia reported scores that were respectively 0.03 and 0.07 points lower, and rural women from kyrgyzstan reported scores that were 0.04 points higher than women from urban areas. education was positively related with women’s comprehensive hiv knowledge across all countries. household wealth had a positive significant association with comprehensive hiv knowledge for women only in one caucasian (georgia) and three central asian (kazakhstan, tajikistan, and uzbekistan) countries (p ≤ 0.001). discussion as expected, the lowest levels of comprehensive hiv knowledge were found among respondents in central asia, whereas the highest levels were reported by women from eastern european countries. the difference between belarus with the highest levels and tajikistan with the lowest levels of comprehensive knowledge was almost threefold. uzbekistan was an exception among central asian countries. the percentage of women in uzbekistan who could identify all five modes of hiv transmission and prevention was the third highest among the seven analyzed countries. it could be partially explained by the high levels of the country’s public expenditure on education. in 2006, among the 26 analyzed countries of central and eastern europe and cis, uzbekistan reported the highest level of expenditure on education (6.3% of gdp).13 overall, the level of comprehensive hiv knowledge among women in all post-soviet countries under investigation remains low. as a comparison, in 2008-2009, 54% of young urban women in kenya, a country greatly affected by aids pandemic, reported having comprehensive hiv knowledge.8 this difference can be attributed to the fact that sub-saharan africa has been heavily affected by hiv/aids and consequently attracted substantial global interest and funding for hiv/aids treatment, raising the population awareness. additionally, variations in public spending on hiv/aids can account for the difference. in 2001-2005, there was a moderate increase of 30% and 10% in domestic public expenditure on hiv/aids from governments of lowermiddle-income and upper-middle-income countries respectively, whereas sub-saharan african countries witnessed an increase of 130% during the same time period.24 among socio-demographic characterstics, we found that age, education, and region were strongly associated with women’s comprehensive hiv knowledge across all countries. with increase in age, women’s comprehensive hiv knowledge also increased. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.295|http://cajgh.pitt.edu yet, this positive effect declined with advanced age. one speculation is women’s loss of interest in the subject, due to their decreasing levels of sexual activity. another explanation can be linked to cohort differences. the older women may be less likely to have received the same information or public health messaging about hiv when compared to the younger women. compared to less educated women, women with higher education reported higher levels of comprehensive hiv/aids knowledge. this finding is consistent with previous studies6,7,8 , and also supported by ethnographic research demonstrating that highly educated women possess more detailed knowledge about hiv/aids.25 interestingly, the association between comprehensive hiv knowledge and the capital city region of residence was positive among women in kazakhstan, kyrgyzstan, and tajikistan, and negative among women in uzbekistan, georgia, ukraine, and belarus. this differential effect could be attributed to varying degrees of access to information and healthcare services. one may speculate that women residing in the capital cities of kazakhstan, kyrgyzstan, and tajikistan have better access to information about hiv/aids, are more aware of hiv, and resort to hiv testing compared to respondents from uzbekistan, georgia, ukraine, and belarus. the effects of several covariates on comprehensive hiv knowledge varied from country to country. being currently married increased comprehensive hiv knowledge among women in uzbekistan, but had a reverse effect on women’s knowledge in kyrgyzstan and ukraine. prior research suggests that married women might benefit from their husbands’ knowledge, as it can be a case for uzbekistan. however, they can also take fewer precautions in their marital sex, neglecting the possibility of their husbands’ sexual relationships outside of marriage.8 mixed results were also found for the area of residence. living in rural areas decreased comprehensive hiv knowledge for women in kazakhstan and georgia, which is consistent with prior studies.6 yet, for women from kyrgyzstan the association was reverse. the positive association between rural area and comprehensive hiv knowledge can be linked to high levels of labor migration among rural dwellers. experts have already raised alarms about the growing numbers of hiv infections among labor migrants, and growing risk for hiv transmission to their home countries.26 household wealth is positively associated with comprehensive hiv knowledge, although the effects were mostly significant for central asian countries. respondents in the middle and upper income tertiles reported significantly higher levels of comprehensive hiv knowledge than those in the lower income tertile. this finding corroborates previous research.6 insignificant effects of wealth on comprehensive hiv knowledge in other countries under investigation are consistent with another group of studies and can be attributed to the association betweeb wealth and education, another proxy of social status.7 the present study has several limitations. first, the exploratory nature and scope of the present study do not allow us to include factors beyond sociodemographic characteristics. future research can explore other potential factors, such as access to hiv testing and care, knowledge of hiv status, and exposure to information on hiv prevention and transmission that could influence women’s comprehensive hiv knowledge. second, although cronbach’s alphas for created scales are within the range of previous studies, they are relatively low. upon availability of other surveys producing scales with relatively high degrees of internal consistency, the study should be replicated to see whether the observed patterns persist across time periods and countries. future studies should also investigate clinical and public health significance of these findings. the recent growth of hiv infection through heterosexual transmission in post-soviet countries of eastern europe and central asia, especially among http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.295|http://cajgh.pitt.edu women, is alarming. this study revealed differences in the comprehensive hiv knowledge, but it was low among the studied countries. across all countries, the strongest predictors of comprehensive hiv/aids knowledge were age, education, and region of residence. the percentage of women who could correctly identify all five modes of hiv/aids transmission and prevention was highest in belarus (34.98%) and ukraine (31.67%), suggesting that knowledge increases as the population level of the hiv epidemic increases. references 1. unaids. world aids day report 2012. geneva: unaids; 2012. http://www.unaids.org/sites/default/files/media_ass et/jc2434_worldaidsday_results_en_1.pdf (accessed 8 january 2018) 2. dehovitz j, uusküla a, el-bassel n. the hiv epidemic in eastern europe and central asia. current hivaids reports. 2014;11:168–176. 3. ecdc/who (european centre for disease prevention and control/who regional office for europe). hiv/aids surveillance in europe 2012. stockholm: european centre for disease prevention and control; 2013. http://www.euro.who.int/__data/assets/pdf_file/001 8/235440/e96953.pdf (accessed 8 january 2018) 4. world bank. reversing the tide: priorities for hiv/aids prevention in central asia, world bank working paper no. 54. washington, d.c.: the world bank; 2005. https://openknowledge.worldbank.org/handle/1098 6/7354 (accessed 8 january 2018) 5. roberts b, karanikolos m, rechel b. health trends. pp. 9-28 in trends in health systems in the former soviet countries, eds. bernd rechel, erica richardson, martin mckee. european observatory on health systems and policies, copenhagen, denmark: who regional office for europe; 2014. 6. siziya s, muula as, rudatsikira e. hiv and aids related knowledge among women in iraq. bmc research notes. 2008;1:123. 7. kejela g, oljira l, dessie y, et al. comprehensive hiv/aids knowledge level among out-of-school youths in wayu tuka district, western ethiopia. european journal of preventive medicine. 2015;3(1):11-16. 8. ochako r., ulwodi d, njagi p, et al. trends and determinants of comprehensive hiv and aids knowledge among urban young women in kenya. aids research and therapy. 2011; 8,11. 9. el-bassel n, gilbert l, terlikbayeva a, et al. hiv among injection drug users and their intimate partners in almaty, kazakhstan. aids and behavior. 2013;17(7):2490-2500. 10. petersen p, myers b., van hout m, et al. availability of hiv prevention and treatment services for people who inject drugs: findings from 21 countries. harm reduction journal. 2011:10,13. 11. spicer n, bogdan d, brugha r, et al. 'it's risky to walk in the city with syringes': understanding access to hiv/aids services for injecting drug users in the former soviet union countries of ukraine and kyrgyzstan. globalization & health. 2011;7,22. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.unaids.org/sites/default/files/media_asset/jc2434_worldaidsday_results_en_1.pdf http://www.unaids.org/sites/default/files/media_asset/jc2434_worldaidsday_results_en_1.pdf http://www.euro.who.int/__data/assets/pdf_file/0018/235440/e96953.pdf http://www.euro.who.int/__data/assets/pdf_file/0018/235440/e96953.pdf https://openknowledge.worldbank.org/handle/10986/7354 https://openknowledge.worldbank.org/handle/10986/7354 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.295|http://cajgh.pitt.edu 12. stachowiak ja, tishkova fk, strathdee sa, et al. marked ethnic differences in hiv prevalence and risk behaviors among injection drug users in dushanbe, tajikistan. drug & alcohol dependence. 2004;82:s7–s14. 13. unicef. innocenti social monitor 2009. child well-being at a crossroads: evolving challenges in central and eastern europe and the commonwealth of independent states. florence, italy: unicef; 2009. https://www.unicef.org/romania/ism_2009.pdf (accessed 8 january 2018) 14. nsc (national statistical committee of the kyrgyz republic). kyrgyzstan multiple indicator cluster survey 2006, final report. bishkek, kyrgyzstan: national statistical committee of the kyrgyz republic; 2007. https://mics-surveysprod.s3.amazonaws.com/mics3/europe and central asia/kyrgyzstan/20052006/final/kyrgyzstan 2005-06 mics_english.pdf (accessed 8 january 2018) 15. scs (state committee on statistics of the republic of tajikistan). tajikistan multiple indicator cluster survey 2005, final report. dushanbe, tajikistan: state committee on statistics of the republic of tajikistan; 2007. www.stat.tj/en/img/e1aef37486b7a4528ba06bfcb91 8347f_1280833057.pdf (accessed 8 january 2018) 16. united nations children’s fund (unicef), agency of the republic of kazakhstan on statistics. kazakhstan multiple indicator cluster survey 2006, final report. astana, kazakhstan: unicef, agency of the republic of kazakhstan on statistics; 2007. https://mics-surveysprod.s3.amazonaws.com/mics3/europe and central asia/kazakhstan/2006/final/kazakhstan 2006 mics_english.pdf (accessed 8 january 2018) 17. unicef and state statistical committee of the republic of uzbekistan. uzbekistan multiple indicator cluster survey 2006, final report. tashkent, uzbekistan: unicef; 2007. https://www.unicef.org/eca/mics3_uzbekistan_fi nalreport_2006_en.pdf (accessed 8 january 2018) 18. sds (state department of statistics of georgia). georgia multiple indicator cluster survey 2005. tbilisi, georgia: state department of statistics of georgia; 2008. https://mics-surveysprod.s3.amazonaws.com/mics3/europe and central asia/georgia/2005/final/georgia 2005 mics_english.pdf (accessed 8 january 2018) 19. msa (ministry of statistics and analysis of the republic of belarus and research institute of statistics of the ministry of statistics and analysis of the republic of belarus). belarus multiple indicator cluster survey 2005, final report. minsk, republic of belarus: ministry of statistics and analysis of the republic of belarus and research institute of statistics of the ministry of statistics and analysis of the republic of belarus; 2007. https://mics-surveysprod.s3.amazonaws.com/mics3/europe and http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.unicef.org/romania/ism_2009.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/kyrgyzstan/2005-2006/final/kyrgyzstan%202005-06%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/kyrgyzstan/2005-2006/final/kyrgyzstan%202005-06%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/kyrgyzstan/2005-2006/final/kyrgyzstan%202005-06%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/kyrgyzstan/2005-2006/final/kyrgyzstan%202005-06%20mics_english.pdf http://www.stat.tj/en/img/e1aef37486b7a4528ba06bfcb918347f_1280833057.pdf http://www.stat.tj/en/img/e1aef37486b7a4528ba06bfcb918347f_1280833057.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/kazakhstan/2006/final/kazakhstan%202006%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/kazakhstan/2006/final/kazakhstan%202006%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/kazakhstan/2006/final/kazakhstan%202006%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/kazakhstan/2006/final/kazakhstan%202006%20mics_english.pdf https://www.unicef.org/eca/mics3_uzbekistan_finalreport_2006_en.pdf https://www.unicef.org/eca/mics3_uzbekistan_finalreport_2006_en.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/georgia/2005/final/georgia%202005%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/georgia/2005/final/georgia%202005%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/georgia/2005/final/georgia%202005%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/georgia/2005/final/georgia%202005%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/belarus/2005/final/belarus%202005%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/belarus/2005/final/belarus%202005%20mics_english.pdf zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.295|http://cajgh.pitt.edu central asia/belarus/2005/final/belarus 2005 mics_english.pdf (accessed 8 january 2018) 20. unicef. multiple indicator cluster surveys (mics). http://mics.unicef.org/surveys (accessed 8 january 2018) 21. letamo g. misconceptions about hiv prevention and transmission in botswana. african journal of aids research. 2007;6(2):193-198. 22. tenkorang ey. myths and misconceptions about hiv transmission in ghana: what are the drivers? culture, health & sexuality. 2013;15(3):296-310. 23. peruga a, celentano dd. correlates of aids knowledge in samples of the general population. social science & medicine. 1993;36(4):509-524. 24. unaids. 2006 report on the global aids epidemic. geneva: unaids; 2006. data.unaids.org/pub/report/2006/2006_gr_en.pdf (accessed 8 january 2018) 25. golobof a, weine s, bahromov m, luo j. the roles of labor migrants’ wives in hiv/aids risk and prevention in tajikistan. aids care. 2011;23(1):91-97. 26. zabrocki c, weine s, chen s, et al. sociostructural barriers, protective factors, and hiv risk among central-asian female migrants in moscow. cent asian j glob health. 2013;2, 1. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/belarus/2005/final/belarus%202005%20mics_english.pdf https://mics-surveys-prod.s3.amazonaws.com/mics3/europe%20and%20central%20asia/belarus/2005/final/belarus%202005%20mics_english.pdf http://mics.unicef.org/surveys a comparison of comprehensive hiv/aids knowledge among women across seven post-soviet countries abstract keywords: hiv infection; comprehensive hiv/aids knowledge; women; heterosexual transmission; post-soviet countries a comparison of comprehensive hiv/aids knowledge among women across seven post-soviet countries research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. publication productivity in central asia and countries of the former soviet union shalkar adambekov1, sholpan askarova2, sharon c. welburn1, sharon l. goughnour4, ayumi konishi3, ronald laporte1, faina linkov4 1graduate school of public health, university of pittsburgh, 2national laboratory astana, nazarbayev university, 3east asia department, asia development bank, 4department of obstetrics, gynecology & reproductive sciences, magee-womens research institute vol. 5, no. 1 (2016) | issn 2166-7403 (online) doi 10.5195/cajgh.2016.261 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ adambekov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.261 | http://cajgh.pitt.edu abstract introduction. despite the significant number of research institutions and rich scientific heritage, published research from central asia (kazakhstan, uzbekistan, kyrgyzstan, tajikistan, and turkmenistan) is traditionally underrepresented in international scientific literature. the goal of this paper was to analyze publication patterns in central asian countries, and to explore the factors that contributed to the publication productivity in kazakhstan. methods. publication productivity was evaluated using data generated by the scimago journal & country rank over the period of 1996-2014 for all of the 15 former soviet union republics for all subject categories. country specific data, including total population, gross domestic product (gdp) per capita, research and development (r&d) expenditure (% of gdp), number of reserchers (per million people), was abstracted from world bank data. anova and ancova analyses compared the mean number of publications among central asian countries. separate analyses was done for publication patterns in the health sciences. multiple comparisons were performed using tukey method results. the analysis of publication productivity showed significant discrepancies in the number of published documents among the central asian countries. kazakhstan demonstrated a significant increase in the number of published documents in the period of 1996-2014, mainly in the areas of natural and multidisciplinary sciences. our analyses also showed that the number of publications are siginicantly associated with gdp and population size. conclusions. we identified large gaps in publication productivity among the central asian countries. the association between publication rate with gdp and population size indicates there is a need to adjust for these factors when planning research policy. keywords: publication productivity, scientific publications, central asia, kazakhstan publication productivity in central asia and countries of the former soviet union shalkar adambekov1, sholpan askarova2, sharon c. welburn1, sharon goughnour4, ayumi konishi3, ronald laporte1, faina linkov4 1graduate school of public health, university of pittsburgh, 2national laboratory astana, nazarbayev university, 3east asia department, asia development bank, 4department of obstetrics, gynecology & reproductive sciences, magee-womens research institute research scientific research conducted in central asia is underrepresented in the international scientific literature. central asia is the region consisting of the former soviet union republics of kazakhstan, kyrgyzstan, tajikistan, turkmenistan, and uzbekistan. all of these countries gained independence after the dissolution of the soviet union in 1991. despite their ethnic and economic diversity, all of the “stans” share common cultural and historical roots.1 the economic crisis that followed the dissolution of the soviet union led to the degradation of the established soviet era scientific research infrastructure, leaving researchers struggling to compete in a more opened and integrated scientific world.2-4 as with most other former soviet republics, much of the research conducted in central asia is government controlled, and research articles are mainly http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.261 | http://cajgh.pitt.edu published in local periodicals in the russian language. these periodicals are generally unknown outside the former soviet union and are not cross referenced in research databases commonly used by global scientists, such as scopus, web of science, medline, embase, etc. therefore, scientific research from these countries is underrepresented in the international literature, despite notable achievements in the fundamental areas of science, such as physics, chemistry, mathematics, etc.5 therefore, the aim of this manuscript was to examine publication productivity of the central asian region by analyzing the number of articles published by each country for the past two decades. given that the crude number of publications and citation indexes are almost uniformly utilized as the major criteria for publication productivity evaluation both within and across countries,6 our study fills an important gap in our understanding of publication productivity in central asia. since most of the journals in central asian countries are available in print only and not indexed in any major databases,5,7 only articles that are accessible to global scientists and indexed in scopus were analyzed. consequently, the data for this study was obtained by analyzing information generated by the scimago journal & country rank.8 this online software provides a free and easy to access tool for comparing the total number of existing scopus referenced journals, publications, and research areas of various countries in different scientific disciplines for the period from 1996 to 2014. detailed analyses of publication productivity trends in kazakhstan and central asia have not been performed to date, a significant gap that our research is aiming to close. the goal of this study was to perform a retrospective analysis of publication patterns in central asian countries between 1996 and 2014 and provide a foundation for improving publication productivity in the region. methods data on the number of publications and the number of journals existing in the region was collected from scimago journal & country rank.8 we analyzed country rankings and the number of published documents for the period of 1996-2014 in the subject areas of “all” and “medicine.” data from “country search” was collected for 15 former soviet union republics (armenia, azerbaijan, belarus, estonia, georgia, kazakhstan, kyrgyzstan, latvia, lithuania, moldova, russia, tajikistan, turkmenistan, ukraine, and uzbekistan). analysis of subject area “medicine” was performed on countries of the central asian region, including kazakhstan, uzbekistan, kyrgyzstan, tajikistan, and turkmenistan in the following categories: “medicine,” “public health, environmental and occupational health,” and “epidemiology.” the number of journals published in each of the 15 postsoviet republics was identified through “journal search” option in the scimago journal & country rank database. data analysis descriptive statistics were used to evaluate the data. latest available complete data on gross domestic product (gdp) per capita, based on purchasing power parity (ppp), research and development (r&d) expenditure (% of gdp), total population in the country (population size), and number of researchers in r&d were collected from the world bank9 for each country included in the study. number of publications, gdp, and population size were log transformed. one-way anova analyses compared mean numbers of publications of central asian countries, and ancova was used to compare the mean numbers of publications of central asian countries after controlling for gdp and population size. multiple comparisons were performed using tukey method. all analyses were conducted in sas version 9.4 (sas institute inc., cary, nc). http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx grosche this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | 10.5195/cajgh.2016.261 | http://cajgh.pitt.edu results of the former 15 soviet union republics, russia and ukraine produced the highest number of scopus referenced documents in the subject area “all” for the period of 1996-2014, publishing 701,029 and 133,650 manuscripts, respectively. of the remaining 13 countries, lithuania produced the most publications with 32,137 articles (table 1). central asian countries published the lower number of publications compared to other former soviet union republics, with kazakhstan leading the central asian region with 9,652 published articles. turkmenistan has the lowest number of publications referenced by scopus in central asian region with 284 documents produced during the period of 1996-2014. table 1. absolute and population adjusted publication rates for 15 former soviet union countries for 19962014 while publication productivity patterns are similar across the central asian region in 1990s and 2000s, kazakhstan demonstrated a major increase in the number of publications starting in 2012 (figure 1). there was a significant difference among countries in the mean number of publications from 1996 to 2014 (f=180.61, p<0.0001). further analysis showed that the mean number of publications was not significantly different between kazakhstan and uzbekistan; however, publication rates were significantly different when kazakhtan and uzbekistan were compared as a group to kyrgyzstan, tajikistan, and turkmenistan, which had the lowest mean number of publications of all the central asian countries at alpha level of 0.05.the breakdown by year shows an increase in the overall number of publications starting in 2012, where kazakhstani authors published 818 scientific papers in 2012, 1,690 in 2013, and 2,032 in 2014. kazakhstan’s contribution to the world’s scientific literature increased from 0.03% in 2012 to 0.08% in 2014. figure 1. general scientific publications trends of central asian countries for 1996-2014 the major contributors to the productivity growth are “biochemistry, genetics and molecular biology,” “engineering,” “multidisciplinary,” and “physics and astronomy” (figure 2). interestingly, publications in the subject area “medicine” contributed only 7% of all the publications produced by kazakhstan during the study period, whereas in the us this percentage was 27%. overall, according to the scimago ranking of scientific contribution to health related disciplines, kazakhstan ranks 126th out of 235 in “medicine,” 119th in “public health, environmental and occupational health” out of 223, and 91st in “epidemiology” out of 216 countries with publications in the respective fields. figure 2. change in the number of publications by subject area in kazakhstan for 1996-2014 from the world bank data, we can see that central asian countries have the lowest expenditures on r&d ranging from 0.12% in tajikistan to 0.16% in kazakhstan. in comparison, russia, ukraine, and latvia spent 1.09%, 0.74%, and 0.7%, respectively, on r&d (table 1). our analyses showed that gdp and population size are significantly associated with mean number of publications for central asian countries (p<0.0001). according to world bank data, russia, ukraine, and latvia have the highest number of individuals involved in the scientific research, as well as the number of published papers per 100,000 population (table 1) in the post-soviet region. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.261 | http://cajgh.pitt.edu discussion our analysis demonstrated that publication productivity is vastly different among post-soviet republics, being relatively low in the central asian countries. among central asian countries, the number of publications from kazakhstan has surged, reaching 2,032 publications in 2014 and 9,632 publications total from 1996 to 2014. however, these numbers are still relatively low compared to other former soviet union republics such as russia or ukraine. this poses a significant problem for the global recognition of publication productivity and scientific credibility of scientists in central asia, as scopus referenced publications are oftentimes used as a measure of scientific productivity of scientists in various regions. a complete analysis of factors associated with differences in publication rates is difficult to produce as publication productivity is driven by complex and multifactorial influences. according to previously published research, the major factors that hinder productivity in developing countries are insufficient funding, low familiarity with foreign languages (i.e. english, in particular), lack of dedicated research centers and international peer-reviewed journals, limited experience with the process of publishing papers in international journals, and insufficient training in the research methods.10,11 one of the biggest strengths of this study is the ability to comprehensively look at the publication record of the entire central asian region over a period of two decades. this approach allows us to objectively evaluate publication trends for multiple disciplines. the limitations of this approach are that it is impossible to evaluate trends prior to 1994, and we are relying on one measure of scientific productivity (publications cross referenced in scopus). another major factor affecting the researchers’ productivity in kazakhstan and other central asian countries is the transition from the soviet style education and centralized scientific infrustructure system into a more modern and less centralized model of science and education.12 kazakhstan, for example, has become a full member of bologna process in 2010.13 according to the unesco institute for statistics,14 the number of people with a bachelor or equivalent degree was 23.1% in kazakhstan, 0.7% in kyrgyzstan, 15.2% in tajikistan, and 15.9% in turkmenistan. however, since proficiency in foreign languages is not required by higher education institutions of central asia, most of the established researchers in post-soviet republics struggle to produce high quality english language papers.5,15 the economic status as well as country population size is important factors that could impact publication productivity and quality. as previously reported, quality of research in developing countries has been found to be dependent on funding available to conduct scientific research.16 in our model, gdp and population size were significantly associated with the mean number of publications in the countries under investigation, which suggest that there is need to adjust for these factors when planning research policy. another important factor is the number of international peer-reviewed journals published by each country. for example, according to scimago database in 2012, russia, ukraine, and lithuania have the largest number of scopus recognized journals with 230, 37, and 38 titles respectively, whereas there are only two scopus recognized journals, eurasian chemicotechnological journal (eurasianchemtech.vub.ac.be) and eurasian mathematical journal (emj.enu.kz), in the remaining central asian countries, and both are published in kazakhstan. kazakhstan has recently been pushing to increase its publication rate with the addition of its own scientific journal, the central asian journal of global health (cajgh.pitt.edu), which was introduced in 2012.17 starting new peer reviewed english language journals could be the best route for encouraging other http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://eurasianchemtech.vub.ac.be/ grosche this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | 10.5195/cajgh.2016.261 | http://cajgh.pitt.edu countries to develop and advance their own publishing capacity. while this study was not able to capture all factors that may potentially play a role in publication productivity of the regions we explored, including region specific insentives for publication, availability of grnat support, etc, this study was one fo the first attempts to analyze a complex and underinvestigated problem. after continued lack of focus on research and development which plagued the former soviet union republics in the 1990s, central asian countries are rebuilding their scientific capacity.13 to our knowledge, kazakhstan is emerging as a leader in publication productivity in central asia as the result of establishing research and development as one of the major goals of national policy. the change in the degree awarding criteria for graduate degrees, effective from early 2011, is an example of such reforms.13 according to the new regulations, a candidate for a phd degree in kazakhstan must publish at least one document in a non-zero impact factor journal included in isi web of knowledge (thomson reuters) or in a journal cited in the scopus database.18 we believe that this is the main reason for the dramatic increase in the number of publications from kazakhstani researchers which occurred in 2012. as a result, we assume that there is an opportunity to increase the publication rate by introducing new and effective regulations and policies, which can reinforce the necessity of publishing scientific developments in international journals. in addition to publication productivity, our future studies need to explore scientific information dissemination in the region, as these two concepts may be closely related. despite the low number of publications in several areas including public health and medicine, the number of articles published in the international journals by kazakhstani authors has significantly increased, whereas other central asian countries demonstrated only a slight increase in publication rates. consequently, we can assume that policies introduced to increase the publication rate of kazakhstani researchers had a positive effect. however, we need to consider that the number of publications is still low compared to other former soviet union republics, and, as a result, more efficient and effective actions are needed to increase the number of publications in kazakhstan and central asia in general. we would like to suggest that with improved policies and increased incentives for publishing in english language peer-reviewed journals for central asian scientists, we can expect an increase in the number of publications coming from the region. acknowledgements authors express their gratitude to nazarbayev university for providing the grant to complete this research. conflicts of interest the authors report no conflicts of interest. references 1. merrill m. central asia: increasing under diversity. international higher education. 2015(59):26-28. 2. habibov n. who wants to redistribute? an analysis of 14 post-soviet nations. social policy & administration. 2013;47(3):262-286. 3. morgan wj, kliucharev ga. higher education and the post-soviet transition in russia. european journal of education. 2012;47(1):38. 4. silova i. higher education reforms and global geopolitics: shifting cores and peripheries in russia, the baltics, and central asia. russian analytical digest. 2011;97:9-12. 5. kirchik o, gingras y, larivière v. changes in publication languages and citation practices and their effect on the scientific impact of russian science (1993–2010). journal of the american society for information science and technology. 2012;63(7):1411-1419. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.261 | http://cajgh.pitt.edu 6. koenig md. lessons from the study of scholarly communication for the new information era. scientometrics. 2001;51(3):511-523. 7. adambekov s, kaiyrlykyzy a, igissinov n, et al. health challenges in kazakhstan and central asia. journal of epidemiology and community health. 2015:jech-2015-206251. 8. scimago journal & country rank. 2015; http://www.scimagojr.com/, november 17, 2015. 9. world bank open data. 2015; http://data.worldbank.org/, november 17, 2015. 10. ynalvez ma, shrum wm. professional networks, scientific collaboration, and publication productivity in resourceconstrained research institutions in a developing country. research policy. 2011;40(2):204-216. 11. gantman e. economic, linguistic, and political factors in the scientific productivity of countries. scientometrics. 2012;93(3):967-985. 12. heyneman sp. a comment on the changes in higher education in the former soviet union. european education. 2010;42(1):76-87. 13. mouraviev n. kazakhstan has joined the bologna process: new challenges for the higher education policy. social policy and administration. 2012;39(4):361-380. 14. unesco institute of statistcs. 2015; http://www.uis.unesco.org/, november 17, 2015. 15. graham lr. science in russia and the soviet union : a short history. cambridge: cambridge university press; 1993. 16. jacob ba, lefgren l. the impact of research grant funding on scientific productivity. journal of public economics. 2011;95(9– 10):1168-1177. 17. adambekov s, dosmukhambetova g, nygymetov g, laporte r, linkov f. why does kazakhstan need new scientific journals? central asian journal of global health. 2014;3(1). 18. torgayeva b. publikuisia ili pogibnesh. novoe pokoleniye 2012; http://www.np.kz/2012/11/20/publikujjsja_ili_ pogibnesh.html, december 5, 2016. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.scimagojr.com/ http://data.worldbank.org/ http://www.uis.unesco.org/ http://www.np.kz/2012/11/20/publikujjsja_ili_pogibnesh.html http://www.np.kz/2012/11/20/publikujjsja_ili_pogibnesh.html grosche this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | 10.5195/cajgh.2016.261 | http://cajgh.pitt.edu table 1. absolute and population adjusted publication rates for 15 former soviet union countries for 1996-2014 country number of published documents per country* population, total** gdp per capita, ppp (constant international $)*** research and development expenditure (% of gdp)*** researchers in r&d (per million people)*** number of published documents per 100,000 population* armenia 11,741 3,006,154 6,803 0.27 n/a 391 azerbaijan 9,048 9,537,823 15,754 0.21 n/a 95 belarus 28,941 9,470,000 16,603 0.70 n/a 306 estonia 25,458 1,313,645 23,576 2.37 3,485 1938 georgia 9,821 4,504,100 6,322 n/a n/a 218 kazakhstan 9,652 17,289,111 20,772 0.16 652 56 kyrgyzstan 1,318 5,834,200 2,921 0.16 n/a 23 latvia 14,403 1,990,351 19,405 0.70 1,904 724 lithuania 32,137 2,929,323 22,530 0.92 2,756 1097 moldova 5,506 3,556,400 4,179 0.40 781 155 russia 701,029 143,819,569 22,570 1.09 3,120 487 tajikistan 1,118 8,295,840 2,229 0.12 n/a 13 turkmenistan 284 5,307,188 11,361 n/a n/a 5 ukraine 133,650 45,362,900 8,282 0.74 1,253 295 uzbekistan 8,719 30,742,500 4,412 n/a 534 28 *scimago journal and country rank, 2014 **the world bank, 2014 *** the world bank, 2011 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.261 | http://cajgh.pitt.edu figure 1. general scientific publications trends of central asian countries for 1996-2014 0 500 1000 1500 2000 2500 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 kazakhstan uzbekistan kyrgyzstan turkmenistan tajikistan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx grosche this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | 10.5195/cajgh.2016.261 | http://cajgh.pitt.edu figure 2. change in the number of publications by subject area in kazakhstan for 19962014 1996 2000 2004 2008 2012 0 100 200 300 400 500 600 500-600 400-500 300-400 200-300 100-200 0-100 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx publication productivity in central asia and countries of the former soviet union abstract keywords: publication productivity, scientific publications, central asia, kazakhstan publication productivity in central asia and countries of the former soviet union research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. challenges to global implementation of infrared thermography technology: current perspective michael shterenshis1 1department of sciences, alexander muss institute for israel education vol. 6, no. 1 (2017) | issn 2166-7403 (online) doi 10.5195/cajgh.2017.289 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ shterenshis this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.289|http://cajgh.pitt.edu abstract medical infrared thermography (it) produces an image of the infrared waves emitted by the human body as part of the thermoregulation process that can vary in intensity based on the health of the person. this review analyzes recent developments in the use of infrared thermography as a screening and diagnostic tool in clinical and nonclinical settings, and identifies possible future routes for improvement of the method. currently, infrared thermography is not considered to be a fully reliable diagnostic method. if standard infrared protocol is established and a normative database is available, infrared thermography may become a reliable method for detecting inflammatory processes. keywords: infrared thermography; mass screening; epidemics challenges to global implementation of infrared thermography technology: current perspective michael shterenshis1 1department of sciences, alexander muss institute for israel education research medical infrared thermography (it) produces an image of the infrared waves emitted by the human body as part of the thermoregulation process that can vary in intensity based on the health of the patient.1 while the technology was originally developed in the 1950s, its development was much slower than ultrasonography, despite the fact that both methods are potentially highly informative, non invasive, and radiation free. on pubmed, there are 1,820 articles on the term “infrared thermography” dating from may 1963 to 2017, while 398,932 articles on “ultrasound” were published during the same period. the it finally gained more attention in the 2000s with the emergence of avian, swine, and h1n1influenza outbreaks, and other similar pandemics. the first articles describing it implementation for mass blind fever screening in international airports appeared in 2004.2,3 detection of febrile passengers by it scanning in airports became a common trend and several more reports supporting the use of this technology were published.4-6 however, other published reports questioned reliability of the it technology as a fever screening procedure, specifically citing technical errors leading to low sensitivity of the screening procedure.7,8 recent progress in improvement of infrared camera technology sensitivity, excellent time resolution, as well as calibration according to heat emissivity, room temperature, humidity, and distance to the object of interest, caught practitioners unprepared to take full advantage of the it capacities that exist today. currently published research papers on it do not provide complete and detailed descriptions of how the camera and/or the software were calibrated and what settings have been used. in 2013, choi et al. detected the mean temperature of healthy cheeks to be 26-27°c,11 which is about 4°c lower than normal. the article does not report room humidity or the distance between the camera and the investigated face. another study reported the surface skin temperature of a healthy knee as median 36°c and maximum of 38.1°c. 12 this reading is about 6-7°c higher than normal and the article provides minimal detail about the data acquisition process (including room temperature, humidity, distance to object, and heat emissivity preset).13 while some papers clearly report laboratory room temperature and a relative air humidity, they may omit other important variables.13,14 for http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.ncbi.nlm.nih.gov/pubmed/20920098 https://www.ncbi.nlm.nih.gov/pubmed/20920098 https://www.ncbi.nlm.nih.gov/pubmed/20920098 https://www.ncbi.nlm.nih.gov/pubmed/20920098 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.289|http://cajgh.pitt.edu example, an article describing the it assessment of joints with active arthritis reported ambient room temperature and skin emissivity, but did not indicate the precise distance to the object ("the camera was positioned directly over the hands") and the room humidity.15 out of 200 recently published (may 2013-may 2017) pubmed research on it implementation as a screening and diagnostic tool for various clinical conditions, only 13 articles (6.5 percent of total articles) have complete data acquisition methodology (correct calibration of the it device and/or software for skin heat emissivity, distance to object, air humidity, air temperature, etc.). general thermography guidelines, standards, and protocols, were introduced in 2002 and were followed by specific guidelines for neuromusculoskeletal, dental-oral, and systemic disorders in 2015 and 2016.16-18 these guidelines articulate that the room temperature range should be maintained between 18 and 23°c during the investigation and that a minimum equilibration period of 15 minutes should be observed for patient acclimation to the room. given varying temperatures at airports and inability to achieve 15 minutes acclimation periods for every passenger, the guidelines may suggest that it cannot be used as an accurate screening method at the airports. the guidelines do not indicate that an it technician or a practitioner must calibrate the camera for human skin heat emissivity (0.98), existing room temperature and humidity, and distance between the camera and the region of interest. most modern it cameras have the program for this preset in their menu.19-21 even without proper camera calibration, the data for these variables can be put into software program directly before image analysis. the time of day during investigation should be indicated as well to accommodate human temperature changes due to circadian rhythm.22-25 with normal circadian rhythm, the human body has its lowest temperature at 4 am and its highest temperature at 6 pm. this variation needs to be adjusted for with proper correction index in order to correctly interpret measurement results. an individual approach to each subject is warranted if it is used for screening. the necessary primary step in any proper it investigation is to establish a normative range of surface skin temperature changes of a given person because of interpersonal vasoconstriction/vasodilatation variations. this scale will provide an it practitioner with an understanding of what is normal and what is abnormal for a given patient. sympathetic skin response and the vasomotor reflex vary in different cases and these variations can be detected by the it.26 review articles on it provide either favorable27,28 or unfavorable29,30 feedback about its applicability for mass screening. the favorable reviews suggest that for certain applications, thermal imaging is shown to provide objective measurement of temperature changes that are clinically significant for the detection of local inflammatory processes, skin lesions, benign and malignant tumors, vasoactivity, and vascular diseases. with properly calibrated it cameras and improved knowledge of normative skin temperatures on various body surfaces, practitioners will be able to assess cutaneous vasoactivity. thus, the it method might be reliable in the clinical settings but not recommended as a screening procedure at the airports. a portable, radiationfree, inexpensive, non-contact, and non-invasive it device could become a welcomed addition to the hospital armamentarium in many developing countries assuming the development and implementation of proper standard guidelines. references 1. diakides na, bronzino jd., eds. medical infrared imaging. london – new york: taylor & francis, 2008. 2. chan ls, cheung gt, lauder ij, kumana cr, lauder ij. screening for fever by remote-sensing infrared thermographic camera. j travel med. 2004;11(5):273-9. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.ncbi.nlm.nih.gov/pubmed/15544710 https://www.ncbi.nlm.nih.gov/pubmed/15544710 shterenshis this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.289|http://cajgh.pitt.edu 3. ng ey, kaw gj, chang wm. analysis of ir thermal imager for mass blind fever screening. microvasc res. 2004;68(2):1049. 4. nishiura h, kamiya k. fever screening during the influenza (h1n1-2009) pandemic at narita international airport, japan. bmc infect dis. 2011;11:111. doi: 10.1186/1471-233411-111. 5. mcbride wj, buikstra e, fitzgerald m. investigation of febrile passengers detected by infrared thermal scanning at an international airport. aust n z j public health. 2010;34(1):5-10. doi: 10.1111/j.1753-6405.2010.00466.x. 6. sun g, saga t, shimizu t, hakozaki y, matsui t. fever screening of seasonal influenza patients using a cost-effective thermopile array with small pixels for close-range thermometry. int j infect dis. 2014;25:56-8. doi: 10.1016/ j.ijid.2014.03.1398. 7. bitar d, goubar a, desenclos jc. international travels and fever screening during epidemics: a literature review on the effectiveness and potential use of non-contact infrared thermometers. euro surveill. 2009;14(6). pii: 19115. 8. canadian agency for drugs and technologies in health. mass thermography screening for infection and prevention: a review of the clinical effectiveness [internet]. ottawa (on); 2014 nov 19. 9. diakides na, diakides m, lupo jc, paul jl, balcerak r. advances in medical infrared imaging. in: diakides na, bronzino jd., eds. medical infrared imaging. london – new york: taylor & francis, 2008, p. 1-1. 10. fujita k, noguchi m, yuzuriha s, yanagisawa d, matsuo k. usefulness of infrared thermal imaging camera for screening of postoperative surgical site infection after the nuss procedure. case rep surg 2013; 2013:946156. doi: 10.1155/2013/946156 11. choi hg, kwon sy, won jy, yoo sw, lee mg, kim sw, park b. comparisons of three indicators for frey's syndrome: subjective symptoms, minor's starch iodine test, and infrared thermography. clin exp otorhinolaryngol 2013; 6(4): 249-53. doi: 10.3342/ceo.2013.6.4.249. 12. romanò cl, d'anchise r, calamita m, manzi g, romanò d, sansone v. value of digital telethermography for the diagnosis of septic knee prosthesis: a prospective cohort study. bmc musculoskelet disord. 2013; 14: 7. doi: 10.1186/1471-2474-147. 13. denoble ae, hall n, pieper cf, kraus vb. patellar surface skin temperature reflects knee osteoarthritis severity. clin med insights: arthritis and musculoskeletal disorders 2010;3:69-75, doi: 10.4137/cmamd.s5916 14. balbinot lf, canani lh, robinson cc, achaval m, zaro ma. plantar thermography is useful in the early diagnosis of diabetic neuropathy. clinics (sao paulo) 2012; 67(12): 1419-25. 15. spalding sj, kwoh ck, boudreau r, et al. threedimensional and thermal surface imaging produces reliable measures of joint shape and temperature: a potential tool for quantifying arthritis. arthritis res ther. 2008; 10(1): r10. doi: 10.1186/ar2360. 16. thermography guidelines, standards and protocols in clinical thermographic imaging (september 2002) [http://www.iactorg.org/professionals/thermogguidelines.html#/imaging] 17. american academy of thermology – aat. guidelines for dental-oral and systemic health infrared thermography. pan am j med thermol 2015:2(1): 44-53, doi: http://dx.doi.org/10.18073/2358-4696/pajmt.v2n1p44-53 18. american academy of thermology – aat. guidelines for neuromusculoskeletal infrared thermography sympathetic skin response (ssr) studies. pan am j med thermol 2016:2(1): 3543, doi: http://dx.doi.org/10.18073/23584696/pajmt.v2n1p35-43 19. thermovision sc6000 science-grade infrared camera. flir systems, inc., 2008. 20. thermacam rtools/hsdr high-spped data recorder. flir systems, inc., 2005. 21. fluke smartview ir analysis and reporting software. everett, usa: fluke corporation, 2007. 22. refinetti r. the circadian rhythm of body temperature. front biosci (landmark ed) 2010; 15: 564-94. 23. cermakian n, boivin db. the regulation of central and peripheral circadian clocks in humans. obes rev 2009; 10 suppl 2: 25-36. doi: 10.1111/j.1467-789x.2009.00660.x. 24. burton ac. temperature of skin; measurement and use as index of peripheral blood flow. methods med res 1948; 1: 14666. 25. scully cg, karaboué a, liuwm, joseph meyer j, innominato pf, chon kh, gorbach am, lévi f. skin surface temperature rhythms as potential circadian biomarkers for personalized chronotherapeutics in cancer patients. interface focus 2011; 1: 48–60. doi:10.1098/rsfs.2010.0012. 26. park es, park ci, jung ki, chun s. comparison of sympathetic skin response and digital infrared thermographic imaging in peripheral neuropathy. yonsei med j 1994; 35(4): 429-37. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.ncbi.nlm.nih.gov/pubmed/15313119 https://www.ncbi.nlm.nih.gov/pubmed/15313119 https://www.ncbi.nlm.nih.gov/pubmed/21539735 https://www.ncbi.nlm.nih.gov/pubmed/21539735 https://www.ncbi.nlm.nih.gov/pubmed/21539735 https://www.ncbi.nlm.nih.gov/pubmed/20920098 https://www.ncbi.nlm.nih.gov/pubmed/20920098 https://www.ncbi.nlm.nih.gov/pubmed/20920098 https://www.ncbi.nlm.nih.gov/pubmed/24858901 https://www.ncbi.nlm.nih.gov/pubmed/24858901 https://www.ncbi.nlm.nih.gov/pubmed/24858901 https://www.ncbi.nlm.nih.gov/pubmed/19215720 https://www.ncbi.nlm.nih.gov/pubmed/19215720 https://www.ncbi.nlm.nih.gov/pubmed/19215720 https://www.ncbi.nlm.nih.gov/pubmed/19215720 https://www.ncbi.nlm.nih.gov/pubmed/25520988 https://www.ncbi.nlm.nih.gov/pubmed/25520988 http://www.ncbi.nlm.nih.gov/pubmed/23878757 http://www.ncbi.nlm.nih.gov/pubmed/23878757 http://www.ncbi.nlm.nih.gov/pubmed/24353866 http://www.ncbi.nlm.nih.gov/pubmed/24353866 http://www.ncbi.nlm.nih.gov/pubmed/24353866 http://www.ncbi.nlm.nih.gov/pubmed?term=roman%c3%b2%20cl%5bauthor%5d&cauthor=true&cauthor_uid=23289768 http://www.ncbi.nlm.nih.gov/pubmed?term=d'anchise%20r%5bauthor%5d&cauthor=true&cauthor_uid=23289768 http://www.ncbi.nlm.nih.gov/pubmed?term=calamita%20m%5bauthor%5d&cauthor=true&cauthor_uid=23289768 http://www.ncbi.nlm.nih.gov/pubmed?term=manzi%20g%5bauthor%5d&cauthor=true&cauthor_uid=23289768 http://www.ncbi.nlm.nih.gov/pubmed?term=roman%c3%b2%20d%5bauthor%5d&cauthor=true&cauthor_uid=23289768 http://www.ncbi.nlm.nih.gov/pubmed?term=roman%c3%b2%20d%5bauthor%5d&cauthor=true&cauthor_uid=23289768 http://www.ncbi.nlm.nih.gov/pubmed?term=sansone%20v%5bauthor%5d&cauthor=true&cauthor_uid=23289768 http://www.ncbi.nlm.nih.gov/pubmed/?term=romano+calamita+manzi## http://www.ncbi.nlm.nih.gov/pubmed/?term=romano+calamita+manzi## http://www.ncbi.nlm.nih.gov/pubmed?term=balbinot%20lf%5bauthor%5d&cauthor=true&cauthor_uid=23295596 http://www.ncbi.nlm.nih.gov/pubmed?term=canani%20lh%5bauthor%5d&cauthor=true&cauthor_uid=23295596 http://www.ncbi.nlm.nih.gov/pubmed?term=robinson%20cc%5bauthor%5d&cauthor=true&cauthor_uid=23295596 http://www.ncbi.nlm.nih.gov/pubmed?term=achaval%20m%5bauthor%5d&cauthor=true&cauthor_uid=23295596 http://www.ncbi.nlm.nih.gov/pubmed?term=zaro%20ma%5bauthor%5d&cauthor=true&cauthor_uid=23295596 http://www.ncbi.nlm.nih.gov/pubmed/?term=balbinot+canali+achaval## http://www.ncbi.nlm.nih.gov/pubmed?term=spalding%20sj%5bauthor%5d&cauthor=true&cauthor_uid=18215307 http://www.ncbi.nlm.nih.gov/pubmed?term=kwoh%20ck%5bauthor%5d&cauthor=true&cauthor_uid=18215307 http://www.ncbi.nlm.nih.gov/pubmed?term=boudreau%20r%5bauthor%5d&cauthor=true&cauthor_uid=18215307 http://www.ncbi.nlm.nih.gov/pubmed/?term=three-dimensional+and+thermal+surface+imaging+produces+reliable## http://dx.doi.org/10.18073/2358-4696/pajmt.v2n1p44-53 http://www.ncbi.nlm.nih.gov/pubmed/20036834 http://www.ncbi.nlm.nih.gov/pubmed/19849799 http://www.ncbi.nlm.nih.gov/pubmed/19849799 http://www.ncbi.nlm.nih.gov/pubmed/18888764 http://www.ncbi.nlm.nih.gov/pubmed/18888764 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.289|http://cajgh.pitt.edu 27. ring ef, ammer k. infrared thermal imaging in medicine. physiol meas. 2012; 33(3): r33-46. 28. chojnowski m. infrared thermal imaging in connective tissue diseases. reumatologia. 2017;55(1):38-43. doi: 10.5114/reum.2017.66686fitzgerald a, berentson-shaw j. thermography as a screening and diagnostic tool: a systematic review. nz med j 2012; 125(1351): 80-91. 29. de jesus guirro rr, oliveira lima leite vaz mm, das neves lms, et al. accuracy and reliability of infrared thermography in assessment of the breasts of women affected by cancer. j med syst. 2017;41(5):87. doi: 10.1007/s10916-017-0730-7 30. fitzgerald a, berentson-shaw j. thermography as a screening and diagnostic tool: a systematic review. nz med j 2012; 125(1351): 80-91 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.ncbi.nlm.nih.gov/pubmed?term=ring%20ef%5bauthor%5d&cauthor=true&cauthor_uid=22370242 http://www.ncbi.nlm.nih.gov/pubmed?term=ammer%20k%5bauthor%5d&cauthor=true&cauthor_uid=22370242 http://www.ncbi.nlm.nih.gov/pubmed/22370242## https://www.ncbi.nlm.nih.gov/pubmed/28386141 https://www.ncbi.nlm.nih.gov/pubmed/28386141 http://www.ncbi.nlm.nih.gov/pubmed?term=fitzgerald%20a%5bauthor%5d&cauthor=true&cauthor_uid=22426613 http://www.ncbi.nlm.nih.gov/pubmed?term=berentson-shaw%20j%5bauthor%5d&cauthor=true&cauthor_uid=22426613 http://www.ncbi.nlm.nih.gov/pubmed/22426613## https://www.ncbi.nlm.nih.gov/pubmed/28405947 https://www.ncbi.nlm.nih.gov/pubmed/28405947 http://www.ncbi.nlm.nih.gov/pubmed?term=fitzgerald%20a%5bauthor%5d&cauthor=true&cauthor_uid=22426613 http://www.ncbi.nlm.nih.gov/pubmed?term=berentson-shaw%20j%5bauthor%5d&cauthor=true&cauthor_uid=22426613 http://www.ncbi.nlm.nih.gov/pubmed/22426613## http://www.ncbi.nlm.nih.gov/pubmed/22426613## challenges to global implementation of infrared thermography technology: current perspective abstract keywords: infrared thermography; mass screening; epidemics research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. erratum to: quantifying socioeconomic and lifestyle related health risks: burden of cardiovascular disease among indian males neetu purohit1, divya k. bhati1, shiv d. gupta1, azad s. kundu2 1indian institute of health management research university; 2indian council of medical research vol. 4, no. 2 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.237 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ purohit this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.237|http://cajgh.pitt.edu erratum to: quantifying socioeconomic and lifestyle related health risks: burden of cardiovascular disease among indian males neetu purohit1, divya k. bhati1, shiv d.gupta1, azad s.kundu2 1indian institute of health management research university; 2indian council of medical research erratum during the type-setting of the final version of the article,1 the title was misspelled on the website, page 2 of word document, and page 2 of pdf. the title was written as “quantifying socioeconomic and lifestyle related health risks: burden of cardiocascular disease among indian males” and the corrected title is “quantifying socioeconomic and lifestyle related health risks: burden of cardiovascular disease among indian males.” references 1. purihot n, bhati dk, gupta sd, kundu as. quantifying socioeconomic and lifestyle related health risks: burden of cardiovascular disease among indian males. cajgh. 2015;4(2). http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. pediatric pulmonary hemorrhage vs. extrapulmonary bleeding in the differential diagnosis of hemoptysis michael vaiman1, baruch klin2, noa rosenfeld3, ibrahim abukishk3 1department of ear nose and throat head and neck surgery, assaf harofeh medical center, sackler faculty of medicine, tel-aviv university, tel-aviv, israel; 2department of pediatric surgery, assaf harofeh medical center, sackler faculty of medicine, tel-aviv university, telaviv, israel; 3pediatric intensive care unit, assaf harofeh medical center, sackler faculty of medicine, tel-aviv university, telaviv, israel vol. 6, no. 1 (2017) | issn 2166-7403 (online) doi 10.5195/cajgh.2017.284 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.284|http://cajgh.pitt.edu abstract introduction: hemoptysis is an important symptom which causes a major concern, and warrants immediate diagnostic attention. the authors compared a group of patients with pediatric pulmonary hemorrhage with pediatric patients diagnosed with extrapulmonary bleeding focusing on differences in etiology, outcome and differential diagnosis of hemoptysis. methods: we performed the retrospective analysis of medical charts of 134 pediatric patients admitted to the emergency department because of pulmonary and extrapulmonary hemorrhage and were diagnosed with suspected hemoptysis or developed hemoptysis (icd10-cm code r04.2). the cases with pulmonary hemorrhage (group 1) were compared with cases of extrapulmonary bleeding (group 2) using the fisher exact test or pearson’s χ2 test for categorical variables. the t-test was used to assess differences between continuous variables of the patients in the two groups. results: bloody cough was the presenting symptom in 73.9% of cases. 30 patients had pulmonary hemorrhage (group 1), while 104 patients had extrapulmonary bleeding (group 2). the underlying causes of bleeding in group 2 included epistaxis, inflammatory diseases of nasopharynx and larynx, foreign bodies, gingivitis, and hypertrophy of adenoids. mortality rate was 10% in group 1, whereas group 2 did not have any mortality outcomes during the observation period. etiologycal factors were significantly different between hemoptysis and extrapulmonary bleeding in children conclusions: our research suggested that pulmonary and extrapulmonary bleeding are two conditions that differ significantly and cannot be unified under one diagnostic code. it is important to differentiate between focal and diffuse cases, and between pulmonary and extrapulmonary hemorrhage due to the diversity of clinical courses and outcomes. keywords: pulmonary hemorrhage; extrapulmonary bleeding; hemoptysis, epistaxis; pediatric pediatric pulmonary hemorrhage vs. extrapulmonary bleeding in the differential diagnosis of hemoptysis michael vaiman1, baruch klin2, noa rosenfeld3, ibrahim abu-kishk3 1department of ear nose and throat head and neck surgery, assaf harofeh medical center, sackler faculty of medicine, telaviv, university, tel-aviv israel; 2department of pediatric surgery, assaf harofeh medical center, sackler faculty of medicine, tel-aviv university, tel-aviv, israel; 3pediatric intensive care unit, assaf harofeh medical center, sackler faculty of medicine, tel-aviv university, tel-aviv, israel research hemoptysis is an important symptom which causes major concern in both patients and physicians, and warrants immediate diagnostic attention. the incidence of pediatric hemoptysis in the general population is not well established because hemoptysis is a symptom associated with numerous diseases and no special symptom-related epidemiological report has been published so far. as a result, hemoptysis is a term with numerous definitions that only partially overlap with each other. the narrowest medical dictionary definition describes hemoptysis as the expectoration of bloodtinged sputum derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage.1 hemoptysis is a rare symptom in children.2 since children tend to swallow their sputum, bloody sputum may go unnoticed unless it is substantial.3 hemoptysis in adults is most often caused by bronchitis, tumors, tuberculosis or bronchiectasis.4,5 however, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.284|http://cajgh.pitt.edu among the pediatric population, blood-tinged sputum is most likely to be secondary to infection, foreign body aspiration, or tracheostomy related problems.2,6,7 in 1990s, cystic fibrosis and congenital heart diseases (mitral stenosis) were reported as predominant etiologic factors for hemoptysis.8 currently, various etiologies are suggested including idiopathic pulmonary hemosiderosis, pulmonary vascular malformation, pulmonary arteriovenous fistula, bronchiectasis, pulmonary tuberculosis, and lung tumors, with cystic fibrosis accounting for only 5% of cases.9 extrapulmonary bleeding, sometimes referred as pseudohemoptysis, is a common umbrella term for all types of hemorrhage not derived from the lungs or bronchial tubes and excluding hematemesis. since both pulmonary and extrapulmonary types of bleeding can be dangerous and sometimes life-threatening, physicians require adequate knowledge in this area in order to provide rapid and effective interventions. while the above definition of hemoptysis clearly localizes the lower respiratory tract as the place of origin of the pathology, this restriction is not always taken into account in the clinical practice. emerging literature included “upper airway bleeding” and “pharyngitis”10 as well as “nasopharyngeal bleeding”11 to describe the etiology of hemoptysis. these inclusions might be based on wider definitions of hemoptysis as “the expectoration from the respiratory tract of both blood-streaked sputum and gross blood”12 or “coughing up blood as a result of bleeding from the respiratory tract.”13 finally, hemoptysis is sometimes defined as just “the expectoration of blood or blood-tinged sputum.”2 this definition is the most inaccurate because it mixes hemoptysis and hematemesis. the differential diagnosis between hemoptysis and hematemesis is relatively simple starting from alkaline or acidic ph of the bloodcontaining sputum. the difference was well described recently,11,14 but it seems that differential diagnosis between hemoptysis/pulmonary hemorrhage and extrapulmonary bleeding requires further clarification. previously published literature suggests that “hemoptysis is rare in children and adolescents”15,16, which highlights the gap in the literature that this paper will attempt to address. the purpose of this study was to review 14 years of experience with hemoptysis and extrapulmonary bleeding among children in a secondary medical center. we will also compare the frequencies of diagnostic presentations between pediatric pulmonary hemorrhage and extrapulmonary bleeding with an emphasis on etiology, clinical course, outcome and differential diagnosis between them, as well as analyzing possible correlations between patents’ personal characteristics and etiology of the bleeding. in the present article, the term “hemoptysis” is used as “the expectoration of blood-tinged sputum derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage”, and the importance of the proper definition is addressed further in the discussion section. methods participants institutional review board approval was obtained for this study from assaf harofeh medical center ethical board (helsinki registration #225-09). the authors conducted a retrospective chart review of pediatric patients, aged 1-18, who were admitted to pediatric intensive care unit, ear, nose, and throathead and neck surgery department, and pediatric surgery department, assaf harofeh medical center, israel, because of suspected hemoptysis or developed hemoptysis (icd10-cm code r04.2) between january 2004 and december 2016. charts of the patients who were hospitalized and who were discharged from the emergency department were analyzed according to the inclusion criteria. the analysis focused on identifying similarities/differences in the general data (age, sex, number of cases), etiology, symptoms, clinical and laboratory findings, and outcomes that might be important for differential diagnosis. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.284|http://cajgh.pitt.edu variables pulmonary bleeding extrapulmonary bleeding p general n 22.4% (n=30) 77.6% (n=104) 0.02* m/f 16/14 56/48 0.44* median age, years 7.6 5.1 0.03** diagnostic findings bloody cough 73.3% (n=22) 74% (n=77) 0.9* diffuse lung infiltrations 53.3% (n=16) 10.6% (n=11) 0.02* focal pathology in lungs 60% (n=18) 0% <0.01* positive sputum cultures 13.3% (n=4) 0% <0.01* positive blood cultures 6.7% (n=2) 0% <0.01* foreign body 16.5% (n=5) 11.54% (n=12) 0.05* symptomatic anemia 33% (n=10) 8.7% (n=9) 0.03* management antibiotic treatment 60% (n=18) 35.6% (n=37) 0.03* mechanical respiratory support 33% (n=10) 0% <0.01* packed cell transfusion 33% (n=10) 8.7% (n=9) 0.02* outcome cessation of the hemorrhage 80% (n=24) 100% (n=104) 0.07* surgery or transfer 10% (n=3) 0% <0.01* mortality rate 10% (n=3) 0% <0.01* *p-values were calculated using chi square or fisher’s test ** p-values were calculated using t-test table 1. comparison between patients with pulmonary and extrapulmonary bleeding. patients were identified using the hospital computerized database and were categorized into two groups: group 1, which included patients with confirmed hemoptysis as a result of pulmonary or bronchial hemorrhage; and group 2, which included patients with extrapulmonary bleeding. the main inclusion criterion for charts was the presence of complete and detailed data that would be sufficient for differential diagnosis. these included detailed health history, clinical data with adequate description of respiratory or hemodynamic symptoms, chest radiography, and bronchoscopy and/or direct laryngoscopy or nasopharyngoscopy. data on microbiology, serology (including serology for vasculitis) and chest computed tomography (ct), were also analyzed. exclusion criteria were iatrogenic bleeding, hematemesis, cases with trauma that caused both internal and external bleeding, and incomplete data in the charts. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.284|http://cajgh.pitt.edu etiology extrapulmonary (n=104) pulmonary bleeding (n=30) p* infections/inflammations 55 (53%) 15 (50%) 0.87 foreign body 12 (11.54%) 5 (16.7%) 0.05 tonsils/adenoids hypertrophy 10 (9.6%) 0 (0%) <0.01 bronchiectasis 0 (0%) 5 (16.7%) <0.01 vascular malformation 0 (0%) 2 (6.7%) <0.01 idiopathic/traumatic epistaxis 23 (22%) 0 (0%) <0.01 massive aspiration 0 (0%) 2 (6.7%) <0.01 toxic effect (cocaine) 0 (0%) 1 (3.3%) severe cough of unknown origin 4 (3.87%) 0 (0%) <0.01 *p-values were calculated using chi square or fisher’s test table 2. etiology of hemoptysis and extrapulmonary bleeding in children. statistical analysis descriptive statistics were used to describe the basic data trends. cases with pulmonary hemorrhage were compared with cases of extrapulmonary bleeding using the fisher’s exact test or pearson’s χ2 test for categorical variables (gender, diagnostic findings, management, outcome) and t-test for continuous variable (age). the pearson correlation coefficient was calculated to detect possible connections between analyzed variables and gender and age of the patients. the data were analysed using spss, standard version 17.0 (spss, chicago, il, 2007). the level of significance for all analyses was set at p<0.05. results over the course of 12 years of observation134 pediatric patients with suspected hemoptysis were admitted to the medical center emergency department (0.2% of all pediatric admissions to the emergency department). of them, 86 (64.2%) were hospitalized for 24 hours or more. the patients had a median age of 5.6 years (range 0.15-17), with no difference between genders (p=0.86). bloody cough was the presenting symptom in 73.9% (n=99), the remainder later developed a non-cough related hemorrhage. further hospital investigation revealed that 30 out of 134 patients (22.4%) presented with expectoration of blood-tinged sputum as a result of pulmonary or bronchial hemorrhage, while the rest had extrapulmonary bleeding (p=0.02). all patients underwent an otolaryngology evaluation including endoscopy/nasopharyngoscopy that excluded or confirmed upper airway sources of bleeding. in all analyzed patient records, the routine blood-containing sputum ph test was performed to rule out hematemesis. chest radiographs were important for classifying diffuse or focal disease, with diffuse pulmonary hemorrhage being a more severe condition (fig. 1a). bronchoscopy was performed mostly in cases with focal signs detected on a chest x-ray images in order to explore the source http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.284|http://cajgh.pitt.edu pt chest imaging bronchoscopy 1. bronchiectasis rml and lingual normal 2. bronchial wall thickening rml & lingual 3. lll consolidation normal 4. rul consolidation and cavitations partially obstructed main bronchus rul 5. diffuse infiltrates 6. lll infiltrates normal 7. diffuse alveolar infiltrates normal 8. rul and lll pneumonia 9. diffuse infiltrates was not performed because of suffocation 10. bilateral basal infiltrates 11. bilateral infiltrates 12. mild rll infiltrates foreign body 13. right diffuse infiltrates foreign body 14. rll atelectasis foreign body 15. bilateral infiltrates 16. bronchiectasis rml normal 17. rul and lll pneumonia 18. right diffuse infiltrates foreign body 19. bronchial wall thickening rml 20. lll infiltrates normal 21. diffuse infiltrates 22. rll infiltrates foreign body 23. non-calcified nodule normal 24. lll infiltrates normal 25. rml consolidation and cavitations obstructed main bronchus rml 26. bronchial wall thickening rml, rll 27. bronchiectasis rml 28. bronchial wall thickening rul bronchopneumonia 29. bronchiectasis rul, infiltrates 30. consolidation area in the lsl normal abbreviations: lll, left lower lobe; lsl, left superior lobe; rll, right lower lobe; rml, right middle lobe; rul, right upper lobe table 3. chest imaging and bronchoscopy of the patients with pulmonary hemorrhage. and cause of bleeding, and when foreign body aspiration was suspected. the characteristics and comparison between patients with pulmonary and extrapulmonary bleeding is presented in the tables 1 and 2. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.284|http://cajgh.pitt.edu pulmonary hemorrhage. among the patients with pulmonary hemorrhage (n=30, mean age 7.6), infection or foreign body aspiration were the leading etiological causes of focal pulmonary hemorrhage. all five patients with foreign body aspiration presented themselves more than 24 hours following the suspected aspiration event. twelve patients with bleeding of pulmonary or bronchial origin (40%) had an underlying pathology (table 3). coagulation function tests and cell blood count were abnormal in four patients, one of them with severe gram negative sepsis and the other three with severe coagulopathy due to fulminant hepatic failure. cardiac evaluation, including echocardiography, was performed in 25 patients (those with foreign body aspiration were excluded) and revealed a small atrial septal defect in one case, and mild pulmonary hypertension in another case. gram negative sepsis was found in one patient and candida sepsis in another patient, while the remaining patients had negative blood cultures. the cases with positive sputum cultures (n=4) revealed mycoplasma, mycobacteria, and pseudomonas. serology for mycoplasma (igg and igm) was positive in one patient. other serology tests such as antinuclear antibodies and antineutrophil cytoplasmic antibodies and complement factors were obtained and found to be within the normal range in 18 patients. while urinalysis excluded renal pathology in all patients, urine toxicology screening indicated one case that was positive for cocaine. a positive bronchoscopic finding was observed in eight patients with focal findings and hemoptysis as a result of pulmonary or bronchial hemorrhage, comprising 44.5% of the patients in whom bronchoscopy was performed. data on chest imaging and bronchoscopy of the patients with hemoptysis are presented in the table 3. infectious bronchopneumonia was diagnosed in nine patients (30%). ct diagnosed bronchiectasis in six patients (20% of pulmonary hemorrhage cases, 4.5% of all cases). the sweat test for cystic fibrosis was uninformative. all patients (n=10) who required mechanical respiratory support had diffuse lung infiltrates. complete cessation of the hemoptysis was observed in 24 patients during their hospitalization period (80%), 22 of them achieving complete radiological and clinical resolution within four weeks. the death of three patients (10%) occurred because of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.284|http://cajgh.pitt.edu severe sepsis and liver failure, all diagnosed with diffuse pulmonary hemorrhage. three patients were transferred to other institutions for surgical treatment and treatment of tuberculosis; their long-term outcomes are not known. the overall outcome of the remaining patients with confirmed pulmonary hemorrhage was good during a follow up period of 6-18 months (median 9 months) with complete resolution of symptoms. extrapulmonary hemorrhage. the group of patients with extrapulmonary bleeding (n=104, mean age 5.1 years) differed in terms of the presentation and the resolution of the disease. infection or foreign body in upper airways and epistaxis (icd10-cm code r04.0) were the leading etiological causes of hemorrhage. in this group, all 12 patients with foreign bodies presented during the first 12 hours following the suspected event. endoscopy and nasopharyngoscopy data were essential for the diagnostic process in all cases. serology tests such as antinuclear antibodies and antineutrophil cytoplasmic antibodies and complement factors were obtained and found to be within the normal range in 26 patients. in this group, complete cessation of the hemorrhage was observed in all patients during their hospitalization period. a follow up period of 6-18 months (median nine months) indicated no recurrent episodes. correlation data no correlation was found between the gender of the patients and etiology of the bleeding and diagnostic findings (r=0.21 and r=0.32 respectively). the positive correlation with younger age (less than six years old) was found for the presence of a foreign body at any location from nasopharynx and larynx to esophagus and bronchi (r=0.83) and idiopathic/traumatic epistaxis (r=0.65). the massive aspiration was detected only in the pulmonary cases. discussion diagnostic code icd-10-cm r04.2 defines hemoptysis as coughing or spitting up blood from the respiratory tract with further clarification as “expectoration or spitting of blood originating from any part of the respiratory tract, usually from hemorrhage in the lung parenchyma (pulmonary alveoli) and the bronchial arteries.” our research suggested (tables 1 and 2) that pulmonary and extrapulmonary bleeding are two conditions that differ significantly and cannot be unified under one diagnostic code. in our series of extrapulmonary bleeding cases, there were 23 (22%) patients with idiopathic or traumatic epistaxis that should be encoded as icd10-cm code r04.0. in pediatric cases; however, some blood often proceeds to nasopharynx and then presents itself as bloody sputum or cough that can mislead a practitioner in correct codification. proper definition for hemoptysis poses both, a research/policy problem and a clinical practice challenge. pediatric patients with extrapulmonary bleeding may be referred to the departments of otorhinolaryngology or maxillo-facial surgery, while patients with pulmonary or bronchial hemorrhage are to be admitted to pediatric intensive care unit and/or the department of pediatric surgery. in our studies, bloody cough was the presenting symptom in 74% of cases. therefore, the “coughing up blood” definition is not entirely correct and further clarification of definition for hemoptysis is desirable. for example, the most recent study of simon et al. reported prevalence rates for the most common causes of hemoptysis in pediatric cases and identified pneumonia, bronchitis, and pulmonary tuberculosis as the most common specific etiologies.17 in this case, the authors used the term “hemoptysis” only in refernce to pulmonary or bronchial hemorrhage. extrapulmonary bleeding very rarely leads to mortality. our cases with mortality were related mostly to the underlying disease (hepatic failure, sepsis and acute respiratory distress syndrome (ards)) and less to the degree of pulmonary hemorrhage. patients with poor http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.284|http://cajgh.pitt.edu prognosis that have been described in the literature mainly present with diffuse pulmonary hemorrhage in a context of autoimmune pulmonary-renal syndrome,18 which is a combination of glomerulonephritis with bleeding in the lungs and is very rare among the pediatric population.19 however, we had no cases with renal pathology in our study. a foreign body aspiration is a specific pediatric problem especially in infancy and early childhood. in our study, all the participants with foreign body aspiration had positive radiological findings, a fact that can be explained by their late referral. however, chest radiographs may be normal in the first 24 hours following foreign body aspiration. the presence of atelectasis, pulmonary infiltrates, and a mediastinal shift suggest foreign body aspiration.20 since cystic fibrosis is the most likely cause of bronchiectasis in children, it was ruled out in these patients. efrati et al. described a similar incidence (9%) of hemoptysis among israeli children with bronchiectasis due to cystic fibrosis, 12.5% of them requiring bronchial artery embolization.21 hematologic bleeding diseases are rarely associated with hemoptysis and pulmonary hemorrhage in children.19 in the current study, 14% of the patients with pulmonary hemorrhage suffered from significant coagulopathy due to hepatic failure or sepsis. the two patients with hepatic failure did not undergo a liver transplant due to a high grade of hepatic encephalopathy on admission; therefore, the high percentage of pulmonary hemorrhage and mortality in these patients is explained by the natural course of their liver disease. cocaine abuse was found to be the cause of anemia, diffuse pulmonary hemorrhage, and respiratory failure in one of our patients (fig. 1b). such case is rare but similar cases were previously reported describing an acute anemia associated with an alveolar hemorrhage after inhalation of cocaine.22,23 the pathogenesis is not clear yet but an opinion was expressed that cocaineinduced vasoconstriction, vascular damage in the lung tissue, platelet activation, and procoagulatory activity could lead to such pathology. hemoptysis related to bacterial, viral, and fungal pulmonary infections was previously described.2426 we confirmed that such patients may have lobar lung infiltrates, concomitant leukocytosis, and high c-reactive protein. a study on 21 symptomatic patients with asthma revealed hemoptysis in 29% of them.27 our single asthmatic patient presented infiltrates in the middle lobe and lingual suggesting the middle lobe syndrome. congenital vascular malformations are relatively rare and we only had two such cases. however, these malformations can remain unnoticed for a long time. recently, a case was described with a 10-month history of recurrent hemoptysis due to unilateral absence of the pulmonary artery.28 within extrapulmonary cases, laryngeal trauma seems to be the most life-threatening cause of bleeding because the direct clinical symptoms rarely correlate with the degree of respiratory tract failure.29 the idea that incidence of extrapulmonary bleeding is significantly higher than pulmonary hemorrhage calls to attention to these cases and to the differential diagnosis process between pulmonary and extrapulmonary hemorrhage. our results demonstrate that the differential diagnostics between extrapulmonary and intrapulmonary bleeding may be based on significant differences of median age, frequency, clinical time-course of foreignbody aspiration, diffuse infiltration of chest x-ray images, and prevalence of severe anemia between the two groups. we believe that for pediatric emegency of this nature, whatever initial suspicion of a physician on duty might be, both a pediatric pulmonologist and a pediatric otorhinolaryngologist should be invited for consultation. pediatricians may appreciate the fact that in the majority of cases the expectoration of blood-tinged sputum has nothing to do with lung diseases. at the same time, pediatric ent specialists should be well prepared http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.284|http://cajgh.pitt.edu to evaluate patient for a serious pulmonary disorder in cases of such expectoration. while our study was limited to pediatric cases, we must point out that while extrapulmonary and intrapulmonary bleeding can occur at any age, the pediatric cases differ from adult cases and warrant further research. for example, the presence of a foreign body in the respiratory tract is a very common pediatric problem while the lung tumor is extremely rare in children and adolescents. another limitation is that our medical center is a large university-affiliated general hospital that does not provide pediatric cardiac surgery, transplantation, or cystic fibrosis services. this could be the reason why patients with these conditions, typically associated with bleeding, were not found in the present study. while extrapulmonary hemorrhage is the main etiology for bloody cough in most of the developed countries, developing countries may have other experiences with this condition. there are countries where pediatric cases of tuberculosis are common. reports from tunisia, turkey, and iran indicate a need to provide a differential diagnosis between cases of tuberculosis and asthma (pulmonary source of hemorrhage) in contrast to allergic rhinitis (extrapulmonary source of hemorrhage).30-32 also, while cystic fibrosis is no longer considered the main cause of hemoptysis in israel, this may not be the same in other countries.33 development of the most precise differential diagnosis between pulmonary and extrapulmonary hemorrhage remains an acute necessity for improvements in public health in many countries of the world. acknowledgments the editing of the final version of the manuscript and technical writing support was provided by dr. michael shterenshis. references 1. hensyl w (ed). stedman's medical dictionary. twenty-fifth edition. baltimore: williams & wilkins, 1990: 701. 2. singh d, bhalla as, veedu pt, arora a. imaging evaluation of hemoptysis in children. world j clin pediatr. 2013;2(4):54-64. doi: 10.5409/wjcp.v2.i4.54 3. pianosi p, al-sadoon h. hemoptysis in children. pediatr rev. 1996;17:344–6. 4. johnston h, reisz g. changing spectrum of hemoptysis: underlying causes in 148 patients undergoing diagnostic flexible fiberoptic bronchoscopy. arch intern med. 1989;149:1666–68. 5. hirschberg b, biran i, glazer m, kramer mr. hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. chest. 1997;112:440–4. 6. fabian mc, smitheringale a. hemoptysis in children: the hospital for sick children experience. j otolaryngol. 1996;25:44–5. 7. thompson jw, nguyen cd, lazar rh, stocks rm, schoumacher ra, hamdan f, van nguyen k. evaluation and management of hemoptysis in infants and children. a report of nine cases. ann otol rhinol laryngol. 1996;105:516–20. 8. coss-bu ja, sachdeva rc, bricker jt, harrison gm, jefferson ls. hemoptysis: a 10-year retrospective study. pediatrics. 1997;100(3):e7. 9. chen hb, lu xx, jiang k. etiology, clinical features, and diagnosis and treatment of recurrent hemoptysis in children. zhongguo dang dai er ke za zhi. 2014;16(3):281-4. 10. sim j, kim h, lee h, ahn k, lee s. etiology of hemoptysis in children: a single institutional series of 40 cases. allergy asthma immunol res. 2009;1(1):41-4. 11. gaude gs. hemoptysis in children. indian pediatrics. 2010;47:245-54. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.284|http://cajgh.pitt.edu 12. isselbacher kj, braunwald e, et al, (eds). harrison’s principles of internal medicine, 13 ed., new york: mcgraw-hill, inc., 1994: 172. 13. beers mh, berrow r (eds). the merck manual of diagnosis and therapy. 17th ed., whitehouse station, n.j.: merck research laboratories, 2012: 517. 14. batra ps, holinger ld. etiology and management of pediatric hemoptysis. arch otolaryngol head neck surg. 2001;127:377-82. 15. hämmerling s, becker s, mall ma. rare cause for hemoptysis in an adolescent: bronchial capillary hemangioma. pediatr pulmonol. 2017 jul;52(7):e40e42. doi: 10.1002/ppul.23673. 16. sismanlar t, aslan at, akkan k, cindil e, onal b, ozcan b. successful embolization in childhood hemoptysis due to abnormal systemic arterial bleeding of the lung and review of the literature. clin respir j. 2016 nov;10(6):693-697. doi: 10.1111/crj.12289 17. simon dr, aronoff sc, del vecchio mt. etiologies of hemoptysis in children: a systematic review of 171 patients. pediatr pulmonol. 2017 feb;52(2):255-259. doi: 10.1002/ppul.23497. 18. gallagher h, kwan jt, jayne dr, pulmonary renal syndrome: a 4-year, single-center experience. am j kidney dis. 2002;39:42–47 19. godfrey s. pulmonary hemorrhage/hemoptysis in children. pediatr pulmonol. 2004;37:476–84. 20. mu lc, sun dq, he p. radiological diagnosis of aspirated foreign bodies in children: review of 343 cases. j laryngol otol. 1990;104:778–82. 21. efrati o, harash o, rivlin j, bibi h, meir mz, blau h, mussaffi h, barak a, levy i, vilozni d, kerem e, modan-moses d. hemoptysis in israeli cf patients: prevalence, treatment, and clinical characteristics. j cyst fibros. 2008;7:301–06. doi: 10.1016/j.jcf.2007.11.007. 22. odronic s, quraishy n, manroa p, kier y, koo a, figueroa p, hamilton a. cocaine-induced microangiopathic hemolytic anemia mimicking idiopathic thrombotic thrombocytopenic purpura: a case report and review of the literature. j clin apher. 2014;29(5):284-9. doi: 10.1002/jca.21316. 23. gallouj k, brichet a, lamblin c, wallaert b. pulmonary hemorrhagic syndrome after inhalation of cocaine. rev mal respir. 1999;16(4):560-2. 24. kim yi, kang hc, lee hs, choi js, seo kh, kim yh, na j. invasive pulmonary mucormycosis with concomitant lung cancer presented with massive hemoptysis by huge pseudoaneurysm of pulmonary artery. ann thorac surg. 2014;98(5):1832-5. doi: 10.1016/j.athoracsur.2013.12.051. 25. marchiori e, zanetti g, hochhegger b. diffuse alveolar hemorrhage in infectious diseases. chest. 2011;139(1):228. doi: 10.1378/chest.10-1627. 26. jean-baptiste e. clinical assessment and management of massive hemoptysis. crit care med. 2000;28:1642–47. 27. kwon ky, myers jl, swensen sj, colby tv. middle lobe syndrome: a clinicopathogical study of 21 patients. human pathol. 1995;26:302–7. 28. zhou y, tsauo j, li y, li x. selective embolization of systemic collaterals for the treatment of recurrent hemoptysis secondary to the unilateral absence of a pulmonary artery in a child. cardiovasc intervent radiol. 2015;38(5):1312-5. doi: 10.1007/s00270-014-0965-3. 29. zawadzka-glos l, jakubowska a, frackiewicz m, brzewski m. external laryngeal injuries in children comparison of diagnostic methods. int j pediatr otorhinolaryngol 2013;77(9):1582-4. doi: 10.1016/j.ijporl.2013.07.016. 30. snène h, berraies a, hamdi b, ammar j, ouali h, hamzaoui a. childhood tuberculosis: a descriptive study in a pneumo-pediatrics department in tunisia. tunis med. 2016 apr;94(4):259-264. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.284|http://cajgh.pitt.edu 31. gedik ah, cakir e, donmez t, ari e, koksalan ok. tuberculin skin test positivity without tuberculosis contact: a major challenge in childhood. j paediatr child health. 2015 jun;51(6):632-8. doi: 10.1111/jpc.12779 32. hasanzad m. bernard-soulier syndrome (bss) &amp; tuberculosis: a case report. int j mycobacteriol. 2014 dec;3(4):283-5. doi: 10.1016/j.ijmyco.2014.10.006 33. halioui-louhaichi s, ben chehida a, hassouna r, massaoud t, ben dridi mf, barsaoui s, et al. cystic fibrosis: a report of 33 pediatric tunisian cases. tunis med. 2015 aug-sep;93(8-9):569-73. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abstract keywords: pulmonary hemorrhage; extrapulmonary bleeding; hemoptysis, epistaxis; pediatric research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. detection of hepatitis e antibodies in kazakhstan: a pilot study francesca cainelli1; gonzalo hortelano2; baurzhan negmetzhanov3; aigerim ibrayeva1; kulpash kaliaskarova4; denis bulanin3; sandro vento1,5 1department of medicine, school of medicine, nazarbayev university, astana, kazakhstan; 2department of biology, school of science and technology, nazarbayev university, astana, kazakhstan; 3department of biomedical sciences, school of medicine, nazarbayev university, astana, kazakhstan; 4hepatology coordinating center, ministry of health, astana, kazakhstan; 5university medical center, astana, kazakhstan vol. 7, no. 1 (2018) | issn 2166-7403 (online) doi 10.5195/cajgh.2018.324 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ cainelli this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.324|http://cajgh.pitt.edu abstract introduction. hepatitis e virus exposure is associated with sporadic cases of acute hepatitis and outbreaks in many countries worldwide. it is particularly dangerous for pregnant women, in whom the mortality rate is high. there are no previously published data reporting circulation of this virus in kazakhstan. methods. we tested blood samples for igg anti-hepatitis e virus antibodies in 199 kazakh participants; of these 119 were workers at the expo 2017 building site in astana, 35 were volunteers who got tested at the astana city hall on the world hepatitis day 2017, and 45 were volunteers who presented for screening at the hepatogastroenterology outpatient clinic of the republican diagnostic center, university medical center. results. 11 (5.5%) individuals were positive for igg anti-hev antibodies, with a higher seroprevalence in males (7; 6.8%) vs females (4; 4.5%). the highest number of positive samples was in the 32-46 years age group. conclusions. this pilot study suggests that hepatitis e virus has been circulating in kazakhstan. studies are needed to determine whether it continues to be present, which viral genotypes are involved and what are the best methodologies for preventing its spread. keywords: hepatitis e; anti-hev antibodies; kazakhstan detection of hepatitis e antibodies in kazakhstan: a pilot study francesca cainelli1; gonzalo hortelano2; baurzhan negmetzhanov3; aigerim ibrayeva1; kulpash kaliaskarova4; denis bulanin3; sandro vento1,5 1department of medicine, school of medicine, nazarbayev university, astana, kazakhstan; 2department of biology, school of science and technology, nazarbayev university, astana, kazakhstan; 3department of biomedical sciences, school of medicine, nazarbayev university, astana, kazakhstan; 4hepatology coordinating center, ministry of health, astana, kazakhstan; 5university medical center, astana, kazakhstan research hepatitis e virus (hev) is the most recently discovered major hepatitis virus, which poses a significant threat to pregnant women. its existence was first suggested in 1980 by khuroo, who studied a non-a, non-b hepatitis outbreak in the kashmir valley (india),1 and its genome was entirely cloned in 1991.2 hev infection causes acute sporadic hepatitis and outbreaks worldwide. the virus has four genotypes. hev 1 and 2 infect humans, are found largely in low and middleincome countries, and are transmitted through the fecaloral route (mainly through contaminated water). genotypes 3 and 4 are found mainly in high-income countries, infect humans as well as animals, and cause sporadic cases of acute hepatitis. hev constitutes an important health problem in lowand middle-income countries, as acute sporadic form of hepatitis e is nowadays likely the most frequent cause of acute viral hepatitis worldwide.3 the worldwide incidence of acute genotypes 1 and 2 hev infection was estimated in 2005 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.324|http://cajgh.pitt.edu to be around 20.1 million cases, with 3.4 million symptomatic cases, 70,000 deaths, and 3,000 stillbirths.4 although hev infection usually causes selflimiting acute hepatitis with a low mortality rate, fulminant hepatitis frequently develops in pregnant women, especially at late gestational stages, and leads to a high maternal mortality rate (up to 31%) in developing countries.5,6,7 hev-infected pregnant women develop obstetric complications, including intrauterine fetal death, preterm delivery, and stillbirth much more frequently than non-hev-infected pregnant women.8 interestingly, during community outbreaks of acute hepatitis e, clinical attack rates were higher among adolescents and young adults than among children or older adults.9 in patients with chronic liver disease of other etiology, acute hev infection can determine flare ups of liver disease, and cause decompensation or liver failure in previously compensated cirrhotic patients.10 hev can also cause chronic hepatitis in immunosuppressed patients, including transplant recipients, human immunodeficiency virus-infected individuals with low cd4 cell count, and patients with hematological malignancies treated with chemotherapy.10 neurologic complications have been observed in large number of patients with hev infection,11 as well as renal and rheumatologic manifestations in a smaller number of cases. outbreaks of hev infection can occur in community-based settings (villages, cities, or provinces), military units, colleges, prisons, factories, and cruise ships. outbreaks have been reported in central asian countries, specifically in kyrgyzstan,12 uzbekistan,13 and turkmenistan;14 the latter was particularly large, occurred in the dashoguz province and affected over 16,000 people.14 in kazakhstan, a likely outbreak of acute hepatitis e occurred during the 1950s in the south, where case fatality rate reached 10% in hospitalized pregnant women.15 currently, tests for igm anti-hev antibodies are performed in pregnant women in some infectious diseases hospitals in kazakhstan, but no results have been published to date. we have performed a cross sectional study and tested for anti-hev antibodies (hev igg 3rd generation eia, dia.pro, sesto san giovanni, italy) 199 kazakh participants who gave their informed consent. participants included 119 workers at the expo 2017 building site in astana who presented consecutively in one day, 35 volunteers at the astana city hall on the world hepatitis day 2017, and 45 volunteers who presented consecutively for screening over a period of ten months at the hepatogastroenterology outpatient clinic of the republican diagnostic center, university medical center (umc). the participants were identified to be kazakh residents in the country either by their employer (in the case of the expo 2017 site) or by the personnel working at the city hall who contributed to the event promotion or by the healthcare staff working at the hepatogastroenterology outpatient clinic of the republican diagnostic center, university medical center (umc). selection of these three sites were based on the idea of screening diverse representation of different population groups of kazakhstan. all participants were briefed about the voluntary nature of the study and its objectives. the institutional review boards of both nazarbayev university and umc granted approval for this study. 5 ml of blood were collected from each individual; serum was separated and stored at -80°c until used in the elisa test. specimens were considered positive at a cut off value ≥ 1, as per manufacturer’s instructions. we collected information about age, gender, place (city, town, or village) of residence, history of jaundice, any previous diagnosis of hepatitis (if yes type was recorded as a, b, c, d or e), and alcohol consumption (current and past) using paper surveys. 103 participants were men and 89 women; in seven cases the gender was unreported (i.e. not indicated in the data http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cainelli this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.324|http://cajgh.pitt.edu sheets filled by the tested individuals). age was available for 194 individuals (mean 39.3 years, range 9 77). overall, 11 (5.5%) individuals sampled were positive for anti-hev antibodies; with higher prevalence among males (7 individuals; 6.8%) compared to females (4 individuals; 4.5%). no positivity was observed in the oldest age groups (over 60 years of age), while the highest number of positive samples were identified in the group between 32 and 46 years of age. in the future, we plan to test all patients with acute and fulminant hepatitis admitted to hospitals in astana to verify whether hev is the etiological factors of some of these cases. should this be the case, we will establish the genotypes of hev that are found in kazakhstan. the identification of genotypes will allow characterizing whether only genotypes hev-1 and hev2 or also genotypes hev-3 and hev-4 circulate in kazakhstan. preventive measures can then eventually be instituted to limit the possible circulation of the hepatitis e virus in the country and nearby regions. references 1. khuroo ms. study of an epidemic of non-a, non-b hepatitis. possibility of another human hepatitis virus distinct from posttransfusion non-a, non-b type. am j med. 1980 jun;68(6):81824. 2. tam aw, smith mm, guerra me, et al. hepatitis e virus (hev): molecular cloning and sequencing of the full-length viral genome. virology. 1991 nov;185(1):120-31. 3. purcell rh, emerson su. hepatitis e: an emerging awareness of an old disease. j hepatol. 2008 mar;48(3):494-503. doi: 10.1016/j.jhep.2007.12.008. 4. rein db, stevens ga, theaker j, wittenborn js, wiersma st. the global burden of hepatitis e virus genotypes 1 and 2 in 2005. hepatology. 2012 apr;55(4):988-97. doi: 10.1002/hep.25505. 5. kamar n, bendall r, legrand-abravanel f, et al. hepatitis e. lancet. 2012 jun 30;379(9835):2477-88. doi: 10.1016/s01406736(11)61849-7. 6. ranjan a, thakur s, mokta j, bhawani r, ranjan v. clinical profile and outcome of pregnant patients with acute hev hepatitis during water borne epidemic in himachal pradesh: a hospital based study. j assoc physicians india. 2017 dec;65(12):44-48. 7. javed n, ullah sh, hussain n, et al. hepatitis e virus seroprevalence in pregnant women in pakistan: maternal and fetal outcomes. east mediterr health j. 2017 oct 30;23(8):559563. 8. patra s, kumar a, trivedi ss, puri m, sarin sk. maternal and fetal outcomes in pregnant women with acute hepatitis e virus infection. ann intern med. 2007 jul 3;147(1):28-33. 9. teo cg. much meat, much malady: changing perceptions of the epidemiology of hepatitis e. clin microbiol infect. 2010 jan;16(1):24-32. doi: 10.1111/j.1469-0691.2009.03111.x. 10. murali ar, kotwal v, chawla s. chronic hepatitis e: a brief review. world j hepatol. 2015; 7(19): 2194-2201. doi: http://dx.doi.org/10.4254/wjh.v7.i19.2194. 11. kamar n, bendall rp, peron jm, et al. hepatitis e virus and neurologic disorders. emerg infect dis. 2011 feb;17(2):173-9. doi: 10.3201/eid1702.100856. 12. usmanov rk, favorov mo, vasil'eva vi, et al. a comparative study of enteral hepatitis e (non-a, non-b) in the valley and mountainous areas of kirghizia [in russian]. vopr virusol. 1991 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.324|http://cajgh.pitt.edu jan-feb;36(1):66-9. 13. sharapov mb, favorov mo, yashina tl, et al. acute viral hepatitis morbidity and mortality associated with hepatitis e virus infection: uzbekistan surveillance data. bmc infect dis. 2009 mar 25; 9: 35. doi: 10.1186/1471-2334-9-35. 14. albetkova a, drobeniuc j, yashina t, et al. characterization of hepatitis e virus from outbreak and sporadic cases in turkmenistan. j med virol. 2007 nov; 79(11): 1696-702. doi: 10.1002/jmv.20991. 15. zhumatov kh zh, dardik fg. epidemic hepatitis in pregnancy [in russian]. akush ginekol (mosk). 1958 nov-dec; 34(6): 2632. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx detection of hepatitis e antibodies in kazakhstan: a pilot study abstract keywords: hepatitis e; anti-hev antibodies; kazakhstan detection of hepatitis e antibodies in kazakhstan: a pilot study research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. `` public health and social desirability in kazakhstan: methodological considerations brett j. craig & martha c. engstrom department of communication, nazarbayev university, kazakhstan vol. 4, no. 2 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.191 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ craig this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.191|http://cajgh.pitt.edu abstract background: as the republic of kazakhstan undertakes new public health efforts to promote healthy lifestyles among its citizens, the local perceptions of health and health behaviors need to be examined and understood from the sociocultural and historical perspectives. the primary aim of this study is to examine the association between perception of control on one’s health and engagement in good and bad health behaviors. methods: students enrolled in a health communication course surveyed 310 citizens of kazakhstan on their perceptions of control over their own health and multiple health behaviors (i.e. smoking status, physical activity, etc.). twenty-seven students were divided into groups and approached every third passerby as a potential participant during common shopping hours in nine popular marketplaces in astana, kazakhstan. perception of control on one’s health was measured using a validated measure of health control: the multidimensional health locus of control scale (mhlc), developed by wallston and colleagues. the mhlc measures three separate loci of control: internal, chance, and powerful others. results: participants perceived themselves as having highest control over their health (mhlc subscale internal: 29.70±0.64), powerful others had second highest control (mhlc subscale power others: 23.72±0.77), and chance had the lowest but still some control on their health (mhlc subscale chance: 20.82±0.85). most participants rated their current health as very good (18.1%), good (45.0%), or moderate (32.3%). approximately 23.4% of participants were smokers, and 22.2% consumed alcohol. physical activity averaged 3.63 days in the past week, and fruit and vegetable consumption averaged 2 servings of each per day. tobacco and the powerful others subscale were significantly negatively correlated (r=-0.17, p<0.05). conclusions: participant reports regarding personal health behaviors and lifestyle did not reflect the national reports regarding lifestyle behaviors. the relationship between powerful others subscale and tobacco smoking indicate that using healthcare providers may open up avenues to lowering tobacco use through patient education; however, social desirability is a notable concern for public health interventions. more importantly, the surveys uncovered future questions for conducting public health research with the general public, including issues of trust in the healthcare system and social desirability bias. additional factors such as distrust in healthcare and government also may play a role in the public’s participation in social scientific research. the students who conducted the surveys reported a general skepticism from the public ranging from unfamiliarity with survey research to explicit distrust in the intentions and purpose of the research itself. keywords: public health, social desirability, control of health, kazakhstan public health and social desirability in kazakhstan: methodological considerations brett j. craig & martha c. engstrom department of communication, nazarbayev university, kazakhstan research health behaviors and public perception of health is an important area of investigation in the republic of kazakhstan. a previous study examining public perceptions of control over health and health behaviors faced methodological issues of survey research.1 cultural and historical factors in kazakhstan’s health services delivery likely influence the public’s http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.191|http://cajgh.pitt.edu reports on their individual health behaviors due to a focus on disease-centric healthcare rather than wellnesscentric.2 the purpose of this study was to examine the relationship between the general public’s perceptions of control of one’s health with health behaviors. this information can then be used to inform early efforts undertaken by the kazakhstan government to promote healthy lifestyles. health and the perception of control efforts in health promotion are generally structured around the general public’s assumptions regarding their current and future health status as related to or as a result of their health choices and behaviors.3 however, the strategies of health promotion using information dissemination or even social appeal are theoretical constructs that assume particular beliefs and perceptions about individual responsibility and control regarding outcomes.2 research shows that different cultural groups demonstrate variance in health beliefs, health behaviors,4-6 and causes of illness.7 furthermore, political backgrounds of healthcare systems contribute to the cultural perceptions of roles and responsibilities regarding healthcare professionals and the public.8 health behaviors and beliefs have been studied extensively in the west, but in post-soviet countries, this phenomenon is in need of further investigation.1,9 the post-soviet republic of kazakhstan, in addition to undergoing significant changes in its healthcare model,10 is also beginning to develop efforts in public health promotion, which present healthy outcomes as a result of an individual’s health behaviors.11 current public health intitiatives aim to address the increasing prevalence of lifestyle-related non-communicable diseases, specifically cardiovascular disease, in kazakhstan. health behaviors, such as smoking, are of particular interest. however, if the public does not see health outcomes as within their locus of control, current efforts in health promotion will not produce changes in behavior towards healthier lifestyles. one established measure of perceived health locus of control is the multidimensional health locus of control scales (mhlc).12,13 the mhlc were developed by wallston and colleagues to assess participants’ reports of how much control they perceive they have over their health. the mhlc contains three subscales: internal (whether you feel that you have control over your own health), chance (whether you feel your health is due to luck, fate, or chance), and powerful others (whether you feel that powerful individuals, such as physicians or other health professionals, control your health). sample questions from these subscales are “if i take care of myself properly i can prevent diseases” (internal), “most of the things that affect my health happened to me accidentally” (chance), and “the best way for me to avoid different sicknesses is to visit a doctor on a regular basis” (powerful others). there are 18 questions in the mhlc, six for each subscale, and participants are asked to respond on a six-item likert scale from 1 (strongly disagree) to 6 (strongly agree). scores range from 6 to 36.5,12,13 each subscale score indicates the degree of control the participant attributes to that source. these three subscales are not mutually exclusive and can be reported as high in all, low in all, or at various levels. the higher the score, the more the participant is placing control in that source. scores can vary across populations and groups, but in general participants who score above the median on any score can be considered "high" on that subscale, and those who score below could be called "low." cultural influences in survey research the culture and social system of kazakhstan is different than the context in which these measurement scales were derived, and the use of surveys among the general public is also a relatively new practice in kazakhstan. previous research has examined the influence of culture on survey research in areas such as social desirability, issues in translation and meaning, and the use of the likert scale format. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx craig this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.191|http://cajgh.pitt.edu social desirability, using the definition of johnson and van de vijver, is “the tendency of individuals to ‘manage’ social interactions by projecting favorable images of themselves, thereby maximizing conformity to others and minimizing the danger of receiving negative evaluations from them.”14 though social desirability is likely to be a universal concept, a participant’s perception of which answer to a question would help him or her appear to be more socially desirable varies across cultures. previous research has indicated that there are cultural influences on social desirability, particularly in collectivistic cultures, where survey respondents tend to answer questions in a manner that would be viewed favorably by others.14-16 honesty with strangers in an interaction is valued more in individualist cultures, whereas a concern for social desirability can bias results to over-report good behavior or under-report bad behavior in collectivist cultures.17 therefore, social desirability may be more of an influence in collectivist cultures than in individualist cultures.18,19 effectively translating survey instruments from their source language is an important part of crosscultural research. if meaning is not preserved across languages, the original intent of the instrument can be lost or distorted, in addition to compromising its validity and reliability.20 embedded in language are the experiences and norms for word usage that can be different across cultures.21 in order to preserve meaning and intent, brislin’s22 model of translation focuses primarily around the notion of back translation. an instrument should be translated to the operative language and then translated back to the source language by someone unfamiliar with the instrument in its source language. this way the back translation can be compared to the original instrument to check for consistent meanings. the use of likert scales, where participants respond by indicating on a scale the degree to which they agree or disagree with a statement, is very popular among instruments used in survey research. research has shown people from different cultural groups tend to respond differently in surveys using likert scales. hui and triandis23 found that some groups are more prone to report extremes on the scales than others, while lee, jones, mineyama, and zhang24 found that some groups favor the midpoint response when cultural beliefs would encourage it. likert scales can include different quantities of items, but most common are 4-point, 5point, 6-point, and 7-point. the mhlc scales used in this study are typically used with a 6-point scale response scale. the objective of this paper is to establish the usability of the mhlc scale as well as explore the issues of survey research through street contacts with the general public in kazakhstan. researchers using these scales, as well as other similar public health measurements, may benefit from learning from the results of this study. methods to begin investigating how culture influences the perception of control and responsibility in health in kazakhstan, surveys were distributed in nine marketplaces in astana, kazakhstan after receiving approval from nazarbayev university’s research and ethics committee. surveys included questions about basic demographic information and health behaviors, such as alcohol and tobacco use, exercise, and diet. we included the mhlc scales as the primary measure to determine levels of perceived control. surveys were translated from their original language (english) into both russian and kazakh by a professional translator. a different professional translator who had not seen the original english version then back translated both translated versions into english. modifications in the translated versions were then made to preserve the meaning and clarity of the original survey. students from the communication course science, health and social influence, a third-year course, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.191|http://cajgh.pitt.edu participated in the collection of survey data for this study. after learning about the scales as a part of coursework, students were trained on how to approach participants and handle the distribution and collection of survey data. their training took place as part of the course work and focused on the ethics of research, confidentiality, interaction with research participants, and techniques of answering questions about the research without biasing the responses. twenty-seven students were divided into groups of three to create nine groups. each group was assigned a popular marketplace within the city limits of astana. the marketplaces and their corresponding locations within the districts are given in table 1. table 1: marketplaces in astana by district the marketplaces were chosen on the basis of improving regional diversity, while using marketplaces that represent common places of general public gathering. on a weekend during common shopping times, students approached every third passerby as a potential participant. this pattern of approaching participants did not create a truly random sample, but it helped prevent bias on the part of the students in whom they chose to approach. though the marketplaces are commonly attended areas by many different groups of people, one limitation is that not all groups would be equally represented at the marketplaces, especially if their health conditions do not permit such activity. records of completed surveys and the numbers of potential participants approached were carefully monitored. students were asked to record their experiences and impressions afterwards to provide further data on this pilot study. data analysis first, we conducted descriptive statistics on participant characteristics. second, we examined the association of participant characteristics (e.g. age, sex, etc.) on mhlc sub-scales using independent-samples ttests. finally, we used bivariate correlation to test the association between participant characteristics and each of the mhlc sub-scales. all analyses were conducted using spss, using p<0.05 as the cut-off for significance. results participants students collectively approached 824 people, 310 of which agreed to participate, yielding a 38% survey response rate. of those who responded, 57.7% were female with a mean age of 32.53 (sd=13.65). details regarding the participant language, ethnicity, and marital status can be found in table 2. table 2: demographic descriptive characteristics of participants descriptives of participant health participants were asked to rate their overall health status. nearly all participants rated their current health as moderate (32.3%), good (45.8%), or very good (18.1%). with regards to health behaviors, 23.4% of participants were smokers and 22.3% consumed alcohol. physical activity averaged around 3.63 days in the past week, and fruit and vegetable consumption averaged 2 servings of each per day. further information on participant health ratings and reported behaviors can be found in table 3. table 3: descriptive characteristics of participant health multidimensional health locus of control scores most participants tended to perceive themselves as having high control over their health (mhlc subscale http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx craig this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.191|http://cajgh.pitt.edu internal: 29.70±0.64). participants perceived others, such as medical providers, as having high control over their health (mhlc subscale power others: 23.72±0.77). participants perceived chance as a somewhat likely entity to have control over their health (mhlc subscale chance: 20.82±0.85). analysis of association and correlation of predictors of mhlc subscales most health behaviors were not significantly correlated with any of the reported mhlc subscales and differences in sex, age, language or ethnicity. tobacco smoking was significantly, though weakly, associated with the powerful others subscale (r=-0.17, p<0.05). discussion in this study, in addition to the results of the mhlc survey, we found methodological issues common to cross-cultural research, such as translation of measurements and social desirability in addition to other issues perhaps more unique to the region. mhlc results such mhlc scores are different than white european cultural groups, but they are similar to south asian cultural groups, especially with the powerful others and internal subscales,5 revealing possible cultural influences on perceptions of health and health behaviors. the subscales, developed in a western cultural setting, often find that those reporting a high level of internal control report lower scores in control residing in external areas such as chance or powerful others. however, as steptoe and wardle3 found in their study of eastern europeans and wrightson and wardle6 found in their study comparing white europeans with south asian and afro-caribbean, these subscales are not always at odds with one another in other cultural groups. our pilot study revealed that this also might be the case in kazakhstan. while these participants reported high levels of internal control, they also reported high levels of control coming from powerful others (influential people in their lives). some possible explanations of this perception include the influence of the soviet model of healthcare that focused on treatment of disease rather than on health and prevention.1,25 healthcare was (and largely still is) provided by the government and, therefore, was seen as the responsibility of the government. while healthy lifestyles are now being promoted and the public may even be reporting a sense of control over their own health through their lifestyle, the perception that health still resides in the hands of powerful others such as healthcare providers may be influencing the powerful others subscale score. the significant negative correlation between tobacco use and the powerful others subscale also deserves further investigation. those who are using tobacco are less likely to perceive healthcare providers as influencing their health, while those who perceive healthcare providers as having some control over their heath are less likely to use tobacco. possible explanations for this phenomenon include anti-tobacco messages from healthcare providers as well as those participants who are generally more health conscious and avoid tobacco also see their healthcare providers regularly. methodological issues though several methodological features of this study were consistent with similar studies done elsewhere such as the response rate of street contacts and the influence of survey fatigue, by using the reported experiences of students distributing the surveys we found that the issues of translation, likert scales, and social desirability may be significantly influencing the effectiveness of using surveys, particularly through street contacts. furthermore, the additional issue of trust was made salient in the interactions between participants and survey distributors. translation and meaning though we had the survey translated and back translated into both russian and kazakh languages so http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.191|http://cajgh.pitt.edu that participants could respond in their native language, participants struggled with many of the questions and some were irritated with the translation. students distributing these surveys reported most frequently that participants made comments about the questions in the mhlc scales being repetitive and not discernibly different from one another. this may be an imperfection in accurately translating subtle differences in the questions, and it may also reveal differences in constructions of concepts and perceptions embedded within the languages themselves regarding relationships with others and control over situations and outcomes. as the government of kazakhstan has been strengthening the use and presence of the kazakh language,26 the need for properly translated instruments will continue to grow. as demonstrated, translation is extremely important for linguistic comprehension and for cultural conceptualization and familiarity. likert scales and time the use of likert scales was not reported by participants as a point of confusion; however, the unfamiliarity with the concept as well as using the 6point scales may have contributed to time and even survey fatigue. many students noted that it took much longer than typical to fill out a two-page questionnaire. other research suggests simplifying a 6-point to a 4-point scale for different populations without a loss in reliability or validity.20 the confusion created by the fact so many questions seemed to be the same according to the participants might have been compounded by the choice in six responses for each question. using 4-point scales or more simplified versions of responses may improve the accuracy of responses and decrease survey fatigue. social desirability and culture the participants’ reports on tobacco and alcohol use are much lower than expected considering the world health organization’s (who) nationwide statistics on usage.27 additionally, their reports on diet and exercise indicate a much healthier sample than the greater population where the prevalence of behaviorally related diseases creates a significant burden and is projected to increase.28 though our sample of participants is not truly random and cannot be expected to closely match generalized figures, the relatively healthy behaviors reported on average indicate the possibility of social desirability influencing responses. as kazakhstan is a more collectivistic than individualistic society, it is likely that many survey responses may be influenced by a strong desire to save face, especially when answers to questions can reflect a negative image. some students reported experiences where participants either ignored or did not understand anonymity and privacy and felt they had to explain and justify each of their answers to the students. a few students rather indignantly reported that they knew participants were not being honest about their behaviors such as tobacco use because students could see packages of cigarettes in participants’ hands or pockets. however, the age of the students needs to be considered in the collection of data because kazakhstan is a hierarchical culture which values age as well as position. thus, their responses to these students may be influenced by these norms and values. if social desirability significantly influenced these participants’ responses, this may further add to the knowledge gained from this pilot study. in order for social desirability to influence participants’ answers regarding health behaviors, the participants must possess a basic knowledge of what a healthy lifestyle is. therefore, though their health behaviors may not actually be as healthy as they reported, participants may have more knowledge of what healthy behaviors are and why they are socially desirable than was expected. if health promotion is to be effective it needs to be informed by research that has examined influences on health behaviors beyond knowledge and information. research in kazakhstan needs to explore social and economic factors that are shaping the population’s health behaviors. more research is needed regarding the public’s perspectives on why they do what they do rather than simply what they know. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx craig this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.191|http://cajgh.pitt.edu trust one unanticipated issue students encountered in administering questionnaires was lack of trust in the healthcare system. participants frequently asked about the purpose of the survey. when students told them it was to help better promote health in kazakhstan, they generally expressed disbelief. some participants laughed and mocked the students for being naïve. others refused to participate because it would be a “waste of time.” some participants shared stories of negative experiences with healthcare system, while others went so far as to name doctors who they felt were responsible for bad care. additionally, participants expressed distrust in the research process itself, claiming such work will not help improve anything. however, some participants were interested in knowing the results of the survey and even expressed appreciation, saying more research like this needed to be done. trust is a common issue in many post-soviet healthcare systems because of soviet-era characteristics, such as paternalism, that current governments are struggling to change. health care during the soviet era was largely underfunded and included non-evidence based practices and beliefs,8 where corruption has been a problem in the form of informal payments.29 these characteristics, coupled with lack of knowledge on preventive practices, results in the general public not seeking timely medical care.30 the perception that utilizing healthcare services will not yield desired results needs to be addressed in future research. the issue of trust may have higher relevance when considering the high mhlc subscale score of powerful others. if the public perceives control over their health to be in the hands of powerful others such as doctors but does not trust doctors, this may influence health behaviors and choices leading to negative outcomes. it may also dissuade the public from using medical services in appropriate and necessary ways. one of the most important methodological approaches utilized in this study was the involvement of students in data collection. we believe that this experience exposed students to the nature of research and data collection and helped them to think more critically about data collection and statistical approaches to use for survey research. it also helped students to see the value in seeking out and measuring the public’s perception because through their experiences these students learned how diverse in opinion and experience their fellow citizens actually are. while we attempted to obtain a diverse sample of participants in this study by going to marketplaces belonging to different socioeconomic classes, we also acknowledge the limitations in the generalizability of this study. astana itself as the capital city of kazakhstan is drawing people from different regions within the country to live there, and as such may not be representative of the entire country. conclusions this pilot study has revealed significant challenges to conducting face-to-face survey research with the general population of kazakhstan. due to cultural influences on social interactions with research staff, participants’ answers to survey questions could be significantly influenced by social desirability. additionally, a history of distrust with authority figures may also influence participants to alter their answers or influence decision to participate in research. these are issues that need to be considered and accounted for in designing and carrying out social scientific research in kazakhstan, and central asia in general. references 1. bobak m, pikhart, h, rose, r, hertzman, c, marmot, m. socioeconomic factors, material inequalities, and perceived control in self-rated health: cross-sectional data from seven post-communist countries. soc sci & med. 2000;51:1343-1350. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.191|http://cajgh.pitt.edu 2. sharman a. a new paradigm of primary health care in kazakhstan: personalized, community-based, standardized, and technology-driven. cent asian j glob health. 2014;3(1). 3. wallerstein n. powerlessness, empowerment, and health: implications for health promotion programs. am j health promot. 1992;6(3):197-205. 4. vaughn l, jacquez, f, baker, rc. cultural health attributions, beliefs, and practices: effects on healthcare and medical education. open med ed j. 2009;2:64-74. 5. steptoe a w, j. . health behavior, risk awareness and emotional well-being in students from eastern europe and western europe. soc sci & med. 2001;53:1622-1630. 6. wrightson k, wardle, j. cultural variation in health locus of control. ethnicity and health. 1997;2:13-20. 7. lundell h nj, clarke, c. public views about health causation, attributions of responsibility, and inequality. j health comm: intern pers. 2013;0:1-15. 8. bond a, beresford, g. healthcare development in the former soviet union postgrad medical j. 2003;79:551-552. 9. perlman f, bobak, m, steptoe, a, rose, r, marmot, m. do health control beliefs predict behavior in russians? prev med. 2003;37:73-81. 10. orynbassarova d. family medicine as a model of primary health services delivery: a pilot study in almaty, kazakhstan. cent asian j of glob health. 2015;4(1). 11. reilly j, methven e, mcdowell z, et al. health consequences of obesity. archives of disease in childhood. 2003;88(9):748-752. 12. wallston k, wallston, bs, devellis, r. development of multidimensional health locus of control (mhlc) scales. health ed mon. 1978;6:160-170. 13. wallston k. the validity of the multidimensional health locus of control scales. j health psych. 2005;10:623-631. 14. johnson tp vdvf. social desirability in cross-cultural research. in: harkness ja vdvf, mohler pp, ed. cross-cultural survey methods. hoboken, nj: wiley; 2002. 15. lalwani ak sl, chiu c. . motivated response styles: the role of cultural values, regulatory focus, and self-consciousness in socially desirable responding. j per & soc psych. 2009;96:870882. 16. triandis h. individualism and collectivism. boulder, co: westview press; 1995. 17. johnson t kp, cho yi, shavitt, s. . the relation between culture and response styles: evidence from 19 countries. j crosscultural psych. 2005;36:264-277. 18. smith p, bond, mh. social psychology across cultures. 2nd ed. hemel hempstead, uk: harvester wheatsheaf; 1998. 19. van hemert d, van de vijver, fjr, poortinga, yh, georgas, j. structure and score levels of the eysenck personality questionnaire across individuals and countries. person & ind diff. 2002;33:1229–1249. 20. chang l. a psychometric evaluation of 4-point and 6-point likert-type scales in relation to reliability and validity. app psych measurement. 1994;18(3):205-215. 21. yu d, lee, dtf, woo, j. issues and challenges of instrument translation. western j nursing res. 2004;26:307320. 22. brislin r. the wording and translation of research instrument. in: lonner wj bj, ed. field methods in cross-cultural research. beverly hills, ca: sage; 1986. 23. hui ch th. effects of culture and response format on extreme response style. j cross-cultural psych. 1989;3:296309. 24. lee jw jp, mineyama y, zhang xe. . cultural differences in responses to a likert scale. res nursing & health. 2002;4:295306. 25. field m. the soviet legacy: the past as prologue. in: mckee m hj, falkingham j, ed. health care in central asia. philadelphia, pa: open university press; 2002. 26. aksholakova a, ismailova, n. the language policy of kazakhstan and the state language in government service. . procedia-social and behav sci. 2013;93:1580-1586. 27. who. risk factors (alcohol & tobacco). 2014; http://www.who.int/countries/kaz/en/. accessed may 30, 2014. 28. aringazina a, gulis, g, allegrante, jp public health challenges and priorities for kazakhstan. central asian j global health. 2012;1:1. 29. radin d. too ill to find the cure?: corruption, institutions, and health care sector performance in the new democracies of central and eastern europe and former soviet union. east euro pol & soc. 2009;23:105-125. 30. balabanova d, roberts, b, richardson, e, haerpfer, c, mckee, m. health care reform in the former soviet union: beyond the transition. health serv res. 2012;47(2):840-864. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/countries/kaz/en/ craig this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.191|http://cajgh.pitt.edu table 1: marketplaces in astana by district market district tsum saryarka west alem saryarka north khan shatyr yesil west near railway station saryarka outer region new central market almaty north anvar food fair yesil south arteom saryarka center gulzhan saryarka center shapagat saryarka east http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.191|http://cajgh.pitt.edu table 2: demographic descriptive characteristics of participants variables m±sd or n(%) age 32.53 ± 13.65 sex male 130 (41.9) female 179 (57.8) unknown 1 (0.3) language russian 231 (74.5) kazakh 79 (25.5) ethnicity kazakh 230 (74.2) russian 51 (16.5) other/unknown 29 (9.3) marital status currently married 131 (42.3) never married 108 (34.8) divorced 19 (6.1) widowed 13 (4.2) cohabitating 10 (3.2) separated 5 (1.6) cohabitating 2 (0.6) unknown 22 (7.2) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx craig this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.191|http://cajgh.pitt.edu table 3. descriptive characteristics of participant health variables total m±sd or n (%) female m±sd or n (%) male m±sd or n (%) physical activity 3.63 ± 0.23 3.08 ± 2.85 3.83 ± 2.63 fruit servings 2.03 ± 0.23 2.08 ± 1.86 1.96 ± 2.02 health status rating very good 56 (18.1) 22 (12.2) 34 (26.2) good 142 (45.8) 84 (46.9) 58 (44.6) moderate 100 (32.3) 66 (36.9) 34 (26.2) bad 3 (1.0) 3 (1.7) 0 (0.0) very bad 1 (0.3) 1 (0.6) 0 (0.0) unknown 8 (2.5) 3 (1.7) 4 (3.0) tobacco smoking daily 37 (12.0) 6 (3.4) 31 (23.8) non-daily 32 (10.3) 13 (7.3) 19 (14.6) did not smoke 224 (72.3) 151 (84.3) 73 (56.2) unknown 17 (5.4) 9 (5.0) 7 (5.4) alcohol consumption (past week) none 215 (69.3) 118 (65.9) 97 (74.6) yes (average of 2.28 drinks) 69 (22.3) 36 (20.1) 33 (25.4) unknown 26 (8.4) 25 (14.0) 0 (0.0) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. the potential contribution of brca mutations to early onset and familial breast cancer in uzbekistan abdulla abdikhakimov1, mukaddas tukhtaboeva1, bakhtiyar adilov2, shahlo turdikulova2 1tashkent institute of postgraduate education, tashkent regional oncological dispensary; 2center for high technologies academy of sciences republic of uzbekistan vol. 5, no. 1 (2016) | issn 2166-7403 (online) doi 10.5195/cajgh.2016.228 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ abdikhakimov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu abstract introuduction: breast cancer is the most common malignancy in women and affects approximately 1 out of 8 females in the us. risk of developing breast cancer is strongly influenced by genetic factors. germ-line mutations in brca1 and brca2 genes are associated with 5–10% of breast cancer incidence. to reduce the risk of developing cancer and to increase the likelihood of early detection, carriers of brca1 or brca2 mutations are offered surveillance programs and effective preventive medical interventions. identification of founder mutations of brca1/2 in high risk communities can have a significant impact on the management of hereditary cancer at the level of the national healthcare systems, making genetic testing more affordable and costeffective. brca1 and brca2 mutations in breast cancer patients have not been characterized in the uzbek population. this pilot study aimed to investigate the contribution of brca1 and brca2 mutation to early onset and familial cases of breast cancer in uzbekistan. methods: a total of 67 patients with breast cancer and 103 age-matched disease free controls were included in this study. utilizing sybr green based real-time allele-specific pcr, we have analyzed dna samples of patients with breast cancer and disease free controls to identify the following brca1 and brca2 mutations: brca1 5382insc, brca1 4153dela, brca1 185delag, brca1 300t>g, brca2 6174delt. results: three unrelated samples (4.5%) were found to be positive for the heterozygous 5382inscbrca1 mutation, representing a possible founder mutation in the uzbek population, supporting the need for larger studies examining the contribution of this mutation to breast cancer incidence in uzbekistan.we did not findbrca1 4153dela, brca1 185delag, brca1 300t>g, and brca2 6174delt mutations. conclusion: this preliminary evidence suggests a potential contribution of brca1 5382insc mutation to breast cancer development in uzbek population. taking into account a high disease penetrance in carriers of brca1 mutation, it seems reasonable to recommend inclusion of the 5382insc mutation test in future research on the development of screening programs for breast cancer prevention in uzbekistan. keywords: brca1, brca2, founder mutation, real-time pcr, breast cancer, uzbek population the potential contribution of brca mutations to early onset and familial breast cancer in uzbekistan abdulla abdikhakimov1, mukaddas tukhtaboeva1, bakhtiyar adilov2, shahlo turdikulova2 1tashkent institute of postgraduate education, tashkent regional oncological dispensary; 2center for high technologies academy of sciences republic of uzbekistan research breast cancer is one of the most commonly diagnosed malignancies around the world with the incidence potentially rising in asia due to an increasingly westernized lifestyle.1 the average lifetime risk of breast cancer in women living in the us is 12.3% (1/8)2, and it is the most prevalent cancer in women other than skin cancer.3 while lifestyle factors such as obesity and reproductive factors play an important role in breast cancer development, in a small percentage of families the risk of developing breast cancer is strongly influenced by hereditary factors. the most significant and well-characterized genetic risk factors for breast http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu cancer published to date are germline mutations of the brca1and brca2 genes.4 in the general population, about 5–10% of all breast cancer cases are linked to the mutations in these genes, which can explain around half of the cases of breast cancer aggregation in some families.5,6 it is estimated that the total frequency of brca1 and brca2 mutation carriers in europe is around 0.2% (1/500), while the prevalence of brca1 mutation carriers is approximately 0.13% (1/800)7; however, it can vary widely among different countries and ethnic groups due to the founder effect.8 according to the data from the republican oncology research center of the ministry of health of the republic of uzbekistan, 2273 new cases of breast cancer were diagnosed in uzbekistan in 2010, which is 784 cases higher than in 2001 (data not published). these numbers demonstrate that the number of reported cases of breast cancer in uzbekistan is potentially increasing. it is possible to approximate that the number of patients with breast cancer diagnosis increased by an average of 87 people per year in this time period. the rate of increase of breast cancer within a 10–year period was 37.3%.9 inherited brca mutations are associated with high disease penetrance. women carrying a brca1 mutation have a lifetime risk of 65–80% of developing breast cancer, while brca2 mutation carriers have a lifetime risk of 45–85%.10 brca1and brca2 are tumor suppressor genes that encode large proteins of 1,863 and 3,418 amino acids, respectively.11 previous research demonstrated that brca proteins are key regulators of important cellular processes such as dna repair, transcription, as well as cell cycle and apoptosis in response to dna damage.12 the identification of brca1 and brca2 mutation carriers is of great clinical significance, since management protocols for mutation carriers are becoming well established13-15 and effective preventive medical interventions exist.16,17 once a mutation is identified in a given family, oncogenetic tests can be applied to all members of the affected family to identify carriers.18 moreover, molecular genetic testing is becoming an important tool in predicting drug response, as new targeted therapeutic agents, such as poly(adpribose) inhibitors19,20, emerge and chemosensitivity to platinum-based therapy has been reported.21 improved knowledge of the genetic make-up of populations where breast cancer is increasing is very important for the development of an effective screening strategy. previous research demonstrated that there is a wide spectrum of mutations in the affected population.5 this fact makes identification of brca carriers difficult. a full analysis of the brca1 and brca2 genes includes not only the complete sequencing of all the coding regions of the genes, but also the detection of mutations by the multiple ligation dependent probe amplification method. in the mid-1990s, it was discovered that some populations are characterized by a pronounced “founder effect” the predominance of the so-called recurring mutations in brca1 and brca2. for example, in ashkenazi jews, virtually all the mutations in brca1 and brca2 genes are related to 185delag, 5382insc, and 6174delt.22 elucidation of founder mutations of brca1/2 genes can have a significant impact on the management of families with hereditary cancer at the level of the national healthcare system, ultimately making genetic testing more affordable and costeffective. to date, brca1 and brca2 mutations in breast cancer patients have not been characterized in the uzbek population. the purpose of this pilot study is to investigate the contribution of common brca1 and brca2 mutations to early onset and familial cases of breast cancer in uzbekistan. methods participants this study included 67 uzbek women who (1) had at least one firstor second-degree relative with breast and/or ovarian cancer, regardless of age; (2) were less than 35 years of age at diagnosis; (3) had bilateral http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abdikhakimov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu breast cancer; (4) had triple negative (tn) or medullary type pathology; (5) had at least one relative with cancers other than breast and ovarian cancer such as stomach and prostate that are known to be related to brca mutations. a standard epidemiological questionnaire, including a detailed family history, was administered to all patients after obtaining informed consent. medical information, including pathology records, was retrieved from the patients’ medical records. information collectected from the epidemiological questionnaires included age at breast cancer diagnosis, history of other primary cancers, and a family history of breast, ovarian, and other cancers in first, second, and third degree relatives. in addition, the questionnaire included information about the usage of alcohol, tobacco, contraceptives (pills, patches, or injections), hormone replacement therapy, and prior use of infertility medications. reproductive history (including history of breastfeeding), as well as menopausal status, was recorded for each patient. age of patients ranged from 27 to 77 years. the median age was 43 years. eighty-six percent of the patients were living in the tashkent district (rural area located in the northeastern part of uzbekistan, between the syr darya river and the tien shan mountains) and the remaining 16% of the patients were residents of the tashkent city. all women underwent cancer treatment in the tashkent regional oncological dispensary, tashkent, uzbekistan. pathological diagnosis of breast cancer was made according to the world health organization (who) classification and the tumor–node–metastases (tnm) staging system. age-matched disease free control group (n=103) was identified through the clinical specialists participating in the study and included women undergoing regular prophylactic breast examinations in the tashkent regional oncological dispensary, tashkent, uzbekistan. they were defined as “disease free” based on the results of their last breast examinations conducted by clinicians with expertise in breast cancer. controls were also screened for family history of breast and ovarian cancer and were determined to be free of family history of these conditions. women in the control group were agematched to cases and resided in tashkent city and tashkent region. all study participants signed informed consents before participating in this research. the study was conducted according to the standards of the national ethic committee of uzbekistan, developed in accordance with the world medical association’s declaration of helsinki "ethical principles for medical research involving human subjects" with amendments.23 laboratory methods blood samples (2 ml) were drawn from an antecubital vein using vacutainers containing sodium citrate, and stored at −20°c for further analysis. genomic dna was extracted from peripheral blood leucocytes using dna extraction kit diatom™ dna prep 200 (“isogen laboratory”, moscow, russia). detection of 5 common mutations (brca1 5382insc, brca14153dela, brca1 185delag, brca1 300t>g, brca2 6174delt) was performed by sybr green based real-time allele-specific pcr.24,25 these five common mutations were chosen based on their widespread pattern of occurrence in the world.25-29 the pcr with allele-specific primers (table 1) was performed in a 25 µl reaction mixture containing 9.3 µl of ddh2o, 1,5 µl 10xpcr buffer containing the intercalating dye sybr green i, 1,5 µl 25 mm mgcl2, 0.3 µl 2.5 mm dntp mix, 0,25 µl (10pkmol/µl) of each oligonucleotide primer, 0.1 ul (0.5 units.) "hot-start" taq-polymerase and 1.8 µl of dna.pcr amplification was carried out in applied biosystems 7500 real-time pcr system. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu table 1.oligonucleotide primers used in the study the pcr conditions were optimized for each mutation and were as follows: brca1 5382insc (95 °c for 5 min, and then 45 cycles of 95 °c for 20 s, 55 °c for 45 sec, and 72 °c for 45 sec), brca1 4153dela (95 °c for 5 min, followed by 42 cycles of 95 °c for 15 sec, 63°c for 30 sec, and 72 °c for 40sec), brca1 185delag (95 °c for 5 min, and then 40 cycles of 95 °c for 20 sec, 67°c for 30 sec, and 72 °c for 40 sec), brca1 300t>g (95 °c for 5 min, and then 45 cycles of 95 °c for 20 s, 50°c for 30 sec, and 72 °c for 40 sec) and brca2 6174delt (95 °c for 5 min, followed by 45 cycles of 95 °c for 10 sec, 65°c for 30 sec, and 72 °c for 45 sec). negative control dna was extracted from a patient who was confirmed not to have brca mutations. positive control dna was extracted from blood obtained from a confirmed brca 5382insc mutation carrier. both control dnas were confirmed by direct dna sequencing. negative control, positive control, and blank tube without dna (reagent contamination control) were included in each run. statistical analysis descriptive statistics were done as the first step of the statistical analysis. associations of mutations with breast cancer were evaluated by pearson’s χ2 test under dominant model of inheritance, followed by risk assessment using odds ratio and 95% confidence interval (ci) computation. all statistical analyses were performed using stata software version 12.0 for windows (stata corporation, usa). a p-value <0.05 (two-sided) was considered statistically significant. results among 67 patients, we detected 3 cases (4.5%) with the 5382insc brca1mutation (fig.1). among these three patients, 1 patient had multiple primary breast cancers (multiple lesions in one breast) and 2 patients had a family history of breast cancer. in the investigated group of patients, 4 other mutations (brca1 4153dela, brca1 185delag, brca1 300t>g and brca2 6174delt) were not found. none of the mutations were found in the control group. comparative analysis of resulting genotypes between patients and controls showed a significant association between 5382insc mutation and breast cancer (p=0.03, pearson’s χ2 test, dominant model of inheritance). figure.1 allele-specific pcr detection of brca15382insc mutation. a) negative control dna(wild type) dna samples show clear difference between cycle thresholds (delta ct) of amplification of wild-type(1) and mutated alleles(2) upon real-time pcr analysis b) positive control dna 5382insc heterozygote mutation is characterized by simultaneous amplification of both wild-type and mutated alleles. c) 5382insc heterozygote mutation in patient №22 table 2. the frequency of brca1 and brca2 mutations in patients with breast cancer and control group table 3. association between 5382insc mutation and breast cancer (χ2 test, df = 1, dominant model of inheritance). discussion to our knowledge, this is one of the first pilot studies to explore the prevalence of brca mutations in women affected by breast cancer in uzbekistan in comparison with disease free controls. the occurrence of the same 5382insc brca1 mutation in the 3 unrelated patients in tashkent, uzbekistan, may imply http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abdikhakimov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu that this recurrent mutation originated from a common ancestor (founder mutation) and may need to be further investigated in uzbekistan, and possibly central asia. the brca1 mutation 5382insc was originally described as a founder mutation in the ashkenazi jewish population. this mutation has also been detected in 13 different population groups: russian, latvian, ukrainian, czech, slovak, polish, danish, dutch, french, german, italian, greek, brazilian, turkish, and iranian.30,31 previously published microsatellite marker study by hamel indicated that the 5382insc mutation of brca1 gene originated about 1,800 years in northern europe and later spread to the many different populations.30 the presence of brca1 5382insc mutations in uzbekistan is consistent with the historical, archaeological, and genetic evidence of the “hybrid zone” ethnic scenario, which postulate several waves of migration of western caucasoid peoples followed by their integration and hybridization with east asian people.32,33 haplotype analysis would help to determine if 5382insc mutation found in our cohort was ancestrally related to the corresponding mutation found in other populations.22,34 it should be noted that it is quite possible that brca1 5382insc mutations found in uzbek women may have its origins in a jewish founder. the exact number of women in uzbekistan with ashkenazi jewish background is difficult to calculate. the first ashkenazim who came to central asia were merchants of the ancient silk road and there is evidence that the historical exchange between ashkenazim and the far east was not confined to cultural alone, but also extended to the sharing of genes.35 large numbers of jewish migrants moved to the central asian region during the second world war when ashkenazi jews from nazi-occupied countries and the soviet union were evacuated to uzbekistan, but many jewish people moved out of central asia after the break down of soviet union in 1991. it should be noted there are several limitations of this study. first, selection of high-risk breast cancer patients in tashkent and surrounding regions may not have accurately reflected the true prevalence of the brca1mutation in the geographically and ethnically diverse population of uzbekistan. a large-scale multiregional study is needed to evaluate the prevalence of brca mutations on a country-wide scale. the small sample size of this study is another limitation, which we plan to address in our future work. since the annual incidence of breast cancers in uzbekistan in 2010 was 2273 people, the 67 women with breast cancer represent 3% of total annual incidence of breast cancers in uzbekistan. despite the small sample size and detecting only 3 cases with the brca1 5382insc mutation, the present and future contributions of this mutation to the incidence of breast cancer in uzbekistan can be significant due to the so-called "founder" effect. the culture of uzbekistan, which supports early marriage, early reproduction, and large family size, generally supports the spread of "founder" mutations. thus, even in cases of early onset breast cancer (≤35 years old), uzbek women with the brca1 mutation would have already had children; therefore, they would have transmitted the mutation to the next generation. in discussing the importance of testing the offspring of mutation carriers identified in this study and in future research and clinical programs, it is necessary to emphasize the need to test the female as well as the male offspring. oncogenetic testing of male members of the family is reasonable, not only because they are might be carriers of brca mutations and transmit the mutations to their future granddaughters, but also because men who carry the mutated brca1 gene have a four times greater chance of developing prostate cancer than other males.36 knowledge about the mutation status for males may potentially have an impact on the screening and treatment procedures with regard to prostate cancer. it should also be noted that we have studied only a small portion of possible mutations (5382insc, 4153dela, 185delag and 300t> g in the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu brca1 gene, and 6174delt in the brca2 gene) in women with breast cancer in uzbekistan. therefore, sequencing all exons of brca1 and brca2 genes is needed to evaluate the full spectrum of brca1 mutations in uzbekistan. conclusion these pilot results suggest that there may be a potential contribution of brca1 5382insc mutation to breast cancer development in the uzbek population. women with confirmed mutations in the brca1 gene should be referred for a comprehensive medical examination for the early detection of breast and ovarian cancers or recieve preventive medical interventions. diagnosis of genetic predispositions for the development of breast cancer is extremely important, as this knowledge will help to better prepare healthcare systems to organize programs for the prevention of adverse health outcomes associated with these mutations. it is very important to continue research in this area, as more data are needed on 5382insc mutation in women with breast cancer in uzbekistan. acknowledgements we thank committee for coordination science and technology development under the cabinet of ministers of uzbekistan. this project was supported by the uzbekistan state research grant (№adcc-27-5) “development of complex method for breast cancer screening and prevention based on detection of several molecular biomarkers in women of uzbek population”. references 1. youlden dr, cramb sm, dunn na, muller jm, pyke cm, baade pd. the descriptive epidemiology of female breast cancer: an international comparison of screening, incidence, survival and mortality. cancer epidemiol. 2012;36(3):237-248. 2. kurian aw, fish k, shema sj, clarke ca. lifetime risks of specific breast cancer subtypes among women in four racial/ethnic groups. breast cancer res. 2010;12(6):r99. 3. american cancer society. 2016; http://www.cancer.org/research/cancerfactsstati stics/cancerfactsfigures2016/index. accessed december 19, 2016. 4. petrucelli n, daly mb, feldman gl. hereditary breast and ovarian cancer due to mutations in brca1 and brca2. genet med. 2010;12(5):245-259. 5. fackenthal jd, olopade oi. breast cancer risk associated with brca1 and brca2 in diverse populations. nat rev cancer. 2007;7(12):937948. 6. ramus sj, gayther sa. the contribution of brca1 and brca2 to ovarian cancer. mol oncol. 2009;3(2):138-150. 7. janavicius r. founder brca1/2 mutations in the europe: implications for hereditary breastovarian cancer prevention and control. epma j. 2010;1(3):397-412. 8. ferla r, calo v, cascio s, et al. founder mutations in brca1 and brca2 genes. ann oncol. 2007;18 suppl 6:vi93-98. 9. murathodzhaev n, madjidov, wv. dynamics of cancer indicators in uzbekistan over the past decade. rpv. 2005:29. 10. balmana j, diez o, rubio it, cardoso f. brca in breast cancer: esmo clinical practice guidelines. ann oncol. 2011;22 suppl 6:vi31-34. 11. venkitaraman ar. cancer suppression by the chromosome custodians, brca1 and brca2. science. 2014;343(6178):1470-1475. 12. yoshida k, miki y. role of brca1 and brca2 as regulators of dna repair, transcription, and cell cycle in response to dna damage. cancer sci. 2004;95(11):866871. 13. clark as, domchek sm. clinical management of hereditary breast cancer syndromes. j mammary gland biol neoplasia. 2011;16(1):17-25. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2016/index http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2016/index abdikhakimov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu 14. granader ej, dwamena b, carlos rc. mri and mammography surveillance of women at increased risk for breast cancer: recommendations using an evidence-based approach. acad radiol. 2008;15(12):15901595. 15. nelson hd, pappas m, zakher b, mitchell jp, okinaka-hu l, fu r. risk assessment, genetic counseling, and genetic testing for brcarelated cancer in women: a systematic review to update the u.s. preventive services task force recommendation. ann intern med. 2014;160(4):255-266. 16. evans dg ba, anderson e, brain a, shenton a, vasen hf, eccles d, lucassen a, pichert g, hamed h, moller p, maehle l, morrison pj, stoppat-lyonnet d, gregory h, smyth e, niederacher d, nestle-krämling c, campbell j, hopwood p, lalloo f, howell a. risk reducing mastectomy: outcomes in 10 european centres. j med genet. 2009;46:254258. 17. kara nm sm. prophylactic mastectomy and risk-reducing salpingo-oophorectomy in brca1/2 mutation carriers. current breast cancer reports. current breast cancer reports. 2012;4(3):199-206. 18. chompret a, nogues c, stoppa-lyonnet d. [oncogenetic consultation for breast cancer]. presse med. 2007;36(2 pt 2):357-363. 19. kaufman b, shapira-frommer r, schmutzler rk, et al. olaparib monotherapy in patients with advanced cancer and a germline brca1/2 mutation. j clin oncol. 2015;33(3):244-250. 20. lee jm, ledermann ja, kohn ec. parp inhibitors for brca1/2 mutation-associated and brca-like malignancies. ann oncol. 2014;25(1):32-40. 21. byrski t ht, dent r, marczyk e, jasiowka m, gronwald j, jakubowicz j, cybulski c, wisniowski r, godlewski d, lubinski j, narod sa. pathologic complete response to neoadjuvant cisplatin in brca1-positive breast cancer patients. breast cancer res. 2014;147(2):401-405. 22. im km, kirchhoff t, wang x, et al. haplotype structure in ashkenazi jewish brca1 and brca2 mutation carriers. hum genet. 2011;130(5):685-699. 23. world medical association declaration of helsinki: ethical principles for medical research involving human subjects. jama. 2013;310(20):2191-2194. 24. sokolenko ap, mitiushkina nv, buslov kg, et al. high frequency of brca1 5382insc mutation in russian breast cancer patients. eur j cancer. 2006;42(10):1380-1384. 25. sokolenko ap, rozanov me, mitiushkina nv, et al. founder mutations in early-onset, familial and bilateral breast cancer patients from russia. fam cancer. 2007;6(3):281-286. 26. el-said el-debaky f, azab, n, alhusseini, n, eliwa, s, musalam, h. breast cancer gene 1 (brca1) mutation infemale patients with or without family history in qalubia governorate. journal of american science. 2011;7(2):82-93. 27. vinodkumar b, syamala v, abraham ek, balakrishnan r, ankathil r. germline brca1 mutation and survival analysis in familial breast cancer patients in kerala; south india. j exp clin cancer res. 2007;26(3):329-336. 28. vaidyanathan k, lakhotia s, ravishankar hm, tabassum u, mukherjee g, somasundaram k. brca1 and brca2 germline mutation analysis among indian women from south india: identification of four novel mutations and high-frequency occurrence of 185delag mutation. j biosci. 2009;34(3):415-422. 29. yazici h, bitisik o, akisik e, et al. brca1 and brca2 mutations in turkish breast/ovarian families and young breast cancer patients. br j cancer. 2000;83(6):737-742. 30. hamel n, feng bj, foretova l, et al. on the origin and diffusion of brca1 c.5266dupc (5382insc) in european populations. eur j hum genet. 2011;19(3):300-306. 31. kooshyar mm, nassiri m, mahdavi m, doosti m, parizadeh a. identification of germline brca1 mutations among breast cancer families in northeastern iran. asian pac j cancer prev. 2013;14(7):4339-4345. 32. devor e, abdurakhmonov, i, zlojutro, m, millis, mp, galbraith, jj, crawford, mh, shermatov, s, buriev, z, abdukarimov, a. gene flow at the crossroads of humanity: http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu mtdna sequence diversity and alu insertion polymorphism frequencies in uzbekistan. . the open genomics journal. 2009;2:1-11. 33. irwin ja, ikramov a, saunier j, et al. the mtdna composition of uzbekistan: a microcosm of central asian patterns. int j legal med. 2010;124(3):195-204. 34. makriyianni i, hamel n, ward s, foulkes wd, graw s. brca1:185delag found in the san luis valley probably originated in a jewish founder. j med genet. 2005;42(5):e27. 35. tian jy, wang hw, li yc, et al. a genetic contribution from the far east into ashkenazi jews via the ancient silk road. sci rep. 2015;5:8377. 36. leongamornlert d, mahmud n, tymrakiewicz m, et al. germline brca1 mutations increase prostate cancer risk. br j cancer. 2012;106(10):1697-1701. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abdikhakimov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu table 1.oligonucleotide primers used in the study mutation primer sequence brca1 5382insc common wt mut 5'-agaacctgtgtgaaagtatctagcactg-3' 5'-aagcgagcaagagaattccag-3' 5'-agcgagcaagagaattccca-3' brca1 4153dela common wt mut 5'-gactgcaaatacaaacaccca-3' 5'-agcccgttcctctttcttc-3' 5'-agcccgttcctctttctca-3' brca1 185delag common wt mut 5'-cagttaaggaaatcagcaattacaatagc-3' 5'-gctatgcagaaaatcttagagtgtcc-3' 5'-atgctatgcagaaaatcttagtgtcc-3' brca1 300t>g common wt mut 5'-attatcttttcatggctatttg-3' 5'-tatatcattcttacataaaggaa-3' 5'-tatatcattcttacataaaggac-3' brca2 6174delt common wt mut 5'-cataaccaaaatatgtctggattggag-3' 5'-ctgatacctggacagattttccac-3' 5'-cctggacagattttcccttgc-3' http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu figure.1 allele-specific pcr detection of brca1 5382insc mutation. a) negative control dna(wild type) dna samples show clear difference between cycle thresholds (delta ct) of amplification of wild-type(1) and mutated alleles(2) upon real-time pcr analysis b) positive control dna– 5382insc heterozygote mutation is characterized by simultaneous amplification of both wild-type and mutated alleles. c) 5382insc heterozygote mutation in patient №22 a b c http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abdikhakimov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu table 2. the frequency of brca1 and brca2 mutations in patients with breast cancer and control group gene mutation breast cancer patients control group (n=103) brca1 5382insc 3(4.5%) 0(0%) 4153dela 0(0%) 0(0%) 185delag 0(0%) 0(0%) 300t>g 0(0%) 0(0%) brca2 6174delt 0(0%) 0(0%) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.228|http://cajgh.pitt.edu table 3. association between 5382insc mutation and breast cancer (χ2 test, df = 1, dominant model of inheritance). genotypes cases controls χ2 p or n = 67 n = 103 value 95% ci wt/wt 0.955 1.000 4.69 0.03 0.09 0.00 – 1.75 wt/5382insc+ 5382insc/5382insc 0.045 1.000 11.23 0.57 – 221.04 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx the potential contribution of brca mutations to early onset and familial breast cancer in uzbekistan abstract keywords: brca1, brca2, founder mutation, real-time pcr, breast cancer, uzbek population the potential contribution of brca mutations to early onset and familial breast cancer in uzbekistan research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. social determinants of maternal health in afghanistan: a review said ahmad maisam najafizada1, ivy lynn bourgeault2, ronald labonté3 1division of community health and humanities, faculty of medicine, memorial university of newfoundland, canada; 2telfer school of management, university of ottawa, canada; 3school of epidemiology, public health and preventive medicine, university of ottawa, canada vol. 6, no. 1 (2017) | issn 2166-7403 (online) doi 10.5195/cajgh.2017.240 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ http://www.sciencedirect.com/science/article/pii/s0149718916301641 najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu abstract introduction: afghanistan has a high maternal mortality rate of 400 per 100,000 live births. although direct causes of maternal morbidity and mortality in afghanistan include hemorrhage, obstructed labor, infection, high blood pressure, and unsafe abortion, the high burden of diseases responsible for maternal mortality arises in large part due to social determinants of health. the focus of this literature review is to examine the impact of various social determinants of health on maternal health in afghanistan, filling an important gap in the existing literature. methods: this narrative review was conducted using arksey and o’malley’s framework of (1) defining the question, (2) searching the literature, (3) assessing the studies, (4) synthesizing selected evidence in context, and (5) summarizing potential programmatic implication of the context. we searched medline, cabi global health database, and google scholar for relevant publications. results: a total of 38 articles/reports were included in this review. we found that social determinants such as maternal education, sociocultural practices, and social infrastructure have a significant impact on maternal health. health care may be the immediate determinant, but it is influenced by other determinants that must be addressed in order to alleviate the burden on health care, as well as to achieve long-term reduction in maternal mortality. conclusion: because of the importance of social factors for maternal health outcomes, committed involvement of multiple government sectors (i.e. education, labor and social affairs, information and culture, transport and rural development among others, alongside health care) is the long-term solution to the maternal health problems in afghanistan. national and international organizations’ long-term commitment to social investment such as education, local economy, cultural change, and social infrastructure is recommended for afghanstan and globally. keywords: maternal health, afghanistan, healthcare utilization, review social determinants of maternal health in afghanistan: a review said ahmad maisam najafizada1, ivy lynn bourgeault2, ronald labonté3 1division of community health and humanities, faculty of medicine, memorial university of newfoundland, canada; 2telfer school of management, university of ottawa, canada; 3school of epidemiology, public health and preventive medicine, university of ottawa, canada research afghanistan has a high maternal mortality of 400 per 100,000 live births, compared to 320 regionally and 280 globally.1 while the maternal mortality rate has decreased dramatically since 20002, there is still a significant burden of maternal morbidity and mortality in afghanistan mainly attributed to hemorrhage, obstructed labor, infection, high blood pressure, and unsafe abortions3. marmot describes the high burden of disease responsible for premature loss of life arising primarily from the conditions in which people are born, grow, live, work, and age.4 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.sciencedirect.com/science/article/pii/s0149718916301641 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu the social determinants of health refer to the societal factors and the unequal distribution of these factors that contribute to the overall health of the population and health inequalities. there is compelling evidence that social injustice, including inequity in social conditions, distrubition of resources, power, and opportunities, takes a massive toll on health of the population of this region, especially for women.4,5 afghanistan is struggling to build an efficient, self-reliant, and sustainable health care system. international organizations such as usaid, world bank, and the european commission are the main donors contributing to the health care system development, with national and international non-governmental organizations providing health care services. other organizations, such as canadian international development agency (cida), the uk’s department for international development (dfid), german department for international cooperation (giz) and other international development agencies help to strengthen the health care system. the afghan ministry of public health plays a stewardship role and is the only organization that most people consider to be responsible for maintaining the general health of the population. the primary health care services provided for the afghan population are delivered through the basic package of health services (bphs). the primary health care is linked to the tertiary services also known as the essential package of hospital services (ephs). the bphs is designed to focus on maternal and newborn health, child health and immunization, public nutrition, communicable diseases, mental health and disability, and the supply of essential drugs. maternal care provided in this package includes antenatal, delivery and postpartum care, family planning, and care for the newborn.6 however, utilization of these services is variable and inconsistent among afghan women7. in general, health care systems are focused on treating and preventing populationbased diseases; however, the comprehensive population health approach intervention takes into account social determinants of health, such as education, income, gender, housing, socioeconomic status, etc. availability of health care services often does not guarantee their utilization. improvement in socioeconomic factors, sociocultural beliefs, and education level has a great poteintal to improve utilization of health services. the level and the pathway of impact of the social determinants of health also differ depending on geographical and geopolitical regions. the aim of this literature review is to examine the impact of various social determinants of health on maternal health in afghanistan, filling an important gap in the existing literature, and to identify the social determinants that influence maternal health, in http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu order to inform policy and programs that target maternal health in afghanistan. methods review process this review was conducted using arksey and o’malley’s framework of (1) defining the question, (2) searching the literature, (3) assessing the studies, (4) synthesizing selected evidence in context, and (5) summarizing potential programmatic implication of the context.8 based on a preliminary literature search of maternal health in afghanistan and social determinants of health, the reviewers developed and then refined the research question. keywords utilized in this research included “maternal health”, “maternal health services”, “maternal mortality”, “women’s health”, “pregnancy”, “pregnancy complications”, “afghanistan”, “health care”, “social determinants of health”, “sociocultural”, “social and cultural factors”, and “socioeconomic factors”. data sources a primary search of the medline database identified 78 relevant citation titles, sociological abstract database identified 8 articles, cabi global health database identified 30 articles, and nursing and allied health database identified 9. overall, 125 citations were reviewed for this research. google scholar was also searched for published articles. after a process of identification and screening of citations identified, 38 article/reports met the inclusion criteria and were included in the review (figure 1). all of the articles were published in academic journals and 32 articles had abstracts. figure 1: flow chart of the review inclusion and exclusion criteria the following inclusion criteria were used: articles and reports on maternal health in afghanistan, articles discussing social determinants of maternal health, reports published between 2000 and 2016, articles and reports written in english, and quantitative and 125 potentially relavant articles extracted from medline, social abstract, cabi global health, nursing and allied health databases 51 articles retrieved for further assessment 15 articles excluded on the basis of full text review 38 articles included in the review 2 articles identified from references of the reviewed article 74 articles excluded on the basis of relevance of title and abstract http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu qualitative studies. articles were excluded according to the following criteria: articles and reports with main focus other than afghanistan, articles and reports with main focus other than maternal health in afghanistan, articles focused on refugees, articles published before 2000 or after 2016, and articles not in english. results articles reviewed in this study included: cross-sectional studies, cluster surveys, study design number of articles observational study household survey (retrospective cohort study, multiple indicator cluster survey) 8 cross-sectional survey 3 administrative data base study (labour and delivery logbook, operating room logbook) 2 case study 3 descriptive survey, 1 needs assessment survey 1 questionnaire/interview/observation 1 baseline and endline survey 1 subtotal 20 experimental study nonrandomized experimental control design 2 community based intervention 1 knowledge-attitude-practice survey 1 subtotal 4 others perspective and observation 6 editorial 4 world report 2 literature review 1 conference proceeding 1 subtotal 14 total 38 table 1: designs of studies and reports http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu facility-based surveillance systems, nonrandomized experimental control designs, and observational and qualitative studies (tables 1 and 2). the most important social determinants identified in this research included health care, education, employment and income, sociocultural practices, food and sanitation. health care healthcare factors were identified as the major determinant in the reviewed studies. accessibility, lack of healthcare professionals, and variability in the utilization of health care services were major problems for afghan women. in a study of maternal mortality conducted in western afghanistan before the start of the bphs program, amowitz et al. found that only 63% of the health facilities listed by who as functional were in operation.9 all health facilities with emergency obstetric centers were located in one district, which was not accessible by women in any of the rural districts. in a reproductive-health knowledge, attitudes, and practices (kap) survey in the capital kabul, egmond et al. found that 18.2% of the population thought the health facility was too far away and 14.2% reported that transportation to the medical facility was a problem.10 the situation was even worse for women residing in the rural areas. in 2002, amowitz et al. found that seven districts of herat province namely adraskan, pashtun zarghon, zendajan, enjil, karokh, herat, and guzarah had only one or two physicians.9 later studies found that the caesarean section (cs) rate was 10% in kabul maternity hospital, and 3.5% in general hospitals,11,12 demonstrating wide variation in the utilization of this life-saving operation. in 2010, in a nonrandomized experimental control study to test the safety, acceptability, feasibility, and effectiveness of community-based education and distribution of misoprostol for prevention of postpartum hemorrhage at home birth, only 16% of women in the intervention group and 21% of women in the comparison group received prenatal care from a midwife.13 lack of human and technical resources were the major reported reasons associated with adverse maternal and infant health outcomes in the poor-resource setting of afghanistan.14–16 the findings of the studies conducted between 2001 and 2011 that there is a need to improve health facilities, and to increase the number of professionals in both urban and rural areas in order to improve maternal health.17–26 published research suggests that the provision of expanded health services alone would not lead to the increased utilization of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu articles design social determinants 1. ahmed, edward, & burnham, 2004 *obs: multiple indicator cluster survey education; sanitation (water and latrine); health care; sociocultural practices 2. amowtiz & iacopino, 2000 perspective health care; sociocultural practices 3. amowitz, ris, & iacopino, 2002 obs: cross-sectional survey food; housing; sanitation (lack of clean water); sociocultural practices 4. ayotte, 2002 perspective sociocultural practices 5. bartlett et al., 2005 obs: household survey health care; education; housing; food 6. bick, 2007 editorial health care 7. bristol, 2006 world report health care 8. brown, 2010 perspective health care 9. currie, azfar & fowler, 2007 case study health care (human resources for health: midwives) 10. del valle, 2004 perspective sociocultural practices 11. stephenson, 2004 editorial health care (hrh) 12. egmond et al., 2004 **exp: kap health care; education 13. garwood, 2006 perspective health care; transport 14. guidotti et al., 2009 obs: administrative database health care 15. gupta et al., 2011 obs: multiple indicator survey health care; education; food 16. hadi et al., 2007 obs: cross-sectional approach education; income/employment; health care 17. hadi et al., 2007 obs: descriptive survey health care 18. huber, saeedi & samadi, 2010 exp: community-based intervention health care; sociocultural practices 19. hussein et al., 2009 obs: cross-sectional health care; sociocultural http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu practices 20. kaartinen & diwan, 2002 obs: needs assessment survey health care; sociocultural practices 21. kandasamy et al., 2009 obs: administrative logbooks health care 22. khorrami et al., 2008 obs: needs assessment survey health care; transport; income 23. mayhew, 2009 perspective health care 24. mayhew et al., 2008 obs: cross-sectional health care; education; income; transport 25. sanghvi et al., 2010 exp: nonrandomized experimental control design health care 26. smith & burnham, 2005 perspective health care; sociocultural practices 27. smith et al., 2008 obs: case study health care; education 28. walraven et al., 2009 perspective health care 29. walsh, 2007 perspective health care 30. williams & mccarthy, 2003 perspective health care 31. wilson, 2011 perspective health care; sociocultural practices 32. rahmani et al., 2015 exp: multiple indicator regression health care; sociocultural practices 33. akseer et al., 2016 exp: household survey analysis health care; sociocultural practices; education 34. rasooly et al., 2014 exp: household survey analysis health care; sociocultural practices, education; income 35. shahram et al., 2015 exp: household survey analysis health care; sociocultural practices; education; income 36. newcomer, 2014 perspective sociocultural practices; education; income http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu 37. tappis et al., 2016 exp: cross-sectional analysis health care; income 38. speakman et al., 2014 case study health care; education *obs = observational **exp = experimental table 2 design of articles and social determinants discussed in the papers antenatal care,19,27 as some women were more likely to use services than others, depending on their education, family income, social status, and beliefs. a national cross-sectional study by mayhew et al. in 2008 found that only 13% of women who gave birth two years prior to the study had a skilled birth attendant at the time of delivery.16 at the same time, access to basic health care (within a two-hour walk) was estimated to be nearly 85%.28 this demonstrates that despite availability of services, utilization of these services remains low, possibly due to low level of education.29,30 in northern afghanistan, (balkh province), hadi et al. found that utilization of antenatal care remained low, mainly due to significant accessibility-related problems.29 their study concluded that inaccessibility, illiteracy, poverty, and involvement of pregnant women in economic activities (farm work) were major barriers to the use of antenatal care. haidi et al. concluded that the health status of the population could not be improved further without fundamental changes in education, income, and quality of life.29 education education was another major determinant of maternal health in afghanistan identified in this review. our review of the literature found that education level has been associated with improved health care utilization, increased birth spacing, and empowered women. 3,10,31–33 bartlett et al. found that 93% of women who died due to maternity-related causes were illiterate. 3 ahmed et al. reported that in western afghanistan less than 5% of pregnant women had ever attended school. 31 egmond et al. found that in the capital city of kabul that 64% of the women participating in the reproductive health survey never attended a regular school, and 62% were illiterate.10 a study by khorrami and his colleagues found that higher levels of education were associated with lower rates of hemorrhagic complications during pregnancy.34 on the other hand, studies have found that years of schooling had a significant positive influence on the level of health services a woman would receive, birth http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu spacing, family planning, and their overall health.10,16,29,34,35 studies found that educated women recognize emergency obstetric complications and seek medical care immediately34, receive antenatal care, use skilled birth attendants, use contraceptives10,16,35, and have lower rates of adolescent pregnancies.10 women’s education, irrespective of other socioeconomic factors, had positive contribution to improved reproductive health.10 sociocultural practices patriarchal societal practices such as early marriage, rights surrounding sexual practices, and need to obtain husband’s permission to receive health care, all have large impact on women’s health in afghanistan.15,27,32,36–39 one study in the capital city revealed the mean age at marriage was 17.2 years with 16% married at age 14 or younger.10 another study in rural western afghanistan found that 47% of women became pregnant before the age of sixteen.31 two studies revealed that 83% and 75% of women respectively, expressed the view that it was a wife’s duty/obligation to have sex with her husband even when she did not want to have sex.9,10 in the same study, 93% of women said that they needed authorization from their husband or a male relative to seek professional health care.10 in addition, published studies reported that that around half of the female respondents (45% and 56% respectively) reported that it was the right of a husband to beat his wife when she disobeys.9,10 these factors are strongly linked to the traditional attitudes that prevail in afghan society, where reproduction remains the predominant role for women. 10,40–42 employment and income there is no published evidence about the link between women’s formal employment and their health status, which may be related to the low employment level among women in afghanistan. published evidence suggests a correlation between the husband’s employment, household income, the woman’s economic activity, and the woman’s health. egmond et al. found a significant association between the husband’s “qualified regular job” and use of family planning, antenatal care, and the woman’s delivery at a health care institution in kabul.10 qualified regular job was defined as employment in a government or non-government organization for men with post-secondary education. however, they did not find any association between the husbands’ general employment and the woman’s health.10 various studies found a positive association between household income/wealth and women’s health care utilization.10,16,29 egmond et al. suggsted that the high cost of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu birth in a health care facility was a reason for women not using health care services.10 mayhew et al. found that wealth was the strongest determinant of skilled birth attendant use.16 women in the poorest quantile had lower odds of skilled birth attendant use compared to women in each of the other quintiles; the strength of the association increased with each wealth quintile.16 while the health system is designed to accomodate the low income population, even a small fee for health care or drugs can prevent the low income population segment from accessing health care specialists. a study by hadi et al., which was carried out in rural areas, showed the association between women’s economic activity and their health.29 the study conducted in northern balkh province indicated that in rural areas, economically active women are much less likely to access antenatal care services compared to noneconomically active women. 29 the relationship is the opposite in the urban areas, where economically active women are slightly more likely to access antenatal care services.29 it probably implies that women participating in farming, agriculture, or cattle-raising do not have control over the income generated from these activities. education played an important role in health care utilization among economically active women. hadi et al. found that in rural areas, among women with at least six years of schooling, those who were economically active were more likely to use antenatal care services.29 also, among women with little or no education, economic activity was an impediment to the use of antenatal care services. therefore, the combination of low education, rural residence, and the need to work outside the home meant that these women were much less likely to use antenatal care services than were those who were not economically active.29 sanitation and food lack of food, clean water, and latrines were identified as primary problems for the population in various studies. 9,10,16,31,43 in a study in western afghanistan in 2002, protected water sources and appropriate control of feces were lacking in districts under investigation.9 latrines were used by 85.1% of households in karokh and 28.4% in chesht-esharif.31 the most common type of latrine was the open-back latrine from which night soil is removed for fertilization of crops. the main alternative to this type of latrine was using an open field.31 in a survey, women participants identified their primary problems such as lack http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu figure 2. pathways through which determinants influence maternal health of food (41%), shelter (18%), and clean water (14%).9 lack of food (malnutrition with subsequent anemia) contributes to the increased risk of complications among pregnant women.9 though some improvement has been made in the first decade of 21st century, 63% of the population have no access to improved toilet facilities in 2010 and 50% were without improved water sources.44 discussion the literature on maternal health in afghanistan reveals that health care, education, sociocultural practices, employment, income, food, and sanitation are important determinants for maternal health. almost every article focusing on maternal health in afghanistan points to the lack of women’s decision-making ability in regards to their marriage, contraceptive use, family planning, birth spacing, and seeking health care. they are all linked to lower levels of education for women, patriarchal traditions, and weak social infrastructure and services in the country. a study in pakistan by agha and carton found that education was the most important predictor of women’s institutional delivery.45 education was linked with better maternal health in other rural settings of lowincome countries such as pakistan, india, laos, and malawi.45–48 women’s education levels demonstrated a significant association http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu figure 3. factors negatively (left side) and positively (right side) influencing maternal health in afghanistan with health care utilization, lower fertility rate, family planning, and improved maternal health. in general, better education decreases unhealthy social practices such as early childhood marriage and adolescent pregnancy. in addition to education, access to primary health care has also been a significant determinant, but the ability to access primary care does not help to address the underlying problems. quantitative and qualitative studies have established that health care services, although increased in numbers, lack quality.9,10,16 there are buildings for clinics, but no doctors or midwives; there are ambulances, but no fuel; there is hightechnology equipment, but not the skills to operate them.49 mayhew argues that there is a need for large-scale implementation of lowtechnology, simple solutions in rural areas where the majority of people live. “defining reality and maintaining simplicity are too often maternal health health care • health care access • health care utilisation • health care quality sociocultural practices • early marriage & adolescent pregnancy • absence of women's right to (reproductive) health • husband's physical abuse • women's internalisation of patriarchal values education • low women's education level • low men's education level income/employment • low household income/wealth • illiterate women's economic activity water/food/sanitation • lack of clean water • unbalanced diet (anaemia during pregnancy & complication of pregnancy • poor sanitation education • mandatory secondary education (until 12th grade) • health related education • woman’s right related education sociocultural practices • criminalisation of marriage below 18 • promoting women’s rights through mass communication campaigns s social services • improved health care access and quality • provision of clean water and sanitation • creating job opportunities http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu forgotten prerequisites for success in such a challenging environment”. 50 the notion that social determinants impact maternal health is well established in the literature.51 studies included in this review suggest that health determinants in afghanistan have either direct impact on maternal health or are mediated by other determinants (figures 2 and 3). health care services including health promotion, disease preventon, treatment facilities, and presence of skilled health personnel have a direct impact on maternal health. 9,10,13,27,30,52,53 studies also documented the direct health effects of local sociocultural practices such as childhood marriage and pregnancy, unwanted sexual activity, physical abuse, and the need to obtain permission to access health services.10,32,38,52 undesirable social conditions such as lack of proper shelter, lack of potable water, and poor waste management definitely impacts maternal health.9,10,29,31 women’s education, on the other hand, improves the social status of women in the family and alters the undesirable and healthdeteriorating sociocultural practices, and thus improves maternal health.3,29–31,34 improved transportation systems such as paved roads and availability of emergency vehicles, for example, provide access to health services, improves health service utilization, and subsequently improves maternal health.10,30 employment, income, and wealth also influence health through access to the health care and through the intersection with education.10,30,54 studies in other developing countries support our findings that social determinants such as education, economic status, sociocultural practices, and weak infrastructure are strongly associated with maternal health.55 however, we attempted to explain the pathways by which these individual determinants intersect and impact maternal health. we believe that individual determinants cannot explain the complexity of maternal health; therefore, a web of correlations between the determinants makes the impact greater compared to the sum of all of the determinants. thus, we suggest that interventions that are targeted to improve maternal health should be comprehensive. improving maternal health is such a complex task that the ministry of public health alone cannot handle it. other governmental and nongovernmental sectors (educational organizations, labor and social services, cultural organizations, and mass media organizations) need to recognize their vital role in improving maternal health, and take appropriate policy level actions to address it. aside from programmed approaches to address immediate maternal health challenges (such as obstetric care, access to skilled birth http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu attendant, antenatal and post-natal care) in the health sector, we propose three other recommendations. first, women’s education should become a cornerstone of maternal health. the literature review suggested that higher level of schooling increases the age of marriage, improves woman’s control over her reproductive health, health care utilization, and overall health. at the policy level, the ministry of education and higher education should recognize the significance of education and work collaboratively with the ministry of public health to encourage eduation of women and girls. second, gender specific initiatives have proven to be very useful in improving women’s health. the afghan ministry of public health’s strategy of deploying female health workers to remote areas to help increase acceptance and utilization of health care among women proved to be effective in secure areas.7 recruiting more female teachers in the schools resulted in higher attendance by female students.56 najafizada found that the presence of female physicians on television health shows leads to an increased number of female callers responding to the show, ultimately resulting in an increased coverage time for topics related to women’s health.57 however, involvement of men in promoting women’s rights is also necessary, as true empowerment takes place only when both men and women believe in the capacities of women as equitable to those of men. finally, without improved social infrastructure such as provision of clean water and sanitation and work opportunities for women, further improvements in maternal health will be difficult to achieveremain a dream. weak social infrastructure is a wellrecognized barrier to health protection and promotion for the entire population in afghanistan. one of the limitations of this review was its inability to include all relevant studies due to limited database selection, exclusion of grey literature, and exclusion of articles published in languages other than english. the goal of this review was to capture the breadth of the available literature, thus allowing for the inclusion of multiand cross-discliplinary articles. using these findings as a starting point, future studies can focus on more indepth analyses of each individual health determinant important for maternal health. references 1. who. afghanistan: who statistical profile.; 2015. http://www.who.int/gho/countries/afg.p df?ua=1. 2. bartlett l a, mawji s, whitehead s, et al. where giving birth is a forecast of death: maternal mortality in four districts of afghanistan, 1999-2002. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu lancet. 2005;365(9462):864-870. doi:10.1016/s0140-6736(05)71044-8. 3. bartlett la, mawji s, whitehead s, et al. where giving birth is a forecast of death: maternal mortality in four districts of afghanistan, 1999-2002. afghanistan ammst, ed. lancet (british ed. 2005;365(9462):864-870. doi:10.1016/s0140-6736(05)71044-8. 4. marmot m. closing the gap in a generation: health equity through action on the social determinants of health. geneva: commission on social determinants of health; 2008. doi:10.1080/17441692.2010.514617. 5. wilkinsn r, marmot m. social determinants of health: the solid facts. (europe ro for, denmark., eds.). world health organization; 2003. 6. health m of p. islamic republic of afghanistan ministry of public health islamic republic of afghanistan ministry of public health. 2010;(july). 7. ameli o, newbrander w. contracting for health services: effects of utilization and quality on the costs of the basic package of health services in afghanistan. bull world health organ. 2008;86(12):920-928. doi:10.2471/blt.08.053108. 8. arksey h, o’malley l. scoping studies: towards a methodological framework. int j soc res methodol. 2005;8(1):1932. doi:10.1017/cbo9781107415324.004. 9. amowitz ll, reis c, iacopino v. maternal mortality in herat province, afghanistan, in 2002: an indicator of women’s human rights. jama, j am med assoc. 2002;288(10):1284-1291. doi:10.1001/jama.288.10.1284. 10. egmond k, bosmans m, naeem a, claeys p, verstraelen h, temmerman m. reproductive health in afghanistan: results of a knowledge, attitudes and practices survey among afghan women in kabul. . disaster. 2004;28(3):269-282. 11. guidotti rj, kandasamy t, betrán ap, et al. monitoring perinatal outcomes in hospitals in kabul, afghanistan: the first step of a quality assurance process. j matern fetal neonatal med. 2009;22(4):285-292. doi:10.1080/14767050802464510. 12. kandasamy t, merialdi m, guidotti rj, et al. cesarean delivery surveillance system at a maternity hospital in kabul, afghanistan. int j gynaecol obstet. 2009;104(1):14-17. doi:10.1016/j.ijgo.2008.08.024. 13. sanghvi h, ansari n, prata nj v, gibson h, ehsan at, smith jm. prevention of postpartum hemorrhage at http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu home birth in afghanistan. int j gynaecol obstet. 2010;108(3):276-281. doi:10.1016/j.ijgo.2009.12.003. 14. bick d. the importance of midwifery to maternal and infant health in afghanistan: midwives making a difference. midwifery. 2007;23(3):219220. doi:10.1016/j.midw.2007.07.002. 15. huber d, saeedi n, samadi ak. achieving success with family planning in rural afghanistan. bull world health organ. 2010;88(3):227-231. doi:10.2471/blt.08.059410. 16. mayhew m, hansen pm, peters dh, et al. determinants of skilled birth attendant utilization in afghanistan: a cross-sectional study. am j public health. 2008;98(10):1849-1856. doi:10.2105/ajph.2007.123471. 17. bristol n. reconstructing afghanistan’s health system. lancet. 2006;366(9503):2075-2076. doi:10.1016/s0140-6736(05)67871-3. 18. brown g. a day in the life. j am acad physician assist. 2010;23(6):15-16. 19. tappis h, koblinsky m, doocy s, warren n, peters dh. bypassing primary care facilities for childbirth: findings from a multilevel analysis of skilled birth attendance determinants in afghanistan. j midwifery women’s heal. 2016;61(2):185-195. doi:10.1111/jmwh.12359. 20. kaartinen l, diwan v. mother and child health care in kabul, afghanistan with focus on the mother: women’s own perspective. acta obstet gynecol scand. 2002;81(6):491-501. doi:10.1034/j.16000412.2002.810604.x. 21. stephenson p. midwives for afghanistan. safe mother. 2004;31:4. 22. williams jl, mccarthy b. observations from a maternal and infant hospital in kabul, afghanistan--2003. j midwifery womens health. 2005;50(4):e31-5. doi:10.1016/j.jmwh.2005.02.009. 23. walsh d. afghanistan’s midwives tackle maternal and infant health. lancet. 2007;370:1299. 24. walraven g, manaseki-holland s, hussain a, tomaro jb. improving maternal and child health in difficult environments: the case for “crossborder” health care. plos med. 2009;6(1):e5. doi:10.1371/journal.pmed.1000005. 25. faso b, caisses r. payment to a pre payment system , whether you use. 2006;84(november):845-847. 26. bartlett l a, dalil s, salama p, mawji s, whitehead s. conceiving and dying in afghanistan. lancet. 2005;365(9476):2006. doi:10.1016/s0140-6736(05)66692-5. 27. hirose a, borchert m, niksear h, et al. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu difficulties leaving home: a crosssectional study of delays in seeking emergency obstetric care in herat, afghanistan. soc sci med. 2011;73(7):1003-1013. doi:10.1016/j.socscimed.2011.07.011. 28. acerra jr, iskyan k, qureshi za, sharma rk. rebuilding the health care system in afghanistan: an overview of primary care and emergency services. int j emerg med. 2009;2(2):77-82. doi:10.1007/s12245-009-0106-y. 29. hadi a, mujaddidi mn, rahman t, ahmed j. the inaccessibility and utilization of antenatal health-care services in balkh province of afghanistan. asia-pacific popul j. 2007;22(1):29-42. 30. shahram ms, hamajima n, reyer ja. factors affecting maternal healthcare utilization in afghanistan: secondary analysis of afghanistan health survey 2012. nagoya j med sci. 2015;77(4):595-607. http://www.pubmedcentral.nih.gov/artic lerender.fcgi?artid=4664591&tool=pmc entrez&rendertype=abstract. 31. ahmed a, edward a, burnham g. health indicators for mothers and children in rural herat province, afghanistan. prehosp disaster med. 2004;19(3):221-225. 32. newcomer j. maternal mortality in afghanistan : an emerging cultural complexity maternal mortality in afghanistan : an emerging cultural complexity. j student nurs res. 2014;3(1). 33. smith jm, currie s, azfar p, rahmanzai aj. establishment of an accreditation system for midwifery education in afghanistan: maintaining quality during national expansion. public health. 2008;122(6):558-567. doi:10.1016/j.puhe.2008.03.009. 34. khorrami h, karzai f, macri cj, amir a, laube d. maternal healthcare needs assessment survey at rabia balkhi hospital in kabul, afghanistan. int j gynecol obstet. 2008;101(3):259-263. doi:10.1016/j.ijgo.2007.11.022. 35. rahmani am, wade b, riley w. evaluating the impact a proposed family planning model would have on maternal and infant mortality in afghanistan. int j health plann manage. 2015;30(1):71-85. doi:10.1002/hpm.2206. 36. amowitz l, iacopino v. women’s health and human rights needs. lancet. 2000;356:s65. doi:10.1016/s01406736(00)92052-x. 37. hussein j, newlands d, d’ambruoso l, thaver i, talukder r, besana g. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu identifying practices and ideas to improve the implementation of maternal mortality reduction programmes: findings from five south asian countries. bjog. 2010;117(3):304-313. doi:10.1111/j.1471-0528.2009.02457.x. 38. raj a, gomez cs, silverman jg. multisectorial afghan perspectives on girl child marriage: foundations for change do exist in afghanistan. violence against women. 2014;20(12):1489-1505. doi:10.1177/1077801211403288. 39. wilson c. a “boots on the ground” perspective of caring for the women and children in afghanistan. j obstet gynecol neonatal nurs. 2011;40(3):255-261. doi:10.1111/j.1552-6909.2011.01251.x. 40. ayotte b. women ’ s health and human rights in afghanistan : continuing challenges. j ambul care manage. 2002;25(2):75-77. 41. currie s, azfar p, fowler rc. a bold new beginning for midwifery in afghanistan. midwifery. 2007;23(3):226-234. doi:10.1016/j.midw.2007.07.003. 42. hadi a, rahman t, khuram d, ahmed j, alam a. raising institutional delivery in war-torn communities: experience of brac in afghanistan. asia pac fam med. 2007;6(1):51. 43. gupta s, shuaib m, becker s, rahman mm, peters dh. multiple indicator cluster survey 2003 in afghanistan: outdated sampling frame and the effect of sampling weights on estimates of maternal and child health coverage. j heal popul nutr. 2011;29(4):388-399. doi:10.3329/jhpn.v29i4.8456. 44. requejo j, bryce j, victora c. countdown to 2015: maternal, newborn & child survival. building a future for women and children. world health organization and unicef; 2012. 45. agha s, carton tw. determinants of institutional delivery in rural jhang, pakistan. int j equity health. 2011;10(1):31. doi:10.1186/1475-927610-31. 46. kitui j, lewis s, davey g. factors influencing place of delivery for women in kenya: an analysis of the kenya demographic and health survey, 2008/2009. bmc pregnancy childbirth. 2013;13(1):40. doi:10.1186/1471-239313-40. 47. nair m, ariana p, webster p. what influences the decision to undergo institutional delivery by skilled birth attendants? a cohort study in rural andhra pradesh, india. rural remote health. 2012;12:2311. http://www.ncbi.nlm.nih.gov/pubmed/2 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx najafizada this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.240|http://cajgh.pitt.edu 3148477. 48. palamuleni m. determinants of noninstitutional deliveries in malawi. malawi med j. 2011;23(4):104-108. http://www.ncbi.nlm.nih.gov/pubmed/2 3451561. 49. tappis h, koblinsky m, winch pj, turkmani s, bartlett l. context matters: successes and challenges of intrapartum care scale-up in four districts of afghanistan. glob public health. 2016;11(4):387-406. doi:10.1080/17441692.2015.1114657. 50. mayhew m. salon shame and simplicity in afghanistan. can med assoc j. 2009;180(8):896. 51. marmot m. social determinants of health inequalities. lancet. 2005;365:1099-1104. 52. hirose a, borchert m, niksear h, alkozai as, gardiner j, filippi v. the role of care-seeking delays in intrauterine fetal deaths among “nearmiss” women in herat, afghanistan. paediatr perinat epidemiol. 2012;26(5):388-397. doi:10.1111/j.1365-3016.2012.01299.x. 53. hirose a, borchert m, cox j, alkozai as, filippi v. determinants of delays in travelling to an emergency obstetric care facility in herat, afghanistan: an analysis of cross-sectional survey data and spatial modelling. bmc pregnancy childbirth. 2015;15(14):(5 february 2015). 54. akseer n, salehi as, hossain smm, et al. achieving maternal and child health gains in afghanistan: a countdown to 2015 country case study. lancet glob heal. 2016;4(6):e395-e413. doi:10.1016/s2214-109x(16)30002-x. 55. ahmed s, creanga aa, gillespie dg, tsui ao. economic status, education and empowerment: implications for maternal health service utilization in developing countries. plos one. 2010;5(6). doi:10.1371/journal.pone.0011190. 56. valle h del. beyond the burqa : addressing the causes of maternal mortality in afghanistan. fmr.:10-12. 57. najafizada sam. health content of afghan media. univ ottawa. 2011;(august). http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx social determinants of maternal health in afghanistan: a review abstract keywords: maternal health, afghanistan, healthcare utilization, review social determinants of maternal health in afghanistan: a review research figure 3. factors negatively (left side) and positively (right side) influencing maternal health in afghanistan cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. pth gene polymorphism and breast cancer risk in kazakhstan nurgul sikhayeva1, zhannur abilova2, ivan shtefanov3, abai makishev3, ainur akilzhanova2 1national center for biotechnology, astana, kazakhstan; 2center for life sciences, astana, kazakhstan; 3department of oncology, astana medical university, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.175 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ sikhayeva this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.175 | http://cajgh.pitt.edu abstract introduction. breast cancer is the most common type of cancer among women. in kazakhstan, breast cancer holds first place among causes of women death caused by cancer in the 45-55 year age group . many studies have shown that the risk of acquiring breast cancer may be related to the level of calcium in the blood serum. one of the important regulators of calcium metabolism in the body is the parathyroid hormone. single nucleotide polymorphisms in the gene encoding the parathyroid hormone (pth) are associated with breast cancer development risk, and may modify the associative interaction between the levels of calcium intake and breast cancer. experimental studies have shown that pth gene has a carcinogenic effect. at least three studies showed a weak positive correlation between the risk of acquiring breast cancer and primary hyperparathyroidism, a state with high levels of pth and often high levels of calcium. the aim of this investigation was to evaluate potential association between pth gene polymorphism and breast cancer risk among kazakhstani women. methods. female breast cancer patients (n = 429) and matched control women (n = 373) were recruited into a case – control study,. genomic dna was extracted from peripheral venous blood of study participants using wizard® genomic dna purification kit (promega, usa). detection of pth gene polymorphism (rs1459015) was done by means of the taqman® snp genotyping assay of real-time pcr. statistical analysis was conducted using spss 19.0. results. pth gene alleles were in hardy–weinberg equilibrium (p > 0.05). distribution was 59% cc, 35% ct, 6% tt in the group with breast cancer and 50% cc, 43% ct, 6% tt in the control group. total difference (between the group with breast cancer and the control group) in allele frequencies for pth polymorphism was not significant (p > 0.05). no association was found between rs1459015 tt and breast cancer risk (or = 1.039; 95%, ci 0.740 1.297; p = 0.893). conclusion. we found no association between pthrs1459015 polymorphism and breast cancer in our present study. further studies are required to confirm our results and clarify role of pth gene genotypes on breast cancer risk. keywords: breast cancer, parathyroid hormone gene, polymorphism http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.promega.com/resources/protocols/technical-manuals/0/wizard-genomic-dna-purification-kit-protocol/ https://www.promega.com/resources/protocols/technical-manuals/0/wizard-genomic-dna-purification-kit-protocol/ http://www.lifetechnologies.com/kz/en/home/life-science/pcr/real-time-pcr/real-time-pcr-assays/snp-genotyping-taqman-assays/single-tube-snp-genotyping.html?icid=search-product cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. comparing the use of uterine artery embolization to gonadotropin-releasing hormone agonists in shrinking fibroid size: a pilot study in kazakhstan balkenzhe imankulova1, alibek mereke2, nazira kamzaeva1, talshyn ukybassova1 1department of obstetrics and gynecology, national research center for maternal and child health, national medical holding, astana, kazakhstan; 2department of epidemiology, graduate school of public health, university of pittsburgh, pittsburgh, pa vol. 4, no. 1 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.232 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ imankulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.232|http://cajgh.pitt.edu abstract introduction: uterine fibroids are the most common benign tumor in women in kazakhstan. in the past two decades, endoscopic surgery has played an important role in the development of gynecologic surgery, particularly in the treatment of uterine fibroids. the goal of this paper is to evaluate whether uterine artery embolization (uae) or gonadotropin-releasing hormone agonists (gnrha) prior to myomectomy was more effective in decreasing fibroid size and improving surgical outcomes in a pilot study of women in kazakhstan. methods: this pilot investigation included 24 patients separated into 2 groups: medication group (pre-treatment with gnrha – 13 patients) and embolization group (pre-treatment with uae – 11 patients). all patients had uterine fibroids, 3-10 cm in diameter, and were treated with myomectomy at the national research center for maternal and child health, astana, kazakhstan. all patient data were obtained by a retrospective medical records review. descriptive statistics were utilized to characterize participant demographics data. independent t-tests were used to analyze continuous variables, and chi-square and fisher’s exact tests were used where appropriate for count data. results: the group treated with gnrha had an operating time of 40±10 minutes longer than the group treated with uae, due to the peri-operative difficulties encountered by surgeons in detecting the layer between the myometrium and fibroid capsule. the group treated with uae experienced better patient outcomes (less blood loss, less surgical time, and reduced use of anesthesia) and was a technically easier surgery due to visible differences in uterine layers. conclusions: despite the fact that both treatments (gnrha and uae) were effective for fibroid shrinking, embolization resulted in more optimal surgical time and improved patient outcomes. results of this pilot study need to be confirmed in a randomized clinical trial, specifically focused on kazakhstan and the central asian region. keywords: fibroids, kazakhstan, gnrha, uterine artery embolization comparing the use of uterine artery embolization to gonadotropinreleasing hormone agonists in shrinking fibroid size: a pilot study in kazakhstan balkenzhe imankulova1, alibek mereke2, nazira kamzaeva1, talshyn ukybassova1 1department of obstetrics and gynecology, national research center for maternal and child health, national medical holding, astana, kazakhstan; 2department of epidemiology, graduate school of public health, university of pittsburgh, pittsburgh, pa research approximately 20-30% of women worldwide over the age of 30 are diagnosed with uterine fibroids.1,2 uterine fibroids are the most common benign tumor diagnosed in women in kazakhstan; however, treatment of this problem remains a complex and difficult challenge. the true prevalence of fibroids is likely to be underestimated in kazakhstan, as access to medical facilities, and medical care in general, varies across the country. symptomatic fibroids are associated with significant morbidity and are typically associated with prolonged and heavy periods, pelvic pain, and in some cases, reproductive problems.3 surgical interventions, such as hysterectomy or laparotomic myomectomy, used to be the primary surgical interventions for uterine http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.232|http://cajgh.pitt.edu fibroids. other methodologies have been emerging in the past several years, such as laparoscopic myomectomy and uterine artery embolization (uae), as well as medicinal interventions to reduce the fibroid volume. hysterectomy is a curative approach for fibroid management; however, patients of reproductive age are in need of interventions that preserve reproductive function. with access to proper laparoscopic equipment and availability of well trained surgeons, laparoscopic surgery is the treatment of choice for symptomatic fibroids. progesterone and its receptors increase the proliferation of fibroid cells in the uterus; therefore, antiprogestins and progesterone receptor modulators are considered reasonable medicinal treatments.2 gonadotropin-releasing hormone agonists (gnrha) are commonly used before hysteroscopic myomectomy to make surgery easier and safer, but they are expensive, have potential side effects, and lack evidence based data to support this practice.4 therapy using gnrha appears to result in a decrease in estrogen and progesterone levels, which decrease the size of the fibroid while gnrha do cause fibroid regression, they . measures temporarycan only be used in the short term, as to operatively -in the perimenopausal women, or pre reduce fibroid size before myomectomy.5 the disadvantages of using gnrha reported in the literature are the rebound growth of the fibroids upon cessation of therapy and major side effects associated with their use.5 in a previously published systematic review of the ues operative gnrh analog-literature on the use of pre for symptom relief, gnrha may improve some outcomes, but there is insufficient evidence to support their routine use prior to hysteroscopic resection of submucous fibroids.4 while gnrha are typically believed to be useful in fibroid reduction,2 our experience (unpublished data) suggests that fibroids exposed to agonists have deeper myometrium invasion that significantly impairs their enucleation during surgery. a previously published study suggested that pre-surgical treatment with embolization prior to myomectomy has the benefits of lowering intra-operative blood loss and increasing efficacy of conservative myomectomy.6 additional benefits of uae include reduction in the volume of fibroids and their vascularization, thus reducing surgical time. furthermore, patients undergoing uae appear to have shorter recovery times and fewer clinical symptoms, such as pain and fever due to resorption, as well as a decrease in uterine size.6,7 despite the fact that multiple papers and reviews have been published on the efficacy of gnrha and uae on fibroid reduction, many unanswered questions still exist in this area. also, no studies have been conducted in kazakhstan or central asia to compare the use of gnrha to uae. thus, our study fills a significant gap in the research by comparing the pretreatment with uterine artery embolization (uae) to gonadotropin releasing hormone agonists (gnrha) prior to myomectomy in their effectiveness in improving surgical outcomes, specifically focusing on women in kazakhstan. methods this is a retrospective review of 24 clinical cases treated at the national research center for maternal and child health in astana, kazakhstan from 2013-2014. in 2012, this center became one of the first clinics in the commonwealth of independent states, which was accredited by the joint commission international. this study was limited to women of reproductive age with symptomatic fibroids undergoing laparoscopic myomectomy. before myomectomy, all women were pre-treated for fibroid volume reduction. these 24 cases were divided into two groups, medication group and embolization group, which were based on the pre-surgical treatment of the fibroids. the medication group included 13 women who underwent laparoscopic myomectomy after pre-treatment with gnrha on an outpatient basis in domiciliary clinics. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.jointcommissioninternational.org/ http://www.jointcommissioninternational.org/ imankulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.232|http://cajgh.pitt.edu gnrha was injected intramuscularly every 4 weeks for a period of 8 weeks (3 doses) prior to surgical intervention. conservative myomectomy was carried out 4 weeks after the last injection. the embolization group included 11 patients who underwent laparoscopic myomectomy 6-12 months after uae. uae was carried out at the national research center for maternal and child health on an inpatient basis. the national research center for maternal and child is a tertiary treatment facility specializing in gynecologic and obstetrical conditions. uae procedures have been carried out at the center since 2008. because this study was limited to the review of medical records, it was exempt from human subject irb review. prophylactic antibiotic therapy (cefazolin, 2000 mg intravenously, 30 minutes before the surgery) was administered to all patients, based on standard treatment protocol. patients came for follow-up assessment 6 to 12 months after the surgery, where vaginal examinations and transvaginal uterine ultrasounds were conducted to assess fibroid symptoms and reduction. data analysis descriptive statistics were utilized to characterize participant demographics data. independent t-tests were used to analyze continuous variables, and chi-square and fisher’s exact tests were used where appropriate for count data. all analyses were conducted in microsoft excel. results patients treated with gnrha (medication group) had a mean age of 34.2±2.2 years, and patients undergoing pre-operative uae (embolization group) had a mean age of 38.6±1.2 years. twenty-three percent of the patients in the medication group complained of infertility during the last 4-5 years, where infertility was defined as the inability to conceive after at least one year of unprotected, regular sexual intercourse. pelvic pain was reported in 38.5% of patients in the medication group, and in 54.5% of patients in the embolization group (p<0.05) algomenorrhea was reported in 15.4% of patients in the medication group, and in 9.0% of patients in the embolization group. hyperpolymenorrhea was reported in 23% of patients in the medication group and 36.4% of patients the embolization group (p<0.05) (figure 1). figure 1. breakdown of patients’ complaints stratified by intervention group the most common complaints reported by patients in the embolization group included pelvic pain (54.5%) and hyperpolymenorrhea (i.e. dysfunctional uterine bleeding – 36.4%), possibly associated with larger fibroids than observed in the medication group. uterine fibroids ranged in size from 3 to 10 cm in diameter and were located in the sub-serous and intramural layers of the uterus. based on transvaginal ultrasound examinations, the medication group had single fibroid nodes located in the fundus of the uterus in 38.5% of patients, in the anterior wall in 38.5% of patients, and in combination of the anterior wall with the transition to the fundus (fundal anterior fibroids) overlapping fallopian tubes in 23.0% of patients. the size of fundal fibroids averaged 5.1x4.3x2.0 cm, anterior wall fibroids averaged 5.1x5.0x2.3 cm, and fundal anterior fibroids averaged 6.0x5.8x3.0 cm. in the embolization group, the single fibroid nodes were located at the fundus of the uterus in 18.2% of patients, in the anterior wall in 36.4% of patients, and in the fundal anterior location in 45.5% of patients. the size of the fundal fibroids averaged 6.5x4.2x3.5 cm, the anterior fibroid nodes averaged 10.0x4.0x3.2 cm, and the fundal anterior fibroids averaged 5.7x5.4x3.5 cm. transvaginal ultrasound demonstrated that 69.2% of patients treated with gnrha had fibroid shrinkage with the uterine volume decreasing by 25%. the group undergoing uae treatment had fibroid shrinkage up to 32% among 81.9% http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.232|http://cajgh.pitt.edu of patients (figure 2). both treatment groups were comparable in terms of gynecologic and obstetric history. surgical times in the medication group were roughly 40 minutes longer than in the embolization group. this is due to the peri-operative difficulties in detecting the layer between myometrium and fibroid capsule. furthermore, blood loss was much higher in the medication group (130.0±20 ml) compared to the embolization group (80.0±10.0 ml). all patients were encouraged to resume physical activity 8 hours postoperatively, and sutures were removed 3 days after the surgery. patients were discharged from the hospital 4.0±1.0 days post-surgery. histological results also confirmed uterine fibroid diagnosis in both groups. furthermore, both groups had transvaginal uterine ultrasound examinations as follow-up assessments between 6 and 12 months. however, during the 12 month post-surgical follow-up, three patients in the medication group reported uterine fibroid recurrence, whereas the embolization group reported only one case of fibroid recurrence. pregnancy during the 12 months after surgery was reported in 53.8% of patients in the medication group (p<0.01), where 28.6% of women became pregnant at 6 months and 72.4% of women at 9 months after onset of normal menstrual function. only one patient in the embolization group became pregnant 12 months after recovery, and which previously had anatomical localization of the fibroid nodes at the fundus of the uterus and fundal anterior wall. overall, this group did not complain of infertility as the primary reason for the decision to undergo embolization. the embolization group only had 2 patients who did not experience fibroid reduction. figure 2. reduction of fibroid size after pretreatment with gnrha or uae discussion this study concluded that despite the fact that both treatments (gnrha and uae) were effective for fibroid reduction, embolization resulted in more optimal surgical time, and improved patient outcomes. this is one of the first studies of this nature conducted in central asia, as previously published studies from the asian continent primarily focused on chinese8,9 and japanese10,11 women. limitations of this study included a very small sample size and the retrospective nature of this investigation. an additional limitation of this study is the varying time period between pretreatment with medication or embolization and fibroid surgery. several women wanted to have surgery at 6 months after pretreatment, while others waited up to 12 months. also, this study did not allow for a more detailed evaluation of infertility, since the authors did not have access to women’s reproductive hormone test results and their sexual partners’ spermiogram results. to date, there is a paucity of published evidence to confirm the safety of uterine artery embolization for the future of reproductive function and fertility. therefore, we discourage uae for patients planning to have children. uae is an acceptable method for surgical preparation, leading to fibroid shrinkage, lower intraoperative blood loss, shorter anesthesia, and surgical times. based on our experience, the laparoscopic myomectomy after uae has been advantageous in the identification of fibroid nodules and normal myometrium by fibroid color, consistency, and its borders. thus, future studies are needed to confirm these findings. overall, we would like to recommend implementation of a randomized clinical trial for comparison of uterine artery embolization and gonadotropin-releasing hormone agonists in shrinking fibroid size and improving surgical outcomes, specifically in the central asian region. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx imankulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.232|http://cajgh.pitt.edu references 1. mahmoud ms, desai k, nezhat fr. leiomyomas beyond the uterus; benign metastasizing leiomyomatosis with paraaortic metastasizing endometriosis and intravenous leiomyomatosis: a case series and review of the literature. arch gynecol obstet. 2015;291(1):223-230. 2. szamatowicz m, kotarski j. [selective progesterone receptor modulator (ulipristal acetate--a new option in the pharmacological treatment of uterine fibroids in women]. ginekol pol. 2013;84(3):219-222. 3. gupta jk, sinha a, lumsden ma, hickey m. uterine artery embolization for symptomatic uterine fibroids. cochrane database of systematic reviews (online). 2014;12:cd005073. 4. kamath ms, kalampokas ee, kalampokas te. use of gnrh analogues pre-operatively for hysteroscopic resection of submucous fibroids: a systematic review and meta-analysis. eur j obstet gynecol reprod biol. 2014;177:11-18. 5. sankaran s, manyonda it. medical management of fibroids. best pract res clin obstet gynaecol. 2008;22(4):655676. 6. nasser f, affonso bb, de jesus-silva sg, et al. [uterine fibroid embolization in women with giant fibroids]. revista brasileira de ginecologia e obstetricia : revista da federacao brasileira das sociedades de ginecologia e obstetricia. 2010;32(11):530-535. 7. bernardo a, gomes mt, castro ra, girao mj, bonduki ce, yokoyama ca. [impact of the myoma arterial embolization by uterine volume, diameter myoma greater and in the ovarian function]. revista brasileira de ginecologia e obstetricia : revista da federacao brasileira das sociedades de ginecologia e obstetricia. 2011;33(8):201-206. 8. zhang y, sun l, guo y, et al. the impact of preoperative gonadotropin-releasing hormone agonist treatment on women with uterine fibroids: a meta-analysis. obstet gynecol surv. 2014;69(2):100-108. 9. yu yh, gong sp, wan sm. [clinical application of gnrha before uterine myomectomy: report of 20 cases]. di 1 jun yi da xue xue bao = academic journal of the first medical college of pla. 2004;24(3):317-319. 10. higashijima t, kataoka a, nishida t, yakushiji m. gonadotropin-releasing hormone agonist therapy induces apoptosis in uterine leiomyoma. eur j obstet gynecol reprod biol. 1996;68(1-2):169-173. 11. uemura t, mori j, yoshimura y, minaguchi h. treatment effects of gnrh agonist on the binding of estrogen and progesterone, and the histological findings of uterine leiomyomas. asia-oceania journal of obstetrics and gynaecology / aofog. 1991;17(4):315-320. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx imankulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.232|http://cajgh.pitt.edu figure 1. breakdown of patients’ complaints stratified by intervention group 23.0 38.5 15.4 23.0 0.0 54.5 9.0 36.4 0.0 10.0 20.0 30.0 40.0 50.0 60.0 infertility pain algomenorrhea hyperpolymenorrhea p er ce n t complaints gnrh uae http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx imankulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.232|http://cajgh.pitt.edu figure 2. reduction of fibroid size after pre-treatment with gnrha or uae 69.23 81.82 30.77 18.18 0 20 40 60 80 100 gnrh uae p er ce n t treatment shrinking no change http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. correlation between reproductive hormonal level and osteoporosis among women in mongolia unentsatsral lkhagvasuren1, sarantuya jav2, battogtokh zagdsuren3 1department of obstetrics and gynecology, health sciences, university of mongolia, ulaanbaatar, mongolia; 2department of molecular biology and genetics, health sciences, university of mongolia, ulaanbaatar, mongolia; 3department of kinesiology, university of alabama, alabama, usa vol. 4, no. 2 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/4.0/ lkhagvasuren this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn | doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu abstract background: postmenopausal osteoporosis is the most common bone metabolic disease associated with low bone mineral density (bmd) and osteopathic fragility fractures, which can lead to significant morbidity. the objective of this study was to investigate the relationship between serum follicle-stimulating hormone (fsh), luteinizing hormone (lh), and estradiol (e2) levels and bone mineral density (bmd) across the stages of menopause in mongolian women. methods: two hundred sixty participants aged 50.1±4.4 years were enrolled in the study. blood samples were obtained from each participant and analyzed using elisa. data were first stratified and analyzed by bone mineral density status (osteoporotic, osteopenic, and normal) and then by menopause status. between group differences were analyzed using t-tests, and correlations were assessed using the spearman rank order test, with bonferonni correction. the data were analyzed using statistical package statistical software version 20.0 (spss inc., chicago, il). significance was set at p<0.05. results: the mean menopausal age was 48.4±3.4, which is comparable to the mongolian population mean menopausal age. the mean serum estradiol level in the normal bmd group was 18.3±13.1 pg/ml and 15.8±10.7 pg/ml in the osteoporotic group. the mean serum fsh in the normal bmd group was 54.5±44.1 pg/ml and 81.3±34.2 pg/ml in the osteoporotic group. the mean serum lh level in the normal bmd group was 53.1±41.2 and 75.1±26.1 pg/ml in the osteoporotic group. the mean t and z score were lower in the osteoporotic group. fsh and lh levels significantly differed across menopause stages in that those who were postmenopausal had higher levels compared to those who were preor peri-menopausal. both hormones, fsh and lh, showed weak negative correlations with bmd level, but not e2. there were significant negative correlations between fsh and speed of sound (sos) (r=-0.16; p<0.01), and between osteoporosis with age (r=-0.30, p<0.05) and number of childbirths (r=-0.14 p<0.05). discussion: osteoporosis is a significant problem with associations to hormone levels in post-menopausal women. in our study, mean serum estradiol levels decreased with age, and the mean fsh and lh levels were higher in women of later menopausal stage. further study is warranted to investigate the bone related studies to establish better statistical references among mongolian women. keywords: osteoporosis, post-menopausal women, reproductive hormone, menopause, mongolia correlation between reproductive hormonal level and osteoporosis among women in mongolia unentsatsral lkhagvasuren1, sarantuya jav2, battogtokh zagdsuren3 1department of obstetrics and gynecology, health sciences, university of mongolia, ulaanbaatar, mongolia; 2department of molecular biology and genetics, health sciences, university of mongolia, ulaanbaatar, mongolia; 3department of kinesiology, university of alabama, alabama, usa research postmenopausal osteoporosis is the most common bone metabolic disease associated with low bone mineral density (bmd) and osteopathic fragility fractures, which has been associated with significant disability and mortality.1 the majority of women spend one third of their lifetime in the postmenopausal period typically accompanied by an estrogen deficit state.2 the world health organization (who) defined osteoporosis as a reduction of 2.5 standard deviations in t-scores below the normal mean for young females at the age of peak bone mass.3 a t score between 1 to 2.5 sds below average indicates osteopenia, which is a pre-osteoporotic state.3 the diagnostic measurement of z-score indicates http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu the bone density relative to patients’ age and sex.4 a zscore below -2.0 is classified as below the expected range for that age, while above -2.0 is considered to be within the expected range for a given age.4,5 worldwide, there are nearly 9 million osteoporotic fractures each year, generating a massive burden both to individuals and to health services.6 about 13-18% of women over the age of 50 years have osteoporosis and 37-50% have osteopenia in the usa.7 unfortunately, no epidemiologic data have been published about the rate of osteoporosis in mongolia. anecdotal evidence suggests that rates in mongolia are similar to those reported in the usa. low estradiol levels are a risk factor for osteoporosis and influences the quality of life for older women.8 estrogen deficiency can lead to excessive bone re-absorption after menopause.9 to the best of our knowledge, there are no published studies on the relationship between serum reproductive hormonal level and bmd in postmenopausal women in mongolia. therefore, the purpose of this study is to evaluate the correlation between reproductive hormone levels such as folliclestimulating hormone (fsh), luteinizing hormone (lh), estradiol (e2), and osteoporosis among postmenopausal women in mongolia. osteoporosis research is inadequate in mongolia due to the lack of reliable diagnostic instruments and poor research infrastructure. conducting such research is valuable to gerontology, endocrinology, and gynecology fields in mongolia. hence, the secondary purpose of this study is to establish a research database for future research in related fields. methods participants two hundred sixty women with a mean age of 50.1±4.4 years were included in the study. participants were recruited from four districts from ulaanbaatar city of mongolia. all participants signed informed consents prior to study participation. the study was approved by the ethical committee of health sciences university of mongolia. participants were interviewed using a questionnaire developed by the investigators, which included demographics, body mass index (bmi), years since menopause, menarche age, menopause age, and health history. the participants were divided into three different groups based on their bmd value: osteoporosis, osteopenia, and normal. the mean age of the osteoporosis (t score: -2.5), osteopenia (t score: -2.5 to -1), and normal (t score: >-1) group was 54.0±3.9, 51.5±4.3, and 48.5±3.8 years, respectively. the participants were further classified into four menopausal stages: premenopausal, perimenopausal, postmenopausal early and postmenopausal late using the staging reproductive aging in women (straw).10 exclusion criteria included: history of bone disease, metabolic and/or endocrine disorders including hyperthyroidism, hyperparathyroidism, diabetes mellitus, liver disease, renal disease, and medications known to affect bone metabolism (e.g., corticosteroids, anticonvulsants, and heparin sodium). none of the participants had a history of medications for the treatment of osteoporosis, such as active vitamin d11, bisphosphonates, selective estrogen receptor modulators (serm), or calcium. laboratory measurements five milliliters of fasting peripheral blood were drawn, centrifuged and kept frozen in the -20o c freezer until assayed. serum samples were evaluated for levels of e2, fsh, lh levels, calcium, phosphorus, and vitamin d by elisa (thermo fisher scientific, usa) method. bone mineral density measurements the bone ultrasound mini-omni (sunlight, beammed, israel) was used to assess bmd. the parameter of speed of sound (sos) m/s is used for the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx lkhagvasuren this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn | doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu analysis.12 the sos refers to the division of transmission time of the sound waves by the length of the body part studied. the forearm and tibia bone scans were performed with the patient on the imaging table using the protocols recommended by the manufacturer. osteoporosis was defined according to the conventional world health organization (who) definition.3,13 data analysis the comparisons of scores between groups were performed using t-tests, and correlations were assessed with the spearman rank order test, with bonferonni correction. the data were analyzed using statistical package statistical software version 20.0 (spss inc., chicago, il). significance was set at p<0.05 and was two-sided. results participant characteristics two hundred sixty (n=260) participants aged 50.1±4.4 years were enrolled in the study. the average bmi was 27.3±5.2 kg/m2 and mean age of menopause was 48.4±3.4 years. factors associated with bone density status the age of menopause (p=0.002), breastfeeding time (p=0.041), and serum vitamin d (p=0.025) were significantly associated with osteoporotic status. however, there were no statistically significant differences of bmi, menarche age, serum calcium, serum phosphorus, and parathyroid hormone levels noted between the three groups. the result of hormone analysis showed serum estradiol levels were lower in the osteoporotic group than in the normal bmd group (normal: 18.3±13.1 pg/ml, osteoporotic: 15.8±10.7 pg/ml). the fsh and lh levels were higher in the osteoporosis group than in the normal bmd group (fsh normal: 54.5±44.1 pg/ml, fsh osteoporosis: 81.3±34.2 pg/ml, lh normal: 53.1±41.2, lh osteoporosis: 75.1±26.1 pg/ml). clinical and laboratory characteristics of the participants are listed in table 1. table 1. demographic and laboratory characteristics of participants correlation of reproductive hormones with menopausal status serum estradiol levels were not significantly different across menopause stages. the fsh and lh levels were higher in the postmenopausal late stage than in the premenopausal stage (table 2). the study found a weak statistical correlation between fsh and sos from the ultrasound (r=-0.16, p<0.01). there was a significant negative correlation between sos and bmi (r=-0.306, p<0.01). the sos was significantly different in all four groups (p<0.05). table 2. levels of reproductive hormones (by straw) stratified by menopausal status analysis of bone mineral density the average t score was -0.18±0.6 in the normal bmd group, 1.67±0.4 in the osteopenia group, and -3.18±0.6 in the osteoporosis group. the z score was 0.29±1.2 in normal patients, -1.64±1.3 in the osteopenia group, and -2.17±1.1 in osteoporosis patient group. t-score and speed of sound progressively decreased with with age (figures 1 and 2). the box plots of t and z scores of the participants stratified by menopausal status are shown in figures 3 and 4. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu figure 1. correlation between age and bone mineral density figure 2. correlation between age and speed of sound figure 3. box plot of t scores stratified by menopausal status figure 4. box plot of z scores stratified by menopausal status discussion the menopausal period is a normal physiological process that is accompanied by various symptoms.8 the researchers identified that the average age of onset of the menopause is 48-52, and it is similar in women across various countries.14 recently published study demonstrated that the average age of menopause onset among mongolian women was 49.3±3.1, 48.6±1.7 and 48.2±2.9 years in 2008, 2010, and 2011, respectively.15 similarly, in our study, the mean age of menopause for our research participants was 48.4±3.4 years. the current study showed that the rate of osteoporosis was 11.2% and osteopenia was 34.6%, rates that were similar to results of other asian women from reports of who in 2008.16 osteoporosis incidence was higher in women with advanced stages of menopause. in our study, fsh and lh levels significantly differed across menopause stages in that those who were postmenopausal had higher levels compared to those who were preor peri-menopausal. both hormones, fsh and lh, showed weak negative correlations with bmd level, but not e2. the result was significant in fsh level and sos (r=-0.16; p<0.01), which was similar to previous studies.17,18 this could indicate that low bmd in later stages of menopause is associated with serum fsh rather than e2. the weak correlation may be due to our small sample size. other limitations of the current study include: participants were only selected from city areas and rural areas were not sampled, and the bmd was only tested in forearm and tibia. ideally, the most common fracture sites, such as hips and spine, should be tested in future studies. this is one of the first studies in mongolia to determine the correlation between the hormonal levels and menopausal status. we concluded that women from older age groups had lower levels of serum estradiol, which were associated with loss of bmd. however, there was significant correlation between fsh and bmd in more advanced stages of menopause. further study is needed to investigate the bone metabolism related studies to establish better epidemiological data sources among mongolian population. authors would like to encourage similar studies in mongolia and central asia, consistent with the need of cental asian region for betterdeveloped chronic disease research.19 conflict of interest the author declares that they have no competing interests. acknowledgement we wish to thank you all volunteers and the consultant gynecologist and the staff of the first maternity hospital. references 1. darba j, kaskens l, perez-alvarez n, palacios s, neyro jl, rejas j. disability-adjusted-life-years losses in postmenopausal http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx lkhagvasuren this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn | doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu women with osteoporosis: a burden of illness study. bmc public health. 2015;15:324. 2. kanis ja, mccloskey ev, johansson h, cooper c, rizzoli r, reginster jy. european guidance for the diagnosis and management of osteoporosis in postmenopausal women. osteoporos int. 2013;24(1):23-57. 3. who. assessment of osteoporosis at primary health care level. summary meeting report 2004; http://www.who.int/chp/topics/osteoporosis.pdf. 4. mckiernan fe, berg rl, linneman jg. the utility of bmd z-score diagnostic thresholds for secondary causes of osteoporosis. osteoporos int. 2011;22(4):1069-1077. 5. kanis ja, melton lj, 3rd, christiansen c, johnston cc, khaltaev n. the diagnosis of osteoporosis. j bone miner res. 1994;9(8):1137-1141. 6. moon r, cooper, c, harvey, nc. osteoporosis: pathophysiology and epidemiology. the duration and safety of osteoporosis treatment: springer international publishing; 2016:1-16. 7. keating nl, cleary pd, rossi as, zaslavsky am, ayanian jz. use of hormone replacement therapy by postmenopausal women in the united states. ann intern med. 1999;130(7):545553. 8. cauley ja, seeley dg, ensrud k, ettinger b, black d, cummings sr. estrogen replacement therapy and fractures in older women. study of osteoporotic fractures research group. ann intern med. 1995;122(1):9-16. 9. boroňová i bj, kľoc j, tomková z, petrejčíková e, mačeková s, blaščáková mm. analysis of opg gene polymorphism t245g (rs3134069) in slovak postmenopausal women. analysis. 2014;2(12859). 10. soules mr, sherman s, parrott e, et al. stages of reproductive aging workshop (straw). j womens health gend based med. 2001;10(9):843-848. 11. heinemann df. osteoporosis. an overview of the national osteoporosis foundation clinical practice guide. geriatrics. 2000;55(5):31-36; quiz 39. 12. chin ky, ima-nirwana s. calcaneal quantitative ultrasound as a determinant of bone health status: what properties of bone does it reflect? int j med sci. 2013;10(12):1778-1783. 13. who. prevention and management of osteoporosis. report of a who scientific group. . geneva: world health organization;2003. 14. palacios s, henderson vw, siseles n, tan d, villaseca p. age of menopause and impact of climacteric symptoms by geographical region. climacteric. 2010;13(5):419-428. 15. ulziinorov g. the relationship between menopause symptoms and the quality of life of women in ulaabaatar city, mongolia. mahidol university: institute for population and social research;2009. 16. mithal a, kaur p. osteoporosis in asia: a call to action. curr osteoporos rep. 2012;10(4):245-247. 17. wu x ys, zhang h, xie h, luo x, peng y, liao e, et al. early bone mineral density decrease is associated with fsh and lh, not estrogen. clinica chimica acta. 2013;415:69-73. 18. xu z wa, wu x, zhang h, sheng z, wu x, liao e. relationship of age-related concentrations of serum fsh and lh with bone mineral density, prevalence of osteoporosis in native chinese women. clinica chimica acta. 2009;400(1-2):8-13. 19. adambekov s, kaiyrlykyzy a, igissinov n, linkov f. health challenges in kazakhstan and central asia. j epidemiol community health. 2016;70(1):104-108. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/chp/topics/osteoporosis.pdf central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu table 1. demographic and laboratory characteristics of participants characteristics osteoporosis n=30 osteopenia n=90 normal n=140 p-value mean age 54.0±3.9 51.5±4.3 48.5±3.8 0.433 bmi (kg/m2) 28.98±4.0 27.97±5.3 26.55±5.2 0.460 age at menopause (years) 48.6±3.6 48.2 ±3.5 48.5±3.2 0.002 age at menarche (years) 14.72±1.8 14.47±1.7 14.98±1.9 0.464 number of birth (n) 3.3±1.5 3.2 ±1.5 2.6±1.2 0.167 serum calcium (mmol/l) 2.17±0.3 2.18 ±0.2 2.14±0.2 0.077 serum phosphorus (mmol/l) 3.63±0.9 3.76 ±1.0 3.55±0.9 0.261 serum pth (pg/ml) 7.91±4.5 7.62 ±4.2 7.61±5.6 0.565 serum vitd (mmol/l) 13.28±6.1 12.52 ±4.9 12.58±6.1 0.025 breastfeeding time (yrs) 2.06±1.2 2.43±1.6 2.38±1.6 0.041 *significant findings are indicated in bold. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx lkhagvasuren this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn | doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu table 2. levels of reproductive hormones (by straw) stratified by menopausal status stage of menopause premenopausal perimenopausal postmenopausal early postmenopausal late n=63 n=77 n=79 n=41 estradiol (pg/ml) 29.9±3.1 30.7±4.7 34.0±1.7 26.3±7.7 fsh (pg/ml) 26.7±4.7 36.9±4.2 64.6±4.9 61.0±6.3 lh (pg/ml) 20.5±3.6 34.4±3.5 62.3±4.7 59.7±6.9 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu figure 1. correlation between age and bone mineral density http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx lkhagvasuren this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn | doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu figure 2. correlation between age and speed of sound http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu figure 3. box plots of t scores stratified by menopausal status http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx lkhagvasuren this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn | doi 10.5195/cajgh.2015.239 | http://cajgh.pitt.edu figure 4. box plots of z scores stratified by menopausal status http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. fetal nerve cell transplantation in early post-resuscitation period in rats damira tazhibayeva1, farkhad olzhayev2, natalya kadbudalieva1, zhaina aitbayeva1, lina zaripova1 1department of pathological physiology, astana medical university, astana, kazakhstan; 2center for life sciences, nazarbayev university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.178 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ tazhibayeva this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.178 | http://cajgh.pitt.edu abstract introduction. fetal cell transplantation is a promising biomedical approach for disease treatment; however, the use of fetal cell therapy is still experimental. this research was deemed a necessity to provide evidence-based research for the application of cell transplantation as a treatment method. the aim of this study was to evaluate the effect of fetal nerve cell transplantation in rat survivors (and non-survivors) after clinical death by mechanical asphyxia. methods. 68 white laboratory rats were divided into two groups of identical age and sex: a control group of 12-month adult male rats (n = 26) and an experimental group (n = 42). rats were fixed under ether anesthesia. we then blocked the oral and nasal regions with cotton wool soaked in saline solution. a four-minute clinical death though acute mechanical asphyxia was simulated by applying the method of n. shim. after the 4-minute clinical death, we resuscitated the rats using external cardiac massage and artifical respiration. suspension of the fetal nerve cells was injected intraperitoneally at 1mm3 per 25g at the time of cardiac activity restoration. lactate dehydrogenase (ldh) and creatine phosphokinase (cpk) levels were examined in the homogenate cerebral cortex of reanimated animals. we recorded the survival rate during the post-resuscitation period and analyzed the integrative brain functions using anxiety-phobic status and latent inhibition. results. after fetal nerve cell transplantation, the enzymatic reactions in the experimental group became normal with a significant decrease in ldh and an increase in cpk levels compared to the control group. in the control group, 10 rats died and 16 lived (62% survival rate), while 7 rats died and 35 lived (83% survival rate) in the experimental group during the first 7 days. rats that did not receive the treatment tended to die sooner than those in the experimental group. as a result of transplantation, the anxiety level in the experimental group was less than in the control group. moreover, cell therapy improved the reflexes in the experimental animals. conclusions. the study revealed the positive neuroprotective effect of the fetal nerve cells on the recovery in the early postresuscitation period. this was confirmed by the normalization of enzymatic reactions, improvement reflective activity, and increase in the survival rate of the resuscitated animals in the group treated with fetal nerve cell transplantation. these findings warrant future research on the mechanisms associated with reflex improvement. keywords: fetal nerve cell transplantation, survival, resuscitation http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.lingvo-online.ru/ru/search/translate/glossaryitemextrainfo?text=%d1%84%d0%b5%d1%80%d0%bc%d0%b5%d0%bd%d1%82%d0%bd%d1%8b%d0%b9&translation=enzymatic&srclang=ru&destlang=en cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. the probiotical potential of lactobacilli from therapeutic preventive beverage kurunga lidia stoyanova1, samat kozhakhmetov2, almagul kushugulova2, talgat nurgozhin2, zhaxybay zhumadilov2, andrey bryukhanov2, maria napalkova2, alexander netrusov2 1department of microbiology, lomonosov moscow state university, russia; 2center for life sciences, nazarbayev university, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.176 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ stoyanova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.176 | http://cajgh.pitt.edu abstract introduction. kurunga is a dairy drink made of a mix of lactic acid and alcoholic fermentation, characterized by high biological value based on protein composition, amino acid spectrum, fatty acid composition of lipids, vitamin and mineral substances, and physiological activity of microbiota containing lactobacilli, lactococci, bifidobacteria, and yeast. among the probiotic correctors of normal microbiota isolated from national products, lactobacilli was of particular interest, with regards to a therapeutic – preventive effect. the aim of the study was to examine the probiotic properties of lactobacilli from kurunga. methods. we isolated lactic acid bacteria strains from kurunga. the isolated cultures were identified using common microbiological methods and phylogenetic analysis. the antibiotic activities of these strains were determined by measuring the growth inhibition zone of test cultures. the probiotic properties were measured as levels of resistance to bile and hydrochloric acids, in addition to the presence of superoxide dismutase (sod) activity using the xanthine oxidase-cytochrome method. proteolitic activity was determined at the various levels of ph (3.0, 4.2, 5.3, and 7.0). results. according to the morphological, cultural, physiological, biochemical properties and the genotypic analysis of the oligonucleotides sequence of specific genes, the most effective strain was identified as lactobacillus diolivorans kl-2 (genbank database kc438372). the isolated strain suppressed the growth of gram-positive bacteria, such as bacillus, staphylococcus, and listeria sp., as well as gram-negative bacteria, such as e.coli, proteus, salmonella sp. they also possessed fungicidal action (based on penicillum, aspergillus sp, and candida sp.). the strain was resistant to the action of the bile acids at concentrations of 0.8% to 1.0% and hydrochloric acid. the strain kl-2 possessed a relatively high sod activity (25.74 u/mg of protein), a low proteolytic activity at a ph 3.0 (4.74·10-3 pu/ml), and high proteolytic activity at ph 4.2 (294.74·10-3 pu/ml), ph 5.3 (330.52·10-3 pu/ml) and ph 7.0 (713.68·10-3 pu/ml). conclusion. the unique properties of this strain, such as stability in the gastrointestinal tract, the wide spectrum of bactericidal and fungicidal action to the pathogenic species, the relatively high superoxide dismutase and proteolytic activities, and the absence of toxicity, make it a prime candidate for probiotic culturing. keywords: kurunga, bacterial strain identification, l.diolivorans, probiotic http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. burden of the cardiovascular diseases in central asia altyn aringazina1, tleuberdi kuandikov2, viktor arkhipov1 1department of population health and social sciences, kazakhstan school of public health, medical university, almaty, republic of kazakhstan; 2department of anesthesiology and intensive care of national scientific centre of surgery, almaty, republic of kazakhstan; vol. 7, no. 1 (2018) | issn 2166-7403 (online) doi 10.5195/cajgh.2018.321 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ aringazina this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.321|http://cajgh.pitt.edu abstract cardiovascular diseases (cvd) are now the number one cause of death in lowand middle-income countries, including those in central asia (ca). lowand middleincome countries (lmics) bear a disproportionate and growing burden of cvd, which constitutes a challenge to national development. cvd account for more than 43% of cases of disability and 9.0% of cases of temporary disability in many developing countries. the high burden of cvd oftentimes results from insufficient preventive care and a lack of education about the prevention and treatment of these diseases. the rapidly growing burden of cvd and other major non-communicable diseases (ncds) is a global public health threat, especially in central asia. information on cardiovascular risk factors, including hypertension, diabetes, tobacco use, and alcohol use, is traditionally obtained from studies conducted in europe and north america, which limits our understanding of these factors in central asia. in this review, we collected all published information on cvd in central asia from 2000 to 2015, which included the websites of the ministries of health, the world health organization, pubmed, and other published sources.this narrative review describes cvd burden, stroke incidence, and common cvd risk factors in the five post-soviet countries of central asia (kazakshstan, kyrgyzstan, tajikistan, turkmenistan, and uzbekistan). keywords: cardiovascular diseases; epidemiology; central asia burden of the cardiovascular diseases in central asia altyn aringazina1, tleuberdi kuandikov2, viktor arkhipov1 1department of population health and social sciences, kazakhstan school of public health, medical university, almaty, republic of kazakhstan; 2department of anesthesiology and intensive care of national scientific centre of surgery, almaty, republic of kazakhstan; research central asia (ca) is a region consisting of five former soviet republics, including kazakhstan (18 million), kyrgyzstan (5.7 million), tajikistan (8.0 million), turkmenistan (5.2 million), and uzbekistan (30 million), with a total population of approximately 66 million inhabitants1. cardiovascular diseases (cvd) are the number one cause of death in lowand middleincome countries (lmics), such as those in ca2. the high burden of these conditions oftentimes results from insufficient preventive care and lack of education about the prevention and treatment of these diseases. the rapidly growing burden of cvd and other major noncommunicable diseases (ncd) is a major public health challenge in ca3. it is projected that ca countries will experience an increase in the total number of deaths due to ncds by 20201. the world health organization (who) estimated that 17.5 million people died of cvd in 2012, accounting for 46% of all ncd deaths3. of these deaths, an estimated 7.4 million were due to coronary heart disease, and 6.7 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.321|http://cajgh.pitt.edu million were due to stroke and hypertension3. more than 80% of these deaths occurred in low and middle-income countries, and cvd are now the number one cause of death in ca4. worldwide, nearly 25.7 million people had strokes in 2013 (71% was ischemic stroke), of which 6.5 million died (51% was ischemic stroke). the mortality from cvd in ca countries is generally higher than that in europe5. information on cardiovascular risk factors, including hypertension, diabetes, tobacco use, and alcohol use are traditionally derived from studies conducted in europe and north america. for this study, we reviewed information from a variety of sources on cvd in central asia from 2000 to 2015 from published sources, including the websites of the ministries of health and the world health organization, as well as pubmed, and other published sources. the purpose of this review is to describe and analyze data on cvd in ca for the following reasons. first, the policy makers of ca countries face enormous difficulties in reforming healthcare in extremely unfavorable economic conditions, and during major domestic and political transformations. to help these countries rebuild their health systems, policymakers need access to reliable information about their own health systems and local public health indicators. second, ca countries have an interest in discovering initiatives that can be successfully adapted from abroad. it should be noted that most data regarding ca healthcare systems is limited or not available for public access. to our knowledge, reliable scientific and statistical publications on cvd in turkmenistan were not available as of 2017. thus, this review does not include the republic of turkmenistan. republic of kazakhstan in 2014, the overall mortality rate from cvd in kazakhstan was 232.4 per 100,000; in 2015 it was 219 per 100,0006. regionally, the highest rate of cvd was reported in the karaganda region with 368.1 deaths per 100,000 in 20156. in rural areas, mortality figures were significantly lower than in urban areas. among urban residents in 2014, the general mortality rate from cvd was 238.3 per 100,000, while in rural areas it was 162.2 per 100,000. kazakhstan has the third highest death rate from ischemic stroke among the countries of the former soviet union7. during the period between 2011 and 2015, a national screening program for cvd and diabetes was introduced in kazakhstan. screening of cvd in kazakhstan takes place every 2 years through free medical care in all district clinics for men and women aged 18, 25, 30, 35, and 40-64 years who have not been diagnosed with heart disease or diabetes. during the screening, patients are given a questionnaire assessing risk factors and had their height, weight, blood pressure, cholesterol, and blood sugar measured6. those with a high risk of cardiovascular mortality received referrals for further care. from 2011 to 2015, over 7.5 million adults in kazakhstan were screened for cvds. as a result, more than 600,000 cases of heart disease were identified (7.9% of those screened)8. arterial hypertension is one of the most common diseases in kazakhstan and poses a serious challenge to public health. between 2009 and 2013 the prevalence of hypertension significantly increased from 10,778 to 13,392 per 100,0008, resulting in 24.3% of adults in kazakhstan having hypertension in 20138,9. mortality rates related to hypertension increased as well and now rank first among causes of death. approximately 40% of the deaths were observed in working age group (20–64 years), 64% of which were males6. to curb this epidemic, the state health system established a screening program for the early detection of cvd and its risk factors9-11. most of the screened patients had not previously received any treatment for their conditions12. according to the who report on the global tobacco epidemic (2013), the prevalence of tobacco use among the adult population of kazakhstan (aged 15-65 years) was 29.8% (48.0% for males and 12.1% for females)13. the consumption of smokeless tobacco http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aringazina this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.321|http://cajgh.pitt.edu among young people was 3.0% (3.4% for males and 2.7% for females)11. in comparison, the results of five national studies on monitoring and surveillance of tobacco consumption in kazakhstan showed a small decrease in smoking over the past 14 years13. in 1998, the prevalence of smoking among young people over the age of 11 was 28.0%, 49.8% among men and 12.2% among women. in 2012 this figure was 26.5%, 41.5% among men and 11.0% among women13. in 2006, kazakhstan joined the framework convention on tobacco control, and committed itself to implementing measures to protect the public from tobacco smoke14. the chief sanitary doctor of the ministry of health of the republic of kazakhstan adopted ban on smoking hookah in public places in march of 201315. the government supports initiatives aimed at the prevention of non-communicable diseases by adoption of a healthy lifestyle in the population. kazakhstan is 34th in the world in terms of alcohol consumption (10.3 liters of alcohol consumed per capita per year) and is the largest consumer of alcohol among the ca countries16. from 2008-2012, the volume of alcoholic beverages sold in kazakhstan increased by 9.6% from 862 million liters to 944.4 million liters. from 2013 to 2017, the growth in sales of alcoholic beverages in kazakhstan was projected to average 1.7% per year. in 2017, estimated domestic sales of alcoholic products were expected to reach 1.028 million liters. according to the 2003 world health survey (total sample size of 2894; 1170 males and 1724 females), the mean value (in grams) of pure alcohol consumed per day among drinkers was 2.9 (total), 4.2 (males) and 2.1 (females). while alcohol consumption in general carries additional health risks unrelated to cvd, extremely high levels of alcohol consumption may increase the risk of cvd in an individual. in kazakhstan, stroke treatment is becoming a priority with 41 world-class stroke centers opening in different regions of the country in the past few years, and 30 more centers projected to open before 202017. under the ministry of health and social development of kazakhstan, a coordinating council was formed to implement an integrated model of health care delivery for socially significant ncds17. the ministry of health focused its efforts on conditions like acute myocardial infarctions, acute cerebrovascular accidents, malignant neoplasms, trauma, and pregnancy complications18. although many health status measures show that kazakhstan is ahead of most nations in the region, it continues to lag behind other countries with similarly sized economies on several important health indicators7. republic of kyrgyzstan among countries incuded in the who european region report, kyrgyzstan has the highest premature mortality rate from cvd, the second-highest death rate from cerebrovascular disease, and the thirdhighest death rate from ischemic heart disease19. in kyrgyzstan, mortality from stroke is much higher, and ischemic heart disease is moderately lower than in other post-soviet countries. life expectancy at birth in kyrgyzstan is 75 years for women and 67 years for men19. ncds are estimated to account for 80% of all deaths; with half of these deaths attributed to cvd. the probability of dying between the ages of 30 and 70 years from the main ncds (ischemic stroke and ischemic heart disease) is 28%20,21. nevertheless, there is a downward trend for premature mortality from ncds (largely driven by reductions in cvd mortality), and projections suggest that kyrgyzstan will reach the global ncd target of a 25% reduction in mortality by 202521. in recent years, there has been a reduction in the total mortality rate due to cvd, with a decrease from 331.3 in 2012 to 300.9 per 100,000 in 201522. mortality rate reduction was also observed for stroke and acute myocardial infarction in men and women, although the reduction in the latter mortality rate was larger in women than men21. in contrast, according to the national statistics, mortality for all ages due to ischemic stroke has increased23. apart from the differences in risk factor prevalence, other reasons for higher mortality among http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.321|http://cajgh.pitt.edu men relate to lack of awareness of the signs, symptoms, and consequences of raised blood pressure and underutilization of health-care services24. kyrgyzstan has a relatively low gross domestic product compared to other post-soviet countries and was categorized as a low-income country by the world bank until 201425. however, the general government expenditure on health as a percentage of total government expenditure is relatively high compared to similar countries, with total expenditure on health close to that of 12 post-soviet median-income countries20. the trends in select causes of death are similar to those in other postsoviet countries, but are slower to change, which can be linked to the health-system’s limited capacity for early detection and treatment20. the prevalence of cardiovascular risk factors is high; these include diet, high blood pressure, and tobacco use21. a recent who study describing the nutritional composition of the foods sold in bishkek, kyrgyzstan, found that the amounts of trans-fatty acids and salt in common foods are extremely high compared to the developed contries26. high blood pressure was always on the top of the list of health problems identified during health assessments in kyrgyzstan population. it was the third most common disease for women, the second most common for men, and exerts a large burden on populations living in poverty20,22. government initiatives have been formed to focus on screening programs to improve people’s awareness of hypertension. since 2011, an annual “hypertension week” has been held, during which village health committees (vhcs) provided blood pressure screenings, and explained the dangers of elevated blood pressure and cvd27. the community action for health (cah) program 201427 has contributed to a significant improvements in the early detection and management of hypertension, and the number of people undergoing screening is increasing annually. since 2011, a total of 1.75 million people were screened for elevated blood pressure, comprising about half of the adult population of kyrgyzstan23. the cah program had a significant nationwide impact on hypertension awareness and control. according to who calculations from the nationally representative integrated household survey, hypertension awareness increased from 27% in 2007 to 45% in 201528. the increase was greater in rural areas, where vhcs work. as a result, a large urban–rural gap in awareness of hypertension status noted in 2007 had disappeared by 201528. compliance with antihypertensive medication also improved during this period. the proportion of people with elevated blood pressure who reported having taken their medication in the past 24 hours was 33% in 2015, in contrast to 14% in 200728. nicotine and alcohol consumption are important factors contributing to cvd mortality in kyrgyzstan. the prevalence of current tobacco smoking among kyrgyzstan population aged 15 years and older in 2013 was 3.7% for women, and 50.5% for men21. the total annual per capita alcohol consumption among people aged 15 years and older was 4.3 liters of pure alcohol per year in 201121. additionally, obesity is a problem in kyrgyzstan. in 2014, the percentage of overweight males and females aged 18 years and above was 45.2% and 49.1% respectively 21. the who steps ncd survey in 2013 reported that 42.9% of adults aged 25–64 years had elevated blood pressure (similar frequency in males and females) and 23.6% had an elevated total cholesterol levels (more common in females than in males)29. almost one in five (17.4%) adults were identified as being at high cardiovascular risk, i.e. the probability of their having a cardiovascular event or death in the next ten years was 30% or more. over a third of adults aged 25–64 years had three or more cardiovascular risk factors; this rate was higher among men (39.5%) and older age groups29. in kyrgyzstan, there is an established political and legislative framework for the prevention and control of cvd. there are a national strategy to combat ncds for 2013-2020, which recently passed a mid-term evaluation, and the national health reform program http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aringazina this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.321|http://cajgh.pitt.edu "den sooluk" for 2012-201622, which prioritizes the health of the cardiovascular system. the regulatory and fiscal framework for tobacco control is underdeveloped, but its scope can be expanded, and its enforcement can be strengthened22. funding of the cvd action plan includes implementation of a package of essential ncd (pen) interventions at the primary health-care level (pen protocols) as well as an article that provides free access to screening22. “den sooluk” was originally planned to end in 2016 but because of a delayed start, the government of kyrgyzstan and donor partners agreed to extend it until the end 2018. a mid-term review of “den sooluk” reported that 25% of the 96 indicators have been achieved or exceeded as part of the main goal of reducing the burden of cvd’s30. republic of tajikistan the epidemiological situation shows that cvd are the leading cause of death in tajikistan31. between 1990 and 2010, tajikistan had an increase in the burden of ncds, especially coronary heart disease and stroke31. in addition, it is estimated that about 40% of the total population is overweight and 9% is obese, which suggests a low level of physical activity and unhealthy dietary habits32. there is limited access to emergency medical services for the acute myocardial infarction. the most important services are provided at the level of the central district hospitals (prescribing aspirin, beta blockers, and angiotensin converting enzyme inhibitors), but access to thrombolytic therapy is limited33. for the treatment of stroke, obsolete methods are used that are not based on evidence-based medicine34. the country lacks evidence-based clinical guidelines for the management of stroke patients34. during 2005-2011, cvd mortality increased from 63 to 67 cases per 100,000, or approximately from 46.8% to 48.82% of the total death rate35. hypertension is among the major risk factors for cvd. many tajik women suffer from hypertension without knowing it; hypertension is often termed the ‘silent killer’ because of the lack of warning signs or symptoms. in the 2012, tajikistan demographic and health survey (tjdhs)32 respondents completed several questions to determine their history of hypertension, including whether they have ever been told by a doctor or other health worker that they had high blood pressure and, if so, whether they had been told that on two or more occasions. if surveyed women reported that on one or more occasions they were told that they had high blood pressure, they were asked additional questions on actions they were taking at the time of the survey to lower their blood pressure. overall, the tjdhs32 results indicate that 12% of women aged 15-49 reported having been told by a doctor or other health worker that their blood pressure was high. seventy-eight percent of women with high blood pressure reported that they were diagnosed with hypertension on two or more occasions. more than eight in ten of those women were taking medication to control their blood pressure. a significant percentage of women reported not taking other measures to lower their blood pressure; only 46% were cutting back on salt in their diet, 39% were controlling or losing weight, and 29% were exercising. as expected, the prevalence of women with high blood pressure increased with age, from 3% of women aged 15-19 to 29% of women aged 45-49. also, being overweight (bmi >25) was strongly correlated with high blood pressure. the proportion of women with high blood pressure was slightly higher in rural women compared to urban women (30% and 21% respectively). this can be explained by the fact that a relatively large proportion of women are receiving medical care in urban health facilities32. tajikistan made progress in the fight against tobacco by amending the law on restricting the use of tobacco products in early 201136 , and ratifying the who framework convention on tobacco control (who fctc)37 which was launched on september 19, 20133840. despite these amendments, the laws on tobacco control still need improvements. in particular, it is necessary to clarify and explain the terminology http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.321|http://cajgh.pitt.edu associated with what is considered to be tobacco products38. nevertheless, youth smoking monitoring and control are better in tajikistan compared to other ca countries. the global youth tobacco survey (gyts), an inter-country study conducted in ca, was conducted in tajikistan in 201441 and showed that in tajikistan only 5.9% of students used any tobacco products (6.8% of men and 2.8% of women), while the average results in other ca countries were reported to be higher (9.6%)41. the level of alcohol consumption in tajikistan is relatively low42. the total annual per capita alcohol consumption among people aged 15 years and above was 4.3 liters of pure alcohol per year42. according to the recent survey of rural population, only 12.2% of men and 0.1% of women consumed alcohol38. among the urban population, 39% of men and 6.7% of women consumed alcohol38. advertising alcohol is prohibited in tajikistan, although it can still be found in retail stores. tajikistan has made progress in promoting healthy eating and physical activity. in 2011, a governmental intersectoral working group was established to develop and implement the strategy for improving nutrition and physical activity, including an action plan for 2013-2020 based on who strategies43. the strategy defines priority areas, such as reducing consumption of salt, trans-fats, and sugar, and promotes exclusive breastfeeding, timely and appropriate supplementary nutrition, as well as a healthy diet and physical activity. since 2004, tajikistan has implemented a series of comprehensive measures to reform the health sector to address the problem of limited access to health services. the reforms envision changing the organization and provision of medical services by moving to the family medicine model and introducing appropriate financial mechanisms to reduce the level of out-of-pocket cash payments44-46. these efforts still face challenges, in particular, the need to expand the coverage of basic individual services, strengthen the tobacco control, increase the level of state funding, strengthen the coordination between providers, and improve the quality of medical services at the level of primary health care. republic of uzbekistan uzbekistan registers more than 1.5 million acute and chronic cvd cases on an annual basis, with more than half a million of them being newly diagnosed cases. over the past 10 years, the level of primary and general morbidity in this population has increased47. since 2003, the primary incidence rate has increased 1.4 times (from 1,291 to 1,759 per 100,000), and the general prevalence increased 1.2 times (from 4,672 to 5,503 per 100,000)48. detection of the primary morbidity and registration of general morbidity from cvd among the adult population increased 1.3 and 1.1 times (7,154 and 6,053 per 100,000) respectively48. morbidity from cvd among children (0-14 years) and teens (15-18 years old) has decreased 1.2 times (4,586 per 100,000) between 2003 and 201348. such a decrease among younger age groups is probably associated with a program on maternal and child health implemented in 1998. the increase in the level of primary and general morbidity from cvd among the adult population is probably due to the increase in life expectancy in the country from 67 to 73.1 years48. in addition, the measures taken in the republic of uzbekistan to improve the quality of primary health care, and the development of healthy lifestyles have increased the number of individuals receiving medical care48. the level of coverage by preventive examinations of certain population groups for the study period increased to 8889% for adults and to 99-99.6% for children49. the level of access to doctors in polyclinics (primary care facilities) and rural medical stations increased 1.3 times when compared to 2003 and amounted to 9 visits per capita per year in 201349. it is estimated that by 2020 the level of the primary and general morbidity from the cvd across the republic will be 2,069 per 100,000 (60% increase) and 6,062 per 100,000 (30% increase) respectively48. cvd traditionally have low-ranking positions on the list of morbidity causes, contributing only 6.8% of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aringazina this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.321|http://cajgh.pitt.edu all causes of morbidity in 2013. this may be explained by the relatively young population; 32% of population is under 18 years of age. however, in the structure of the causes of death in the country, they occupy a leading place, and in 2012 their share was 61.6%48. among all leading causes of the overall morbidity 40.4% is occupied by diseases characterized by an elevated blood pressure, including hypertension with target organ damage (14.2%), angina (7.7%), chronic ischemic disease heart disease (7.0%), cerebrovascular disease (4.1%), acute myocardial infarction (0.54%), and 5.9% by chronic rheumatic heart disease48. a study aimed at hypertension, the women's and men's questionnaires for the uzbekistan health examination survey (uhes), was performed in 2002 with no more recent data available. rates of hypertension among women aged 15-49 and men aged 15-59 were 7 to 8% respectively50. 74% of women had a blood pressure reading in the optimal range (< 120/80 mmhg) compared to 48% of men50. in general, rates of hypertension were positively associated with age, education, urban residence, and being overweight/obese. more hypertensive women than men were aware of their condition (62% versus 37%), and higher number of women than men managed their condition with medication (37% versus 10%)50. in uzbekistan, a study based on the who steps methodology was conducted between january and april of 201451. this study suggested that the prevalence of smoking among adults (18-64 years) was 14.4% (26.8% of men and 1.4% of women)51. smoking is prohibited in all enclosed public places except for designated smoking areas. however, there are no specially allocated funds to enforce this ban, nor is there a system for filing and considering citizens' complaints about violations of the smoking ban52. in accordance with the law on advertising, adopted in 1998, which was subsequently amended53, and the law on restricting the distribution and consumption of alcohol and tobacco products adopted in 2011, certain types of direct and indirect advertising of tobacco products are banned. however, in the event of violation of these prohibitions, a penalty in the form of a fine is not enforced52. according to the recent rural population survey, only 12.2% of men and 0.1% of women used alcohol38. these figures were 39% for men and 6.7% for women in urban populations37,54. the total annual per capita alcohol consumption among people aged 15 years and above was 4.6 liters of pure alcohol per year51. prices on alcohol are quite low and may stimulate an increase in alcohol consumption. conclusions ncds, and particularly cvd, present a challenge for the ca. ischemic heart disease and stroke are major causes of premature mortality, and the prevalence of cardiovascular risk factors is high within the ca population. some of the regional governments have committed themselves to tackling the problem, as evidenced by the policy framework and some of the measures already in place. in ca countries stroke and ischemic heart disease are more prominent among ncds. this is most likely due to a higher prevalence of cvd risk factors in ca countries. reduction in salt consumption in ca countries is important for the reduction of cvd, especially for stroke. the high prevalence of elevated blood pressure is of great concern due to the fact that some with elevated blood pressure may be unaware of their condition. such persons should be followed up and advised to utilize existing primary and secondary prevention opportunities. secondly, those who were previously diagnosed with high blood pressure and were not effectively treated need to be followed up with by health care providers. prevention of smoking is also an important strategy for reducing cvd in most ca countries, especially for men. smoking increases the risk of developing cvd by approximately 30%55. the steps survey will provide invaluable information needed to inform policy and planning. tobacco smoking is an http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.321|http://cajgh.pitt.edu important modifiable behavioral risk factor in ca. second hand smoking is something that has been rarely evaluated in ca and needs to be considered in future research. heavy alcohol consumption remains an important risk factor for global burden of cvd56. nearly all the data on humans exploring the relationship between alcohol consumption and cvd risk, including some indications of potential cvd benefits associated with low-to-moderate alcohol consumption, are derived from epidemiologic studies. therefore, because there are no randomized controlled trials, health care professionals should not recommend alcohol consumption as a primary or secondary lifestyle intervention. instead, clinicians should continue to recommend strategies such as a healthy diet and exercise. for example, certain levels of alcohol consumption that lower risk for chd may increase it for other cv conditions, such as stroke. in addition, data from studies using new research methods, including mendelian randomization, suggest that the relationship between low-to-moderate alcohol consumption and cardioprotection merits more critical appraisal56. the prevalence of obesity is also increasing in the region, potentially leading to the increased prevalence of diabetes, impaired glucose control, and metabolic syndrome. since these conditions influence cardiovascular health, we will focus on these conditions in our future research. as of 2017, there were no major studies focusing on these problems in the region. we believe that the problem of obesity and diabetes deserves close attention from the regional institutions, who, and other international organizations. references 1. feigin vl, forouzanfar mh, krishnamurthi r, et al. global and regional burden of stroke during 1990–2010: findings from the global burden of disease study 2010. lancet. 2014;383(9913):245-254. 2. feigin vl, krishnamurthi rv, parmar p, et al. update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: the gbd 2013 study. neuroepidemiology. 2015;45(3):161-176. 3. yusuf s rs, ounpuu s, anand s. global burden of cardiovascular diseases: part i: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. circulation. 2001;104(22):2746-2753. 4. world health organization. world health statistics 2009. http://www.who.int/whosis/whostat/2009/en/. accessed 11 june, 2018. 5. starr sf. lost enlightenment: central asia's golden age from the arab conquest to tamerlane. 2015. 6. health of the population of the republic of kazakhstan and the activities of health organizations in 2014. ministry of health of the republic of kazakhstan;2015. 7. aringazina a. development and sustainability: the challenge of social change. london: zed books ltd.; 2016. 8. health of population and health care in the republic of kazakhstan in 2013. 2013; www.medinfo.kz. accessed 11 june, 2018. 9. state program on health systems' development for the years 2011 2015. ministry of health of the republic of kazakhstan;2010. 10. order of the ministry of health #145. ministry of health of the republic of kazakhstan; 2011. 11. order of the ministry of health #704. ministry of health of the republic of kazakhstan; 2010. 12. basic indicators of population health and activity of health organizations of the republic of kazakhstan from 2000 to the present. http://www.medinfo.kz/#/dpsraion. accessed 11 june, 2018. 13. report on the global tobacco epidemic, 2013. world health organization;2013. 14. law of the republic of kazakhstan on ratification of the who framework convention on tobacco control. 2006. 15. decision no. 6 of the chief sanitary doctor: "on the introduction of a ban on smoking hookah in public places.". ministry of health of the republic of kazakhstan; 2013. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/whosis/whostat/2009/en/ http://www.medinfo.kz/ http://www.medinfo.kz/#/dpsraion aringazina this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.321|http://cajgh.pitt.edu 16. organization wh. global status report on alcohol and health 2014. geneva2014. 17. state programme "densaulyk" for health care system development in republic of kazakhstan 2016 2019. 2016. 18. v.v. benberin vyd, a.k. kaptagaeva, т.а. voshchenkova, т.т. kulkhan brain stroke as the cause of death in the republic of kazakhstan: some risk management factors. the journal of neuroscience of bm mankovskyi. 2016;4(1). 19. jill farrington frp, alexei yakovlev, oxana rotar. review of acute care and rehabilitation services for heart attack and stroke in kyrgyzstan. world health organization;2017. 20. national statistics data 2015. bishkek: centre for medical information, 2015. 21. institute of health metrics and evaluation. kyrgyzstan. http://www.healthdata.org/kyrgyzstan. accessed 11 june, 2018. 22. mid-term review report of den sooluk national health reform program of the kyrgyz republic for 2012-2016 bishkek2016. 23. m jakab lh, b loring, j tello, t egruder, m kontas. better noncommunicable disease outcomes: challenges and opportunities for health systems. kyrgyzstan country assessment. copenhagen: world health organization;2014. 24. aida abdraimova ai, aida zurdinova reasons for low health care seeking among men with hypertension in kyrgyzstan. bishkek: world health organization;2016. 25. world bank. kyrgyz republic. https://data.worldbank.org/country/kyrgyzrepublic. 26. global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the global burden of disease study. the lancet. 2015;385(9963):117-171. 27. community action for health. http://www.cah.kg. accessed 11 june, 2018. 28. t schuth ea. the community action for health programme in the kyrgyz republic. swiss red cross;2014. 29. kyrgyzstan steps survey 2013: fact sheet. world health organization;2015. 30. anderson i bm, obermann k, temirov a, ibragimova g. independent review of den sooluk and project in support of the mid-term review. world health organization;2016. 31. non-communicable disease country profile: tajikistan. world health organization;2011. 32. tajikistan demographic and health survey statistical agency under the president of the republic of tajikistan;2012. 33. baktygul akkazieva jt, barton smith, melitta jakab, konstantin krasovsky,nina sautenkova, lola yuldasheva, mekhri shoismatuloeva. better non-communicable disease outcomes: challenges and opportunities for health systems. world health organization;2015. 34. baktygul akkazieva jt, barton smith, melitta jakab, konstantin krasovsky,nina sautenkova, lola yuldasheva, mekhri shoismatuloeva, et al. improving indicators for noncommunicable diseases: barriers and opportunities for health systems. world health organization. 35. rose g. sick individuals and sick populations. international journal of epidemiology. 2001;30(3):427-432. 36. law on restriction of the use of tobacco products. dushanbe: government of the republic of tajikistan; 2011. 37. who framework convention on tobacco control. world health organization;2003. 38. rural population survey (2009-2010). state statistical agency under the president of the republic of tajikistan;2011. 39. framework convention on tobacco control. dushanbe: the government of the republic of tajikistan; 2013. 40. health of the population and the effectiveness of the work of medical institutions in the republic of tajikistan republican center for medical statistics and information;2013. 41. global youth survey on the use of tobacco products republic of tajikistan. world health organization;2014. 42. o smith sn. improving the situation: the results of the health system in europe and central asia. the world bank;2013. 43. list of vital medicines. world health organization;2014. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.healthdata.org/kyrgyzstan https://data.worldbank.org/country/kyrgyz-republic https://data.worldbank.org/country/kyrgyz-republic http://www.cah.kg/ central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.321|http://cajgh.pitt.edu 44. national development strategy of the republic of tajikistan for 2005-2015. government of republic of tajikistan;2005. 45. strategy of health financing for 2005-2015. government of republic of tajikistan;2005. 46. national health strategy of the republic of tajikistan for 2010-2020. the government of the republic of tajikistan;2010. 47. babadzhanov as, rustamova h. y., stozharova n. k., eshboeva k. u. retrospective analysis of the incidence of the population of uzbekistan bulletin of the tashkent medical academy. 2011(3):97-100. 48. stozharova n.k. mmd, sadullaeva k.a., sharipova s.a. analysis of prevalence of the cardiovascular diseases in the population of uzbekistan. young scientist. 2015;90(10). 49. zhaldasov a. evaluation of experimental results in urban experimental phc facilities tashkent: center for social and marketing research;2010. 50. uzbekistan health examination survey 2002. 2002. 51. uzbekistan steps survey 2014. world health organization;2014. 52. who report on the global tobacco epidemic. world health organization;2015. 53. tobacco control database for the who european region 2016; http://data.euro.who.int/tobacco/. accessed 27 december, 2016. 54. urban population survey (1998-2003). dushanbe: state statistical agency under the president of the republic of tajikistan 2011. 55. rehm j, mathers c, popova s, thavorncharoensap m, teerawattananon y, patra j. global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. lancet. 2009;373(9682):2223-2233. 56. holmes mv, dale ce, zuccolo l, et al. association between alcohol and cardiovascular disease: mendelian randomisation analysis based on individual participant data. bmj : british medical journal. 2014;349. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://data.euro.who.int/tobacco/ burden of the cardiovascular diseases in central asia abstract keywords: cardiovascular diseases; epidemiology; central asia burden of the cardiovascular diseases in central asia research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. association of rs2294008 and rs9297976 polymorphisms in psca gene with gastric cancer susceptibility in uzbekistan shahlo turdikulova1, dilbar dalimova1, abror abdurakhimov1, bekzod adilov1, sarimbek navruzov2, abror yusupbekov2, mirjalol djuraev2, suleyman abdujapparov2, dilshod egamberdiev2, rustam mukhamedov1 1institute of bioorganic chemistry academy of sciences republic of uzbekistan; 2national cancer center of the ministry of health of the republic of uzbekistan vol. 5, no. 1 (2016) | issn 2166-7403 (online) doi 10.5195/cajgh.2016.227 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ turdikulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu abstract introduction: genetic factors play an important role in the development of gastric cancer (gc), a prevalent malignancy in central asia. recent studies have shown that single-nucleotide polymorphisms (snps) in several genes are associated with increased gc risk, indicating that genetic variation contributes to gastric carcinogenesis. located on chromosome 8q24.2, the prostate stem cell antigen (psca) gene encodes a 123-amino acid glycoprotein related to the cell-proliferation inhibition and cell-death induction activity. snps in psca gene have been found to be associated with gastric cancer risk in a genome-wide association study, but results were not conclusive. this study aimed to investigate the association between two polymorphic variants of psca gene (rs2294008 and rs9297976) and the susceptibility to gastric cancer in uzbekistan. methods: two hundred sixty eight patients with gastric cancer and a control group of 248 healthy individuals were included in this study. dna samples isolated from these groups were genotyped using pcr-rflp method. comparative analysis of resulting genotypes showed a statistically significant association between ct genotype and gastric cancer (p=0.03, additive model of inheritance, cochran-armitage trend test). results: comparative analysis of the distribution of genotypes of rs2976392 polymorphism did not show a statistically significant difference; however, analysis of the distribution of the rs2976392 genotypes in a subgroup of young women revealed a statistically significant (p = 0.04, additive model of inheritance, cochran-armitage trend test) increase in the incidence of aa (38%) and ag (56%) genotypes in patients with gc, compared to the controls (20% and 40%). conclusion: our findings support that psca rs2294008 and rs9297976 polymorphism may contribute to the susceptibility to gastric cancer. genotyping of these polymorphisms can potentially be recommended as one of the criteria for identification of high risk groups for gastric cancer development in uzbekistan. keywords: gastric cancer, rs2294008, rs9297976, genotyping, uzbekistan association of rs2294008 and rs9297976 polymorphisms in psca gene with gastric cancer susceptibility in uzbekistan shahlo turdikulova1, dilbar dalimova1, abror abdurakhimov1, bekzod adilov1, sarimbek navruzov2, abror yusupbekov2, mirjalol djuraev2, suleyman abdujapparov2, dilshod egamberdiev2, rustam mukhamedov1 1institute of bioorganic chemistry academy of sciences republic of uzbekistan; 2national cancer center of the ministry of health of the republic of uzbekistan research gastric cancer (gc) is the fifth most common cancer in the world, with 952,000 new cases diagnosed in 2012.1 although the incidence of gastric cancer has declined in the general population in the us and in many countries around the world,2 it remains highly prevalent in asia as compared to the west. the estimated rate of gastric cancer in uzbekistan is 18.4% out of all cancer cases3 and gc remains a significant cause of cancer morbidity and mortality in central asia. therefore, gc represents one of the key challenges in the development of cancer prevention and control strategy in uzbekistan. carcinogenesis is multi-stage process resulting from both exogenous factors (environmental and lifestyle) and endogenous factors (genetic, hormonal, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu immune). in asia, the prevalence of helicobacter pylori (h. pylori) infection varies markedly in different countries, and is an important etiological factor for the occurrence of gastric adenocarcinoma.4 previous study on the role of nutritional factors associated with gc in urban dwellers of uzbekistan showed that the most important factors associated with this malignancy were intake of un-boiled water, artesian water, unrefined vegetable oil, margarine, animal fats, dietary salt, and daily consumption of meat-broth.5 the link between gc and water consumption may be explained by salt content in drinking water in some regions of uzbekistan.6 genetic factors also play an important role in the development of gastric cancer (gc). previously published systematic review suggested that individuals who carry high-risk genetic variants and demonstrate particular dietary habits (such as high consumption of salty foods) may have an increased risk of gastric cancer compared with those who do not carry high-risk genetic variants.7 recent studies have shown that singlenucleotide polymorphisms (snps) in several genes are associated with increased gc risk, indicating that genetic variation contributes to gastric carcinogenesis. the prostate stem cell antigen (psca) gene is located on chromosome 8q24.2 and encodes a 123amino acid cell surface protein with 30% homology to stem cell antigen type 2 (sca-2).8 psca has been reported to be expressed mainly in differentiating cells rather than stem cells.9,10 psca belongs to the thy1/ly-6 family. members of this family show a remarkable functional diversity ranging from t-cell activation to apoptosis regulation in the nervous system.11 psca is expressed in the epithelium of several organs, such as prostate, bladder, gallbladder, and stomach. in the gastric epithelium, the main expression sites are the isthmus and neck regions, which contain differentiating cells. the expression of psca is downregulated in the gastric tissue with intestinal metaplasia.9 the first genome-wide association study (gwas) on gc, performed in japanese population, revealed an association between snp rs2294008 of psca and risk of the diffuse type of gc. substitution of c to t at rs2294008 in the first exon creates a novel translation start site (met instead of thr), which leads to the extension of the protein by 9 amino acids which changes the transcriptional activity of the gene.2 the association between rs2294008 and gc risk has been replicated in caucasian and in some asian populations.12-16 two other snps (rs9297976 and rs12155758) were also discovered to be associated with gc in europeans.13 to date, an exploration of the association of the psca gene snps with gc has not been performed in the central asia populations. uzbeks are the ideal group to investigate in this context, as they represent the largest and fastest growing population in central asia. uniquely positioned on the route of the ancient silk road, the uzbek population is a very interesting population to investigate in regard to its cultural, socioeconomic, and genetic diversity. it is remarkable to note that uzbek population has been formed by admixture of two or more ancestral populations, thus it offers a unique opportunity for studying the interaction between gene polymorphisms, ethnicity specific genetic factors, as well as environmental contributions to disease occurrence. the epidemiology of gastric cancer subtypes suggests there is a difference in the genetic background between asian and caucasian groups. for example “allele flip” between asian and non-asian groups is observed, most prominently in polymorphisms of il1b and il-10.17 in addition, an ethnic difference in terms of mutation frequency in mlh1 (an important gene for dna mismatch repair that is associated with gc) between eastern asians and western populations have been revealed.18 the key aim of this research is to investigate the association between two polymorphic variants of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx turdikulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu psca gene (rs2294008 and rs2976392) and link them to gc susceptibility in uzbek populations. methods participants a total of 268 patients (168 males and 100 females) with gastric cancer who underwent surgery in the internal medicine department at the national cancer center of the ministry of health of the republic of uzbekistan (ncc moh uzb) and tashkent regional oncological dispensary, were recruited from 2011 to 2013. all subjects were unrelated uzbeks from tashkent city and various regions of uzbekistan. all cancer diagnoses were pathologically confirmed. clinical data and pathological characteristics of patients were collected and confirmed from both their medical records and questionnaire data. the control group constituted of 248 healthy individuals (131 males and 117 females) without a family history of gastric cancer. cancer patients were recruited through tashkent regional oncological dispensary. control cases were obtained from previously implemented study of healthy uzbekistan people residing in the same catchment area as the majority of our cancer cases. before taking part in a study all study participants gave their informed consent. the study was conducted according to the standards of the national ethic committee of uzbekistan developed in accordance with the world medical association’s declaration of helsinki "ethical principles for medical research involving human subjects" with amendments (2013) and approved by ncc moh uzb. according to the previously published data, the prevalence of gc in young patients ranged from 4.4% to 16.2% of all gc cases when the cut-point was set at 40 years old.19,20 in light of these studies and also due to the fact that intestinal metaplasia, an aging process due to acid reflux affecting the gastric mucosa, mostly affects patients above the age of 40 years with no significant gender difference,21 we also have used this cut-point, when dividing the participants into 4 subgroups. these subgroups were as follows: men older than 40 years (n=139), women over 40 years (n=84), men up to 40 years (n=29), and women up to 40 years of age (n=16). laboratory methods blood samples (2 ml) were drawn from an antecubital vein, which were collected using vacutainers containing sodium citrate. samples were stored at −20°c until they were ready for analysis. genomic dna was extracted from peripheral blood leucocytes by using dna extraction kit diatom™ dna prep 200 (isogen laboratory,22 moscow, russia). rs2294008 and rs2976392 polymorphisms were genotyped by means of polymerase chain reaction-restriction fragment length polymorphism (pcr-rflp). primer sequences for rs2294008 and rs2976392 were as follows: sense5’-gaaacccgctggtgttgactgt3’ andantisense5’-gggcaagcagcacagcctac-3’ forrs2294008; sense 5’atctttctggccatctgtccgcagct-3’ and antisense5’-ggcagatggaccacccgctg-3’ for rs2976392. pcr mixture(25 µl) consisted of 13 µl of ddh2o, 2.5 µl 10xpcr buffer, 2.5 µl 25 mm mgcl2, 2.5 µl 2.5 mmdntp mix, 1,5 µl (10pkmol/µl) of each oligonucleotide primer, 0.3 µl (1.5 units) "hot-start" taq-polymerase, and 3 µl of dna. pcr amplification was carried out in geneamp 9700(applied biosystems). the pcr conditions were as follows for rs2294008: 95 °c for 5 minutes, and then 33 cycles of 94°c for 45 seconds, 62°c for 30 seconds, and 72 °c for 30 seconds, and a final extension step of 72°c for 5 minutes. pcr conditions for rs2976392 were: 95 °c for 5 minutes, and then 33 cycles of 95°c for 40 seconds, 60°c for 30 seconds, and 72 °c for 40 seconds, and a final extension step of 72°c for 5 minutes. protocol for implementing these studies has been developed at the laboratory where this study was conducted. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu pcr products were digested overnight at 370c with hpych4iv (new england biolabs) for rs2294008 and pvuii (new england biolabs) for rs2976392 and then separated by electrophoresis on 3% agarose with ethidium bromide staining and were visualized using wisedoc wgd-30 (daihan, korea). statistical analysis the hardy-weinberg equilibrium was tested by a goodness-of-fit χ2 test to compare the observed genotype frequencies with the expected ones among the control subjects. genotypic associations of snps were evaluated by cochran-armitage trend test, followed by risk assessment using odds ratio (or) and 95% confidence of interval (ci) computation. all statistical analyses were performed by using stata software version 12.0 for windows (stata corporation, usa). a p<0.05 (two-sided) was considered statistically significant. results genotype frequencies of psca rs2294008 and rs2976392 polymorphisms in patients with gastric cancer and controls are shown in figures 1 and 2. the genotype distributions of these polymorphisms were in hardy–weinberg equilibrium in control groups (p >0.05). figure 1: genotype distribution of prostate stem cell antigen rs2294008 polymorphism in control group and in subgroup of young women with gastric cancer figure 2: genotype distribution of prostate stem cell antigen rs2976392 polymorphism in control group and in patients with gastric cancer (both males and females included) comparative analysis of rs2294008 genotypes between patients and controls showed a significant association between the ct genotype and gastric cancer (p=0.03, additive model of inheritance, cochranarmitage trend test) (see table 1). the or of increased relative risk of developing gastric cancer for ct genotype carriers was 3.11 (95% ci: 2.16 – 4.47). table 1: association between the genotypes of rs2294008 and gastric cancer comparative analysis of the genotype distribution for rs2976392 polymorphism did not show a statistically significant difference between the cases and controls. for the further analysis of rs2976392 genotypes, the group of patients with gastric cancer was divided into 4 subgroups according to gender and age. comparative analysis of the distribution of alleles and genotypes of rs2976392 polymorphism did not show a statistically significant difference between subgroups of patients and controls for both men and women of advanced age (over 40 years) and young men (up to 40 years)(see table 2 and 3). however, analysis of the distribution of the rs2976392 genotypes in subgroup of young women revealed a statistically significant (p=0.04, additive model of inheritance, cochran-armitage trend test and p=0.03, fisher’s exact test) increase in the incidence of aa (38%) and ag (56%) genotypes in patients with gc, compared to the controls (20% and 41%). the or of developing gastric cancer for carriers of the aa and ag genotype was 2.35 (95% ci: 0.71-7.76) and 1.88 (95% ci: 0.61-5.72), respectively. table 2: comparative analysis of the distribution of alleles of rs2976392 and gastric cancer http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx turdikulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu table 3: association between the genotype frequencies of rs2976392 and gastric cancer discussion results of our study confirm the association between the t allele of rs2294008 (ct genotype) with gc risk. three previous gwas studies revealed a significant association of the t allele of rs2294008 with the risk of gc9,23,24 and the c allele for duodenal ulcer.25 several case-control studies replicated the association of this snp with gc in asian and caucasian populations.26,27 the results of the present study also indicated that genetic effect of psca rs2976392 polymorphism in uzbek population is only present in the subgroup of women under the age of 40. this is consistent with the fact that complex genetic diseases, such gc are likely to arise due to multiple, potentially interacting, genetic and environmental factors, and therefore are challenging to study. presumably, many of these environmental and genetic risk factors are interconnected, with other factors, such as ethnicity, specific genetic background, and endocrine factors, and are likely to be key modifiers of these risk factors. this general phenomenon is known as effect modification, and represents an interaction between two or more variables. there is some evidence regarding the potential role of estrogen receptors in the regulation of normal development and functioning of the gastric mucosa cells, as well as in the process of tumorogenesis28, which provide an intriguing reason to investigate the stomach in relation to estrogen exposure. in this respect, some authors have suggested a close link between receptor mechanism of estrogen action and the growth and proliferation of gastric tumor cells. in one-third of patients with gastric cancer, estrogen receptors have been identified in gastric tumors, suggesting a possible involvement of estrogens in gc development.29 at the molecular level, the estrogen receptors function as ligand dependent transcriptional factors that activate or inhibit the expression of target genes in response to hormonal stimulation. it is also interesting to note that estrogen receptors regulate psca gene expression, since there is an "er-binding site" in the promoter region of psca gene.30 perhaps this may explain the association of rs2976392 with gc in the subgroup of young women, since they have high levels of estrogen hormones. it should be noted that there are several limitations of this study. the data concerning subgroup of young women (under the age of 40) with gc may not accurately reflect the prevalence of rs2976392 genotypes in the general population of young women of uzbekistan because of the small sample size of this subgroup. a large-scale study of young women with gc is needed to evaluate more precisely the contribution of these genotypes to the development of gc in this cohort. our future studies will evaluate more closely the contribution of helicobacter pylori infection to the gc in our cohorts. overall, considering the burden of gc in asia, this study is very important for uzbekistan and the entire asian continent. in addition, further research on deep sequencing of the psca gene is needed to determine the full allelic spectrum of causal variants underlying predisposition to gc and to discover rare variants. it is reasonable to hypothesize that not only the common gwas variants are responsible for gc risk in uzbekistan, but also that these loci may contain high effect rare risk variants that have gone undetected by gwas. it is plausible that future analyses of lowfrequency (0.5% ≤ maf < 5%) and rare (maf < 0.5%) variants of the psca gene using next-generation sequencing (ngs) technologies could explain additional gc disease risk in uzbekistan. in summary, the results of our research provided preliminary evidence that psca rs2294008 and rs9297976 polymorphism may contribute to gastric cancer risk in uzbekistan. as studies of this nature are rare in uzbekistan, this research has important http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.google.ru/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0ccsqfjacahukewjzptqek4diahwf9hikhzfkcwo&url=http%3a%2f%2fwww.sciencedirect.com%2fscience%2farticle%2fpii%2fs106345841100029x&usg=afqjcnhvwi0h6w0tr89tqohcpcrgxnomsg&bvm=bv.102829193,d.bgq https://www.google.ru/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0cbsqfjaaahukewjzptqek4diahwf9hikhzfkcwo&url=http%3a%2f%2fwww.nature.com%2farticles%2fncomms9018&usg=afqjcneu_b61wbzeojir7xfvnkhjbt4txa&bvm=bv.102829193,d.bgq https://www.google.ru/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0cbsqfjaaahukewjzptqek4diahwf9hikhzfkcwo&url=http%3a%2f%2fwww.nature.com%2farticles%2fncomms9018&usg=afqjcneu_b61wbzeojir7xfvnkhjbt4txa&bvm=bv.102829193,d.bgq central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu implications for both uzbekistan, and central asian population due to high burden of gc. genotyping of these polymorphisms can potentially be recommended as a criterion for identification of high risk groups for the development of gastric cancer in uzbekistan. references 1. world cancer research fund internaltional stomach cancer statistics. 2012; http://www.wcrf.org/int/cancer-factsfigures/data-specific-cancers/stomach-cancer-statistics. accessed june 9, 2016. 2. crew kd, neugut ai. epidemiology of gastric cancer. world j gastroenterol. 2006;12(3):354-362. 3. machii r, saika k. burden of cancer in asia extrapolated from the who mortality database. jpn j clin oncol. 2013;43(2):218. 4. fock km, ang tl. epidemiology of helicobacter pylori infection and gastric cancer in asia. j gastroenterol hepatol. 2010;25(3):479-486. 5. yu y, assesorva, v, kireev, g. the role of several nutritional factors in causing gastric cancer in city-dwellers of uzbekistan. oncosurgery. 2012;4(1):76-79. 6. kawabata y, aparin, v, nagai, m, fujii, y, yamada, m, hirano, t, onwona-agyeman, s, katayama, y. changes in water quality of amu-darya river and ground water in karakalpakstan, uzbekistan. j of arid land studies. 2015;25(3):125-128. 7. kim j, cho ya, choi wj, jeong sh. gene-diet interactions in gastric cancer risk: a systematic review. world j gastroenterol. 2014;20(28):9600-9610. 8. reiter re, gu z, watabe t, et al. prostate stem cell antigen: a cell surface marker overexpressed in prostate cancer. proc natl acad sci u s a. 1998;95(4):1735-1740. 9. sakamoto h, yoshimura k, saeki n, et al. genetic variation in psca is associated with susceptibility to diffusetype gastric cancer. nat genet. 2008;40(6):730-740. 10. tran cp, lin c, yamashiro j, reiter re. prostate stem cell antigen is a marker of late intermediate prostate epithelial cells. mol cancer res. 2002;1(2):113-121. 11. saeki n, gu j, yoshida t, wu x. prostate stem cell antigen: a jekyll and hyde molecule? clin cancer res. 2010;16(14):3533-3538. 12. lochhead p, frank b, hold gl, et al. genetic variation in the prostate stem cell antigen gene and upper gastrointestinal cancer in white individuals. gastroenterology. 2011;140(2):435-441. 13. sala n, munoz x, travier n, et al. prostate stem-cell antigen gene is associated with diffuse and intestinal gastric cancer in caucasians: results from the epic-eurgast study. int j cancer. 2012;130(10):2417-2427. 14. song hr, kim hn, piao jm, et al. association of a common genetic variant in prostate stem-cell antigen with gastric cancer susceptibility in a korean population. mol carcinog. 2011;50(11):871-875. 15. wang m, bai j, tan y, et al. genetic variant in psca predicts survival of diffuse-type gastric cancer in a chinese population. int j cancer. 2011;129(5):1207-1213. 16. zeng z, wu x, chen f, et al. polymorphisms in prostate stem cell antigen gene rs2294008 increase gastric cancer risk in chinese. mol carcinog. 2011;50(5):353-358. 17. juwon k, yoonjung, k, kyung al. ethnic differences in gastric cancer genetic susceptibility: allele flips of interleukin gene. world j gastroenterol. 2014;20(16):4558–4565. 18. zhi w, xue b, wang l, et al. the mlh1 2101c>a (q701k) variant increases the risk of gastric cancer in chinese males. bmc gastroenterol. 2011;11:133. 19. kunisaki c, akiyama h, nomura m, et al. clinicopathological features of gastric carcinoma in younger and middle-aged patients: a comparative study. j gastrointest surg. 2006;10(7):1023-1032. 20. hsieh fj, wang yc, hsu jt, liu kh, yeh cn. clinicopathological features and prognostic factors of gastric cancer patients aged 40 years or younger. j surg oncol. 2012;105(3):304-309. 21. bashar a, khesar, hk, zobayda, as. prevalence of intestinal metaplasia and dysplasia in infectious and noninfectious chronic gastritis. int j res med sci. 2015;3(9):22282231 22. isogen life science. 2016; http://www.isogenlifescience.com. accessed june 20, 2016. 23. rothman n, garcia-closas m, chatterjee n, et al. a multi-stage genome-wide association study of bladder cancer identifies multiple susceptibility loci. nat genet. 2010;42(11):978-984. 24. wu x, ye y, kiemeney la, et al. genetic variation in the prostate stem cell antigen gene psca confers susceptibility to urinary bladder cancer. nat genet. 2009;41(9):991-995. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.wcrf.org/int/cancer-facts-figures/data-specific-cancers/stomach-cancer-statistics http://www.wcrf.org/int/cancer-facts-figures/data-specific-cancers/stomach-cancer-statistics http://www.isogen-lifescience.com/ http://www.isogen-lifescience.com/ turdikulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu 25. tanikawa c, urabe y, matsuo k, et al. a genome-wide association study identifies two susceptibility loci for duodenal ulcer in the japanese population. nat genet. 2012;44(4):430434, s431-432. 26. chandra v, kim jj, gupta u, mittal b, rai r. impact of dcc (rs714) and psca (rs2294008 and rs2976392) gene polymorphism in modulating cancer risk in asian population. genes (basel). 2016;7(2). 27. gu y, dai qs, hua rx, et al. psca s2294008 c>t and rs2976392 g>a polymorphisms contribute to cancer susceptibility: evidence from published studies. genes cancer. 2015;6(5-6):254-264. 28. singh s, poulsom, r, wright, na, shephard, mc, langman, mjs. differential expression of oestrogen receptor and oestrogen inducible genes in gastric mucosa and cancer. gut. 1997;40:516-520. 29. johansson j, thulin l, ferno m, andren-sandberg a. estrogen receptors in gastric cancer. acta oncol. 1991;30(7):870-872. 30. merrell kw cj, smith rl, sin jh, kmetzsch ke, merrell a, miguel ro, candelaria nr, lin cy. differential recruitment of nuclear receptor coregulators in ligand-dependent transcriptional repression by estrogen receptor-a. oncogene. 2011;30:1608–1614. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu figure 1: genotype distribution of prostate stem cell antigen rs2294008 polymorphism in control group and in subgroup of young women with gastric cancer 0% 10% 20% 30% 40% 50% 60% cc ct tt 20% 41% 39% 38% 56% 6% control cases genotype http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx turdikulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu figure 2: genotype distribution of prostate stem cell antigen rs2976392 polymorphism in control group and in patients with gastric cancer (both males and females included) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu table 1: association between the genotypes of rs2294008 and gastric cancer genotype controls cases additive model* or (95% ci) n (%) n(%) cc 119 (48) 78 (29) χ2= 4.97 p=0.03 0.45 (0.31 – 0.64) ct 109 (44) 190 (71) 3.11 (2.16 – 4.47) tt 20 (8) 0 (0) 0.02 (0.00 – 0.35) *using cochran-armitage trend test http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx turdikulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu table 2: comparative analysis of the distribution of alleles of rs2976392 and gastric cancer subgroup genotype controls cases additive model or (95% ci) n (%) n (%) men (>40 yrs) aa 14 (24) 40 (29) χ2= 0.12 p=0.73 1.70 (0.86 – 3.39) ag 38 (52) 51 (36) 0.53(0.30 – 0.95) gg 21 (24) 48 (35) 1.31(0.71 – 2.42) women (>40 yrs) aa 12 (21) 21 (25) χ2=1.16 p=0.28 1.28 (0.57 – 2.86) ag 21 (36) 35 (42) 1.26 (0.63 – 2.51) gg 25 (43) 28 (33) 0.66 (0.33 – 1.32) men (≤40 yrs) aa 9 (16) 7 (24) χ2=0.11 p=0.74 1.73(0.57 – 5.25) ag 31 (53) 12 (41) 0.61(0.25 – 1.51) gg 18 (31) 10 (35) 1.17(0.45 – 3.01) women (≤40 yrs) aa 12 (20) 6 (38) χ2= 6.45 p=0.04 2.35 (0.71-7.76) ag 24 (41) 9 (56) 1.88(0.61-5.72) gg 23 (39) 1 (6) 0.10(0.01-0.84) *using cochran-armitage trend test http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu table 3: association between the genotype frequencies of rs2976392 and gastric cancer subgroup genotype controls cases p-value* n (%) n (%) men (>40 yrs) aa 14 (24) 40 (29) p=0.09 ag 38 (52) 51 (36) gg 21 (24) 48 (35) women (>40 yrs) aa 12 (21) 21 (25) p=0.49 ag 21 (36) 35 (42) gg 25 (43) 28 (33) men (≤40 yrs) aa 9 (16) 7 (24) p=0.49 ag 31 (53) 12 (41) gg 18 (31) 10 (35) women (≤40 yrs) aa 12 (20) 6 (38) p=0.03 ag 24 (41) 9 (56) gg 23 (39) 1 (6) *using fisher’s exact test http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx association of rs2294008 and rs9297976 polymorphisms in psca gene with gastric cancer susceptibility in uzbekistan abstract keywords: gastric cancer, rs2294008, rs9297976, genotyping, uzbekistan association of rs2294008 and rs9297976 polymorphisms in psca gene with gastric cancer susceptibility in uzbekistan research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. nutritional status and basic hygiene practices of rural school age children of savar region, dhaka, bangladesh sahadat hossain1, fahad ahmed2, shakhaoat hossain1, tajuddin sikder1 1department of public health and informatics, jahangirnagar university, dhaka, bangladesh; 2department of environmental sciences, jahangirnagar university, dhaka, bangladesh vol. 7, no. 1 (2018) | issn 2166-7403 (online) doi 10.5195/cajgh.2018.282 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.282|http://cajgh.pitt.edu abstract introduction: school children in the developing countries are susceptible to nutrition related health problems due to demographic and socio-economic factors, as well as limited access to food. since bmi is a common proxy measure used to evaluate nutritional status, the aim of this study was to investigate the bmi categories in school-aged children in dhaka, bangladesh. methods: a cross sectional study of 155 children, aged 6-12 years was conducted at jahangirnagar university school in dhaka, bangladesh. the data collection was performed by in-person interviews and semi-structured questionnaires. descriptive statistics, χ2 test, fisher’s exact test, and one-way anova test were performed to compare the variables based on bmi percentiles. data were analyzed using the microsoft excel program (version 2010). results: mean bmi of the students was 17.27 (sd=3.16). the prevalence of underweight and overweight/obesity was 11.0% and 25.8%, respectively. categories of bmi percentiles were associated with birth order (p=0.026), personal hygiene practices (washing hands after coming home from outside (p<0.001) and before meal (p=0.045)), brushing teeth (p<0.001), the number of food items consumed daily (p<0.001), and mothers’ occupation (p=0.006). in context of basic hygiene practice, 61.3 % of respondents washed hands after coming home from outside, and 93.5 % reported washing hands before the meals. conclusions: this study revealed that more than one third of the students had abnormal bmi. bmi screening in rural schools needs to be recommended in early grades for all children. keywords: children; nutritional status; hygiene; body mass index; bangladesh nutritional status and basic hygiene practices of rural school age children of savar region, dhaka, bangladesh sahadat hossain1, fahad ahmed2, shakhaoat hossain1, tajuddin sikder1 1department of public health and informatics, jahangirnagar university, dhaka, bangladesh; 2department of environmental sciences, jahangirnagar university, dhaka, bangladesh research the school age (6–12 years old) is a dynamic period of growth and development,1 with rapid changes in physical, mental, and social skills.2 in the developing countries, the burden of morbidity and mortality associated with malnutrition and infectious diseases among the school age children is growing.3 undernutrition still remains a problem in school age children in developing countries, and is associated with stunted growth, lower body weights, and shorter heights.4, 5 a large proportion of children in these countries is impacted by anemia,6 vitamin a deficiency,7 and parasitic infections8, which negatively impact their nutritional status,8 cognitive development, and school performance.9,10 though multiple factors are associated with malnutrition, poor hygiene practice is one of the major factors linked to malnutrition among the school age children.11, 12 nutritional status of children in many http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.282|http://cajgh.pitt.edu total (%l) male (%) female (%) age group 6 9 81 (52.3) 46 (51.1) 35 (53.8) 10 12 74 (47.7) 44 (48.9) 30 (46.2) birth order 1st 40 (25.8) 22 (24.4) 18 (27.7) 2nd 67 (43.2) 38 (42.2) 29 (44.6) >2nd 48 (31.0) 30 (33.3) 18 (27.7) family structure small (≤ 4 members) 127 (81.9) 75 (83.3) 52 (80) large (> 4 members) 28 (18.1) 15 (16.7) 13 (20) father’s occupation service 77 (49.7) 45 (50) 32 (49.2) unemployed/business/other 78 (50.3) 45 (50) 33 (50.8) mother’s occupation service/other 25 (16.1) 75 (83.3) 55 (84.6) homemaker 130 (83.9) 15 (16.7) 10 (15.4) total 155 90 65 table 1. socio-demographic characteristics of the participants developing countries is affected by hygiene status, such as lack of clean water, poor sanitation, poor hygiene practices, and lack of access to toilets.13 this is an especially important issue for children under the age of five, as waterand sanitation-related diseases are the leading causes of early morbidity and mortality.13 bangladesh, a densely populated developing country in south asia, has experienced rapid demographic and epidemiological transition over the past few decades. it is facing paradoxical health challenges related to high prevalence of both underweight and overweight problems.14 according to the 2014 bangladesh health and demographic survey, 33% of children in the country were underweight.15 on the other hand, a recent countrywide epidemiological study reported that among 6-15 years old children 9.5% were overweight and 3.5% were obese.16 according to the world health organization (who), childhood obesity is a universal problem gradually affecting a large number of low-and middleincome countries.17 the prevalence of childhood obesity is approaching an epidemic proportion in many economically developed countries such usa, canada, australia, and several european countries.18 however, its prevalence in developing countries oftentimes reaches epidemic proportions faster than in the developed world.19 it has been reported that overweight and obesity in childhood is associated with increased risk of both, premature mortality and morbidity in adults, particularly due to cardiometabolic factors.20 these studies suggest that even in a resource-poor setting like bangladesh, where under-nutrition is still prevalent, overweight and obesity could emerge as a major public health challenge in the near future. lack of information concerning nutrition and hygiene practices among school children in bangladesh increases the complexity of providing appropriate public heath intervention programs. although several studies on hygiene practices were performed with different population groups in bangladesh,21, 22 to our knowledge, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.282|http://cajgh.pitt.edu total (%) underweight (%) healthy weight (%) overweight/ obese (%) p value 95% ci age group 6 9 81 (52.3) 6 (35.3) 51 (52.0) 24 (60.0) 0.213 0.148 – 0.277 10 12 74 (47.7) 11 (64.7) 47 (48.0) 16 (40.0) sex male 90 (58.1) 6 (35.3) 62 (63.3) 22 (55.0) 0.077 0.035 – 0.119 female 65 (41.9) 11 (64.7) 36 (36.7) 18 (45.0) birth order 1st 40 (25.8) 5 (29.4) 17 (17.3) 18 (45.0) 0.026a 0.001 – 0.051 2nd 67 (43.2) 8 (47.1) 47 (48.0) 12 (30.0) >2nd 48 (31.0) 4 (23.5) 34 (34.7) 10 (25.0) father’s occupation service 77 (49.7) 9 (52.9) 47 (48.0) 21 (52.5) 0.845 0.788 – 0.902 unemployed/business/ other 78 (50.3) 8 (47.1) 51 (52.0) 19 (47.5) mother’s occupation service/others 25 (16.1) 6 (35.3) 18 (18.4) 1 (2.5) 0.006a 0.000 – 0.019 homemaker 130 (83.9) 11 (64.7) 80 (81.6) 39 (97.5) washing hand after coming home from outside yes 95 (61.3) 11 (64.7) 46 (46.9) 38 (95.0) <0.001 0.000 – 0.019 no/irregular 60 (38.7) 6 (35.3) 52 (53.1) 2 (5.0) washing hand before meal yes 145 (93.5) 17 (100) 88 (89.8) 40 (100) 0.045a 0.012 – 0.078 no/irregular 10 (6.5) 10 (10.2) washing hand after toilet with soap yes 152 (98.1) 17 (100) 95 (96.9) 40 (100) 0.677a 0.604 – 0.751 no/irregular 3 (1.9) 3 (3.1) brushing teeth per day one time 140 (90.3) 17 (100) 97 (99.0) 26 (65.0) <0.001a 0.000 – 0.019 two times 15 (9.7) 1 (1.0) 14 (35.0) total 155 (100) 17 (11.0) 98 (63.2) 40 (25.8) afisher’s exact test table 2. distribution of socio-demographic characteristics and hygiene practices by the categories of bmi percentile http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.282|http://cajgh.pitt.edu none of the existing studies focused on the school aged children. thus, due to the limited published data on the bmi status and basic hygiene practices of school aged children in rural bangladesh, the goal of this study was to assess bmi status and basic hygiene practices in school age children studying at jahangirnagar university school. methods study population before the data collection, investigators obtained school management’s permission to approach prospective study participants. the school management notified students and their parents or guardians about the objectives of the study. at the time of data collection, we also took verbal consent from the respondents. in the initial recruitment step, the school’s management provided the research team with the list of enrolled students. prospective participants were selected from this list based on the following inclusion criteria: age group of 6–12 years, record of being present in the school for at least 90% of the school days, and interest in participating. after creating a list of students that met the inclusion criteria, we obtained a simple random sample of the respondents who were later asked to participate in the interview. school children (155 participants, 90 males and 65 females) from families with varied levels of income (high, middle, low, and extremely low) were enrolled into a cross-sectional survey study by using random sampling method in may-june of 2015 at jahangirnagar university school, savar region, dhaka, bangladesh. measurements a pre-designed and pre-tested semi-structured questionnaire was used to interview the participants to collect information on socio-demographic characteristics, hygiene practices, and the number of food items consumed on the daily basis. the semi-structured questionnaire was pre-tested with 25 children of comparable age and socioeconomic characteristics from a neighboring school. necessary modifications were made to the questionnaire before the start of the data collection. to better understand the socio-demographic characteristics of the respondents, information related to their age, sex, birth order, and parents’ occupation was collected. hygiene practices were assessed with the questions focusing on washing hands before a meal, after coming home from outside, and after using the toilet. for washing hands, there was a question assessing if soap or detergent was used for hand washing. in order to assess oral hygiene, respondents were asked how many times they brush their teeth in a typical day. to assess the dietary history, students were asked how many meals they typically consumed in a typical day. they were also asked to comment on the types of foods they consumed in a typical day, and how many food items their meals included. by following standard procedures, anthropometric measurements (height and weight) were collected from all participants by trained field workers.23 the zzjkh-01 scale was used to measure the height and weight of the participants. at the time of measurement, the students were dressed in light clothing and their shoes were removed. to calculate body mass index (kg/m2), weight was measured in kilograms and divided by the squared height in meters.24 participants with a bmi < 5th percentile were classified as underweight, those with a bmi 5th to < 85th percentile was considered as healthy weight, bmi 85th to < 95th percentile were classified as overweight, and the bmi ≥ 95th percentile was categorized as obese.25 statistical analysis descriptive statistics were used to analyze the study results. chi-square test and fisher’s exact test were used to identify the significant relationship between categorical variables, including demographic (age, sex http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.282|http://cajgh.pitt.edu table 3. comparison of mean bmi between categories of socio-demographic characteristics and daily food intake birth order, and parents’ occupation), anthropometric (bmi categories), nutrition, and hygiene. bmi was compared based on gender, parents’ occupation, and frequency of daily food intake categories using one-way anova test. data were processed and analyzed using the microsoft excel program (version 2010). all the p values were two-tailed and statistical significance was set at the conventional cut-off of p ≤ 0.05. results a total of 155 children were interviewed (table 1) of which 90 were male (58.1%) and 65 were female (41.9%), 81 (52.3%) were aged 6-9 and 74 (47.7 %) were aged 10-12. almost 82% of them were from the nuclear families with four or less members in the household, and 43.2% of the children were in the second birth order. we found that 16% of mothers were employed outside of their households, whereas about 50% of fathers were involved in service jobs. the prevalence of underweight, healthy weight, and overweight/obese children was 11.0%, 63.2%, and 25.8% respectively (table 2). more than one-third of the students deviated from the healthy weight category. female students were underweight (64.7%) more often than males, whereas male students were overweight/obese (55.0%) more often than females. the study showed that birth order was significantly associated with the categories of bmi percentile (pvalue=0.026; 95% ci: 0.001 0.051). mother’s occupation was also a significant factor in determining the health status of the study students (χ²(2, n=155)=11.17, p=0.006). we found that almost 93% of students reported washing their hands before the meals. similarly, about 98% students reported washing hands with soap after using toilet. in addition, the rate of hand washing after coming home from outside was relatively low (61%). majority of the students (53.1%; χ²(2, n=155)=27.75, p<0.001) who were in the healthy weight category did not wash or irregularly washed hands after coming home from outside. the study revealed that 90.3% of students reported brushing their teeth once per day, and 9.7% reported brushing their teeth twice per day. n mean (±sd) 95% confidence interval for mean p valuea lower bound upper bound gender male 90 17.63 (3.25) 16.95 18.31 0.092 female 65 16.76 (2.97) 16.03 17.50 father’s occupation service 77 17.62 (3.55) 16.81 18.42 0.169 unemployed/business/other 78 16.92 (2.68) 16.31 17.53 mothers occupation service/other 25 15.70 (2.16) 17.01 18.13 0.006 homemaker 130 17.57 (3.23) 14.50 15.96 daily food intake frequency less than 3 times 87 15.30 (1.59) 14.96 15.64 <0.001 3 to 4 times 33 18.42 (2.19) 17.64 19.19 more than 4 times 35 21.08 (2.84) 20.10 22.05 aone-way anova test http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.282|http://cajgh.pitt.edu daily food intake frequency (%) p value 95% confidence interval less than 3 times 3 to 4 times more than 4 times lower upper age group 6 9 42 (48.3) 24 (72.7) 15 (42.9) 0.026 0.001 0.051 10 12 45 (51.7) 9 (27.3) 20 (57.1) gender male 50 (57.5) 22 (66.7) 18 (51.4) 0.426 0.348 0.504 female 37 (42.5) 11 (33.3) 17 (48.6) birth order 1st 19 (21.8) 14 (42.4) 7 (20.0) 0.174 0.111 0.234 2nd 41 (47.1) 10 (30.3) 16 (45.7) >2nd 27 (31.0) 9 (27.3) 12 (34.3) categories of bmi percentile underweight 17 (19.5) <0.001a <0.001 0.019 healthy weight 68 (78.2) 21 (63.6) 9 (25.7) overweight/obese 2 (2.3) 12 (36.4) 26 (74.3) washing hand after coming home from outside yes 39 (44.8) 22 (66.7) 34 (97.1) <0.001a <0.001 0.019 no/irregular 48 (55.2) 11 (33.3) 1 (2.9) brushing teeth per day one time 85 (97.7) 30 (90.9) 25 (71.4) <0.001a <0.001 0.019 two times 2 (2.3) 3 (9.1) 10 (28.6) total 87 (100) 33 (100) 35 (100) afisher’s exact test table 4. association of daily food intake frequency with socio-demographic characteristics, bmi percentiles, and hygiene practices table 3 shows that more than half of the students (56%) consumed less than three food items per day, and their average bmi was 15.30 (sd=1.59). on the other hand, 22.6% of students who consumed more than four items of foods daily had on average bmi of 21.08 (sd=2.84). table 4 summarizes the association of daily food intake frequency with other variables. daily food intake frequency was significantly different between age groups, χ²(2, n=155)= 7.34, p=0.026, and categories of bmi percentile, χ²(4, n=155)= 76.08, p<0.001. the study showed that 74.3% of overweight/obese students consumed foods more than four times per day. no cases of underweight were reported among students who consumed food three or more times daily. all of the respondents reported that they ate rice regularly. rice, fish, pulses, and beans (such as dry pea and lentils) were the most commonly consumed foods among the respondents who reported consuming two food items daily. very few children reported consuming vegetables and fruits in their daily meals. we also found that there is a significant relationship between daily food intake frequency and the dental hygiene, χ²(2, n=155)= 17.11, p<0.001. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.282|http://cajgh.pitt.edu discussion the key finding of this study is that more than one third of the students deviated from healthy body weight. age, sex, birth order, mother’s occupation, hand hygiene, and total daily number of meals were significantly associated with bmi level. female students were found to be underweight more often than male students, while male students were more often found to be overweight/obese. the findings of this study showed that the number of underweight students was six percent lower and the number of overweight/obese students was twice as high when compared to the recent large scale study conducted in bangladesh.16 additionally, the number of underweight in this study was lower than that reported in the countrywide epidemiological study, and the overall number of overweight/obese students was almost doubled compared to what was previously reported.26 these findings warrant additional investigation. in this study, it was found that more than half of the respondents (56%) who consumed foods less than three times per day had the average bmi of 15.30 kg/m2 (sd=1.59), which has important implication for children’s nutritional status. access to food is hypothesized to be the primary reason behind low food intake frequency. published evidence suggests that food unavailability is associated with poor health status, lower cognitive and academic attainment, and psychosocial problems among school age children.27 a study in malaysia showed that children in food-insecure households were 2.15 times more likely to be underweight.28 from previously published reports on food consumption patterns in bangladesh, we found that the main sources of carbohydrate were rice and wheat, while fish, poultry, eggs, and pulses were the main sources of protein.29, 30 the overall personal hygiene practices reported in this study were similar to the previous studies among different population groups in the country.22, 31, 32 a major strength of this study is that it followed the standard operating procedures with uniform methodology for data collection from all participants. the other strength is that participants of this study came from heterogeneous family background because the school consisted of high, middle, low, and extremely low family income children. thus, our findings are generalizable to multiple population groups. this study has some limitations, including study implementation in small geographic area, insufficient data on dietary patterns of the local populations, and lack of ability to compare these data to the populations outside this rural area. in addition, hygiene practices could have been over reported, as it is common with all self-reported practices in personal interviews. nutritional status of school age children should be closely monitored in order to improve their physical and mental health. parents from all income categories (high, middle, low, and extremely low family income) should be trained to maintain healthy diet irrespective of their financial status, such as increasing consumption of plant proteins, dietary fiber, fresh fruits, and vegetables. in this study, very few children reported consuming vegetables and fruits in their daily meals, suggesting that most students do not fulfill their nutritional needs by current food consumption patterns. this study demonstrates that although basic self-reported hygiene practice of rural school age children is satisfactory and the prevalence of underweight is in relatively low, the prevalence of overweight/obesity is relatively high in comparison with previously reported countrywide statistics. the overweight and/or obesity of school aged children can be an emerging public health problem in bangladesh. this represents a unique public health challenge that will need to be addressed with future targeted public health interventions. nutrition programs and active lifestyle health policies should be focused on school-aged children, especially in rural bangladesh. health monitoring study for the school aged children would be http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.282|http://cajgh.pitt.edu further conducted to better understand behavioral patterns of these children along with the general perception of obesity. this study can be viewed as a baseline work for other researchers focusing on childhood nutrition in bangladesh and similar countries. references 1. hu x, zhong j. the study of design of children’s anti-lost clothing based upon ergonomics. 7th international conference, dhm, toronto, canada. 2016; 9745:13-21. 2. hasan mm, hoque ma, hossain ma, mollah ah, islam mn. nutritional status among primary school children of mymensingh. mymensingh med j. 2013; 22: 267-74. 3. das p, basu m, dhar g, mallik s, pa r. nutritional status and morbidity pattern of government primary school children in north kolkata of west bengal, india. south east asia journal of public health. 2012; 2:13-7. 4. degarege d, degarege a, animut a. undernutrition and associated risk factors amongschool age children in addis ababa, ethiopia. bmc public health. 2015; 15:375. 5. wateraid. undernutrition and water, sanitation and hygiene (wash). 2017; http://www.wateraid.org/np/~/media/publicatio ns/eu-docs/undernutrition-and-watersanitation-and-hygiene-wash.pdf?la=en-np. (accessed 5 march 2018). 6. singh v, west kp. vitamin a deficiency and xerophthalmia among school-aged children in southeastern asia. eur j clin nutr. 2004; 58:1342-9. 7. brooker s, clements ac, hotez pj, hay si, tatem aj, bundy da, et al. the codistribution of plasmodium falciparum and hookworm among african schoolchildren. malaria journal. 2006; 5:99. 8. awill-bethi s, bundy d. intestinal nematode infection and anaemia in developing countries. bmj 2007; 334:1065-6. 9. pollitt e. early iron deficiency anemia and later mental retardation. am j clin nutr. 1999; 69:4-5. 10. singh m. role of micronutrients for physical growth and mental development. indian j pediatr. 2004; 71:59-62. 11. mustufa ma, jamali ak, sameen i, burfat fm, baloch my, baloch ah, et al. malnutrition and poor oral health status are major risks among primary school children at lasbela, balochistan, pakistan. journal of health, population, and nutrition. 2017; 36:17. 12. marshak a, young h, bontrager en, boyd em. the relationship between acute malnutrition, hygiene practices, water and livestock, and their program implications in eastern chad. food and nutrition bulletin. 2017; 38:115-27. 13. brown j, cairncross s, ensink jh. water, sanitation, hygiene and enteric infections in children. archives of disease in childhood. 2013; 98:629-34. 14. khan sh, talukder sh. nutrition transition in bangladesh: is the country ready for this double burden. obesity reviews : an official journal of the international association for the study of obesity. 2013; 14 suppl 2:126-33. 15. mohfw. demographic and health survey. national institute of population research and training, ministry of health and family welfare dhaka, bangladesh. 2014; https://dhsprogram.com/pubs/pdf/fr311/fr31 1.pdf. (accessed 5 march 2018). 16. bulbul t, hoque m. prevalence of childhood obesity and overweight in bangladesh: findings from a countrywide epidemiological study. bmc pediatrics. 2014; 14:86. 17. who. the double burden of malnutrition: policy brief. world health organization. 2017; http://apps.who.int/iris/bitstream/10665/25541 3/1/who-nmh-nhd-17.3-eng.pdf?ua=1 (accessed 5 march 2018). 18. sultan k, habiba t. prevalence of overweight and obesity in infancy. bangladesh med res counc bull. 2008; 34:69-70. 19. bhurosy t, jeewon r. overweight and obesity epidemic in developing countries: a problem with diet, physical activity, or socioeconomic status? scientific world journal. 2014; 2014:964236. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.wateraid.org/np/%7e/media/publications/eu-docs/undernutrition-and-water-sanitation-and-hygiene-wash.pdf?la=en-np http://www.wateraid.org/np/%7e/media/publications/eu-docs/undernutrition-and-water-sanitation-and-hygiene-wash.pdf?la=en-np http://www.wateraid.org/np/%7e/media/publications/eu-docs/undernutrition-and-water-sanitation-and-hygiene-wash.pdf?la=en-np http://apps.who.int/iris/bitstream/10665/255413/1/who-nmh-nhd-17.3-eng.pdf?ua=1 http://apps.who.int/iris/bitstream/10665/255413/1/who-nmh-nhd-17.3-eng.pdf?ua=1 hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.282|http://cajgh.pitt.edu 20. reilly jj, kelly j. long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: systematic review. international journal of obesity. 2011; 35:8918. 21. raihan mj, farzana fd, sultana s, haque ma, rahman as, waid jl, et al. examining the relationship between socio-economic status, wash practices and wasting. plos one. 2017; 12:e0172134. 22. halder ak, tronchet c, akhter s, bhuiya a, johnston r, luby sp. observed hand cleanliness and other measures of handwashing behavior in rural bangladesh. bmc public health. 2010; 10:545. 23. who. physical status: the use and interpretation of anthropometry. world health organization. 2018; http://www.who.int/childgrowth/publications/p hysical_status/en/. (accessed 5 march 2018). 24. lohman t, roche af, martorell r. anthropometric standardization reference manual. human kinetics books, champaign, ill. 1988; isbn: 0873221214, 9780873221214. 25. cdc. healthy weight: about child & teen bmi. centers for disease control and prevention, usa. 2015; https://www.cdc.gov/healthyweight/assessing/b mi/childrens_bmi/about_childrens_bmi.html. (accessed 5 march 2018). 26. de onis m, blossner m, borghi e. prevalence and trends of stunting among pre-school children, 1990-2020. public health nutrition. 2012; 15:142-8. 27. jyoti df, frongillo ea, jones sj. food insecurity affects school children's academic performance, weight gain, and social skills. j nutr. 2005; 135:2831-9. 28. ali naser i, jalil r, wan muda wm, wan nik ws, mohd shariff z, abdullah mr. association between household food insecurity and nutritional outcomes among children in northeastern of peninsular malaysia. nutr res pract. 2014; 8:304-11. 29. basak jk, titumir ram, baten ma, dey nc. a review study on food consumption and hovered nutrition in bangladesh: progress and determinants of food security. bangladesh j environ sci. 2015; 29:29-36. 30. birdem. dietary guidelines for bangladesh. bangladesh institute of research and rehabilitation in diabetes, endocrine and metabolic disorders. 2014; http://dabbd.org/newsphotos/dietary_guidelines_for_bangladesh.pd f. (accessed 5 march 2018). 31. zohura f, bhuyian si, monira s, begum f, biswas sk, parvin t, et al. observed handwashing with soap practices among cholera patients and accompanying household members in a hospital setting (chobi7 trial). the american journal of tropical medicine and hygiene. 2016; 95:13148. 32. nizame fa, nasreen s, halder ak, arman s, winch pj, unicomb l, et al. observed practices and perceived advantages of different hand cleansing agents in rural bangladesh: ash, soil, and soap. the american journal of tropical medicine and hygiene. 2015; 92:11116. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/childgrowth/publications/physical_status/en/ http://www.who.int/childgrowth/publications/physical_status/en/ http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html http://dab-bd.org/news-photos/dietary_guidelines_for_bangladesh.pdf http://dab-bd.org/news-photos/dietary_guidelines_for_bangladesh.pdf http://dab-bd.org/news-photos/dietary_guidelines_for_bangladesh.pdf http://dab-bd.org/news-photos/dietary_guidelines_for_bangladesh.pdf nutritional status and basic hygiene practices of rural school age children of savar region, dhaka, bangladesh abstract keywords: children; nutritional status; hygiene; body mass index; bangladesh nutritional status and basic hygiene practices of rural school age children of savar region, dhaka, bangladesh research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. the universal non-neuronal nature of parkinson’s disease: a theory andré x. c. n. valente1,2,3, altynai adilbayeva4,tursonjan tokay4, albert a. rizvanov3 1center for neuroscience and cell biology, university of coimbra, cantanhede, portugal; 2biocant biotechnology innovation center, cantanhede, portugal; 3institute of fundamental medicine and biology, kazan federal university, kazan, russia; 4national laboratory astana, nazarbayev university, astana, kazakhstan vol. 4, no. 1 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2016.231 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ valente this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.231|http://cajgh.pitt.edu abstract parkinson's disease (pd) is one of the most common neurodegenerative disorders, yet the etiology of the majority of its cases remains unknown. in this manuscript, relevant published evidence is interpreted and integrated into a comprehensive hypothesis on the nature, origin, and inter-cellular mode of propagation of sporadic pd. we propose to characterize sporadic pd as a pathological deviation in the global gene expression program of a cell: the pd expression-state, or pd-state for short. a universal cell-generic state, the pd-state deviation would be particularly damaging in a neuronal context, ultimately leading to neuron death and the ensuing observed clinical signs. we review why ageing associated accumulated damage caused by oxidative stress in mitochondria could be the trigger for a primordial cell to shift to the pd-state. we propose that hematopoietic cells could be the first to acquire the pd-state, at hematopoiesis, from the disruption in reactive oxygen species homeostasis that arises with age in the hematopoietic stem-cell niche. we argue that cellular ageing is nevertheless unlikely to explain the shift to the pd-state of all the subsequently affected cells in a patient, thus indicating the existence of a distinct mechanism of cellular propagation of the pd-state. we highlight recently published findings on the inter-cellular exchange of mitochondrial dna and the ability of mitochondrial dna to modulate the cellular global gene expression state and propose this could form the basis for the intercellular transmission of the pd-state. keywords:parkinson’s disease, the universal non-neuronal nature of parkinson’s disease: a theory andré x. c. n. valente1,2,3, altynai adilbayeva4, tursonjan tokay4, albert a. rizvanov3 1center for neuroscience and cell biology, university of coimbra, cantanhede, portugal; 2biocant biotechnology innovation center, cantanhede, portugal; 3institute of fundamental medicine and biology, kazan federal university, kazan, russia; 4national laboratory astana, nazarbayev university, astana, kazakhstan research parkinson’s disease (pd) is a common neurodegenerative disorder associated with old age. the number of worldwide affected individuals is estimated at 7 to 10 million.1 with population ageing, particularly in developing countries2, this number is expected to increase steeply in the upcoming decades. unfortunately, there is currently no cure for pd, with available medications only providing symptomatic relief.3 pd is a movement disorder clinically characterized by tremor, bradykinesia, rigidity, and postural instability.4 the motor dysfunctions are a direct consequence of the death of dopamine-producing neurons in the substantia nigra pars compacta region of the midbrain. histologically, the most noticeable feature of pd are abnormal aggregates of proteins, called lewy bodies and lewy neurites, that appear in the cell body http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.231|http://cajgh.pitt.edu and neurites of pd patient neurons. their major constituent is the protein alpha-synuclein. familial genetic linkage studies have unequivocally associated six genes with mendelian inheritable forms of pd.4 still, these individual gene mutations account for fewer than 10% of pd cases. they generally lead to juvenile or early onset pd (before 50 years of age). naturally, genetics still impacts the risk of an individual acquiring nonmonogenic sporadic pd later in life. over a dozen single nucleotide polymorphisms (snps) have been statistically linked with sporadic pd through genomewide association studies (gwass).5,6 however, the differential risks associated with carrying these snps, although statistically significant, are mostly very small in absolute terms. similarly, although some environmental factors, such as exposure to metals or pesticides, have been statistically linked with pd, the associations do not appear to be sufficiently widespread to explain beyond a minority of pd cases.7 thus, the etiology of the over 90% of cases classified as sporadic pd remains undetermined. we briefly highlight some of the major theories being pursued regarding the nature of sporadic pd. different aspects of these hypotheses will be presented in more detail as relevant, throughout the article. an overarching hypothesis on the etiology of sporadic pd is that it is triggered by an external agent. pesticides and metals would be two candidate environmental agents, given their statistical association with pd.7 another proposed factor suggested in the literature is a neurothropic pathogen, such as a virus8 or a prion-like protein.9 entry into the organism could be via the peripheral olfactory system10 or via the gastrointestinal tract,11 two sites associated with early prodromal clinical symptoms of pd. these two sites have also been combined into a dual-hit hypothesis, centered on an external agent simultaneously entering the organism via the two routes.12 whether with an initially external origin or endogenously generated, the theory that a misfolded, prion-like self-propagating form of alphasynuclein is responsible for the disease is another major hypothesis currently under investigation.9,13 more endogenous, aging-related perspectives of sporadic pd focus on the role of oxidative stress and mitochondrial damage, for which there is significant evidence in pd patients. 14,15 finally, although the view of sporadic pd as an autoimmune disease is not typical, the aggravating contribution of the neuro-inflammatory response to the disease is commonly acknowledged.16,17 starting from the analysis of sporadic pd blood gene-expression data, we have previously argued that sporadic pd could have a hematopoietic origin.18 in the present article, we review and expand on this original hypothesis, placing it in the context of recent developments in both pd and the broader biological research. the article first addresses why sporadic pd may be a systemic, rather than solely neuronal, condition. then, it discusses why inter-cellular propagation of the pathology may be involved, rather than the pathology being purely associated with cell ageing phenomena. in particular, we present the possibility that the disease transmission may be enabled by the inter-cellular exchange of the mitochondrial dna. finally, the article revisits our previously published hypothesis that the pathology may initially begin at hematopoiesis. the universal nature of the pd-state in this section, we argue for the systemic nature of sporadic pd. our case is centered on the interpretation of recently published evidence obtained by applying induced pluripotent stem cell (ipsc) technology to pd research.19,20 using ipsc techniques, conveniently collected cells from pd patients, such as skin fibroblasts, can be reverted to a pluripotent state and subsequently differentiated into dopaminergic neurons. we believe that early pd ipsc experimental http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx valente this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.231|http://cajgh.pitt.edu results support a fundamental re-evaluation of the nature of the sporadic non-monogenic form of the disease. we summarize the main observations from two of the published pd ipsc studies.19,20 in both studies, skin fibroblasts from sporadic pd patients (presuppose sporadic henceforth) were reprogrammed back into pluripotent stem cells, which were then differentiated into dopaminergic neurons. sánchez-danés et al.19 reported that, in comparison with neurons derived from fibroblasts from disease-free controls, neurons originating in fibroblasts from pd patients consistently showed pd phenotype associated alterations. these included reduced numbers of neurites, more limited neurite arborizations, and increases in caspase-3 activity, a marker for cell apoptosis. woodard et al.20 utilized neurons derived from fibroblasts of two monozygotic twins discordant for pd. multiple alterations that can be linked with a pd phenotype were present exclusively in the fibroblasts derived from the pd twin. these included lower dopamine levels, an elevation of alpha-synuclein in neurites, a delay in the emergence of spontaneous action potentials, and an absence of synchronous neuronal activity. an epidemiological study by tanner et al.21 reported a mere 15.5% concordance of monozygotic twins in developing pd. an analogous study in sweden published by wirdefeldt et al.22 corroborated this result, placing the concordance rate at 11%. thus, excluding the monogenic cases, heredity does not ensure the emergence of pd. therefore, the consistent, regular emergence of a pd phenotype in neurons derived from fibroblasts from pd patients cannot be attributed to a pd favorable germline genetic background in the patients. the conclusion is that the disease must have been present in the skin fibroblasts from the patients. pd is thus a systemic condition, not confined to neuronal cells. we propose to characterize pd as a pathological deviation in the expression program of a cell: the pd expression-state, or pd-state for short.18,23 reports of a characteristic pd gene-expression signature across multiple tissues support this view.18,24-26 the recent observation of a unique, concordant pattern of methylation in post-mortem frontal cortex samples and peripheral blood leukocytes from pd patients27 reinforces this standpoint, further suggesting that the pd-state may be stabilized by dna epigenetic modifications. the role of ageing in pd in spite of possessing a multitude of self-repair mechanisms, all cells undergo the ageing process.28 they gradually accumulate dysfunctional molecules, as well as random mutations and other assorted alterations in their genetic code, ultimately resulting in the ageing phenotype. as a source of free radicals, mitochondria and the mitochondrial dna are particularly vulnerable to oxidative stress damage.29 this observation has led to the theory that the mitochondrial dysfunction caused by oxidative stress plays a central role in ageing.30,31 with pd arising at old age and with mitochondrial function specifically known to be compromised in a variety of cell types in pd patients,32-35 the mitochondrial theory of aging broadly views pd as yet another manifestation of this phenomenon.14 it is conceivable that accumulated random damage, possibly in mitochondrial dna and due to oxidative stress, eventually triggers the gene expression program of a cell to shift to the pd-state. this shift to the pd-state in a cell could thus be viewed as a probabilistic event, its likelihood being a (nonlinearly) increasing function of the accumulated damage. however, we argue that it is impossible for all the pdstate cells in an affected individual to have acquired the pd-state in this fashion. the following valid scenario may be considered. imagine two monozygotic twins, one diagnosed with pd in the past, with the other being disease-free at the present time. let the unaffected twin http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.231|http://cajgh.pitt.edu presently exhibit a greater amount of age accumulated damage than the affected twin did at the time of his pd diagnosis – this would be the case given enough years had elapsed since the original diagnosis. now, assume that accumulated random damage is the only possible trigger of the pd-state in a cell. then, the observed greater age accumulated damage in the undiagnosed twin at present would guarantee a currently greater probability for his or her individual cells to acquire the pd-state than that probability was for the cells of the affected twin at the time of his pd-diagnosis. yet, the unaffected twin continues to show no clinical signs of pd at present, in contrast with the affected twin at the time of his pd diagnosis. thus, assuming that accumulated random damage is the only possible trigger of the pd-state in a cell leads to a probabilistic paradox. we make two remarks on the argument presented in the previous paragraph. firstly, accumulated random damage causing a cell to shift to the pd-state does not pose a paradox. only the presence of most of the pd-state cells in the organism cannot be explained by such a process. therefore, ageingassociated damage, caused by oxidative stress in mitochondria, could still be the trigger for a primordial cell in the organism to shift to the pd-state. secondly, ageing-associated cellular damage may not be required for the subsequent dissemination of the pd-state across the organism since, as argued, this dissemination would occur via a distinct mechanism. there are two direct pieces of evidence supporting a propagation dynamic in pd. first, analyses of post-mortem neuronal tissue from patients who died at different stages of the disease appear to support a chronological, physical spread of lewy-bodies across the nervous system.36 second, there is published evidence on the surgical transplantations of fetal ventral mesencephalic dopaminergic neurons as a treatment of pd. a number of post-mortem analyses, performed over 10 years after the transplant, detected lewy-bodies and lewy neurites in grafted neurons, in spite of the still young age of the transplanted tissue.37,38 this latter fact is in addition evidence of the non-essentiality of cellular ageing to the acquisition of the pd-state. in this section, we argued that ageingassociated damage caused by oxidative stress in mitochondria could be the trigger for a primordial individual cell to shift its gene expression program to the pd-state. the shift to the pd-state would be a probabilistic event, its likelihood increasing nonlinearly with that accumulated damage in the cell. on the other hand, the subsequent appearance of the pd-state in numerous other cells could no longer be explained by cell ageing. rather, it likely involves a separate mechanism of propagation of the pd-state. the propagation of the pd-state the spread of the pd-state is a slow process, as evidenced by the approximate decade that it takes an implanted fetal neuron in the brain of a pd patient to develop lewy bodies.37,38 the mechanism of propagation of the pd-state remains undetermined. however, new modes of inter-cellular communication continue to be discovered.39 in this section, we discuss how propagation of the pd-state may occur. one hypothesis posits that alpha-synuclein can behave as a prion and that pd is a prion disorder.9,13 under this theory, there exists a misfolded form of alpha-synuclein that is self-propagating, having the ability to induce similar misfolding in well-conformed alpha-synuclein. the transfer of the misfolded form of alpha-synuclein from cell to cell would thus result in the inter-cellular spread of pd. however, a western blot analysis did not detect any alpha-synuclein in the fibroblasts utilized in the pd ipsc experiments discussed earlier.20 therefore, a pd phenotype in fibroblast-derived neurons cannot be explained by the lingering presence of a hypothetical infectious form of alpha-synuclein. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx valente this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.231|http://cajgh.pitt.edu nevertheless, there is the possibility that a different biological entity is responsible for propagating the pd-state. recently, the inter-cellular exchange of mitochondrial dna (mtdna) has been demonstrated.40,41 we propose that mtdna could be the vehicle for the inter-cellular transmission of the pdstate. comprehensive research with neuron-platelet cytoplasmic hybrids supports that anomalous mtdna may suffice to set off the pd-state in a cell. a pd cybrid cell is created in vitro by the fusion of a neuronal cell depleted of endogenous mtdna with an enucleated platelet from a pd donor. thus, the mtdna of the cybrid cell is that of the platelet from the pd patient, while its nuclear dna is that of the disease-free neuronal cell. various pd characteristic alterations have been observed in pd cybrids, most prominently, inclusions that replicate the essential biochemical and structural features found in lewy-bodies in the brain of pd patients.15,42,43 the sufficiency of mtdna to trigger the pdstate in a cell is supported by its ability to induce epigenetic modifications and to modulate geneexpression in nuclear dna. in the context of tumorigenesis, work by smiraglia et al.44 and by xie et al.45 shows that alterations to mtdna affect the methylation pattern of various nuclear genes. bellizzi et al.46 report that methylation and gene expression patterns of nuclear genes in cybrids depend on the mtdna donor haplogroup. kelly et al.47 proposed that mtdna haplotypes play a pivotal role in the process of differentiation and mediate the fate of the cell. in mouse undifferentiated and differentiating embryonic stem cells, with the same nuclear dna haplotype but distinct mtdna haplotypes, they observed mtdna haplotypespecific expression of genes involved in pluripotency, differentiation, mitochondrial energy metabolism, and dna methylation. no specific mutations in mtdna have been consistently associated with pd.48 however, heteroplasmy of mtdna (i.e., the presence of multiple mtdna variants within a cell) is now widely appreciated.41 thus, undetected lower frequency mtdna variants could potentially be involved in the transmission of the pd-state. additionally, the number of pd-state triggering variants could be too large for effective statistical detection. alternatively, the pd-state could be a result of mtdna epigenetic modifications. whether mtdna can be methylated is currently a matter of active debate.49,50 hong et al.51 make a strong case for the absence of mtdna methylation, at least under most biological conditions. on the other hand, a recent publication by bacarelli et al.52 reports the presence of significant mtdna methylation in platelets of cardiovascular disease patients. for instance, in sequenced sites in the mt-co1 gene region, bacarelli et al. report average percentage site methylation to be on the order of 25%.52 a site of origin for the pd-state we have mentioned that ageing-associated damage caused by oxidative stress in mitochondria could be the trigger for a primordial cell to shift its gene expression program to the pd-state. the next relevant question is: where would an initial pd-state cell most commonly arise? in this section, we suggest the hematopoietic stem cell niche as a site to consider. research based on gene expression,18,25 dna methylation,27 neuron-platelet cybrid,15,42,43 and bioenergetic33 analyses supports the presence of the pdstate in circulating hematopoietic cells. given the short lifespan of blood cells (days for platelets53 and granulocytes54 and weeks for lymphocytes, with the exception of memory cells55) by comparison with the decade long timescale for the transmission of pd across the neuronal system,36-38 the above signs of pd in blood point to circulating hematopoietic cells acquiring the pd-state at hematopoiesis, rather than after maturation. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.231|http://cajgh.pitt.edu hematopoiesis is altered with ageing. in terms of global gene expression in hematopoietic stem cells (hscs), nitric oxide mediated signal transduction, the nf-kb cascade and the pro-inflammatory response are the most age up-regulated processes, while chromatin silencing, single-strand break repair, smad protein nuclear translocation and chromatin remodeling are the most down-regulated ones.56 alterations at the hsc epigenetic level are supported by many chromosomal regions showing a coordinated change in transcriptional activity.56 fate-wise, a skewing to the myeloid line and a diminished lymphoid potential are observed with ageing.57 it has been known for a long time that reactive oxygen species (ros), if not properly checked, have the potential to cause indiscriminate cellular damage.30 today, it is recognized that ros may also play a functional signaling role in activating processes such as the inflammatory and stress responses.28,58 additionally, there is indication that ros play a role in regulating hematopoiesis.59 in particular, evidence associates abnormal ros levels at old age with a dysfunction in both the proliferation and the differentiation dynamics of hscs. in vitro research has shown that exposure to h2o2 can lead to chromosomal translocations in hscs.60 ionizing radiation is also known to affect hscs, as it has been found to promote differentiation, short-term apoptosis and long-term senescence of hscs.61 work with drosophila supports the role of ros in the regulation of hematopoietic cell fate. increasing ros beyond its basal level in drosophila multipotent hematopoietic progenitor cells triggers their precocious differentiation.62 conversely, scavenging ros from these hematopoietic progenitors retards their differentiation into mature blood cells.62 it is wellestablished that serial transplantation of human hscs into immunodeficient mice leads to both elevated intracellular ros levels and to premature hsc senescence.63-65 yahata et al.63 and ito et al.65 independently reported that antioxidant pharmacological inhibition of ros can mitigate this deteriorating hsc phenotype. caloric restriction in balbc mice was similarly shown to postpone hsc senescence.64 finally, the same protective effect was achieved by sirt3 upregulation in hscs.66 hscs are highly-enriched in this mammalian sirtuin, except for its suppressionat old age.66 sirt3 regulates the global acetylation landscape of mitochondrial proteins and reduces oxidative stress.66 mechanistically, the foxo transcription factors67 and the p53,68 akt,69 mapk,65 and atm70 pathways have all been implicated in the ros modulation of hematopoiesis. at the genetic level, emerging evidence may also connect pd and the hematopoietic system, although its interpretation is not yet completely clear. a new study by xiao et al.71 found hematologic abnormalities in alpha-synuclein knock-out mice indicative of a role of alpha-synuclein in late-stage hematopoiesis. a genome-wide association study found that a rare nonsynonymous mutation in dzip1 is a risk factor for pd.72 dzip1 is a component of the hedgehog signaling pathway.73 besides its role in directing embryonic pattern formation, the hedgehog pathway has been implicated in the maintenance of adult stem cell niches, including both neuronal74 and hematopoietic stemcells.75 finally, pd patients are over five times more likely to be carriers of the mutated form of gba responsible for the gaucher's autosomal recessive disease.76 gaucher's disease is characterized by low blood platelet levels, anemia, and the accumulation of the glycolipid glucocerebroside in the mononuclear phagocyte system.77 in summary, we argued for the hematopoietic stem cell niche as a possible site for the appearance of a primordial pd-state cell based on evidence that supports: i) pd patients consistently having circulating hematopoietic cells in the pd-state; ii) those hematopoietic cells more plausibly having acquired the pd-state at hematopoiesis, rather than after maturation; and iii) the critical role of ros in regulating the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx valente this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.231|http://cajgh.pitt.edu hematopoietic niche and the disruption of this homeostasis with ageing. conclusion based on recently published findings that we considered relevant to the pd field, as well as on various established lines of pd research, we presented a comprehensive theory on the nature, origin, and intercellular mode of propagation of sporadic parkinson's disease. we propose to define pd as a characteristic pathological deviation in the global gene expression program of a cell: the pd expression-state, or pd-state for short. most significantly, we argue that any cell could be in the pd-state. however, due to the cell processes it affects the most, the pd-state deviation would be particularly damaging to neurons, ultimately leading to neuron death and the clinical manifestations of pd. ageing-associated accumulated damage caused by oxidative stress in mitochondria could be the trigger for a primordial cell to shift to the pd-state. in particular, hematopoietic cells could be the first to acquire the pd-state, at hematopoiesis, as a result of the disruption in ros homeostasis that arises with age in the hematopoietic stem-cell niche. the small correlation of pd incidence with genetic and environmental factors would mostly follow from this pd initiation dynamics. propagation of the pd-state across the organism would occur in a second phase and via a distinct mechanism. we proposed that the ability of mtdna to move across cells and to modulate the cellular global gene expression state could form the basis for this inter-cellular propagation of the pd-state. the mtdna-based pd propagation dynamics would occur on a time-scale of years, as observed in patients, and not be ageing-dependent, in contrast with the pd initiation dynamics. under physiological conditions, mice are not susceptible to pd late in life, in spite of clearly showing an ageing phenotype just as humans do.78 this absence of a pd phenotype in mice could thus more likely follow from the ageing-independent pd spread dynamics, than from the ageing-associated pd initiation dynamics. namely, going from human to mouse, the mtdna propagation dynamics would not scale appropriately time-wise to permit the condition to reach the neuronal system in the lifetime of a mouse. early symptoms of pd in humans include impaired sense of smell10 and gastrointestinal dysfunction.79 both have been reported as much as a decade before the appearance of symptoms at the motor level. they are typically interpreted as supporting the role of an external agent entering via the olfactory or gastro-intestinal entry points in inducting pd.12 however, another characteristic shared by the olfactory bulb and the gastro-intestinal tract is that they are both sites of very active stem-cell based tissue regeneration.80,81 the rapid cell renewal and the plasticity of immature cells could facilitate both the cellular uptake of carriers of external mtdna and the global cellular reprogramming to the pd-state, explaining the olfactory bulb and the gastro-intestinal tract being some of the earlier sites to which the pdstate would spread. finally, although our theory was presented in the context of pd, we note its general potential relevance to other pathologies where systemic bioenergetic cellular deficiency is a prominent feature. acknowledgements the authors would like to thank the montepio foundation for financial support; the center for neuroscience and cell biology (project pestc/sau/la0001/2013-2014); the portuguese national funds via the programs feder and compete; the fundação para a ciência e tecnologia; the program of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.231|http://cajgh.pitt.edu competitive growth of kazan federal university; a subsidy to kazan federal university for the state assignment in the area of scientific activities. references 1. statistics on parkinson's. 2. shrestha lb. population aging in developing countries. health aff. vol 19 (3)2000:204-212. 3. davie ca. a review of parkinson's disease. vol 862008:109-127. 4. beitz jm. parkinson's disease: a review. front biosci. vol 62014:65-74. 5. imputation of sequence variants for identification of genetic risks for parkinson's disease: a meta-analysis of genome-wide association studies. lancet. vol 377 (9766)2011:641–649. 6. nalls ma, pankratz n, lill cm, et al. largescale meta-analysis of genome-wide association data identifies six new risk loci for parkinson's disease. nat genet. vol 462014:989–993. 7. monte dad, lavasani m, manning-bog ab. environmental factors in parkinson's disease. neurotoxicology. vol 23 (4-5)2002:487-502. 8. takahashi m, yamada t. viral etiology for parkinson's disease a possible role of influenza a virus infection. jpn j infect dis. vol 52 (3)1999:89-98. 9. olanow cw, prusiner sb. is parkinson's disease a prion disorder? proc natl acad sci u s a. vol 106 (31)2009:12571-12572. 10. lerner a, bagic a. olfactory pathogenesis of idiopathic parkinson disease revisited. mov disord. vol 23 (8)2008:1076-1084. 11. phillips rj, walter gc, wilder sl, baronowsky ea, powley tl. alpha-synucleinimmunopositive myenteric neurons and vagal preganglionic terminals: autonomic pathway implicated in parkinson's disease? neuroscience. vol 153 (3)2008:733-750. 12. hawkes ch, del tredici k, braak h. parkinson's disease: a dual-hit hypothesis. neuropath appl neuro. vol 33 (6)2007:599614. 13. desplats p, lee h-j, bae e-j, patrick c, rockenstein e, crews l. inclusion formation and neuronal cell death through neuron-toneuron transmission of α-synuclein. vol 106 (31)2009:13010-13015. 14. henchcliffe c, beal mf. mitochondrial biology and oxidative stress in parkinson disease pathogenesis. nat clin pract neuro. vol 4 (11)2008:600-609. 15. swerdlow rh. does mitochondrial dna play a role in parkinson's disease? a review of cybrid and other supportive evidence. antioxid redox signal. vol 16(9)2012:950964. 16. monahan aj, warren m, carvey pm. neuroinflammation and peripheral immune infiltration in parkinson's disease: an autoimmune hypothesis. cell transplant. vol 17 (4)2008:363-372. 17. whitton p. inflammation as a causative factor in the aetiology of parkinson's disease. br j pharmacol. vol 150 (8)2007:963-976. 18. valente axcn, sousa jab, outeiro tf, ferreira l. a stem-cell ageing hypothesis on the origin of parkinson's disease. in: valente axcn, ed. science and engineering in highthroughput biology including a theory on parkinson's disease: lulu books; 2011:43-73. 19. sánchez-danés a, richaud-patin y, carballocarbajal i, et al. disease-specific phenotypes in dopamine neurons from human ips-based models of genetic and sporadic parkinson's disease. embo mol med. vol 42012:380-395. 20. woodard cm, campos ba, kuo s-h, et al. ipsc-derived dopamine neurons reveal differences between monozygotic twins discordant for parkinson's disease. cell reports. vol 92014:1173-1182. 21. tanner cm, ottman r, goldman sm, et al. parkinson disease in twins: an etiologic study. jama j am med assoc. vol 2811999:341346. 22. wiredefeldt k, gatz m, reynolds ca, prescott ca, pedersen nl. heritability of parkinson disease in swedish twins: a longitudinal study. neurobiol aging. vol 322011:1923.e19211923.e1928. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx valente this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.231|http://cajgh.pitt.edu 23. valente axcn, oliveira pj, khaiboullina sf, palotás a, rizvanov aa. biological insight, high-throughput datasets and the nature of neuro-degenerative diseases. curr drug metab. vol 14 (7)2013:814-818. 24. simunovic f, yi m, wang y, et al. gene expression profiling of substantia nigra dopamine neurons: further insights into parkinson's disease pathology. brain. vol 1322009:1795-1809. 25. scherzer cr, eklund ac, morse lj, et al. molecular markers of early parkinson's disease based on gene expression in blood. proc natl acad sci u s a. vol 104 (3)2007:955–960. 26. mandel s, grunblatt e, riederer p, et al. gene expression profiling of sporadic parkinson's disease substantia nigra pars compacta reveals impairment of ubiquitin-proteasome subunits, skp1a, aldehyde dehydrogenase, and chaperone hsc-70. ann n y acad sci. vol 10532008:356–375. 27. masliah e, w. dumaop dg, desplats p. distinctive patterns of dna methylation associated with parkinson disease. epigenetics. vol 8 (10)2013:1030-1038. 28. lane n. a unifying view of ageing and disease: the double-agent theory. j theor biol. vol 225 (4)2003:531-540. 29. murphy mp. how mitochondria produce reactive oxygen species. biochem j. vol 4172009:1-13. 30. harmann d. aging a theory based on freeradical and radiation chemistry. j gerontol. vol 111956:298-300. 31. barja g. updating the mitochondrial freeradical theory of aging: an integrated view, key aspects, and confounding concepts. antioxid redox signal. vol 192013:1420-1445. 32. wiedemann fr, winkler k, lins h, wallesch c-w, kunz ws. detection of respiratory chain defects in cultivated skin fibroblasts and skeletal muscle of patients with parkinson's disease. ann n y acad sci. vol 8932006:426429. 33. barroso n, campos y, huertas r, esteban j, molina ja. respiratory chain enzyme activities in lymphocytes from untreated patients with parkinson disease. clin chem. vol 391993:667-669. 34. yoshino h, nakagawa-hattori y, kondo t, mizuno y. mitochondrial complex i and ii activities of lymphocytes and platelets in parkinson's disease. j neural transm vol 4 (1)1992:27-34. 35. mytilineou c, werner p, molinari s, rocco ad, cohen g, yahr md. impaired oxidative decarboxylation of pyruvate in fibroblasts from patients with parkinson's disease. j neural transm. vol 8 (3)1994:223-228. 36. braak h, tredici kd, rüb u, vos raid, steur enhj, braak e. staging of brain pathology related to sporadic parkinson’s disease. neurobiology aging. vol 242003:197–211. 37. li jy, englund e, holton jl, et al. lewy bodies in grafted neurons in subjects with parkinson's disease suggest host-to-graft disease propagation. nat med. vol 142008:501-503. 38. kordower jh, chun y, hauser ra, freeman tb, olanow cw. lewy body-like pathology in long-term embryonic nigral transplants in parkinson's disease. nat med. vol 142008:504506. 39. valadi h, ekström k, bossios a, sjöstrand m, lee jj. exosome-mediated transfer of mrnas and micrornas is a novel mechanism of genetic exchange between cells. nat cell biol. vol 92007:654 659. 40. tan as, baty jw, dong l-f, et al. mitochondrial genome acquisition restores respiratory function and tumorigenic potential of cancer cells without mitochondrial dna. cell metab. vol 21 (1)2015:81-94. 41. jayaprakash ad, benson ek, gone s, et al. stable heteroplasmy at the single-cell level is facilitated by intercellular exchange of mtdna. nucleic acids res. vol 43 (4)2015:2177-2187. 42. trimmer pa, borland mk, keeney pm, jr. jpb, jr. wdp. parkinson's disease transgenic mitochondrial cybrids generate lewy inclusion bodies. vol 882004:800-812. 43. esteves ar, domingues af, ferreira il, et al. mitochondrial function in parkinson's disease cybrids containing an nt2 neuron-like nuclear http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.231|http://cajgh.pitt.edu background. mitochondrion. vol 82008:219228. 44. smiraglia dj, kulawiec m, bistulfi gl, gupta sg, singh kk. a novel role for mitochondria in regulating epigenetic modification in the nucleus. cener biol ther. vol 72008:11821190. 45. xie ch, naito a, mizumachi t, evans tt, douglas mg, cooney ca. mitochondrial regulation of cancer associated nuclear dna methylation. biochem biophys res commun. vol 656-6612007:364. 46. bellizzi d, d'aquila p, giordano m, montesanto a, passarino g. global dna methylation levels are modulated by mitochondrial dna variants. epigenomics. vol 42012:17-27. 47. kelly rd, rodda ae, dickinson a, et al. mitochondrial dna haplotypes define gene expression patterns in pluripotent and differentiating emrbyonic stem cells. stem cells. vol 312013:703-716. 48. schapira ahv. mitochondria in the aetiology and pathogenesis of parkinson's disease. lancet neurol. vol 72008:97-109. 49. maresca a, zaffagnini m, caporali l, carelli v, zanna c. dna methyltransferase 1 mutations and mitochondrial pathology: is mtdna methylated? front genet. vol 6 art. no. 92015. 50. ghosh s, singh kk, sengupta s, scaria v. mitoepigenetics: the different shades of grey. mitochondrion. vol 252015:60-66. 51. hong ee, okitsu cy, smith ad, hsieh c-l. regionally specific and genome-wide analyses conclusively demonstrate the absence of cpg methylation in humann mitochondrial dna. mol cell biol. vol 33 (14)2013:2683-2690. 52. bacarelli aa, byun h-m. platelet mitochondrial dna methylation: a potential new marker of cardiovascular disease. clinical epigenetics. vol 7 (44)2015. 53. stuart mj, murphy s, oski fa. a simple nonradioisotope technic for the determination of platelet life-span. n engl j med. vol 2921975:1310-1313. 54. simon si, kim m-h. a day (or 5) in a neutrophil's life. blood. vol 116 (4)2010:511 512. 55. tough df, sprent j. lifespan of lymphocytes. immunol res. vol 14 (1)1995:1-12. 56. chambers sm, shaw ca, gatza c, fisk cj, donehower la, goodell ma. aging hematopoietic stem cells decline in function and exhibit epigenetic dysregulation. plos biol. vol 5 (8)2007:e201. 57. rossi dj, bryder d, zahn jm, et al. cell intrinsic alterations underlie hematopoietic stem cell aging. proc natl acad sci usa. vol 1022005:9194-9199. 58. hamanaka rb, chandel ns. mitochondrial reactive oxygen species regulate cellular signaling and dictate biological outcomes. trends biochem sci. vol 35 (9)2010:505–513. 59. pervaiz s, taneja r, ghaffari s. oxidative stress regulation of stem and progenitor cells. antioxid redox signal. vol 11(11)2009:27772789. 60. francis r, richardson c. multipotent hematopoietic cells susceptible to alternative double-strand break repair pathways that promote genome rearrangements. genes dev. vol 212007:1064-1074. 61. shao l, luo y, zhou d. hematopoietic stemcell injury induced by ionizing radiation. antioxid redox signal. vol 202014:1447-1462. 62. owusu-ansah e, banerjee u. reactive oxygen species prime drosophila hematopoietic progenitors for differentiation. nature. vol 4612009:537-541. 63. yahata t, takanashi t, muguruma y, et al. accumulation of oxidative dna damage restricts the self-renewal capacity of human hematopoietic stem cells. blood. vol 118 (11)2011:2941-2950. 64. chen j, astle cm, harrison de. hematopoietic senescence is postponed and hematopoietic stem cell function is enhanced by dietary restriction. exp hematol. vol 312003:1097-1103. 65. ito k, hirao a, arai f, et al. reactive oxygen species act through p38 mapk to limit the lifespan of hematopoietic stem cells. nat med. vol 122006:446–451. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx valente this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.231|http://cajgh.pitt.edu 66. brown k, xie s, qiu x, et al. sirt3 reverses aging-associated degeneration. cell rep. vol 32013:319-327. 67. tothova z, kollipara r, huntly bj, et al. foxos are critical mediators of hematopoietic stem cell resistance to physiologic oxidative stress. cell. vol 1282007:325–339. 68. abbas ha, maccio dr, coskun s, jackson jg, hazen al, sills tm. mdm2 is required for survival of hematopoietic stem cells/progenitors via dampening of rosinduced p53 activity. cell stem cell. vol 72010:606-617. 69. yalcin s, marinkovic d, mungamuri sk, et al. ros‐mediated amplification of akt/mtor signalling pathway leads to myeloproliferative syndrome in foxo3−/− mice. embo j. vol 29 (24)2010:4118–4131. 70. ito k, hirao a, arai f, et al. regulation of oxidative stress by atm is required for selfrenewal of haematopoietic stem-cells. nature. vol 4312004:997-1002. 71. xiao w, shameli a, harding cv, meyerson hj, maitta rw. late stages of hematopoiesis and b cell lymphopoiesis are regulated by αsynuclein, a key player in parkinson's disease. immunobiology. vol 2192014:836-844. 72. valente axcn, shin jh, sarkar a, gao y. rare coding snp in dzip1 gene associated with late-onset sporadic parkinson's disease. sci rep. vol 2 art. no. 2562012. 73. sekimizu k, nishioka n, sasaki h, takeda h, karlstrom ro, kawakami a. the zebrafish iguana locus encodes dzip1, a novel zincfinger protein required for proper regulation of hedgehog signaling. vol 131 (11)2004:25212532. 74. palma v, lim da, dahmane n, sánchez p, brionne tc. sonic hedgehog controls stem cell behavior in the postnatal and adult brain. development. vol 132 (2)2004:335-344. 75. bhardwaj g, murdoch b, wu d, baker dp, williams kp. sonic hedgehog induces the proliferation of primitive human hematopoietic cells via bmp regulation. nature immunol. vol 22001:172-180. 76. sidransky e, nalls ma, aasly jo, et al. multicenter analysis of glucocerebrosidase mutations in parkinson's disease. n engl j med. vol 3612009:1651-1661. 77. mingyi c, jun w. gaucher disease: review of the literature. arch pathol lab med. vol 132.52008:851-853. 78. dawson tm. new animal models for parkinson's disease. cell. vol 101 (2)2000:115–118. 79. natale g, pasquali l, ruggieri sap, fornai f. parkinson's disease and the gut: a well known clinical association in need of an effective cure and explanation. neurogastroenterol motil. vol 20 (7)2008:741-749. 80. creamer b, shorter rg, bamforth j. the turnover and shedding of epithelial cells. i. the turnover in the gastro-intestinal tract. gut. vol 2 (2)1961:110-116. 81. mouret a, lepousez g, gras j, gabellec mm, lledo pm. turnover of newborn olfactory bulb neurons optimizes olfaction. j neurosci. vol 29 (39)2009:12302-12314. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx the universal non-neuronal nature of parkinson’s disease: a theory abstract keywords:parkinson’s disease, the universal non-neuronal nature of parkinson’s disease: a theory research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. family medicine as a model of primary health services delivery: a pilot study in almaty, kazakhstan dilara orynbassarova kimep university, mpa, almaty, kazakhstan vol. 4, no. 1 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.209 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ orynbassarova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.209|http://cajgh.pitt.edu abstract introduction. advanced models of delivering primary health care are being implemented in various countries of the world. this is especially true for countries undergoing a healthcare transition in central asia, such as kazakhstan, which obtained independence from soviet union in 1991. the kazakhstan national program of health reform, implemented between 2005-2010, aimed to create an effective system of primary care. one of the key directions of healthcare reform implemented in kazakhstan included the development of family medicine, which has become cutting-edge agenda for kazakhstan health ministry over the past 10 years. while many papers have been published about the importance of family medicine and primary healthcare models, few have focused on analyzing family medicine effectiveness in kazakhstan and its impact on access to family doctor services and patient satisfaction. the key aims of this pilot investigation were 1) to assess the model’s impact on access to primary care and patients’ satisfaction, and 2) to explore the model’s effectiveness in some central asian and transitional countries in the literature. methods. this pilot study was based on semi-structured interviews and questionnaires about the perception and impact of the primary care model to 86 respondents aged 19-51 (54% females, 46% males). the majority of respondents were almaty city residents (71%), while the rest were almaty province rural residents (22%) and residents of other kazakhstan regions (7%). results. respondents from rural areas associated general practitioners, or family doctors, with community clinics (also referred to as feldsher posts). even though urban area respondents use family doctor services, they were more likely to get those services in private rather than public clinics. rural residents appear to have better access to primary care providers than urban residents participating in our study. also, respondents from rural areas were more satisfied with services provided by family doctors than respondents from urban areas. conclusions. this pilot study helped to improve our understanding of primary health care reforms implemented in kazakhstan, a topic that is not traditionally covered in international literature. this pilot study suggests that primary care is more effectively implemented in rural areas of kazakhstan (almaty province); however, future full-scale research in this area is needed to fully understand the complexity of primary healthcare access in kazakhstan. keywords: central asia, kazakhstan, primary health care, family medicine, access to care, general practice family medicine as a model of primary health services delivery: a pilot study in almaty, kazakhstan dilara orynbassarova kimep university, mpa, almaty, kazakhstan research advanced models of delivering primary health care are being implemented in various countries around the world. this is especially true for countries undergoing a healthcare transition in central asia, such as kazakhstan, which obtained independence from soviet union in 1991. many international declarations and forums recognized the importance of implementing an effective primary health care system.1 primary health care is an effective vehicle to “improve health care access and outcomes while narrowing equity gap.”2 qualitative analysis of empirical evidence indicates one of the directions that most countries undertake while reforming their primary care system is the development of family medicine centered care, which has become a critical component of western public health systems. published evidence indicates that 90% of various patients in http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.209|http://cajgh.pitt.edu different countries around the world begin and end their medical treatment at the level of a family doctor, seeking help of highly specialized professionals only in exceptional cases.2-4 as a country in transition, kazakhstan is seeking the most appropriate model for improving public health practice, traditionally challenged by a focus on a curative medicine approach rather than prevention.5-7 despite the fact that several drawbacks of primary healthcare models have been recognized, including access to care, various publications recognized positive aspects of primary care models, including slower growth in healthcare spending.8 recent publications by sharman,9-11 emphasized the need for change from kazakhstan’s current disease-centric healthcare paradigm to a new primary health and wellness-centric health care paradigm.11 the concept of primary care is not unknown in kazakhstan, as historically, in the countries of the former soviet union, many functions of primary care doctors have been performed by feldshers.12 feldsher is a middle level healthcare provider with training similar to physician assistants in the us or an advanced nursing degree, providing primary care mainly in rural areas in the countries of former soviet union. also, while it had many weaknesses, semashko’s centralized model of healthcare, as was practiced during the soviet period, paid particular attention to prevention, especially in the area of vaccinations.13 one of the major objectives of the kazakhstani health program 2005-2010 and part of 2020 strategic development plan, included the development of family medicine and strengthening the principles of general medical practice. as a part of this program’s vision, family doctors would gradually replace current healthcare providers, such as district physicians and pediatricians, thus unifying the primary care services delivery system.14,15 family medicine-centered care in kazakhstan is not new health care developmenal approach; it was introduced in kazakhstan over twenty years ago. the history of introducing the family medicine model started in 1990s, when the first pilot clinic of mixed type (district physicians practicing with family doctors) was created in alma ata (almaty) in 1989.16-18 little has been published about assessing family medicine practice implications for kazakhstan, and almost no research has been conducted about the impact of the model on access to primary care services and satisfaction with those services by kazakhstani citizens. the main aim of this pilot investigation was to investigate the care given under the family medicine model in kazakhstan, and observe if any disparity between rural and urban settings exist regarding access to care and satisfaction with these services. results of this pilot study can serve as a foundation for further full-scale research studies in the fields of primary care, family medicine, and general medical practice in kazakhstan. this research would be of special interest to those with interest in central asian region. methods survey development for this study was based on elements of hsiao evaluation framework elements, including organizational arrangements, financing, resource allocation, and provision elements,which refers to allocation of health care goods and services.19,20 since this pilot study focused on finding out the family medicine effectiveness in providing healthcare services, the service provision element was the key target for the analysis. effective service provision indicators included access to primary care services, patient satisfaction, and capacity of effectively managing acute and chronic diseases by family doctors. data were collected from november 1, 2009january 12, 2010. the main data collection technique was a survey tool composed of semi-structured interviews and questionnaires created for this study. the questionnaire was divided into five major parts as per effective service provision indicators. interviews were http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx orynbassarova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.209|http://cajgh.pitt.edu conducted by two highly trained professionals, including a district pediatrician and district therapist. this pilot study consisted of 86 respondents aged 19-51 (54% females, 46% males). the majority of respondents were almaty city residents (71%), while the rest were almaty province rural residents (22%), and residents of other kazakhstan regions (7%). descriptive statistics have been conducted to report the findings. convenience sampling technique was applied in a randomly chosen almaty city polyclinic #8 and almaty diagnostic hospital. interviews were conducted by specialists, who had approximately 7 years of experience working with the association of family doctors of kazakhstan, district pediatricians, who had roughly 15 years of experience working in the almaty child city polyclinic #8, and district therapists, who had approximately 11 years of experience working in almaty city polyclinic #8 and worked part-time as a family doctor in the republican family-doctor center in almaty. patients who were available to complete the survey were surveyed. while no formal ethics review was conducted, this project was approved as thesis work by kimep university. each questionnaire also had a heading that informed participants of the aims of the study in addition to the confidentiality of their responses. results one of the key findings of this study was that rural area respondents associated feldshers with primary care doctors. it was observed that the majority of respondents (75%) from rural areas responded that the community feldsher doctor was their first contact, while 15% of respondents had difficulties in replying to the survey, and 10% of respondents cited other as their primary contact in the case of a health issue. even though urban area patients used family medicine services, they preferred to get those services in private clinics vs. public ones. specifically, 71% of urban respondents indicated a preference for private clinics, 26% indicated preference for public clinic services, and 3% found it difficult to respond. respondents reported that the reasoning for this may be that quality doctors are not motivated to work in public clinics due to low financial incentives. also, there is a lack of incentives for serving children, adults, and women all together by one family doctor, as district therapists are better reimbursed by serving mainly the adult population. despite the small sample size, it appears that rural residents have higher access to family medicine services compared to urban residents. almost half of rural respondents (49%) agreed with the statement “patients can contact family doctor easily by telephone to obtain advice.” the majority of urban respondents (55%) disagreed with the statement “the appointments are easy to make whenever i need them” compared to 45% of rural patients agreeing with this statement. 55% of urban patients indicated that the public polyclinic they visited did not employ a family doctor. rural area respondents in this study were more satisfied with services provided by family doctors than respondents from urban areas. overall, 51% of respondents were dissatisfied with the quality of services provided by family doctors, 2% very dissatisfied, 12% moderately satisfied, 31% satisfied, and 4% very satisfied. groups of dissatisfied respondents (51%) and satisfied (31%) were targeted for selective analysis by their place of residence. considerable difference in answers was revealed. among 51% respondents dissatisfied by family doctor services, 82% were almaty city residents, and among 31% respondents satisfied, 71% of respondents were from rural areas. based on qualitative interview data, it appears that patients living in rural communities in kazakhstan are more satisfied with services provided by family doctors since they have less access to specialist care, and urban area patients prefer directly accessing specialists in secondary and tertiary care specialized hospitals, since those are available in almaty city. data analysis revealed http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.209|http://cajgh.pitt.edu that rural patients considered the family doctor as point of first contact for acute and some of the chronic health problems, while urban respondents considered the district therapist as doctor of first contact for acute health problems, and preferred narrow field specialists as a first contact doctor for chronic illnesses. the majority of urban respondents would rarely refer to family doctors when having chronic illness, including gastritis, allergy, chest pain, or ent problems, and prefer to visit specialists for those. in allergy cases, the majority of urban respondents (52%) would refer to allergologyst, chest pain (63%) to cardiologist, applying plaster cast (66%) to surgeon, and vision problem 48% to ophthalmologist. however, different answers revealed from rural patients. the majority rural respondents would consider the family doctor as the doctor of first contact when having health problems and some chronic illnesses, such as gastritis and ent problems. discussion in summary, the family medicine model is being practiced in kazakhstan, and appears to be accessible to rural residents. an interesting finding is that even though urban area respondents used family doctor services, they preferred to get those services in private clinics. countries in transition, including armenia, russia, kyrgyzstan, and turkmenistan that inherited the sovietsemashko model of health care, and characterized by a centrally controlled healthcare service provision, were found to have similarly developed levels of a family medicine model, with rural areas being more positively affected by the primary care model compared to urban ones. for comparison, the same trend is observed in the kyrgyzstan study, where rural family doctors in issyk kul (rural area) managed the initial visit with health concerns 80-100% of the time more frequently than in bishkek city (capital city).21 the presence of a large number of highly trained specialists in urban areas as an alternative to family doctors have adversely impacted family doctors’ ability to solve first-contact chronic health problems. a higher density of population in urban vs. rural areas, as well as a high concentration of specialists in urban areas may potentially prevent urban area family doctors to fully realize their potential. limitation of this research includes small sample size, poor representatives of rural population, and non-randomized nature of our sampling technique. while these weaknesses limited the generalizability of study findings to the general population of kazakhstan, these limitations will be addressed in future research. however, since there is a paucity of published research on primary healthcare models in kazakhstan, this pilot investigation has been designed to fill this important gap. to generate more nationally representative samples, further research is suggested that would capture a wider variety of geographic catchment areas, with random selection of research participants. future studies should specifically address rural-urban differences in perception and use of primary care. kazakhstan is a good country to implement this research, as it has undergone substantial economic and political transition in a relatively short time frame. family medicine model care was found to be effective and accessible, especially in rural areas of kazakhstan. better policies targeting primary care integration should be considered for furthering primary care in kazakhstan. while it early to judge the overall effectiveness of the model, work to date clearly indicates that impacts and challenges of this model for kazakhstan need to be assessed. advantages and disadvantages of this model need to be clearly explored before further integration, as previous publication suggested that overall health expenditures were higher in countries with stronger primary care structures, perhaps because maintaining strong primary care structures is costly and promotes developments such as decentralization of services delivery.8 as an interesting comparison, studies in kyrgyzstan, armenia, and turkmenistan suggested that family care models improved rural access of those http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx orynbassarova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.209|http://cajgh.pitt.edu residents with low income and low education.22-24 in kyrgyzstan study, increased access to services positively impacted waiting time and out of pocket payments of (73%), as rural patients no longer needed to travel to urban centers for specialists’ care.24 turkmenistan study indicated 2 fold decrease of sayat chardzhou rural total health expenditure and 3-fold decrease in patient hospitalization rate.25 in moldova study, rural patients (68%) living in village near to laloveni city expressed satisfaction with increased access to services.26 ukrainian study of dneprodzerzhinsk indicated a 3-fold decrease in ambulatory call frequency, and patient hospitalizations became lower than average city level.27 in armenia, the proportion of self-referrals by patients to specialist care in rural areas decreased from 26% to 20%, in contrast, self-referrals rate in urban areas increased 22% to 38%.24 this pilot study helped to improve our understanding of primary health care reforms implemented in kazakhstan, a topic that is not traditionally covered in international literature. this pilot study seems to suggest that primary care is more effectively implemented in rural areas of kazakhstan (almaty province); however, future full-scale research in this area is needed to fully understand the complexity of primary healthcare access in kazakhstan. competing interests the author declares that they have no competing interests. acknowledgment the author would like to thank the college of social sciences of kimep university, particularly our honorable professors dennis soltys, john dixon, john couper and aigerim rollanovna for suggestions on previous versions of this paper. references 1. world health organization (who), united nations children's fund. primary health care. international conference on primary health care 1978; http://www.searo.who.int/entity/primary_health_care/documen ts/hfa_s_1.pdf. accessed april 4, 2015. 2. starfield b. primary care and health: a cross-national comparison. jama. 1991;266(16):2268-2271. 3. starfield b. global health, equity, and primary care. jabfm. 2007;20(6):511-513. 4. parfitt b. health reform: the human resource challenges for central asian commonwealth of independent states (cis) countries. collegian. 2009;16(1):35-40. 5. government of the republic of kazakhstan. the governmental program on reforming and developing the health care system of kazakhstan for 2005-2010 periods. 2013; http://ru.government.kz/resources/docs/doc9. accessed september 8, 2010. 6. yarnall ksh, pollak ki, østbye t, krause km, michener jl. primary care: is there enough time for prevention? am j public health. 2003;93(4):635-641. 7. jaén cr, stange kc, nutting pa. competing demands of primary care: a model for the delivery of clinical preventive services. j fam practice. 1994;38(2):166-171. 8. kringos ds, boerma w, van der zee j, groenewegen p. europe's strong primary care systems are linked to better population health but also to higher health spending. health affair. 2013;32(4):686-694. 9. sharman a. modernization and growth in kazakhstan. cajgh. 2012;1(1). 10. sharman a. new era in medicine. central asia monitor 2002; http://camonitor.com/archives/3994. accessed march 31, 2015. 11. sharman a. a new paradigm of primary health care in kazakhstan: personalized, community-based, standardized, and technology-driven. cajgh. 2014;3(1). 12. world health organization (who). the training and utilization of feldshers in the ussr. 1974; http://apps.who.int/iris/bitstream/10665/39783/1/who_php_5 6.pdf?ua=1. accessed april 4, 2015. 13. groenewegen pp, dourgnon p, greß s, jurgutis a, willems s. strengthening weak primary care systems: steps towards stronger primary care in selected western and eastern european countries. health policy. 2013;113(1-2):170-179. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.searo.who.int/entity/primary_health_care/documents/hfa_s_1.pdf http://www.searo.who.int/entity/primary_health_care/documents/hfa_s_1.pdf http://ru.government.kz/resources/docs/doc9 http://camonitor.com/archives/3994 http://apps.who.int/iris/bitstream/10665/39783/1/who_php_56.pdf?ua=1 http://apps.who.int/iris/bitstream/10665/39783/1/who_php_56.pdf?ua=1 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.209|http://cajgh.pitt.edu 14. national programme of health reform and development for 2005-2010. health monitor2004. 15. katsaga a, kulzhanov m, karanikolos m, rechel b. kazakhstan: health system review. health systems in transition. 2012;14(4). 16. rawaf s, maeseneer jd, starfield b. from alma-ata to almaty: a new start for primary health care. lancet. 2008;372(9647):1365-1367. 17. chan m. return to alma-ata. lancet. 2008;372(9642):865-866. 18. beasley jw, dovey s, geffen ln, et al. the contribution of family doctors to primary care research: a global perspective from the international federation of primary care research networks (ifpcrn). prim health care res dev. 2004;5:307-316. 19. world health organization (who). the world health report 2000 health systems: improving health. 2000; http://www.who.int/whr/2000/en/. accessed march 19, 2015. 20. world health organization (who). social determinants of health: the solid facts. 2nd ed: world health organization; 2003. 21. world bank. review of experience of family medicine in europe and central asia. vol 4. washington, dc: kyrgyz republic case study; 2005. 22. unicef. unicef evaluation report standards. 2004; http://www.unicef.org/evaldatabase/files/unicef_eval_report _standards.pdf. accessed april 4, 2015. 23. world bank. review of experience of family medicine in europe and central asia. vol 1. washington dc: executive summary; 2005. 24. world bank. review of experience of family medicine in europe and central asia. vol 2. washington, dc: armenia case study; 2005. 25. omarova hp. the need for family doctors in rural area of turkmenistan. paper presented at: international conference n211992; venesian medical university. 26. turcanu g, domente s, buga m, richardson e. republic of moldova: health system review. health systems in transition. 2012;14(7). 27. world health organization (who). evaluation of structure and provision of primary care in ukraine: a survey-based project in the regions of kiev and vinnitsa. 2010; http://www.euro.who.int/__data/assets/pdf_file/0016/129022/ e94565.pdf. accessed april 4, 2015. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/whr/2000/en/ http://www.unicef.org/evaldatabase/files/unicef_eval_report_standards.pdf http://www.unicef.org/evaldatabase/files/unicef_eval_report_standards.pdf http://www.euro.who.int/__data/assets/pdf_file/0016/129022/e94565.pdf http://www.euro.who.int/__data/assets/pdf_file/0016/129022/e94565.pdf cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. knowledge and perception of diabetes and available services among diabetic patients in the state of qatar al-anoud al-thani1, aiman farghaly1, hammad akram1, shamseldin khalifa1, benjamin vinodson1, alma loares1, abdulbadi abou-samra2 1ministry of public health, state of qatar; 2department of medicine, hamad medical corporation, state of qatar vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.333 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu abstract introduction: diabetes is a major public health concern in qatar. this study examined diabetes knowledge and perception of available services for diabetes control among diabetic patients in qatar. methods: data from 300 diabetic patients were collected through face-to-face interviews using a semi-structured questionnaire between february and may 2015 at hamad medical corporation healthcare facilities in qatar. survey responses were represented as frequencies, and chi-square tests were used to compare proportions across gender. a p-value of 0.05 was considered statistically significant. results: 31% of patients had type 1 diabetes (t1d) (females 36.6%, males 26.5%) and 54% had type 2 diabetes (t2d) (males 56.6%, females 50%). knowledge about diabetes types did not differ by sex (p=0.16). 32.3% of patients were treated for diabetesrelated complications including: high cholesterol (39.2%), vision problems (33.1%), hypertension (30.0%), and foot problems (25.1 %). most patients were diagnosed at primary care clinics (41.7%). during visits, 78.3% of patients reported that they were fully advised about different diabetes tests. 57.0% of patients had ≥4 visits for diabetes checkups in the past 12 months. 66.7% of patients reported that they were confident or very confident in managing their diabetes as a result of their healthcare visits in the past year. the majority of patients reported receiving diabetes-related guidance from physicians (89.7%). conclusions: study participants had variable knowledge of diabetes, its complications and risk factors, and services available to diabetics. more comprehensive education and awareness about diabetes is recommended for both patients and family members. at the provider level, further improvement in patient counseling and promotion of available services can be beneficial. keywords: diabetes, diabetes knowledge, diabetes health services, diabetic patient survey, qatar knowledge and perception of diabetes and available services among diabetic patients in the state of qatar al-anoud al-thani1, aiman farghaly1, hammad akram1, shamseldin khalifa1, benjamin vinodson1, alma loares1, abdul-badi abou-samra2 1ministry of public health, state of qatar; 2department of medicine, hamad medical corporation, state of qatar research introduction morbidity and mortality associated with chronic diseases are growing in qatar. diabetes is one of the major public health problems in qatar, which requires attention of policy makers, clinicians, and public health officials. risk factors associated with diabetes, such obesity and sedentary lifestyle, are common in qatar.1, 2 as evident from a national population-based survey conducted in 2012, the prevalence of diabetes among qatari nationals was 16.7%, which is significantly higher compared to 11.6% reported in a 2006 survey.3,4 recent studies also indicate that the diabetes prevalence is associated with social and behavioral characteristics of the population in qatar, including obesity, low educational status, marital status (ever or currently married), older age, and a family history of diabetes.3,5 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu characteristics n (%) age 16-24 years 20 (6.7) 25-34 years 72 (24.0) 35-54 years 123 (41.0) 55-64 years 58 (19.3) 65 years and above 27 (9.0) gender male 166 (55.3) female 134 (44.7) nationality group qatari 88 (29.3) arab expatriates 110 (36.7) asian 92 (30.7) caucasian 10 (3.3) marital status single 29 (9.7) married with children 240 (80.0) married without children 18 (6.0) widowed/ divorced 13 (4.3) total 300 table 1. demographic characteristics of the sample the high burden of diabetes and related risk factors inspired the development and implementation of the qatar national health strategy (nhs) aimed at preventing, monitoring, and educating patients and the general public about diabetes. diabetes was recognized as one of nhs’s highpriority diseases for preventive healthcare.6 an nhs report revealed that in 2015, chronic diseases such as heart disease, cancer, and diabetes, were responsible for 70% of the mortality in qatar, with 9% of total mortality in qatar attributed to diabetes.6 the nhs target is to reduce overall cause-specific mortality due to the preventable diseases to 5%, and preventable hospital admissions (that can be addressed in primary care setting, such as diabetes-associated health issues) to 15%.6 through the national diabetes strategy (nds), the diabetes initiative aimed to decrease the incidence and complications of diabetes by raising public awareness through adoption of multipronged health promotion approaches.7 in 2015, the ministry of public health (moph) of qatar, in collaboration with yougov (an international market research organization), carried out a comprehensive research study examining the burden of diabetes, availability of services for diabetes management, public perception of diabetes, knowledge of diabetes by diabetic patients and the general population, and diabetes-related health system access in http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu total, n (%) male, n (%) female, n (%) p value diabetes type (a1) t1d 93 (31.0) 44 (26.5) 49 (36.6) 0.16 t2dm 161 (53.7) 94 (56.6) 67 (50.0) others/ unspecified 46 (15.3) 28 (16.9) 18 (13.4) duration of diabetes (a2) months [median(iqr)] 60 (24, 144) 61 (24, 132) 60 (24, 156) 0.70* treated with complications (a1c) yes 97 (32.3) 58 (34.9) 39 (29.1) 0.28 no 203 (67.7) 108 (65.1) 95 (70.9) location of diagnosis (a3) screening bus 6 (2.0) 3 (1.8) 3 (2.2) <0.001ϯ primary care 125 (41.7) 77 (46.4) 48 (35.8) diabetes clinic 39 (13.0) 22 (13.3) 17 (12.7) emergency room 51 (17.0) 31 (18.7) 20 (14.9) women’s hospital 23 (7.7) 23 (17.2) professional test following a self-test 38 (12.7) 22 (13.3) 16 (11.9) other 18 (6.0) 11 (6.5) 7 (5.2) level of information at first time of diagnosis (a5) too little information 113 (37.7) 67 (40.4) 46 (34.3) 0.45 received right amount of information 133 (44.3) 72 (43.4) 61 (45.5) received too much information 32 (10.7) 14 (8.4) 18 (13.4) don’t know/ can’t remember 22 (7.3) 13 (7.8) 9 (6.7) brochures on diabetes at time of diagnosis (a6) yes 148 (49.3) 74 (44.6) 74 (55.2) 0.07 no 146 (48.7) 90 (54.2) 56 (41.8) don’t know 6 (2.0) 2 (1.2) 4 (3.0) satisfied with brochures (a7) extremely dissatisfied 3 (2.1) 1 (1.4) 2 (2.7) 0.11 dissatisfied neither satisfied/ dissatisfied 11 (7.4) 6 (8.1) 5 (6.8) satisfied 94 (63.5) 53 (71.6) 41 (55.4) extremely satisfied 40 (27.0) 14 (18.9) 26 (35.1) fully advised on all of diabetes tests (a9) yes 235 (78.3) 125 (75.3) 110 (82.1) 0.009* no 46 (15.3) 34 (20.5) 12 (9.0) don’t know/ can’t remember 19 (6.3) 7 (4.2) 12 (9.0) total 300 166 134 *mann whitney test; ϯchi-squared test table 2. sample characteristics by diabetes types, duration, and diagnosis associated factors http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu figure 1. percentage of treated complications among diabetic patients the state of qatar. the aim of this collaborative project was to improve general public awareness and education on behavioral and lifestyle choices for diabetes prevention. our present study describes the results from a diabetic patient-based survey and examines findings from patients who sought medical care at local hospitals and healthcare facilities in qatar. we intend to present demographic data on diabetic patients, participant knowledge of diabetes-related complications and risk factors, and participant perception on diabetes-related services in the state of qatar. methods this study was conducted at the major public hospitals and clinics of hamad medical corporation (hmc) healthcare system, serving patients from all socioeconomic groups. hmc is the main public nonprofit health care provider offering about 90% of acute services in the state of qatar. 8-10 quality and accessible healthcare can be accessed using a health card system at hmc, which provides subsidized and/or free health services to citizens and residents.9,10 for this study, participants were recruited from the adult and pediatric diabetes clinics, women’s clinics, renal centers, and podiatry clinics. qatar residents (qatari and non-qatari nationals) of both sexes who were 16 years or older with diabetes were included in the study. individuals who were under 16 years of age, did not have diabetes, and non-residents of qatar (e.g. visitors), were excluded. patients were approached in the waiting areas or walk-in rooms of these healthcare facilities. using a purposive sampling approach, the trained research personnel carried out the surveys during working hours of these health facilities until the study reached the target sample 39% 45% 31% 46% 35% 35%33% 19% 54% 33% 41% 20% 30% 34% 23% 33% 19% 45% 25% 21% 31% 31% 24% 15% 8% 9% 8% 5% 14% 5% 0% 10% 20% 30% 40% 50% 60% overall male female qatari arab expat asian expat pe rc en t gender and nationality * the percentages do not add up to 100% since some patients reported multiple complications percentage of treated complications* among diabetic patients by sex & nationality high cholesterol vision problems high blood pressure foot problems kidney problems http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu total, n (%) male, n (%) female, n (%) p value* diabetes follow up visits in the past 12 months once 26 (8.7) 16 (9.6) 10 (7.5) 0.79 twice 39 (13.0) 20 (12.1) 19 (14.2) three times 42 (14.0) 23 (13.9) 19 (14.2) four times or more 171 (57.0) 97 (58.4) 74 (55.2) received advice and guidance in relation to diabetes physician 269 (89.7) 153 (92.2) 116 (86.6) nurse 5 (1.7) 1 (0.60) 4 (2.9) support groups 2 (0.70) 1 (0.60) 1 (0.90) friends 2 (0.70) 2 (1.2) family 9 (3.0) 2 (1.2) 7 (5.2) dietician 6 (2.0) 3 (1.8) 3 (2.2) personal trainer 2 (0.70) 2 (1.2) others 3 (1.0) 3 (2.2) nobody 2 (0.70) 2 (1.2) value of advice and support provided by nurse yes 208 (69.3) 106 (63.9) 102 (76.1) 0.01 no 57 (19.0) 33 (19.9) 24 (17.9) worked with the health professionals to set goals about the best way to manage diabetes yes, completely each time i visit them 67 (22.3) 32 (19.3) 35 (26.1) 0.09 yes, to some extent-sometimes at visit 101 (33.7) 67 (40.4) 34 (25.4) no, but i would have liked to 77 (25.7) 38 (22.9) 39 (29.1) received advice to change diet that could help manage diabetes yes, definitely 103 (34.3) 57 (34.3) 46 (34.3) 0.85 yes, to some extent but not enough 82 (27.3) 47 (28.3) 35 (26.1) no, but i would have liked help/advice 56 (18.7) 33 (19.9) 23 (17.2) received advice on physical activity from clinic staff yes, definitely 128 (42.7) 79 (47.6) 49 (36.6) 0.001 yes, to some extent but not enough 63 (21.0) 38 (22.9) 25 (18.7) no, but i would have liked help/advice 42 (14.0) 27 (16.3) 15 (11.2) thinking back to your last visit, were you given a copy of your diabetes plan? yes 172 (57.3) 103 (62.1) 69 (51.5) 0.11 no 119 (39.7) 60 (36.1) 59 (44.0) diabetes plan includes any of the following: your next appointment time and place 164 (95.3) 100 (97.1) 64 (92.8) name of contact person 71 (41.3) 40 (38.8) 31 (44.9) info. on managing diabetes between appointment 56 (32.6) 33 (32.0) 23 (33.3) personal goal and targets about diabetes 43 (25.0) 31 (30.1) 12 (17.4) advice on your diet and what foods to eat 67 (38.9) 41 (39.8) 26 (37.7) advice on physical activity 51 (29.6) 34 (33.0) 17 (24.6) your results of the diabetes tests 92 (53.5) 50 (48.5) 42 (60.9) a plan for medicines & lifestyle 91 (52.9) 58 (56.3) 33 (47.8) your health information & diabetes status 45 (26.7) 18 (17.5) 27 (39.1) confidence in managing diabetes due to the health check-up in past 12 months very confident 66 (22.0) 42 (23.5) 27 (20.2) 0.006 confident 134 (44.7) 84 (50.6) 50 (37.3) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu not sure 77 (25.7) 35 (21.1) 42 (31.3) fairly confident 20 (6.7) 5 (3.0) 15 (11.2) sometimes, a health professional will use complex medical terms and words that are not always understood by patients. has this ever happened to you? yes 47 (15.7) 16 (9.6) 31 (23.1) 0.002 no 247 (82.3) 148 (89.2) 99 (73.9) don’t know/ can’t remember 6 (2.0) 2 (1.2) 4 (3.0) in the last 12 months, have you undergone any of the following diabetes related tests? (yes/no) weight/ body mass index (bmi) 238 (79.3) 128 (77.1) 110 (82.1) blood pressure 234 (78.0) 135 (81.3) 99 (73.9) cholesterol 208 (69.3) 129 (77.7) 79 (59.0) hba1c (long term blood glucose test) 204 (68.0) 128 (77.1) 76 (56.7) blood test for kidney function 158 (52.7) 92 (55.4) 66 (49.3) urine test 220 (73.3) 126 (75.9) 94 (70.1) foot examination 140 (46.7) 71 (42.8) 69 (51.5) eye screening 161 (53.7) 79 (47.6) 82 (61.2) don’t know/ can’t remember 8 (2.7) 3 (1.8) 5 (3.7) were the results of these tests fully explained to you? (b14) yes, and i understood them clearly 181 (61.9) 87 (53.4) 94 (72.9) 0.007 yes, but i did not really understand them 26 (8.9) 18 (11.0) 8 (6.2) no, i didn’t need them to be 41 (14.2) 30 (18.4) 11 (8.5) no, not at all 22 (7.5) 12 (7.4) 10 (7.8) don’t know/ can’t remember 22 (7.5) 16 (9.8) 6 (4.7) *chi-square test table 3. follow up visits and treatment planning of 300 individuals. the 20-30 minute survey was carried out between february and may of 2015. a pre-tested and validated english and arabic-translated semi-structured questionnaire was utilized to collect the data. study participants were then categorized into qataris, arab expatriates, asian expatriates, and caucasian expatriates. no personal identifiers were collected for this survey. sample selection was based on gender, age, and nationality representation as described elsewhere. 11 the age groups were corresponded to the approximate 2015 qatar census proportion. 11 survey questions were used to obtain patient data on the general demographic characteristics, knowledge about diabetes-related complications, risk factors and management, and degree of diabetes service level support received from health facilities, health providers, and other local diabetes support groups. knowledge and perception of diabetes and diabetesrelated factors were measured using a 5-point likert scale question style (nothing, very little, some, enough, and a lot). ethical procedures were followed during the survey implementation and data handling procedures. informed (verbal) consent was obtained before the survey. patients were assured that the collected information would only be used for scientific purposes without sharing personal or identifiable information with third parties. parental consent was obtained for respondents below 18 years of age. supreme council of health, doha, qatar (now moph) provided ethical approval for this protocol. participant characteristics, including demographics, diabetes diagnosis and management, and diabetes support were reported using frequency and percentages. chi-squared tests or fisher exact test (where http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu total, n (%) male, n (%) female, n (%) p value* do you have a contact number for addressing concern about the diabetes yes 76 (25.3) 36 (21.7) 40 (29.9) 0.09 no 223 (74.4) 130 (78.3) 93 (69.4) don’t know 1 (0.30) 0 (0.0) 1 (0.70) which of the following do you feel you would be able to receive support from in relation to your diabetes?ϯ doctor at local clinic 247 (82.3) 137 (82.5) 110 (82.1) nurse at local clinic 98 (32.7) 48 (28.9) 50 (37.3) specialist consultant at hospital 101 (33.7) 61 (36.7) 40 (29.8) specialist nurse at hospital 30 (10.0) 19 (11.4) 11 (8.2) counselor 31 (10.3) 13 (7.8) 18 (13.4) telephone helpline 22 (7.3) 9 (5.4) 13 (9.7) support group 18 (6.0) 11 (6.6) 7 (5.2) coordinator 15 (5.0) 9 (5.4) 6 (4.5) other people with diabetes (other than a support group) 53 (17.7) 17 (10.2) 36 (26.9) family friend 111 (37.0) 44 (26.5) 67 (50.0) other 7 (2.3) 4 (2.4) 3 (2.2) none of these 5 (1.7) 4 (2.4) 1 (0.75) since you have been diagnosed with diabetes, would you want to talk to other people who also have diabetes? yes 193 (64.3) 110 (66.3) 83 (61.9) 0.43 no 107 (35.7) 56 (33.7) 51 (38.1) have you been able to meet and talk to other people with diabetes? yes 173 (57.7) 91 (54.8) 82 (61.2) 0.26 no 127 (42.3) 75 (45.2) 52 (38.8) are you aware of any local or national diabetes support / patient advocacy groups? yes, and i have contacted them 47 (15.7) 26 (15.7) 21 (15.7) 0.72 yes, but i have not contacted them 72 (24.0) 37 (22.3) 35 (26.1) no 181 (60.3) 103 (62.0) 78 (58.2) would you be willing to participate in any future studies on diabetes in qatar? yes 169 (56.3) 98 (59.0) 71 (53.0) 0.29 no 131 (43.7) 68 (41.0) 63 (47.0) *chi square test; ϯmultiple responses table 4. local or social support on diabetes in qatar response frequency was less than 5) were performed to compare categorical variables by gender. mann-whitney test was used to compare duration of diabetes by gender. the threshold level of significance was set at p<0.05. statistical analyses were performed using the spss software version 22.0 (ibm corporation, chicago, il, usa). http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu results a slightly higher percentage of males (55.3%) participated in this study. the highest percentage of participants were in the age group of 35-54 years (41.0%), followed by 25-34 years (24.0%). arab expatriates comprised 36.7% of the participants, followed by asian expatriates (30.7%) and qataris (29.3%). most of the respondents were married with children (80%). details about study participants are outlined in table 1. among overall sample, 31.0% of respondents reported having type 1 diabetes (t1d), 53.7% type 2 diabetes (t2d) and 15.3% did not specify the type (table 2). among men, 56.6% reported t2d and 26.5% t1d while among females 50.0% and 36.6% reported to have had t2d and t1d respectively (table 2). the proportion of respondents knowledgeable about their type of diabetes did not significantly differ by sex (p =0.16). about 32.3% of respondents who were treated for diabetes complications (single or multiple) reported having high cholesterol (39.2%), vision problems (33.1%), hypertension (30.0%), and foot problems (25.1%) (figure 1). most of the respondents were diagnosed with diabetes at primary care clinics (41.7%). 44.3% reported that they received sufficient diabetesrelated information. about 78.3% of survey participants were fully advised regarding the different types of diabetes tests; a significantly higher proportion of females (82.1%) compared to males (75.3%) reported that they were fully advised (p=0.009). more than half of patients (57.0%) had four or more visits for their disease-related checkups in the past 12 months. the majority of patients received diabetesrelated guidance from physicians (89.7%) (table 3). most of the patients (66.7%) reported that they were confident or very confident in managing their diabetes themselves as a result of their diabetes follow-up visits during the past 12 months. responses regarding number of patients undergoing diabetes related tests ranged from 46.7% (for foot examination) to bmi or body weight calculation (79.3%) (table 3). moreover, 82.3 % of participants reported that doctors at the clinics would be able to provide them with diabetes-related support (table 4). 64.3% of participants expressed their interest in talking with other diabetes patients. 15.7% contacted diabetes support or advocacy groups, 24.0% despite knowing advocacy groups did not contact them, and 60.3% of patients were not aware of diabetes support or advocacy groups. it is important to note that more than half of the patients had no idea about the effect of drinking alcohol (58.0%) or smoking (53.3%) on diabetes. furthermore, 47.7 % had no (33.0%) or very little knowledge (14.7%) while 52.3% had some (23.3%), enough (17.0%) and a lot (12.0%) knowledge about the adverse effects of taking diabetes medications (table 5). discussion diabetes is one of the top causes of death in the state of qatar.12 of the 300 patient-respondents, more than half were found to have t2d, with males having a slightly higher prevalence than females. a higher prevalence of t2d among males was also reported in other local and regional studies.13-22 common identified complications were high blood cholesterol concentrations, hypertension, vision, and foot problems. primary care clinics (42%) were identified as the primary place where patients were diagnosed with diabetes. the majority of respondents indicated that they have at least “some” or “enough” knowledge about most of the risk factors influencing diabetes (table 5). moreover, more than half indicated that they were informed “enough” or “a lot” about the importance of having regular visit with healthcare providers (65.3%). qatar’s diabetes registry for 2014-2016 showed that out of 2000 registered patients, about 95% had t2d, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu nothing n (%) very little n (%) some n (%) enough n (%) a lot n (%) the effects of being ill: ex. having flu 89 (29.7) 50 (16.7) 89 (29.7) 50 (16.7) 22 (7.2) maintaining weight 51 (17) 49 (16.3) 76 (25.3) 854 (28.3) 39 (13.1) blood glucose drops too low 17 (5.7) 65 (21.7) 95 (31.7) 75 (25.0) 48 (16.0) regular check-ups with doctor/ nurse 12 (4.0) 26 (8.7) 66 (22.0) 111 (37.0) 85 (28.3) cholesterol levels 60 (20.0) 52 (17.3) 81 (27.0) 84 (28.0) 23 (7.7) blood pressure 59 (19.7) 53 (17.7) 89 (29.7) 74 (24.7) 25 (8.3) checking and looking after eyes 54 (18.0) 38 (12.7) 86 (28.7) 58 (19.3) 64 (21.3) checking and looking after feet 64 (21.3) 56 (18.7) 79 (26.3) 66 (22.0) 35 (11.7) drinking alcohol 174 (58.0) 18 (6.0) 29 (9.7) 34 (11.3) 45 (15.0) smoking 160 (53.3) 12 (4.0) 53 (17.7) 33 (11.0) 42 (14.0) stress 31 (10.3) 68 (22.7) 108 (36.0) 56 (18.7) 37 (12.3) tiredness 28 (9.3) 58 (19.3) 110 (36.7) 71 (23.7) 33 (11.0) adverse effects taking medication 99 (33.0) 44 (14.7) 70 (23.3) 51 (17.0) 36 (12.0) severe complications left untreated 24 (8.0) 46 (15.3) 93 (31.1) 67 (22.3) 70 (23.3) table 5. likert scale responses “to what extent do you understand the following factors in relation to your diabetes?” with the remaining having t1d, pre-diabetes and secondary diabetes respectively, indicating a high prevalence of t2d among diabetic patients.23 by 2050, both the prevalence and incidence of t2d are forecasted to increase by at least 43% and 147%, respectively in qatar.24 the rise in t2d prevalence is projected to increase national diabetes related health expenditure from 20% currently to 32% by 2050.24 our results showed a relatively higher than expected proportion of t1d (31.0%) among diabetic patients surveyed for qatar. this is likely due to the fact that the survey was carried out at a tertiary hospital setting. another possible explanation of the high percentage of t1d among participants could be the high prevalence of vitamin d deficiency among adults and children in qatar reported in previous studies.25-27 these studies suggested a possible relationship between vitamin d deficiency and t1d; however, more studies are needed to explore this relationship in qatar.26,27 almost one-third of the patients surveyed were receiving treatment for diabetes-related complications. according to the national health and nutrition examination survey (nhanes), 1999–2004 (usa), the prevalence of diabetes complications among diabetics in the us were mainly due to kidney disease (27.8%), foot problems, (22.9%), and retinopathy (18.9%).28 in a saudi http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu review article investigating diabetes-related complications, the frequency of neuropathy and foot disease combined were alarmingly high at 82.0%, and the prevalence of retinopathy was 31%, and the prevalence of kidney disease requiring dialysis was between 30% to 45%.29,30 in comparison to nhanes data, only 8% of patients were receiving treatment for kidney issues, 25.1% for foot problems, and 33.1% for vision problems in our sample.28 we found that most of the patients received care at primary healthcare clinics and emergency rooms, and about half reported that they received adequate information about their diagnoses. almost all the patients who received brochures during their visits were happy about them. our survey findings provided valuable information because patient satisfaction in most healthcare services predicts the quality of care and management given by health providers.31 we found that most patients reported that they were confident in managing their disease after 12 months of checkups. in terms of patient-provider relationship, the majority of patients received guidance from their doctors and they were fairly able to work with healthcare professionals to set goals on the best ways to manage their diabetes. as expected, most patients cited doctors as their primary source of knowledge about their disease.32 the patient-provider relationship is important since it is evident that lack or insufficient communication between provider and patient with diabetes could lead to poor compliance.33, 34 furthermore, the patients who less frequently receive information about diabetes are also less likely to manage their disease themselves.35 in our study, the participants understood the importance of relationships with healthcare providers, family members and other diabetics for support, and advocacy groups. in another study, the patient-provider collaboration, positive attitude, social support, and participation in group educational activities were considered as the essential components of effective diabetes selfmanagement strategy.36 in general, a greater proportion of respondents had at least some understanding of their diagnosis and disease, such as the significance of their blood glucose levels, cholesterol levels, blood pressure, and disease management (maintaining weight, having regular checkups, checking their feet, and other preventative behaviors). on the other hand, more than half had no or very little understanding of specific diabetes-related factors such as alcohol use, smoking, and medication side effects. although our findings might not be comparable due to differences in the survey used, a study conducted in the uae showed low levels of overall awareness on diabetes, while we found a higher degree of diabetes knowledge and awareness among our study participants.32 this study examined perception and knowledge of services, risk factors, symptoms and certain disease risk factors among diabetic patients. certain diabetesrelated knowledge areas e.g. smoking, alcohol use, and adverse effects of medicines, require further education and counseling. patients were found to be generally satisfied regarding the level of information and support they received from the healthcare system. it would be beneficial to further expand diabetes-related programs in qatar by taking innovative approaches, such as diabetes hotline numbers, using social media, and health campaigns and events to address disease-related concerns. this study was an initial attempt to understand the patient perspective on diabetes and services provided to them. the findings from this study will be beneficial in garnering support from key stakeholders and policymakers for diabetes programs in qatar and will help in further strengthening ongoing projects targeting the country’s diabetes epidemic. application of appropriate surveillance approaches including that can also be used for other conditions are essential in studying diabetes and diabetes-related factors, especially factors that have already been identified in the country.2,5,37-45 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu acknowledgements we thank the survey participants, hamad medical corporation, qatar and primary health care corporation for their support in this project. references 1. badran m, laher i. obesity in arabic-speaking countries. j obes. 2011;686430. 2. al-thani mh, al-thani aa, al-chetachi wf, khalifa sah, akram h, poovelil b, et al. dietary and nutritional factors influencing obesity in qatari adults and the modifying effect of physical activity. j obes weight-loss medic. 2015;1(1). 3. qatar stepwise report for chronic disease risk factor surveillance. 2012. https://www.mdps.gov.qa/en/statistics/surveys/ste pwise_report.pdf. accessed 23 january 2019. 4. ali fm, nikoloski z, reka h, gjebrea o, mossialos e. the diabetes-obesity-hypertension nexus in qatar: evidence from the world health survey. popul health metr. 2014;12(1):1–10. 5. al-thani m, al-thani aa, al-chetachi w, khalifa se, vinodson b, al-malki b, et.al. situation of diabetes and related factors among qatari adults: findings from a community-based survey. jmir diabetes. 2017; 2(1):e7. 6. national health strategy. qatar national health strategy 2011–2016. https://www.moph.gov.qa/healthstrategies/pages/national-health-strategy.aspx. accessed 23 january 2019. 7. qatar national diabetes strategy 2018-2022. ministry of public health. https://www.moph.gov.qa/hsf/documents/short% 20report%20eng%2020.03.2018.pdf. accessed 23 january 2019. 8. hamad medical corporation, our organization. https://www.hamad.qa/en/about-us/ourorganization/pages/default.aspx. accessed 23 january 2019. 9. hukoomi, health insurance, health card. 2018. http://portal.www.gov.qa/wps/portal/topics/health/ healthinsurance. accessed 23 january 2019. 10. annual report hamad medical corporation (2012/2013). https://www.hamad.qa/en/ourpublications/annualreports/annual%20report%202016/en/pdf/hmc_ download_full_report_12.pdf. accessed 23 january 2019. 11. al-thani aa, farghaly ah, akram h, khalifa s, vinodson b, loares am, abou-samra ab. public awareness and perceptions about diabetes in the state of qatar. cureus 10(5): e2671. 12. el hajj ms, abu yousef se, basri ma. diabetes care in qatar: a survey of pharmacists’ activities, attitudes and knowledge. int j clin pharm. 2017. 13. bener a, kim ej, mutlu f, eliyan a, delghan h, nofal e, et.al. burden of diabetes mellitus attributable to demographic levels in qatar: an emerging public health problem. diabetes & metabolic syndrome: clinical research & reviews. 2014 oct 1;8(4):216-20. 14. al-hariri mt, al-enazi as, alshammari dm, bahamdan as, al-khtani sm, al-abdulwahab aa. descriptive study on the knowledge, attitudes and practices regarding the diabetic foot. journal of taibah university medical sciences. 2017 dec 1;12(6):492-6. 15. al bimani zs, khan sa, david p. evaluation of t2dm related knowledge and practices of omani patients. saudi pharmaceutical journal. 2015 jan 1;23(1):22-7. 16. al-adsani am, moussa ma, al-jasem li, abdella na, al-hamad nm. the level and determinants of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.mdps.gov.qa/en/statistics/surveys/stepwise_report.pdf https://www.mdps.gov.qa/en/statistics/surveys/stepwise_report.pdf https://www.moph.gov.qa/health-strategies/pages/national-health-strategy.aspx https://www.moph.gov.qa/health-strategies/pages/national-health-strategy.aspx https://www.moph.gov.qa/hsf/documents/short%20report%20eng%2020.03.2018.pdf https://www.moph.gov.qa/hsf/documents/short%20report%20eng%2020.03.2018.pdf https://www.hamad.qa/en/about-us/our-organization/pages/default.aspx https://www.hamad.qa/en/about-us/our-organization/pages/default.aspx http://portal.www.gov.qa/wps/portal/topics/health/healthinsurance http://portal.www.gov.qa/wps/portal/topics/health/healthinsurance https://www.hamad.qa/en/our-publications/annual-reports/annual%20report%202016/en/pdf/hmc_download_full_report_12.pdf https://www.hamad.qa/en/our-publications/annual-reports/annual%20report%202016/en/pdf/hmc_download_full_report_12.pdf https://www.hamad.qa/en/our-publications/annual-reports/annual%20report%202016/en/pdf/hmc_download_full_report_12.pdf https://www.hamad.qa/en/our-publications/annual-reports/annual%20report%202016/en/pdf/hmc_download_full_report_12.pdf central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu diabetes knowledge in kuwaiti adults with type 2 diabetes. diabetes & metabolism. 2009 apr 1;35(2):121-8. 17. al shafaee ma, al-shukaili s, rizvi sg, al farsi y, khan ma, ganguly ss, et.al. knowledge and perceptions of diabetes in a semi-urban omani population. bmc public health. 2008 dec;8(1):249. 18. kheir n, greer w, yousif a, al geed h, et al. knowledge, attitude, and practices of qatari patients with type 2 diabetes mellitus. int j pharm pract. 2011 jun;19(3):185-91. 19. al-sarihin k, bani-khaled m, haddad f, althwabia i. diabetes knowledge among patients with diabetes mellitus at king hussein hospital. jrms. 2012 mar;19(1):72-7. 20. al-bustan m, majeed s, bitar m, al-asousi a. socio-demographic features and knowledge of diabetes mellitus among diabetic patients in kuwait international quarterly of community health education. 1997;17(1): 65–76 21. o’beirne sl, salit j, rodriguez-flores jl, staudt mr, khalil ca, fakhro ka, robay a, ramstetter md, al-azwani ik, malek ja, zirie m. type 2 diabetes risk allele loci in the qatari population. plos one. 2016 jul 6;11(7): e0156834. 22. bener a, zirie m, janahi im, al-hamaq ao, musallam m, wareham nj. prevalence of diagnosed and undiagnosed diabetes mellitus and its risk factors in a population-based study of qatar. diabetes research and clinical practice. 2009 apr 1;84(1):99-106. 23. diabetes in qatar, hamad medical corporation. https://www.hamad.qa/en/allevents/mefqsh2017/presentations/documents/sund ay/d6e6_diabetes.pdf. accessed 23 january 2019. 24. awad sf, o'flaherty m, critchley j, abu-raddad lj. forecasting the burden of type 2 diabetes mellitus in qatar to 2050: a novel modeling approach. diabetes res clin pract. 2017. 25. badawi a, arora p, sadoun e, al-thani aa, al thani mh. prevalence of vitamin d insufficiency in qatar: a systematic review. journal of public health research. 2012 dec 28;1(3):229. 26. bener a, alsaied a, al-ali m, hassan as, basha b, al-kubaisi a, abraham a, mian m, guiter g, tewfik i. impact of lifestyle and dietary habits on hypovitaminosis d in type 1 diabetes mellitus and healthy children from qatar, a sun-rich country. annals of nutrition & metabolism. 2009 feb 1;53(3-4):215. 27. di cesar dj, ploutz-snyder r, weinstock rs, moses am: vitamin d deficiency is more common in type 2 than in type 1 diabetes. diabetes care 2006; 29: 174. 28. deshpande ad, harris-hayes m, schootman m. 2008. epidemiology of diabetes and diabetesrelated complications. physical therapy 88(11):1254-1264. doi:10.2522/ptj.20080020. 29. elhadd ta, al-amoudi aa, alzahrani as. epidemiology, clinical and complications profile of diabetes in saudi arabia: a review. annals of saudi medicine. 2007 jul 1;27(4):241. 30. akbar dh, mira sa, zawawi th, malibary hm. subclinical neuropathy a common complication in saudi diabetics. saudi med j 2000; 21(5):433-37. 31. cleary pd, mcneil bj. patient satisfaction as an indicator of quality care. inquiry. 1988 apr 1:2536. 32. al-maskari f, el-sadig m, al-kaabi jm, et al. knowledge, attitude and practices of diabetic patients in the united arab emirates. plos one. 2013; 8(1): e52857. 33. ciechanowski ps, katon wj, russo je, walker ea. the patient-provider relationship: attachment http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.hamad.qa/en/all-events/mefqsh2017/presentations/documents/sunday/d6e6_diabetes.pdf https://www.hamad.qa/en/all-events/mefqsh2017/presentations/documents/sunday/d6e6_diabetes.pdf https://www.hamad.qa/en/all-events/mefqsh2017/presentations/documents/sunday/d6e6_diabetes.pdf al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.333|http://cajgh.pitt.edu theory and adherence to treatment in diabetes. american journal of psychiatry. 2001;158(1):2935. 34. nam s, chesla c, stotts na, kroon l, janson sl. barriers to diabetes management: patient and provider factors. diabetes research and clinical practice. 2011 jul 1;93(1):1-9. 35. ayele k, tesfa b, abebe l, tilahun t, girma e. self care behavior among patients with diabetes in harari, eastern ethiopia: the health belief model perspective. plos one. 2012;7(4):e35515. 36. nagelkerk j, reick k, meengs l. perceived barriers and effective strategies to diabetes self‐ management. j adv nurs. 2006;54(2):151-8. 37. mohamed h, a-lenjawi b, amouna p, zotor f, el mahdi h, barakat n. knowledge, attitude, and practice of type2 arab diabetic patients in qatar: a cross-sectional study. int j diabetes dev ctries. 2015; 35(2): 205. 38. kheir n, greer w, yousif a, al geed h, al okkah r. knowledge, attitude and practices of qatari patients with type 2 diabetes mellitus. international journal of pharmacy practice. 2011 jun 1;19(3):185-91. 39. stone k, horney ja. methods: surveillance. in: horney jh, editor. disaster epidemiology: methods and applications; 2018. p. 11-23. https://doi.org/10.1016/b978-0-12-8093184.00002-2 40. akram h. role of school-based absenteeism data in surveillance and prediction of flu season. cjmb 2018; 5: 268–269. http://www.cjmb.org/text.php?id=213 41. akram h. west nile virus: epidemiological and surveillance approaches. int j basic sci med. 2017;2(3):111-112. doi: 10.15171/ijbsm.2017.21 42. al-thani m, al-thani a, al-chetachi w, akram h. obesity and related factors among children and adolescents in qatar. int j basic sci med. 2017;2(4):161-165. doi:10.15171/ijbms.2017.30 43. al-thani m, al-thani aa, a-mahdi n, al-kareem h, barakat d, al-chetachi w, et.al. an overview of food patterns and diet quality in qatar: findings from the national household income expenditure survey. cureus 9(5): e1249. 44. al-thani m, al-thani a, alyafei s, et al.: the prevalence and characteristics of overweight and obesity among students in qatar [epub ahead of print]. public health. 2018, 10.1016/j.puhe.2018.03.020 45. al-thani m, al-thani a, alyafei s, et al.: prevalence of physical activity and sedentaryrelated behaviors among adolescents: data from the qatar national school survey [epub ahead of print]. public health. 2018. al http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://doi.org/10.1016/b978-0-12-809318-4.00002-2 https://doi.org/10.1016/b978-0-12-809318-4.00002-2 knowledge and perception of diabetes and available services among diabetic patients in the state of qatar abstract keywords: diabetes, diabetes knowledge, diabetes health services, diabetic patient survey, qatar knowledge and perception of diabetes and available services among diabetic patients in the state of qatar research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. examining students’ motivations to pursue a bachelor’s degree in nutrition allison moreno arriaga, rosa dejanira medina terán, cecilia flores martínez, maría josé campos zamora, hilda lissette lópez lemus, cuauhtémoc sandoval salazar* department of nursing and obstetrics, celaya-salvatierra campus, university of guanajuato, mexico *e-mail: cuauhtemocss@gmail.com vol. 8, suppl. (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.378 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ navruzov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, suppl. (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.378|http://cajgh.pitt.edu abstract introduction: with high level of obesity in mexico, there is a growing need to train more students in nutrition. understanding what motivates students to choose pursuing degree in nutrition is very important for in post-secondary education. better understanding of motivating factors may help educators to make sure that students complete their degress. the aim of this paper was to determine factors influencing student motivations for pursuing a bachelor’s degree in nutrition at the university of guanajuato. methods: this was a survey study targeting 50 students at the university of guanajuato. questions in the survey targeted the following issues: general student characteristics, main reason for the choice of study area, objectives of higher education, university study field, and future plans. the descriptive statistics were calculated for the data obtained. the z test was applied to analyze the differences between the ages. results: the mean age of these students was 19 years; 74% were female while 26% were male. the students reported that the main reason for choosing a career in nutrition was personal preference and pointed out that such degree will give them better career options in the future, including better financial renumeration in comparison to other careers. most of the students stated that their main reason for choosing university of guanajuato was its prestige at the national and international level. conclusion: our study corroborates previously published study suggesting that students pursuing healthcare professions are motivaed by prestige and financial renumeration. with importance of nutrition in tackling obesity epidemic, it is very important to continue research on factors motivating students to choose careers in nutrition keywords: motivation; nutrition; university of guanajuato http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abstract keywords: motivation; nutrition; university of guanajuato new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. trends in the leading causes of childhood mortality from 2004 to 2016 in qatar mohammed al-thani, al-anoud al-thani, amine toumi, shamseldin khalifa, muhammad asif ijaz, hammad akram ministry of public health, state of qatar vol. 7, no. 1 (2018) | issn 2166-7403 (online) doi 10.5195/cajgh.2018.334 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.334|http://cajgh.pitt.edu abstract introduction: childhood mortality is an important health indicator that reflects the overall health status of a population. despite the decrease in global childhood mortality rates over the past decades, it still remains an important public health issue in qatar. methods: the data from 2004-2016 were extracted from the qatar ministry of public health birth and death database. international classification of diseases (icd-10) was used for coding the causes of death. the childhood mortality rate was defined as the probability of a child dying between the first and the fifth birthday, expressed as the number of deaths per 1,000 children surviving to 12 months of age. the sex ratio was calculated by dividing the mortality rate of males by that of females. mannkendall trend test was performed to examine time trends. relative risks were calculated to examine differences by nationality (qatari and non-qatari) and sex. results: a significant decrease in mortality rate of children aged one to five was observed from 1.76 to 1.05 per 1000 children between 2004 and 2016 (kendall tau=-0.6, p=0.004). three prominent causes of mortality were motor vehicle accidents, congenital malformations of the circulatory system, and accidental drowning/submersion. a statistically non-significant decrease in childhood mortality from motor vehicle accidents was oberved for all nationalities (total (kendall tau=-0.03), qatari (kendall tau=-0.14), and non-qatari (kendall tau=-0.12)). a significant decrease was seen for total accidental drowning and submersion (kendall tau=-0.54, p=0.012), while no statistically significant decrease was seen for total congenital malformations of the circulatory system (kendall tau=-0.36, ns). the qatari population did have a significant decrease in childhood mortality due to congenital malformations of the circulatory system (kendall tau=-0.67, p=0.003) and accidental drowning and submersion (kendall tau=-0.55, p=0.016). conclusion: the study is a first attempt to evaluate childhood mortality statistics from qatar and could be useful in supporting qatar’s ongoing national health strategy programs. keywords: childhood mortality, qatar, childhood mortality causes, sex ratio, public health, epidemiology trends in the leading causes of childhood mortality from 2004 to 2016 in qatar mohammed al-thani, al-anoud althani, amine toumi, shamseldin khalifa, muhammad asif ijaz, hammad akram ministry of public health, state of qatar research introduction the mortality rate for children under the age of five is defined as the number of deaths before the age of five per 1,000 live births in a region of interest and is a commonly used health indicator.1 decline in under-five mortality is a global trend reaching 58% reduction from 1990 to 2017.2 however, under five mortality is still high among countries in the world health organization (who) african region, reaching 100 deaths per 1,000 live births in some countries.2,3 it is an important health indicator that represents the health access, needs, and access to services in a region.1,2 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.334|http://cajgh.pitt.edu year children surviving to 12 months of age one to five mortality childhood mortality rate count count total (per 1000) qatari non-qatari male female 2004 13082 23 1.76 1.55 1.96 1.63 1.89 2005 13291 27 2.03 2.41 1.7 2.66 1.38 2006 14009 33 2.36 2.15 2.53 2.52 2.18 2007 15570 24 1.54 1.12 1.9 2.5 0.53 2008 17530 30 1.71 1.71 1.61 1.13 2.31 2009 18449 28 1.52 1.34 1.64 1.49 1.55 2010 19380 31 1.6 1.17 1.88 2.03 1.16 2011 20617 27 1.31 1.44 1.23 0.67 1.97 2012 21674 37 1.71 1.24 1.95 1.73 1.69 2013 23739 25 1.05 1.02 1.07 1.32 0.77 2014 25469 37 1.45 0.88 1.72 1.85 1.04 2015 26427 39 1.48 1.22 1.59 1.55 1.39 2016 26656 28 1.05 0.38 1.33 1.11 0.99 table 1. childhood mortality rates by year, sex and nationality despite the fact that global mortality rates have been decreasing over the past few decades, there is a focus on further reduction of under-five mortality in some nations.4 for example, under-five mortality rates ranged from 152 per 1000 live births in guinea bissau to 2.3 per 1000 live births in singapore.5 in 2013, annualized rates of change from the year 1990 to 2013 ranged from -6.8% to 0.1%.5 the united nations’ sustainable development goal (sdg) aims to reduce the under-five mortality in all countries to at least as low as 25 per 1,000 live births by 2030.2 according to the global statistics, over 5.6 million children, or 15,000 every day, died in this age group in 2016, making mortality under five years of age a major public health issue globally.2 childhood mortality (defined as death between the first and the fifth birthday) was approximately 13.3 per 1000 live births globally in 2013.5 childhood mortality in the north africa/middle east region and qatar was approximately 5.4 and 2.1 per 1000 live births respectively in 2013.5 generally, the sex ratio of male to female mortality aged between one and five years is greater than one, and females tend to have better survival up to five years when compared to males. in east asian countries, there was an increase in sex ratio from 1.02 in 1990 to 1.14 in 2012.6 in this study, we aimed to investigate the trends in childhood mortality and the leading causes of death http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.334|http://cajgh.pitt.edu population cause of death (with icd codes) mean minimum maximum kendall tau p valueϯ 2004-2016 year mortality rate year mortality rate 2004-2016 2004-2016 total v01-v99 transport accidents 0.24 2011 0.05 2005 0.60 -0.03 ns* r95-r99 ill-defined and unknown causes of mortality 0.18 2009 0.11 2012 0.55 -0.01 ns q20-q28 congenital malformations of the circulatory system 0.11 2012 0.05 2009 0.22 -0.36 ns w65-w74 accidental drowning and submersion 0.11 2016 0.04 2011 0.19 -0.54 0.012 c00-c97 malignant neoplasms 0.05 2016 0.04 2004 0.15 -0.08 ns j95-j99 other diseases of the respiratory system 0.05 2008 0.06 2015 0.19 0.10 ns g90-g99 other disorders of the nervous system 0.04 2015 0.04 2008 0.17 -0.07 ns qatari v01-v99 transport accidents 0.25 2016 0.12 2005 0.64 -0.14 ns r95-r99 ill-defined and unknown causes of mortality 0.13 2016 0.12 2006 0.46 -0.10 ns q20-q28 congenital malformations of the circulatory system 0.06 2010 0.13 2004 0.16 -0.67 0.003 w65-w74 accidental drowning and submersion 0.09 2009 0.13 2005 0.32 -0.55 0.016 c00-c97 malignant neoplasms 0.04 2016 0.13 2012 0.27 0.10 ns j95-j99 other diseases of the respiratory system 0.06 2016 0.13 2015 0.37 0.10 ns g90-g99 other disorders of the nervous system 0.05 2013 0.13 2008 0.39 -0.14 ns non qatari v01-v99 transport accidents 0.23 2013 0.13 2005 0.57 -0.12 ns r95-r99 ill-defined and unknown causes of mortality 0.21 2008 0.10 2012 0.83 -0.01 ns q20-q28 congenital malformations of the circulatory system 0.14 2012 0.07 2009 0.27 -0.33 ns w65-w74 accidental drowning and submersion 0.11 2016 0.05 2007 0.24 -0.23 ns c00-c97 malignant neoplasms 0.06 2012 0.07 2004 0.30 -0.10 ns j95-j99 other diseases of the respiratory system 0.04 2008 0.10 2016 0.16 0.21 ns g90-g99 other disorders of the nervous system 0.04 2015 0.05 2006 0.13 0.03 ns ϯp-values based on mann-kendall trend test, *ns – not significant table 2. the trends in the mortality rate across the top leading causes of child mortality by nationality http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.334|http://cajgh.pitt.edu figure 1. annual rate and sex ratio of childhood mortality in qatar by nationality by nationality and sex in qatar from 2004 to 2016. the mortality trends and characteristics among infants under one year of age in qatar have already been discussed in our previous publication.7 methods data management and handling ethical procedures as per qatar ministry of public health (moph) regulations were followed while carrying out the data handling and analysis. the data were maintained in a secure environment to assure privacy of personally identifiable information. childhood mortality data were extracted from the moph birth and death registry. causes of death were coded in accordance with the international classification of diseases guidelines (icd-10, version 2016). the detailed process of data collection and “cause of death” coding was described elsewhere.7 the data contained information on date, place, and cause of death, as well as included demographic information like sex, age, and nationality (qatari or non-qatari).7 definition the childhood mortality rate was defined as “the probability of a child dying between the first and the fifth birthday, expressed as deaths per 1,000 children surviving to 12 months of age.”8 this parameter is different than under-five mortality rate which also includes children who are under 1 year of age.1 an alternative approach to calculate childhood mortality (not used here) takes into account the number of deaths per 1000 live births, but the calculation method used in the present article is also acceptable and has been used globally in demographic health surveys.5, 8 statistical analysis the sex ratio was calculated by dividing the mortality rates of males by that of the females. to assess the trends by sex ratio and each cause of childhood mortality, a mann-kendall trend test was performed. the mann-kendall trend test is a nonparametric test for monotonic trends in a time series, based on the kendall rank correlation between the value of interest and time.9 medcalc® was used to calculate the difference in the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.334|http://cajgh.pitt.edu relative risk of the mortality due to selected causes by gender and nationality. all trend tests and plotting of changes in the mortality rates were carried out using r version 3.0.3 (r foundation for statistical computing, vienna, austria). lowess (locally weighted scatterplot smoother) smoothing lines were added to the plots. results overall, a total of 389 deaths were registered among children aged one to five in qatar from 2004 to 2016 (table 1). figure 1 shows that the annual childhood mortality rates for all populations decreased significantly from 1.76 (kendall tau=-0.6, p=0.004) in 2004 to 1.05 in 2016 (kendall tau=-0.03, p=0.951), with an average rate of 1.6 per 1000 live births between these years (20042016). based on the kendall tau, this decrease was more significant for qataris (kendall tau=-0.6, p=0.004) than for non-qataris (kendall tau=-0.4, p=0.044). however, there was no clear trend in sex ratio for the total study population (kendall tau=0.03). we also found that the trend in sex ratio for qatari population decreased from 1.41 in 2004 to 0.49 in 2016 but was not significant (kendall tau=-0.39, p=0.086), and that it increased from 0.59 in 2004 to 1.24 in 2016 for non-qataris but again was not significant (kendall tau=-0.18, p=0.428). figure 2. proportion of deaths by age for 2004-2016. overall (across all years), the majority of deaths occurred among children aged one (33%), followed by children aged two (27%), three (24%) and four (16%) (figure 2). table 2 shows the trends in mortality rates across the top leading causes of mortality in qatar by nationality. for the total population, even though transport accident-related mortality was prevalent, a decline was observed over time (kendall tau= -0.03). deaths in the “external cause of death” icd category (not shown in the table) decreased (kendall tau=-0.41, pvalue = 0.06) as well. furthermore, since 2004, the mortality due to congenital malformation of the circulatory system (kendall tau=-0.36) and accidental drowning and submersion (kendall tau=-0.54, p=0.012) also decreased. by nationality, the qatari population had a significant decrease in childhood mortality due to the congenital malformation of the circulatory system (kendall tau=-0.67, p=0.003) and accidental drowning and submersion (kendall tau=-0.55, p=0.016). even though a decline in childhood mortality was seen among non-qataris, the trends were not statistically significant (table 2). the relative risk (rr) of death for qataris versus non-qataris for the congenital malformations of the circulatory system was low (rr = 0.44, ci = 0.18 1.07, p = 0.07) (table 3). a decline in transport accidentrelated mortality was observed among qataris (kendall tau= -0.14) and non-qataris (kendall= -0.12); however, this decline was not statistically significant (table 2). table 4 shows the mean sex ratio and the trend of sex ratio by leading causes of death from 2004 to 2016. for the total population, the sex ratio was more than 1 for a majority of the causes of death and reached 2.75 for accidental drowning and submersion with a significant decrease in males over the observed period (kendall tau=-0.72, p < 0.001). qatari males had a higher relative risk of mortality due to accidental drowning and submersion in comparison to females (rr=7.77, ci = 0.97 – 62.15, p = 0.053) (data not shown). 1 year 33% 2 years 27% 3 years 24% 4 years 16% http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.334|http://cajgh.pitt.edu cause of death total number of deaths (2004-2016) % of total childhood mortality (n=389) qatari child mortality rate non-qatari child mortality rate rr (95% ci) male cmr (n) female cmr (n) rr (95% ci) overall 389 100% 1.32 1.63 0.81 (0.66 1.00)* 1.63 1.4 1.17 (0.95 1.42) external causes 127 33% 0.47 0.51 0.93 (0.64 1.33) 0.57 0.42 1.34 (0.94 1.91) transport accidents 61 16% 0.25 0.23 1.33 (0.79 2.22) 0.28 0.20 1.39 (0.83 2.31) congenital malformations of the circulatory system 29 7% 0.06 0.14 0.44 (0.18 1.07) 0.09 0.14 0.68 (0.32 1.42) accidental drowning and submersion 27 7% 0.09 0.11 0.83 (0.37 1.86) 0.15 0.06 2.75 (1.16 6.50)ϯ malignant neoplasms 14 4% 0.04 0.06 0.67 (0.21 2.13) 0.07 0.04 1.73 (0.58 5.17) *p=0.0551, ϯ p=0.0212 table 3. prominent causes of childhood mortality and relative risks by sex and nationality for 2004-2016 despite a significant decrease in the mortality trend for females (kendall tau=-0.45, p=0.038) was observed, the sex ratio was found to be less than 1 (0.68) for congenital malformations of the circulatory system. the qatari population showed a higher mean sex ratio for congenital malformations of the circulatory system (q20-q28) and accidental drowning and submersion (w65-w74), which were 2.59 and 3.89 respectively. for congenital malformations of the circulatory system, the mortality trends significantly decreased for males (kendall tau=-0.61, p=0.008), and not significantly for females (kendall tau=-0.30). however, for accidental drowning and submersion there were no differences amongst both sexes for qataris (table 4). for accidental drowning and submersion, the mortality of the total population had a higher relative risk for males than females (rr = 2.75, ci= 1.16 – 6.50, p = 0.0212) (table 3). for the congenital malformations of the circulatory system among the non-qatari population, the mean sex ratio was less than 1 with a significantly higher decline in mortality for females (kendall tau=-0.45, p=0.038). moreover, a higher mean sex ratio for malignant neoplasms was seen (2.23) but no significant figure 3. the distribution of the three major causes of child mortality from 2004 to 2016. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.334|http://cajgh.pitt.edu change in the mortality trends between the years 2004 and 2016 was seen among both sexes. the sex ratio for diseases of the respiratory system was 0.72, with a significantly increasing trend among non-qatari males from 2004 to 2016 (kendall tau = 0.54, p = 0.031). figure 3 shows the distribution of the three major causes of childhood mortality from 2004 to 2016. while a declining trend in transport accidents was observed from 2004 to 2016, it was not significantly different for the total population and nationality subgroups. the qatari population showed a significant decrease in mortality rates for congenital malformations of the circulatory system (kendall tau = -0.67, p = 0.003) population cause of death (icd code) mean kendall tau males p value kendall tau females p valueϯ 2004-2016 2004-2016 2004-2016 2004-2016 2004-2016 total v01-v99 transport accidents 1.39 -0.13 ns -0.04 ns r95-r99 ill-defined and unknown causes of mortality 1.32 -0.09 ns 0.13 ns q20-q28 congenital malformations of the circulatory system 0.68 -0.15 ns -0.45 0.038 w65-w74 accidental drowning and submersion 2.75 -0.72 0.001 -0.16 ns c00-c97 malignant neoplasms 1.73 0.04 ns 0.1 ns j95-j99 other diseases of the respiratory system 1.12 0.21 ns 0.14 ns g90-g99 other disorders of the nervous system 0.8 0.02 ns -0.1 ns qatari v01-v99 transport accidents 1.15 -0.24 ns 0.04 ns r95-r99 ill-defined and unknown causes of mortality 1.94 -0.07 ns 0.1 ns q20-q28 congenital malformations of the circulatory system 2.59 -0.61 0.007 -0.3 ns w65-w74 accidental drowning and submersion 3.89 0.07 ns 0.07 ns c00-c97 malignant neoplasms 1.46 -0.41 ns 0.35 ns j95-j99 other diseases of the respiratory system 0.97 -0.17 ns 0.33 ns g90-g99 other disorders of the nervous system 0.65 0.02 ns -0.26 ns non qatari v01-v99 transport accidents 1.57 0.01 ns -0.01 ns r95-r99 ill-defined and unknown causes of mortality 1.15 0.03 ns 0.1 ns q20-q28 congenital malformations of the circulatory system 0.62 -0.05 ns -0.45 0.038 w65-w74 accidental drowning and submersion 1.91 -0.3 ns -0.1 ns c00-c97 malignant neoplasms 2.23 0.16 ns -0.12 ns j95-j99 other diseases of the respiratory system 0.72 0.54 0.031 0.07 ns g90-g99 other disorders of the nervous system 0.96 0.12 ns 0.02 ns ϯp-values based on mann-kendall trend test, *ns – not significant table 4. the sex ratio (males to females) for total mortality and for the leading causes of child mortality in qatar (2004-2016) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.334|http://cajgh.pitt.edu and accidental drowning/submersion (kendall tau= 0.55, p = 0.016). the latter was also significant for the total population (kendall tau = -0.54, p = 0.012). discussion based on the data from moph, this study described the trends in childhood mortality in the state of qatar from 2004 to 2016. we found that the rates of mortality among children declined significantly from 1.76 per 1000 in 2004 to 1.05 per 1000 in 2016 (figure 1). globally, child mortality rates (per 1000 live births) reduced from 22.1 in 2000 to 13.1 in 2013 respectively.5 in 2013, the childhood mortality rates (per 1000 live births) were slightly higher in nearby kuwait (1.8) and oman (2.0) in comparison to qatar (1.05); however, the rates were calculated using a different approach in our study and may not be comparable with other countries mentioned here.5 moreover, the childhood mortality trends for the three leading causes of deaths have been decreasing over the past 12 years in qatar. there was no clear trend of change in sex ratio found for the total study population. moreover, the average childhood mortality rates by nationality (2004-2016) were 1.4 and 1.7 for qataris and non-qataris respectively, which are somewhat similar. this may be attributed to the universal healthcare access available in qatar. the state offers a special health-card system for both non-nationals as well as nationals to obtain subsidized and, in some instances, free health services through a major public healthcare system. our study indicated that deaths due to external causes, including transport accident related deaths in qatar, were similar to the findings from other countries such as the republic of korea, japan, the united states, and the united kingdom.10-13 a decreasing pattern in mortality due to external causes was also seen among these countries, similar to our findings in qatar.10-13 a decline in transport accident related mortality was observed in the present study, and even though this trend was not statistically significant, it could be an early reflection of the effectiveness of programs implemented in qatar. in 2007, a new law was passed in qatar to control morbidity and mortality associated with road traffic accidents.14 the law included provisions for prohibiting children under 10 years of age to sit in the front seats of moving vehicles and also forbade the use of any portable devices such as mobile phones while driving.14 furthermore, educational programs have been introduced in qatar, including those targeting child passenger safety and promoting the use of a child/infant car seats.15 in addition, a national road safety strategy 2013-2022 has been developed to decrease traffic accident related morbidity and mortality. the strategy multi-dimensionally targets traffic-related policies and infrastructure, as well as community education and awareness.16 the other two common causes of mortality discussed in this publication are accidental drowning/submersion and the congenital malformation of the circulatory system. a statistically significant decline from 2004 to 2016 was observed for accidental drowning and submersion for both the total population and qataris. for the non-qatari population, a nonsignificant decline was noticed. among the qatari population, the mortality due to the congenital malformations of the circulatory system has significantly decreased. for all three leading causes of mortality, the non-qatari population had a non-significant decline. mortality risk due to accidental drowning and submersion was higher among males compared with females for all national groups. the higher predisposition of drowning-related mortality among males has also been observed in other studies.17,18 however, in a brazilian study, a slightly higher rate of childhood mortality due to malformations of the circulatory system was seen among females.19 significant decreases were found for congenital malformations of the circulatory system among females in the total population, among qatari males and nonhttp://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.334|http://cajgh.pitt.edu qatari females (table 4). furthermore, a significant decline in mortality due to accidental drowning and submersion was also seen among males in the total population (table 4). the major strength of this study was that the data came from a comprehensive birth and death registry system with a uniformly collected and accurate countrylevel childhood mortality information for 2004-2016. data pertaining to the unknown causes of mortality is one of the challenges of our data collection system that may potentially impact mortality rates. the state of qatar has a relatively stable qatari citizens’ population compared to non-qataris or expatriates. this can potentially lead to the selection bias in mortality indicators since expatriate population consists of relatively young healthy individuals. our results could be useful in supporting qatar’s current national health strategy initiatives and also align with sustainable development goal that focus on ensuring healthy lives and promote well-being for citizens of all ages.2,20 these findings could also be essential for policymakers, researchers, and other professionals from regional countries as a reference or as a guideline tool. in summary, childhood mortality, though steadily decreasing, requires ongoing efforts and resources to be further reduced. references 1. unicef. definitions: basic indicators, underfive mortality rate. https://www.unicef.org/infobycountry/stats_po pup1.html. accessed 26 october, 2018. 2. who. global health observatory data: underfive mortality. http://www.who.int/gho/child_health/mortality/ mortality_under_five_text/en/. accessed 26 october, 2018. 3. unicef. committing to child survival: a promise renewed. progress report 2013. https://www.unicef.org/publications/index_703 54.html. accessed 26 october, 2018. 4. un. millenium declaration. http://www.un.org/millennium/declaration/ares 552e.htm. accessed 26 october, 2018. 5. wang h, liddell ca, coates mm, et al. global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990-2013;2013: a systematic analysis for the global burden of disease study 2013. the lancet. 2014;384(9947):957-979. 6. alkema l, chao f, you d, pedersen j, sawyer cc. national, regional, and global sex ratios of infant, child, and under-5 mortality and identification of countries with outlying ratios: a systematic assessment. the lancet global health. 2014;2(9):e521-e530. 7. al-thani m. an overview of infant mortality trends in qatar from 2004 to 2014.cureus 9(9). e1667 8. malawi demographic and health survey. zomba: national statistical office; 2004. https://www.dhsprogram.com/pubs/pdf/fr175/ fr-175-mw04.pdf. accessed 26 october, 2018. 9. kendall, m.g. (1948). rank correlation methods. oxford, england: griffin. 10. choe sa, cho si. causes of child mortality (1 to 4 years of age) from 1983 to 2012 in the republic of korea: national vital data. j prev med public health. 2014 nov;47(6):336-42. doi: 10.3961/jpmph.14.024. 11. sekii h, ohtsu t, shirasawa t, ochiai h, shimizu t, kokaze a. childhood mortality due to unintentional injuries in japan, 2000–2009. international journal of environmental research and public health. 2013;10(2):528540. 12. johnston bd, ebel be. child injury control: trends, themes, and controversies. academic pediatrics. 2013;13(6):499-507. 13. hill k, upchurch dm. gender differences in child health: evidence from the demographic and health surveys. population and development review. 1995;21(1):127-151. 14. almeezan. law no. (19) of 2007 regarding the the traffic law. http://www.almeezan.qa/lawview.aspx?opt& lawid=3993&language=en. accessed 26 october, 2018. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.unicef.org/infobycountry/stats_popup1.html https://www.unicef.org/infobycountry/stats_popup1.html http://www.un.org/millennium/declaration/ares552e.htm http://www.un.org/millennium/declaration/ares552e.htm http://www.almeezan.qa/lawview.aspx?opt&lawid=3993&language=en http://www.almeezan.qa/lawview.aspx?opt&lawid=3993&language=en al-thani this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.334|http://cajgh.pitt.edu 15. hamad international training center. child passenger safety. https://www.hamad.qa/en/your%20health/ha mad%20international%20training%20center/ kulluna/pages/default.aspx. accessed 26 october, 2018. 16. the qatar national road safety strategy 20132022. http://www.ashghal.gov.qa/en/services/lists/s erviceslibrary/nrss_eng.pdf. accessed 26 october, 2018. 17. lindholm p, steensberg j. epidemiology of unintentional drowning and near-drowning in denmark in 1995. injury prevention. 2000;6(1):29-31. 18. iqbal a, shirin t, ahmed t, et al. childhood mortality due to drowning in rural matlab of bangladesh: magnitude of the problem and proposed solutions. journal of health, population, and nutrition. 2007;25(3):370-376. 19. salim tr. mortality from circulatory system diseases and malformations in children in the state of rio de janeiro. arq bras cardiol. 2016 jun; 106(6): 464–473. 20. national health strategy 2018-2022. https://www.moph.gov.qa/hsf/pages/nhs18-22.aspx. accessed 26 october, 2018. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.hamad.qa/en/your%20health/hamad%20international%20training%20center/kulluna/pages/default.aspx https://www.hamad.qa/en/your%20health/hamad%20international%20training%20center/kulluna/pages/default.aspx https://www.hamad.qa/en/your%20health/hamad%20international%20training%20center/kulluna/pages/default.aspx http://www.ashghal.gov.qa/en/services/lists/serviceslibrary/nrss_eng.pdf http://www.ashghal.gov.qa/en/services/lists/serviceslibrary/nrss_eng.pdf https://www.moph.gov.qa/hsf/pages/nhs-18-22.aspx https://www.moph.gov.qa/hsf/pages/nhs-18-22.aspx trends in the leading causes of childhood mortality from 2004 to 2016 in qatar abstract keywords: childhood mortality, qatar, childhood mortality causes, sex ratio, public health, epidemiology trends in the leading causes of childhood mortality from 2004 to 2016 in qatar research new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. hysterectomy pathway as the global engine of practice change: implications for value in care amin sanei-moghaddam1, sharon goughnour1, robert edwards2, john comerci2, joseph kelley2, nicole donnellan3, faina linkov1, suketu mansuria3 1magee-womens research institute, department of obstetrics, gynecology and reproductive sciences; 2division of gynecologic oncology, department of obstetrics, gynecology and reproductive sciences, university of pittsburgh medical center, mageewomens hospital; 3divisions of minimally invasive gynecologic surgery, department of obstetrics, gynecology and reproductive sciences, university of pittsburgh medical center, magee-womens hospital vol. 6, no. 1 (2017) | issn 2166-7403 (online) doi 10.5195/cajgh.2017.299 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ sanei-moghaddam this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.299|http://cajgh.pitt.edu abstract introduction: in 2012, university of pittsburgh medical center (upmc) introduced a hysterectomy clinical pathway to reduce the number of total abdominal hysterectomies performed for benign gynecological indications. this study focused on exploring physician and patient factors impacting the utilization of hysterectomy clinical pathways. methods: an online survey with 24 questions was implemented to explore physicians’ attitudes and perceived barriers toward implementing the pathway. a survey consisting of 27 questions was developed for patients to determine the utility of a pathwaybased educational tool for making surgery decisions and to measure satisfaction with the information provided. descriptive statistics were used to describe survey results, while thematic analysis was performed on verbal feedback submitted by respondents. results: physician respondents found the clinical pathway to be practical, beneficial to patients, and up-to-date with the latest evidence-based literature. key barriers to the use of the pathway that were identified by physicians included perceived waste of time, inappropriateness for some of the patient groups, improper incentive structure, and excessive bureaucracy surrounding the process. overall, patient respondents were satisfied with the tool and found it to be helpful with the decision-making process of choosing a hysterectomy route. conclusions: physicians and patients found the developed tools to be practical and beneficial. findings of this study will help to use pathways as a unifying framework to shape future care of patients needing hysterectomy and add value to their care. keywords: clinical pathways; hysterectomy; decision support tools; survey research hysterectomy pathway as the global engine of practice change: implications for value in care amin sanei-moghaddam1, sharon goughnour1, robert edwards2, john comerci2, joseph kelley2, nicole donnellan3, faina linkov1, suketu mansuria3 1magee-womens research institute, department of obstetrics, gynecology and reproductive sciences; 2division of gynecologic oncology, department of obstetrics, gynecology and reproductive sciences, university of pittsburgh medical center, magee-womens hospital; 3divisions of minimally invasive gynecologic surgery, department of obstetrics, gynecology and reproductive sciences, university of pittsburgh medical center, magee-womens hospital research hysterectomy is one of the most common gynecologic procedures in the us, with approximately 600,000 women undergoing a hysterectomy each year.13 hysterectomy is a common procedure used to treat endometrial cancer, the most common gynecologic malignancy in the us women. published evidence points to the excessive use of open surgical approaches for hysterectomy when minimally invasive approaches may be used.4 reducing the overutilization of open hysterectomy has many benefits: lessening patient recovery time, reducing surgical complications, such as infection and thromboembolic events, and decreased healthcare expenditures.4-7 one way of reducing this variability in care is by adopting clinical pathways. clinical pathways became an essential part of patient care management in the us. by the late 1990s, more than 80% of us hospitals used at least some clinical pathways to manage patient care.8 clinical http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx sanei-moghaddam this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.299|http://cajgh.pitt.edu pathways are evidence-based, multidisciplinary care algorithms that outline essential steps in the medical management of a specific clinical condition.9 a recent study by hripcsak et al. characterized treatment pathways on a global scale and found that the pathways improved consistency of therapy across diseases and locations.10 in 2012, university of pittsburgh medical center (upmc) introduced a hysterectomy clinical pathway to reduce the number of total abdominal hysterectomies being performed for benign gynecological indications.4,11 we hypothesized that pathways could be a unifying vehicle of change for both providers and patients in choosing the most optimal surgical approach to hysterectomy, which can have very important implications for gynecologic care and healthcare in general. the first aim of this study was to examine physicians’ perceptions and attitudes toward utilization of the hysterectomy clinical pathway 3 years after its implementation. the second aim of this study was to investigate if a “pathways-oriented” patient education tool would be helpful for patient decision-making. patients do not always have an effective decision support infrastructure when it comes to making decisions about which hysterectomy route is the best for them. additionally, physicians and other healthcare providers may not necessarily have the time to go into the details of all surgical options. to fill this gap, our group sought to develop and introduce a hysterectomy pathway informed online educational tool for patients considering elective hysterectomy, and pilot this effort in upmc facilities. by using the internet to educate patients about various hysterectomy types/routes, we are employing technology that is already used by many women to obtain health information. by empowering a larger number of women to opt for minimally invasive surgery at specialized centers, we can potentially improve patients’ clinical outcomes by reducing adverse outcomes associated with open procedures, while also controlling costs associated with hospital stay that can be reduced by roughly 1.5 days4. we hypothesized that using this innovative online educational tool will encourage patients to be active partners in selecting hysterectomy route that works best for each individual woman. thus, following the implementation of physician satisfaction survey, we surveyed patients on the utility of a pathways-based educational tool in the decision-making process when choosing a hysterectomy route. methods physician survey an online survey with 24 questions for physicians was designed based on the review of the literature12-14 and local experts’ opinions to explore surgeons’ attitudes and perceived barriers toward implementing the clinical pathway. ninety-two gynecologic surgeons who were exposed to the pathway were identified in the upmc system by utilizing upmc healthplan data. in december 2015, an invitation email along with a link to the survey was sent to academic email accounts of all physicians utilizing pathways. this was an anonymous survey, and no identifiable information was collected. the first item on the survey was informed consent. the survey was distributed using the qualtrics platform (qualtrics labs, provo, ut). qualtrics protocols were followed to minimize the risk of emails being trapped in spam folders.15 reminders were sent at two weeks and four weeks after the initial invitation to those who either did not open the survey or did not finish the survey. two weeks after the second reminder was sent the survey was closed. demographics, education and training, practice characteristics (including number of hysterectomies performed in a typical month by route of surgery), and their opinions on different aspects of the pathway (using linkert-type ranking questions where a score of 1 indicated a favorable attitude and score of 5 indicated an http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx sanei-moghaddam this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.299|http://cajgh.pitt.edu unfavorable attitude) were collected. this study was approved by the university of pittsburgh institutional review board (#pro15060194). patient survey for the patient educational tool, we solicited the input from the hysterectomy pathway algorithm, from healthcare providers, and materials from the healthwise12 website to develop the hysterectomy pathway informed decision making tool. the package explained the different types of hysterectomy procedures, benefits and complications associated with each type of hysterectomy procedure, as well as links to pictures and videos designed to illustrate the nature of the procedures. with the help of clinical providers and researchers, we developed a patient survey consisting of 27 questions to determine the utility of this pathways based educational tool from the patient prospective. the survey was administered using the university of pittsburgh qualtrics survey software site and ascertained their thoughts regarding the utility of the site, ease of use, likes and dislikes pertaining to the site, and suggestions for additions and improvements.13 approval to conduct this research survey study was obtained from the university of pittsburgh internal review board (irb #pro16020590). study population direct recruitment of study participants was conducted during their visits to gynecologic surgical specialists. participants were identified by the clinical co-investigators of this study based on the criterion of them considering hysterectomy for benign indications (either currently or in the past). we recruited 20 women from the gynecology specialties clinic at mageewomens hospital of the upmc health system. when the patient agreed to participate and verbal consent was obtained, the experimental educational package and research survey were presented to her in the same room as her visit or in the consult room of the clinic (as appropriate based on clinic flow). participants were able to review materials at their own pace and fill out the survey if/when they felt ready to fill it out. the participants were given the option of filling out the survey on an ipad or using a paper version. the survey answers were stored in a password protected electronic format on a secure university of pittsburgh server and all responses remained anonymous. data analysis this was a mixed methods study consisting of quantitative and qualitative analyses. descriptive statistics were used to describe the characteristics of both the physician and patient survey populations. we conducted a thematic analysis on all verbal feedback by coding the key points and categorizing them into concepts, sub-themes, and themes.14 two authors coded and categorized key themes/concepts individually and then with the help of a third author we aggregated the two sets of codes and developed the final coding scheme. statistical analyses were carried out using sas version 9.4 (sas institute, inc., carey, nc). results physician survey all survey invitations to physicians were successfully delivered to the recipients’ email addresses. out of 92 identified surgeons, 26 (28.2 %) started the online survey and 22 (23.9%) completed the survey. the mean age of respondents was 46.6 years (standard deviation 8.8) and 50% were female. half of the respondents (11) finished their residency after the year 2000 and the rest (11) finished before or during the year 2000. ten physicians (45.5%) had fellowship training. the respondents reported performing as many as 25 and as low as 0 (only 1 observation) hysterectomies in a typical month (median = 7.5). on average, in a typical month, the respondents performed 185 hysterectomies (group data). one respondent http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx sanei-moghaddam this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.299|http://cajgh.pitt.edu reported zero number of hysterectomies. only one of the remaining 21 respondents reported performing a low volume of minimally invasive hysterectomies (mih) (<30%). laparoscopic surgery was the most common route of surgery with 120 cases (64.8%) followed by vaginal 34 (18.3%), robotic 19 (10.2%), and abdominal 12 (6.4%) routes. all of the respondents unanimously reported the positive benefits of minimally invasive approaches for women that are appropriate candidates for mih. one respondent commented that the benefits of mih are so positive that they are willing to refer to another physician to ensure the patient has the minimally invasive option. when asked whether they believe they need to do more mih, two respondents (one with no hysterectomies and the one with low mih volume) answered yes. the remaining respondents believe they perform an appropriate number of mih. while overall perception of pathways was favorable, three respondents (13.64%) had either “unfavorable” or “very unfavorable” attitude toward the pathway, and 7 (31.8%) found it “unhelpful” or “very unhelpful” in decision making (table 1). one respondent reported the pathway as “difficult to follow” and 2 respondents reported that the software interface was “not userfriendly”. overall, 19 respondents (86.36%) believed the clinical pathway was up-to-date with the latest evidence-based literature, while 17 respondents (77.27%) would recommend it to their colleagues. none of the respondents reported any resistance from the patients when mih was offered to them. lastly, when asked what route of surgery they would prefer should they or an immediate family member (spouse, mother, sister, or daughter) need a hysterectomy for a benign indication, all of them chose mih. thirteen respondents (59.09%) preferred vaginal approach, followed by laparoscopic route (27.27), and robotic route (13.64%). the three main themes that emerged during the analysis of verbal feedback are practice pattern, barriers, and benefits. the key barriers to use of pathways reported by the respondents included: not being appropriate for all cases, perceived waste of time, forgetting to use it, improper incentive structure, and excess bureaucracy around the process. patient survey we surveyed 20 women who visited the gynecology specialties clinic at magee-womens hospital of the upmc health system between may 5, 2016 and june 1, 2016. fifteen (75%) were caucasian, 4 (20%) were african-american, and 1 (5%) was hispanic. the average age of the thirteen women who reported their age, was 46 years old (standard deviation: 7.3). out of 18 participants who were considering having a hysterectomy, 6 reported “fibroids” as their chief complaint, 3 reported “heavy periods, 5 had “painful periods, endometriosis,” 2 had “ovarian cysts,” 1 was brca mutation positive, and 1 did not specify her compliant. when asked whether they found the information on the website helpful, 12 out of 18 (66.6%) answered “definitely yes”, 5 (27.7%) answered “probably yes” and 1 (5.5%) answered “might or might not”. all participants were asked to rank the source of information they relied on the most in making the decision about the type of surgery. seventeen (85%) ranked physicians as their primary source, while the other 3 ranked the internet, family member or friends as their primary sources. they were also asked to rank the main factors that can influence their decision on choosing the type of surgery. fourteen (70%) ranked “effectiveness in symptoms relief” as the first factor, 2 (10%) ranked “complications”, 1 (5%) ranked “cost”, 1 (5%) ranked “length of stay in the hospital”, 1 (5%) ranked “pain”, and 1 (5%) ranked “incision size”. when asked who was the main decision maker for the type of surgery, 2 (10%) said it was a shared decision between the primary care physician and the obstetrics and gynecology specialist. twelve (60%) said this was a decision that should be made by the obstetrics and gynecology specialist. four (20%) said they themselves http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx sanei-moghaddam this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.299|http://cajgh.pitt.edu overall attitude towards clinical hysterectomy pathways number percent very favorable 4 18.18% favorable 12 54.55% neutral 3 13.64% unfavorable 2 9.09% very unfavorable 1 4.55% helpfulness of the hysterectomy pathway in decision making very helpful 3 13.64% helpful 0 0% neutral 12 54.55% unhelpful 4 18.18% very unhelpful 3 13.64% practicality of the pathway in their health care facility? very practical 5 22.73% practical 8 36.36% neutral 6 27.27% impractical 1 4.55% very impractical 2 9.09% easy to follow very easy 10 45.45% easy 8 36.36% neutral 3 13.64% difficult 1 4.55% very difficult 0 0% software interface “user-friendliness” very user-friendly 2 9.09% user-friendly 14 63.64% neutral 4 18.18% not user-friendly 1 4.55% not user-friendly at all 1 4.55% being up-to-date with the evidence-based literature? yes 19 86.36% no 3 13.64% whether the pathway changed the way they practice? yes 3 13.64% http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx sanei-moghaddam this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.299|http://cajgh.pitt.edu no 19 86.36% whether they would recommend the hysterectomy pathway to their colleagues? yes 17 77.27% no 5 22.73% whether the pathway is applicable to their patients’ pool? yes 11 50% not sure 3 13.64% no 8 36.36% perceived barriers to the use of the pathway it is very time consuming 0 0% needs lot of effort 1 4.55% i am not sure if that is helpful 8 36.36% others 13 59.09 table 1. respondents’ evaluation of the clinical hysterectomy pathway are the ones who should make the final decision, and 2 (10%) said it should be a shared decision between them and their obstetrics and gynecology specialist. participants were also asked to report what they liked and disliked about the educational materials. twelve (60%) believed it was “easy to follow,” 16 (80%) liked the “comprehensiveness of the material”, and 11 (55%) believed that the links and picture were informative. of all participants, only one believed the content was “hard to understand.” no one thought that the material was either “too much information,” or “too little information”. on the scale of 1-10 (1 = very little, 10 =very much), participants were asked to rank whether a) the content was explained clearly, b) the presented information were new to them, and c) there was any discrepancy between what they read in the provided material and what they already knew. the average scores for the questions above were 9.15, 4.5, and 7.3, respectively. suggestions for improvements included: “including more pictures,” “testimonials from patients undergoing each type of surgery,” “videos from real procedures,” “explaining the difference between partial and total hysterectomy,” and “explaining the indications for bilateral salpingo-oophorectomy” were the main comments. discussion physicians and patients found the developed tools to be practical and beneficial. this study is very innovative in capturing both patients and providers in the exploration of how pathway-based systems can fuel change in the way hysterectomy decisions are approached. this approach can have significant implications for changes in practice for patients considering hysterectomy locally and globally. the majority of physicians believed that the material is up-to-date and consistent with evidencebased medicine, and reported that they would recommend it to their colleagues. however, when they were asked whether the pathway has changed their practice, 19 answered “no”. the reason behind this discrepancy is the fact that 20 out of 22 respondents (90.9%) were already practicing a high volume (>30%) of mih. therefore, it appears that there is a considerable self-selection bias in our sample, since http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx sanei-moghaddam this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.299|http://cajgh.pitt.edu only those physicians who were already pro-mih opted in and completed the survey. the above findings suggest that the respondents overall found the pathway to be adequate for their educational purposes. there was even a suggestion to integrate extra-uterine conditions such as ovarian cyst and endometriosis into the pathway. moreover, lack of awareness about the presence of the pathway was not an issue since the pathway was mandatory in the upmc system. regarding the software interface, 95.45% of the physicians reported that the software is easy to navigate and is user-friendly or were neutral. all respondents agreed that using the pathway did not affect their own workflow, while interestingly they reported that it could be potentially perceived as a barrier. the main limitations of the physician component of the study are the low response rate (23.9%) and self-selection bias. we only heard from 1 physician with a low mih volume, and this is the population on whom we should focus more and try to actively engage. this makes it difficult to address this population’s concerns about the pathway in the future. the small sample size and homogeneity of the respondents did not allow us to run any inferential statistics; however, the respondents formed a balanced sample regarding age, gender, and training. being a mixed methods study (partially qualitative and partially quantitative in nature), this research provided an insight into the gynecology surgeons’ attitudes towards a clinical pathway and how pathways might engineer practice change. however, quantitative studies are needed in future to parse out all the factors we identified in this study. when patients are considering a hysterectomy for a benign condition, deciding on the route of surgery is commonly an overwhelming task for the patient, considering the plethora of surgical approaches available. our future studies will also focus on exploring decision support options for patients considering non-surgical management, as well as evaluate decisions that patients with malignancies are facing. this study represents evaluation of one of the first pathway based decision tool kits developed to assist patients in making these difficult decisions. overall, the educational materials were very well received by the participants. we will continue to build on our current experience and improve the materials based on the comments we received from participants. decision support systems, including computer programs designed to assist in the visualization of tradeoffs inherent in the decision-making process, are needed to educate patients more effectively and help them make a fully informed decision based on evidencebased approaches. decision support tools have been shown to help healthcare providers and patients make more informed decisions, especially when multiple treatment options are available with various degrees of risks and benefits.15,16 however, they have rarely been used for hysterectomy decision making. this shared decision making pathway informed model is especially important for hysterectomy, where multiple approaches/techniques are available. clinical pathways are an effective instrument to decrease undesired practice variability, improve clinician performance, and provide consistent therapy for diseases on a global scale.10,17 the pathway systems could become a driver of change in clinical practice in the us and around the world, influencing both the patient and provider side of healthcare. in addition, clinical pathways can serve as a framework for moving forward and increasing the efficiency of care while decreasing the variation in care. acknowledgements supported by the beckwith institute’s bench at the bedside program.  http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx sanei-moghaddam this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.299|http://cajgh.pitt.edu references 1. cdc. inpatient surgery. cdc/national center for health statistics. http://www.cdc.gov/nchs/fastats/inpatientsurgery.htm. accessed september 24, 2017. 2. wright jd, herzog tj, tsui j, et al. nationwide trends in the performance of inpatient hysterectomy in the united states. obstet gynecol. 2013;122(2 pt 1):233-241. 3. wu jm, wechter me, geller ej, nguyen tv, visco ag. hysterectomy rates in the united states, 2003. obstet gynecol. 2007;110(5):1091-1095. 4. sanei-moghaddam a, ma t, goughnour sl, et al. changes in hysterectomy trends after the implementation of a clinical pathway. obstetrics and gynecology. 2016;127(1):139147. 5. gandaglia g, ghani kr, sood a, et al. effect of minimally invasive surgery on the risk for surgical site infections: results from the national surgical quality improvement program (nsqip) database. jama surg. 2014;149(10):1039-1044. 6. aagl. aagl position statement: route of hysterectomy to treat benign uterine disease. j minim invasive gynecol. 2011;18(1):1-3. 7. acog. acog committee opinion no. 444: choosing the route of hysterectomy for benign disease. obstet gynecol. 2009;114(5):11561158. 8. pearson s. et tu, critical pathways? am j med. 1999;107:397-398. 9. rotter t, kinsman l, james e, et al. clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. the cochrane database of systematic reviews. 2010(3):cd006632. 10. hripcsak g, ryan pb, duke jd, et al. characterizing treatment pathways at scale using the ohdsi network. proc natl acad sci u s a. 2016;113(27):7329-7336. 11. mansuria sm cj, edwards r, sanei moghaddam a, ma t, linkov f. changes in hysterectomy trends and patient outcomes following the implementation of a clinical pathway. obstet gynecol. 2016;127:1-3s. 12. healthwise incorporated. 2016; http://www.healthwise.org/about.aspx. accessed september 24, 2017. 13. qualtrics survey service. 2015; http://technology.pitt.edu/service/qualtricssurvey-service. accessed september 24, 2017. 14. braun v, clarke, v. using thematic analysis in psychology. qual res psychol. 2006;3:77-101. 15. o'connor am, tugwell p, wells ga, et al. a decision aid for women considering hormone therapy after menopause: decision support framework and evaluation. patient educ couns. 1998;33(3):267-279. 16. tariman jd, berry dl, cochrane b, doorenbos a, schepp k. preferred and actual participation roles during health care decision making in persons with cancer: a systematic review. ann oncol. 2010;21(6):1145-1151. 17. lenz r, blaser r, beyer m, et al. it support for clinical pathways--lessons learned. int j med inform. 2007;76 suppl 3:s397-402. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hysterectomy pathway as the global engine of practice change: implications for value in care abstract keywords: clinical pathways; hysterectomy; decision support tools; survey research hysterectomy pathway as the global engine of practice change: implications for value in care research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. do people with type 2 diabetes think they are unhealthy? a cross-sectional study in celaya, mexico karla c. paz-salinas1, nicolas padilla-raygoza1,2, silvia c. delgado-sandoval1,2, georgina olvera-villanueva1,2, ma laura ruiz-paloalto1,3 1division of health sciences and engineering, campus celaya salvatierra, university of guanajuato, mexico; 2department of nursing and obstetrics, campus celaya salvatierra, university of guanajuato, mexico; 3department of clinical nursing, campus celaya salvatierra, university of guanajuato, mexico vol. 4, no. 1 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.207 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ paz-salinas this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.207|http://cajgh.pitt.edu abstract background: type 2 diabetes is a chronic disease that presents a significant burden on health care systems in many countries. with the rise of obesity, the incidence of type 2 diabetes has also been steadily increasing. a healthy lifestyle and understanding of diabetes management are important factors for delaying the onset of comorbidities associated with type 2 diabetes. the objective of this study was to evaluate the self-perception of health in individuals with type 2 diabetes as it relates to bmi status, which has important implications for the implementation of preventive programs. methods: a cross-sectional lifestyle survey was implemented in the region of celaya, guanajuato, mexico, targeting 100 participants diagnosed with type 2 diabetes. anthropometric measurements and participant characteristics were also obtained. fisher’s exact test was used to determine if the proportions of lifestyles perceptions differed by bmi status. results: participants had a mean age of 56.12 ± 10.26, a mean bmi of 29.13 ± 5.48 kg/m2, were mostly married (67.0%), and female (70.0%). none of the normal weight participants perceived themselves as unhealthy. 95% of overweight/obese participants perceived themselves to be healthy, despite a diagnosis of diabetes and being overweight/obese, while only 5% perceived themselves to be unhealthy. however, these differences in the perceptions of health classified by bmi status were not statistically significant (p = 0.42). conclusion: our findings indicate that overweight and obese persons with type 2 diabetes in celaya, mexico may have misperceptions about their own health, even though these findings were not statistically significant. these preliminary data highlight the importance of implementing prevention and educational programs among those with diabetes, in order to combat health misperceptions and raise awareness about the dangers of diabetes and obesity. furthermore, more research with larger sample sizes is needed in order to fully understand the effects of perception of health on actual health. keywords: type 2 diabetes, lifestyle, overweight, obesity do people with type 2 diabetes think they are unhealthy? a cross-sectional study in celaya, mexico karla c. paz-salinas1, nicolas padillaraygoza1,2, silvia c. delgadosandoval1,2, georgina olveravillanueva1,2, ma laura r. paloalto1,3 1division of health sciences and engineering, campus celaya salvatierra, university of guanajuato, mexico; 2department of nursing and obstetrics, campus celaya salvatierra, university of guanajuato, mexico; 3department of clinical nursing, campus celaya salvatierra, university of guanajuato, mexico research type 2 diabetes is a chronic disease, which presents a significant burden on health services in many countries,1,2 including low income nations such as afghanistan3 and bangladesh,4 and middle income countries such as kazakhstan5 and india.6 type 2 diabetes is a metabolic disorder characterized by a deficit in the production or release of insulin, increasing glucose levels in plasma.7,8 this chronic disease and its complications are a major cause of morbidity and mortality in mexico,9 with over 400,000 new cases reported in mexico each year.10 despite the benefits of maintaining a healthy lifestyle to control type 2 diabetes, many diabetic patients do not make healthy lifestyle choices. for example, mexico is now one of the most obese countries http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.207|http://cajgh.pitt.edu in the world with over 1 in 3 adults classified as obese.11 lifestyle is the set of behaviors a person adopts in the maintenance of health or the occurrence/prevention of disease. healthier lifestyles generally lead to better outcomes while unhealthier lifestyles lead to multiple diseases or disorders.12,13 kickbusch et al. defined lifestyle as the general way of life based on the interaction of life conditions and individual behavior patterns, determined by social-cultural factors and an individual´s personal characteristics.14 physical activity levels and dietary habits are related to body mass index (bmi), blood glucose levels, hdl cholesterol, and triglycerides, which are in turn related to type 2 diabetes.12,15,16 it is essential to engage in regular physical activity and to carefully monitor food consumption in order to avoid diabetic complications. lifestyle is a major contributor to disease and health outcomes, with a general understanding that if one wants to be a healthier person, have a healthier family, and live in a healthier community, one must make good lifestyle choices. however, since adverse effects of unhealthy lifestyles do not manifest immediately, people can fall into a vicious cycle of unhealthy behaviors and resist healthy lifestyle options due to the fact that they do not feel ill, causing a slow but progressive deterioration of health which gives rise to expensive chronic diseases.13,15,16 self-perception of one’s health impacts the individual’s choice of lifestyle. self-perception is the looking inward of oneself. low concordance has been reported between nutritional status and self-perception of body image;17 for example, previous research in europe demonstrated that 65% of men and 32% women underestimated their body weight.18 lifestyle according to self-perception can be modified by improving knowledge of what is a desirable healthy lifestyle, and reversing misperceptions of self-health. this study is of particular importance due to the high rates of obesity in mexico,11 as self-perception of health can contribute to obesity, which in turn can exacerbate type 2 diabetes. to our knowledge, no studies of this nature have been implemented in mexico. the objective of this study was to determine if there is a relationship between the self-perception of lifestyle and bmi status in people with type 2 diabetes residing in celaya, mexico. methods the study protocol was reviewed and approved by the research committee and the bioethics committee of the division of health sciences and engineering campus celaya salvatierra, university of guanajuato, mexico. participants were asked to provide written informed consent. post-consent, participants completed a lifestyle questionnaire19 and anthropometric measurements were taken. this study was a cross-sectional, communitybased study on people with type 2 diabetes registered in mutual help groups (mhg) in the region of celaya, guanajuato. participants were selected by simple random sampling. inclusion criteria were the following: prior diagnosis of type 2 diabetes, age of 18 years and older, male or female. exclusion criteria were the following: individuals under 18 years of age and those without a diagnosis of type 2 diabetes. the lifestyle questionnaire provided a dichotomous variable: self-perception lifestyle (spls), which takes into consideration habits regarding physical activity, diet, smoking, alcohol consumption, self-care, accident prevention, moral values, environment, stress and social support, and sexuality.19 a healthy perception is categorized as 41-80 points, and an unhealthy perception is categorized as ≤40 points.19 the questionnaire measures self-perception of lifestyle but cannot measure actual health status. bmi status was categorized as a dichotomous variable. normal bmi status was categorized as ≤25 kg/m2, and overweight/obese bmi status was categorized as >25 kg/m2. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx paz-salinas this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.207|http://cajgh.pitt.edu sample size based on previous studies, sample size was calculated by assuming that 70% of those with an unhealthy lifestyle perception were overweight/obese and 40% of those with a healthy lifestyle were overweight/obese. the minimum required sample size was 42 for both groups (unhealthy lifestyle perception and healthy lifestyle perception), with 95% precision and 80% power (epidat, 3.1, 2006, xunta de galicia and pan american health organization). statistical analysis descriptive statistics were obtained for basic participant characteristics. fisher’s exact test was used to analyze the association of lifestyle perception and bmi status. all statistical tests were performed using stata 13.0® (stata corp., college station, tx, usa). results the 100 participants had a mean age of 56.12 ± 10.26 years (70% female, 67% married, mean bmi of 29.13 ± 5.48 kg/m2). participant characteristics are summarized in table 1. table 1: qualitative socio-demographic characteristics of participants with type 2 diabetes 81% of participants were classified as overweight/obese, and 96% of all participants perceived that they had a healthy lifestyle (table 2). in the overweight/obese group, 5% perceived themselves as having an unhealthy lifestyle, while 95% perceived themselves as having a healthy lifestyle. this demonstrates that these people may have a distorted lifestyle perception; however, these findings were not statistically significant (p = 0.42). table 2: tabulation between perceived lifestyle and status of overweight and obesity in participants with type 2 diabetes discussion the purpose of this study was to evaluate the self-perception of health in individuals with type 2 diabetes. only 4% of all participants were found to perceive themselves as having an unhealthy lifestyle; however, more were expected from the initial power analyses, which was a major disadvantage. one disadvantage was that the sample size was insufficient to detect statistically significant associations. another disadvantage is that the sample was largely of a lower level of education, which has been found to be associated with obesity and negative health outcomes.20,21 in this particular sample, a large percentage of study participants was female. this could be due to the fact that females tend to utilize health services more than males; however, similar results were reported by lopez-carmona et al. in a diabetic lifestyle instrument validation study.22 of the 81% classified as overweight/obese, only 5% reported having an unhealthy lifestyle perception, while 95% reported having a healthy lifestyle. this confirmed that there is a distorted perception of lifestyle, which can lead to exacerbation of diabetes symptoms. in a ugandan study, mayega et al., reported that only 14% of people with a high intake of fat perceived their diet as unhealthy.23 in uganda, obesity is seen as "success" in non diabetic subjects and is desirable among women ("big is better"); weight loss is stigmatized as being sick and associated hiv / aids.23 in denmark, ulrichsen et al., reported that among 680 people with type 2 diabetes, 36% were obese and 25% had a healthy diet.24 in mexico, chavez-courtois, et al. studied a group of women with gestational diabetes and reported that women perceive physical activity and food as fundamental in controlling diabetes, although this does not mean that the measures on adequate physical activity http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.207|http://cajgh.pitt.edu and nutrition were implemented as part of treatment for diabetes.25 patients with type 2 diabetes typically perceived themselves as leading a healthy lifestyle; however, 81% of participants were overweight/obese, which is not desirable in diabetic patients due to the increased risk of diabetic complications or an earlier presentation of diabetic complications. patients with type 2 diabetes receive a large amount of information concerning the benefits of a healthy lifestyle, and it is possible that this knowledge can generate an appropriate perception of a healthier lifestyle. this is especially important for those who are overweight or obese. we concluded that self-perception or self-reported lifestyle is not necessarily accurate and cannot be used in future research studies of this population without adding objective measures. future research should focus on 1) the association of the selfperception of lifestyle and co-morbidities in diabetic patients, such as eye diseases, circulatory diseases, stroke, heart diseases, and 2) designing effective educational interventions to increase the awareness of unhealthy lifestyles among diabetic patients. acknowledgements the authors thank the faculty improvement program of the secretary of public education of mexico for its support to the members of the healthy lifestyle academic group of university of guanajuato for the realization of this project. references 1. monroy ov, equeda al, marroquin mym, flores fm. [the detection integrated as a tool to link primary prevention, early treatment and epidemiological surveillance in diabetes and hypertension]. rev endocrinol y nutr. 2000;8(4):129-135. 2. bertoldi ad, kanavos p, frança gv, et al. epidemiology, management, complications and costs associated with type 2 diabetes in brazil: a comprehensive literature review. global health. 2013;9:62. 3. saeed kmi. prevalence of risk factors for noncommunicable diseases in the adult population of urban areas in kabul city, afghanistan. cajgh. 2013;2(2). 4. sayeed ma, mahtab h, khanam pa, begum r, banu a, azad khan ak. diabetes and hypertension in pregancy in a rural community of bangladesh: a population-based study. diabet med. 2005;22(9):1267-1271. 5. aringazina a, gulis g, allegrante jp. public health challenges and priorities for kazakhstan. cajgh. 2012;1(1). 6. dave vr, rana bm, sonaliya kn, et al. screening of gestational diabetes and hypertension among antenatal women in rural west india. cajgh. 2014;3(1). 7. mexican diabetes federation. [diabetes numbers in mexico]. 2008; http://www.fmdiabetes.org/v2/paginas/d_numeros.php. accessed may 20, 2015. 8. u.s. national library of medicine. diabetes mellitus. 2015; http://www.ncbi.nlm.nih.gov/pubmedhealth/pmht0024704/. accessed may 20, 2015. 9. national institute of statistics geography and informatic. [causes of death: death general totals by main causes of death]. 2008; http://www.inegi.org.mx. accessed may 20, 2015. 10. mexican official standard. [for prevention, treatment, and control of diabetes mellitus]. 2007; http://www.salud.gob.mx/unidades/cdi/nom/m015ssa24.html. accessed may 20, 2015. 11. oecd directorate for employment labour and social affairs. obesity update. 2014; http://www.oecd.org/els/healthsystems/obesity-update-2014.pdf. accessed may 20, 2015. 12. mandal a. study of prevalence of type 2 diabetes mellitus and hypertension in overweight and obese people. j family med prim care. 2014;3(1):25-28. 13. balcazar p, gurrola gm, bonilla p, colín hg, esquivel ee. [lifestyle in adults with diabetes mellitus 2]. 2008; http://www.researchgate.net/profile/esteban_esquivelsantovena/publication/257022309_105-388-1pb/links/0deec52433fb670a5a000000.pdf. accessed may 20, 2015. 14. kickbusch i. life-styles and health. soc sci med. 1986;22(2):117-124. 15. yates t, davies mj, gray lj, et al. levels of physical activity and relationship with markers of diabetes and cardiovascular disease risk in 5474 white european and south asian adults screened for type 2 diabetes. prev med. 2010;51(34):290-294. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.fmdiabetes.org/v2/paginas/d_numeros.php http://www.ncbi.nlm.nih.gov/pubmedhealth/pmht0024704/ http://www.inegi.org.mx/ http://www.salud.gob.mx/unidades/cdi/nom/m015ssa24.html http://www.oecd.org/els/health-systems/obesity-update-2014.pdf http://www.oecd.org/els/health-systems/obesity-update-2014.pdf http://www.researchgate.net/profile/esteban_esquivel-santovena/publication/257022309_105-388-1-pb/links/0deec52433fb670a5a000000.pdf http://www.researchgate.net/profile/esteban_esquivel-santovena/publication/257022309_105-388-1-pb/links/0deec52433fb670a5a000000.pdf http://www.researchgate.net/profile/esteban_esquivel-santovena/publication/257022309_105-388-1-pb/links/0deec52433fb670a5a000000.pdf paz-salinas this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.207|http://cajgh.pitt.edu 16. adeniyi af, akinwonmi ao, fasanmade aa. links between adiposity, physical activity and self-reported fatigue in patients with type 2 diabetes mellitus. int j diabetes dec ctries. 2014;34(3):144-149. 17. atalah e, urteaga c, rebolledo a. [self-perception of nutritional status in adults from santiago]. rev med chile. 2004;132(11):1383-1388. 18. madrigal h, sánchez-villegas a, martínez-gonzález ma, et al. underestimation of body mass index through perceived body image as compared to self-reported body mass index in the european union. public health. 2000;114(6):468-473. 19. baños benitez a, gallart-magaña g. [application of questionnaires healthy lifestyle to students and teachers of the latin american school of medicine]. 2005. scv004. 20. cohen ak, rai m, rehkopf dh, abrams b. education attainment and obesity: a systematic review. obes rev. 2013;14(12):989-1005. 21. chandola t, clarke p, morris j, blane d. pathways between education and health: a causal modelling approach. j r stat soc series a. 2006;169(2):337-359. 22. lópez-carmona jm, ariza-andraca cr, rodríguezmoctezuma jr, munguía-miranda c. [development and initial validation of an instrument to measure the lifestyle in patients with type 2 diabetes mellitus]. salud publ de mex. 2003;45(4):259-268. 23. mayega rw, etajak s, rutebemberwa e, tomson g, kiguli j. 'change means sacrificing a good life': perceptions about severity of type 2 diabetes and preventive lifestyles among people afflicted or at high risk of type 2 diabetes in iganga uganda. bmc public health. 2014;14:864. 24. ulrichsen sp, mor a, svensson e, larsen fb, thomsen rw. lifestyle factors associated with type 2 diabetes and use of different glucose-lowering drugs: cross-sectional study. plos one. 2014;9(11):e111849. 25. chavez-courtois m, graham c, romero-perez i, sanchezmiranda g, sanchez-jimenez b, perichart-perera o. [experience and perceptions of gestational diabetes and its management in a group of overweight women multiparous]. ciënc saúde coletiva. 2014;19(6). http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.207|http://cajgh.pitt.edu table 1: qualitative socio-demographic characteristics of participants with type 2 diabetes participants with type 2 diabetes variables n (%) gender male 30 (30.0) female 70 (70.0) marital status single 13 (13.0) married 67 (67.0) divorced 3 (3.0) separated 4 (4.0) widowed 9 (9.0) free union 4 (4.0) education none 28 (28.0) elementary (grades 1-6) 27 (27.0) secondary (grades 7-8) 19 (19.0) high school (grades 9-12) 12 (12.0) bachelor degree 12 (12.0) graduate degree 2 (2.0) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx paz-salinas this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.207|http://cajgh.pitt.edu table 2: tabulation between perceived lifestyle and status of overweight and obesity in participants with type 2 diabetes variables normal weight n (%) overweight/obese n (%) perceived lifestyle unhealthy 0 (0.0) 4 (4.9) healthy 19 (100.0) 77 (95.1) note. normal weight are those with a bmi < 25 kg/m2. overweight/obese are those with a bmi ≥ 25 kg/m2. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. abo blood group genotyping by real-time pcr in kazakh population pavel tarlykov, daniyar raiymbek, elena zholdybayeva, erlan ramanculov national center for biotechnology, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.177 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ tarlykov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.177 | http://cajgh.pitt.edu abstract introduction. abo blood group genotyping is a new technology in hematology that helps prevent adverse transfusion reactions in patients. identification of antigens on the surface of red blood cells is based on serology; however, genotyping employs a different strategy and is aimed directly at genes that determine the surface proteins. abo blood group genotyping by real-time pcr has several crucial advantages over other pcr-based techniques, such as high rapidity and reliability of analysis. the purpose of this study was to examine nucleotide substitutions differences by blood types using a pcr-based method on kazakh blood donors. methods. the study was approved by the ethics committee of the national center for biotechnology. venous blood samples from 369 healthy kazakh blood donors, whose blood types had been determined by serological methods, were collected after obtaining informed consent. the phenotypes of the samples included blood group a (n = 99), b (n = 93), o (n = 132), and ab (n = 45). genomic dna was extracted using a salting-out method. pcr products of abo gene were sequenced on an abi 3730xl dna analyzer (applied biosystems). the resulting nucleotide sequences were compared and aligned against reference sequence nm_020469.2. real-time pcr analysis was performed on cfx96 touch™ real-time pcr detection system (biorad). results. direct sequencing of abo gene in 369 samples revealed that the vast majority of nucleotide substitutions that change the abo phenotype were limited to exons 6 and 7 of the abo gene at positions 261, 467, 657, 796, 803, 930 and 1,060. however, genotyping of only three of them (261, 796 and 803) resulted in identification of major abo genotypes in the kazakh population. as a result, taqman probe based real-time pcr assay for the specific detection of genotypes 261, 796 and 803 was developed. the assay did not take into account several other mutations that may affect the determination of blood group, because they have a low occurrence rate and therefore have not been found in the population sample. conclusion. real-time pcr based method for fast and reliable abo genotyping was developed. this assay may be used as a complement to classic serological blood typing. keywords: genotyping, real-time pcr, blood groups, kazakh population http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. pregnancy outcomes complicated by preterm premature rupture of membranes: retrospective review of cases in three institutions in kazakhstan balkenzhe imankulova, gulzhanat aimagambetova, layzzat saiddildina, talshyn ukybassova national research center for maternal and child health, astana, kazakhstan vol. 3, suppl. (2014) | issn 2166-7403 (online) doi 10.5195/cajgh.2014.222 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ imankulova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 3, suppl. (2014) | issn 2166-7403 (online) | doi 10.5195/cajgh.2014.222|http://cajgh.pitt.edu abstract introduction. pre-term premature rupture of membranes (pprom) is one of the leading causes of perinatal morbidity and mortality. this complication is diagnosed in 3% of pregnant women in kazakhstan, and it is the leading cause of pre-term deliveries. the aim of this study was to determine the outcomes of pregnancies complicated by pprom in gestation periods between 24 to 32 weeks among three institutions in kazakhstan. methods. this is descriptive analysis of 154 cases with pprom observed between 24 to 32 weeks of gestation at perinatal centers #2 and #3 and the national research center for maternal and child health, astana, kazakhstan. cases were selected on the basis of retrospective chart review where pprom diagnosis occurred in 2013. descriptive statistics were utilized for data analysis. results. the most frequent complications associated with pprom were threat of miscarriage (13.6% of cases) and chronic placental insufficiency (7.8%). the mean time between pprom and onset of spontaneous labor was 12.1 ± 2.3 days. spontaneous labor within 3 days after pprom started in patients with an amniotic fluid index of 3.0 ± 0.2 cm. complications experienced by pprom women during delivery and early postpartum period included: precipitous labor (6.4%), weakness of labor activity (16.2%), atonic hemorrhage (1.2%), and chorioamnionitis (3.2%). 37.6% of newborns in this study were admitted to the intensive care unit. their health complications included pneumonia (7.7%), conjunctivitis (1.3%), omphalitis and infectious-toxic shock (3.8%), intraventricular hemorrhage (7.8%), and respiratory distress (10.3% ). conclusion. thus, preterm rupture of membranes is associated with preterm delivery and an increase of neonatal morbidity. therefore, it is necessary to find ways to effectively manage pprom, including developing new techniques to restore the amniotic fluid volume in women experiencing pprom during 24 to 32 weeks of gestation. keywords: perinatal mortality, perinatal morbidity, pre-term membrane rupture, pre-term delivery http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. scientific banana republics: do they exist? faina linkov1, shalkar adambekov1, sharon goughnour1, sharon c. welburn2 nicolas padilla-raygoza3, musa kana4,5, eugene shubnikov6, mustapha m. mustapha7, aamir sheikh8, ronald laporte2 1department of ob/gyn, university of pittsburgh school of medicine, pittsburgh, pa,usa; 2department of epidemioloy, graduate school of public health, university of pittsburgh, pittsburgh, pa, usa; 3department of nursing and obstetrics, division of health sciences and engineering, university of guanajuato, mexico; 4epiunit, institute of public health, university of porto, porto, portugal; 5department of community medicine, faculty of medicine, kaduna state university, kaduna, nigeria; 6institute of internal medicine, novosibirsk, russian federation; 7center for innovative antimicrobial therapy school of medicine, university of pittsburgh, pittsburgh, pa, usa; 8lincoln memorial university, harrogate, tn, usa vol. 5, no. 1 (2016) | issn 2166-7403 (online) doi 10.5195/cajgh.2016.249 | http://cajgh.pitt.edu http://creativecommons.org/licenses/by/3.0/us/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx linkov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.249 | http://cajgh.pitt.edu scientific banana republics: do they exist? faina linkov1, shalkar adambekov1, sharon goughnour1, sharon c. welburn2 nicolas padilla-raygoza3, musa kana4,5, eugene shubnikov6, mustapha m. mustapha7, aamir sheikh8, ronald laporte2 1department of ob/gyn, university of pittsburgh school of medicine, pittsburgh, pa,usa; 2department of epidemioloy, graduate school of public health, university of pittsburgh, pittsburgh, pa, usa; 3department of nursing and obstetrics, division of health sciences and engineering, university of guanajuato, mexico; 4epiunit, institute of public health, university of porto, porto, portugal; 5department of community medicine, faculty of medicine, kaduna state university, kaduna, nigeria; 6institute of internal medicine, novosibirsk, russian federation; 7center for innovative antimicrobial therapy school of medicine, university of pittsburgh, pittsburgh, pa, usa; 8lincoln memorial university, harrogate, tn, usa editorial the history of the first banana republic begins with the introduction of the banana to the us markets in 1870, when bananas were brought from jamaica and sold in boston at a 1,000 percent profit. 1 not long after the banana’s introduction, this novel nutritious tropical fruit became much cheaper than the locally grown fruits. the global appetite for bananas lead jamaica, as well as several other caribbean countries, to reinvent their economies to those almost solely dependent on the banana production by the end of the 19 th century. 2 the term “banana republic” was introduced by american writer o’henry to describe the fictional republic of anchuria in the book cabbages and kings (1904), 3 a collection of short stories inspired by his experiences in honduras at the turn of the 20 th century. global demand for bananas during that time period led to several international fruit companies controlling the road, rail, and port infrastructure of honduras. depending largely on banana exports, economies of countries cultivating the precious crop became fragile, vulnerable, unstable, and much dependent on foreign influence. 4 since the times of o’henry, “banana republic” or “banana state” became a political science term for unstable economies that are largely dependent on exporting a limitedresource product such as bananas. though the times of the first banana republics have long passed, the concept has not lost its validity in modern times. economies of many developing countries around the world are still dependent on exporting a limited resource raw products to wealthier states. 5 it is not uncommon for the raw product exported by the developing country to be transformed into a commercial commodity in the developed country, and subsequently imported back to the developing country as a new commercial product. 6 however, the term transcends beyond the fields of economics or political science. as scientists, we are no foreigners to the banana republic concept, with petsko suggesting that the concept may be relevant to the biological research. 7 scientific data produced around the world in forms of databases, laboratory experiments, publications, reports, policies, etc., can be considered as exchange products that can be transported and cultivated from country to country. 8 just like fruit producers can be enticed to produce and export one agricultural product that is in high demand; scientists can be tempted to focus on one research topic, for example, zika, hiv/aids, or malaria. the reality is that just like the businessmen, scientists rely on income from local and global funding agencies to “cultivate” their scientific products. sadly, in many developing countries, relying on local research resources is not http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.249 | http://cajgh.pitt.edu always enough to produce quality research and this is where international sponsors and collaborators play a huge supporting role. international sponsors, funding agencies, philanthropists, etc. contribute tremendously to health research and improvement in both developed and developing world. 9 for example, the gates foundation funded much needed polio, hiv, and malaria prevention programs on the african continent. 10 similarly, the national institutes of health (nih) in the us funds a number of efforts in the area of infectious disease in africa. while it is wonderful for the developing countries to get this financial aid to promote their research, the potential pitfall is that some of the health needs of these countries (such as chronic disease) may get overshadowed and not receive much needed support. for example, out of the 100 recently funded nih awards targeting africa, close to 60% are associated with infectious diseases, such as hiv, tuberculosis, and malaria. 11 the remaining grants are aimed maternal and child health, education, and nutrition and not necessarily chronic diseases, which are the key cause of age related morbidity in the majority of african countries. 12 nih funds, as well as funds from other agencies, provided for conducting research in the developing world are really important, as they not only support research but also improve laboratory infrastructures (as applicable) and establish training programs for the researchers in the developing world. 11 without such support, many important discoveries would not be possible. on the other hand, relying heavily on foreign aid in supporting research may be limiting scientific diversity in the developing world by focusing the research on a relatively small group of specific research topics. for example, with zika, nih supported a national scientific research organization linked to the brazilian ministry of health, to conduct a multi-country study to evaluate the magnitude of health risks that zika virus infection poses to pregnant women and their developing fetuses and infants. 13 while zika is a very important disease to investigate, these particular funding mechanisms potentially encourages study sites in puerto rico, brazil, colombia, and other areas that are experiencing active local transmission of the virus to depend on nih to conduct a very specific line of infectious disease research. on one hand, research infrastructure of countries affected by zika will benefit from these resources. on the other hand, the research priorities of these developing regions are potentially determined not by local policy makers or researchers, but by funding agencies of the developed world. as a consequence, what we are observing is that the dependence on much needed foreign grants to investigate major public health concerns in the developing world establishes the concept of scientific banana republic. a scientific banana republic is a country that is very limited in the kind of biomedical (or scientific) research it can do, due to mostly focusing on producing and exporting raw research data, predominantly in the various fields of infectious diseases. this concept is related to a well published concept of scientific imperialism and safari research, where science may be dominated by the scientific interests of developed countries. table 1 reviews similarities between agricultural and scientific banana states. 14 table 1. agricultural banana state vs. scientific banana state similarly, if we explore scientific productivity in africa in the form of scientific publications, we see that publication rate follows funding areas very closely. if we explore the top 100 research articles recently produced by the african continent (using web of science), we can see that a large portion (35%) of these articles focus on infectious diseases especially hiv/aids. moreover, scientists from these countries http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx linkov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.249 | http://cajgh.pitt.edu rely heavily on international collaborations to publish their results instead of collaborating with local institutions. 15 as a result, such countries produce “raw” scientific product, which is oftentimes transformed into “final product” (published research) by scientists in developed countries. 16 increasing research collaboration between industrialized and developing countries also raised concerns about ethical review process of the us and international ethics review boards. a survey of health researchers from developing and developed countries suggested a desire for focused capacity development in supporting local ethical review of research with effective implementation of culturally appropriate studies in the developing world. 17 globalization and its consequences have many implications for health locally and globally. the concept of global health has become extremely popular in the past two decades, as the global thirst for knowledge on old diseases and newly emerging infections is increasing. new global health degrees and certificate programs open each day in us schools and around the world. global health is becoming increasingly more interesting to public health and medical workers, especially with the zika virus in brazil, the continued hiv epidemic along with outbreaks of ebola in subsaharan africa, and the global threat from malaria. scientists in countries, oftentimes impoverished, that are affected by these diseases obtain international funds to explore these problems and share this knowledge with the rest of the world. is this good or bad? indeed, hiv and malaria are problematic for many african countries causing many preventable deaths. despite the fact that infectious diseases are extremely important problems that should be investigated, analysis of top causes of deaths for countries with a high hiv burden such as south africa and zimbabwe reveal that chronic diseases such as stroke and cardiovascular disease are found in the top 5 leading causes of death. in addition, trauma associated deaths are very important in the developing countries, leading to the “triple burden of disease” commonly experienced by developing countries undergoing epidemiologic transition. 18 thus, exploration of chronic diseases and trauma in the developing world is very important and relevant to improving health locally and globally. the focus on infectious disease in the developing world, without taking into account chronic disease and trauma may not comprehensively address the health challenges of the 21 st century. in political science, we learned to recognize the dangers of agricultural banana states. we would like to argue that in the 21 st century, it is time for us to recognize the problems potentially associated with scientific banana republics. there are several possible solutions to the problems identified above. one of the common myths associated with healthcare in developing countries is that that their healthcare systems are not equipped to handle the triple burden of disease. however, numerous examples demonstrate how by using grassroots approaches and relying on local inexpensive public health interventions, public health officials in the developing countries were able to make significant progress by using local resources. 19,20 thus, mobilizing existing resources to improve local cost effective and culturally appropriate interventions is one of the best solutions to improving “local” health. local resources can be shared through global networks, such as the supercourse (www.pitt.edu/~super1) or the research methods library of alexandria (http://ssc.bibalex.org/helpdesk/introduction.jsf), both of which help investigators with research methods, statistical analysis education, and publications. new journals, such as the central asian journal of global health (http://cajgh.pitt.edu/), target publications from scientists in under-served countries by providing mentorship and guidance to authors who may have difficulties in publishing their research findings in english speaking journals. it is important for governments of developing countries to allocate more funds for public health. it is also important to encourage http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.pitt.edu/~super1 http://ssc.bibalex.org/helpdesk/introduction.jsf http://cajgh.pitt.edu/ central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.249 | http://cajgh.pitt.edu discussion between policy makers in developing and developed countries to ensure that global health priorities fit the local health priorities when it comes to funding from international funding agencies. it may also make sense to identify and actively engage local stakeholders in identifying ways to improve scientific productivity in the developing world. local stakeholders, such as medical doctors, nurses, university researchers, and community representatives, may represent the voices of people that are not typically represented in the policy making process. we would like to conclude this editorial by pointing out that scientific banana republics may be good for the scientific infrastructure of developing countries, as research may not be possible without foreign support. at the same time, we would like to increase awareness of this concept, as without recognizing such concept it may not be possible to effectively address the triple burden of disease in the developing world. references 1. acker a. honduras: the making of a banana republic. between the lines; 1988. 2. koeppel d. banana: the fate of the fruit that changed the world. hudson street press; 2008. 3. henry o. cabbages and kings. bibliobazaar; 2008. 4. white ra. the morass: united states intervention in central america. harper & row; 1984. 5. venables aj. using natural resources for development: why has it proven so difficult? journal of economic perspectives. 2016;30(1):161-184. 6. sachs j, warner am, research nboe. natural resource abundance and economic growth. national bureau of economic research; 1995. 7. petsko ga. banana republic. genome biology. 2002;3(12):comment1016.1011-comment1016.1013. 8. wagner cs, brahmakulam i, jackson b, wong a, yoda t. science and technology collaboration: building capability in developing countries. dtic document;2001. 9. kates rw, clark wc, corell r, et al. sustainability science. science. 2001;292(5517):641-642. 10. bill and melinda gates foundation. http://www.gatesfoundation.org/. accessed july 15, 2016. 11. nih reporter version 7.10.0. https://projectreporter.nih.gov/reporter.cfm. accessed june 30, 2016. 12. de-graft aikins a, unwin n, agyemang c, allotey p, campbell c, arhinful d. tackling africa's chronic disease burden: from the local to the global. globalization and health. 2010;6:5. 13. nih launches large study of pregnant women in areas affected by zika virus. https://www.nih.gov/newsevents/news-releases/nih-launches-large-study-pregnantwomen-areas-affected-zika-virus. accessed july 15, 2016. 14. acosta-cazares b, browne e, laporte re, et al. scientific colonialism and safari research. clinical medicine and health research, january. 2000;11. 15. dahdouh-guebas f, ahimbisibwe j, van moll r, koedam n. neo-colonial science by the most industrialised upon the least developed countries in peer-reviewed publishing. scientometrics. 2003;56(3):329-343. 16. salager-meyer f. scientific publishing in developing countries: challenges for the future. journal of english for academic purposes. 2008;7(2):121-132. 17. hyder aa, wali sa, khan an, teoh nb, kass ne, dawson l. ethical review of health research: a perspective from developing country researchers. journal of medical ethics. 2004;30(1):68-72. 18. santosa a, wall s, fottrell e, hogberg u, byass p. the development and experience of epidemiological transition theory over four decades: a systematic review. global health action. 2014;7:23574. 19. frost lj, reich m. access: how do good health technologies get to poor people in poor countries? : bibliomotion, inc.; 2014. 20. brooks ad, wells wa, mclean td, et al. ensuring that developing countries have access to new healthcare products: the role of product development partnerships. innov strat today. 2009;3:1-5. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.gatesfoundation.org/ https://projectreporter.nih.gov/reporter.cfm https://www.nih.gov/news-events/news-releases/nih-launches-large-study-pregnant-women-areas-affected-zika-virus https://www.nih.gov/news-events/news-releases/nih-launches-large-study-pregnant-women-areas-affected-zika-virus https://www.nih.gov/news-events/news-releases/nih-launches-large-study-pregnant-women-areas-affected-zika-virus linkov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.249 | http://cajgh.pitt.edu table 1. agricultural banana state vs. scientific banana state characteristic agricultural banana republic scientific banana republic single resource product raw material export banana, orange, and raw materials exported at low prices raw data oftentimes sent to be analyzed at western institutions unstable government stratification of social classes oligarchy large income gaps between people of different classes excessive power in the hands of scientific leaders (deans, chairs, etc) difficulties in climbing academic ladder for junior scientists foreign entities supporting infrastructure foreign fruit companies supporting railroads and other infrastructure in traditional banana states to support agricultural infrastructure foreign funding agencies supporting research, laboratory and other infrastructure for institutions and groups focusing on one or several types of research questions, mostly related to infectious disease economy dominated by foreign interest economy dominated by international fruit companies research topics “suggested” by international funding agencies in the form of requests for applications on specific topics http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. role of ‘one stop crisis centre’ in identifying and assisting victims of violence in an indian health care setup prachi verma1*, payal puri2, dhruv sharma2, shreya singh2 1school of management studies, punjabi university, patiala, india; 2district hospital, panchkula, india *corresponding author vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.297 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ verma this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.297 | http://cajgh.pitt.edu abstract introduction: cases of female targeted violence often go uncounted in india. to identify the unreported cases of violence, sukoon was established in 2014 as a hospital-based ‘one stop crisis centre’ (oscc). sukoon provides counselling, police assistance and legal aid to the victims. the aim of the present study was to recognize the role of sukoon in preventing violence against women (vaw) in the region. methods: secondary data was extracted from 430 victims who approached sukoon from august 2014 through january 2017. data was collected on different variables: age, marital status, nature of violence, medium through which victims approached sukoon and type of assistance provided. significance of association of studied factors with the type of assault was investigated using χ2 test. results: age of study-victims ranged from 4 to 75 years with a median age of 26 years and mean age of 27.61 years with standard deviation of 10.56 years. major types of vaw (96.51%) were domestic violence, sexual assault, physical assault and poisoning. the types of violences were significantly associated with victims’ age (χ2 =5.76, d.f.=1, p<0.05) and marital status (χ2 = 98.23, d.f=4, p<0.001). about 78% of victims were identified from sukoon through screening and counseling. around 69% of the cases were resolved directly by sukoon or through police assistance. conclusion: the above results indicate a significant role of sukoon in screening victims of violence and providing them required assistance within the hospital environment in one location. such centers should be further promoted by the government to address the issues of vaw. keywords: violence against women; victims of violence; one stop crisis centre; screening; north india role of ‘one stop crisis centre’ in identifying and assisting victims of violence in an indian health care setup prachi verma1, payal puri2, dhruv sharma2, shreya singh2 1school of management studies, punjabi university, patiala, india; 2district hospital, panchkula, india research the indian culture is male dominated, and violence is used as a power to control and discipline women1. it is estimated that almost 35% of females experience abuse to physical, social and psychological violence at some point of life2. domestic violence is especially prevalent in indian society and usually, most of the violence is inflicted by husbands to control their wives3. major risk factors include, alcohol consumption by husbands, poor socioeconomic status, lower level of education, harassment for dowry4, family history of violence, age, marriage, size & type of family, culture and caste5-7. domestic violence in india is believed to be an individual’s personal issue8. thus, it is usually accepted and allowed to become a norm of married life or a husband’s right9. various social stigmas and psychological indoctrination of the society prevent women from seeking any help, according to studies conducted in other countries9-14. about 75-86% of the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.297 | http://cajgh.pitt.edu women in india do not report that they are victims of violence15. according to the report from national crime records bureau (ncrb)16, crime against women in india rose to 55.2% in 2016. the crimes included cases of cruelty by husband or his relatives (32.6%), followed by sexual assault (25.0%), kidnapping (19.0%) and rape (11.5%)16. violence against women (vaw) is a growing problem in india but varies across the regions. the state of haryana has the sixth highest rate of crime against women as per the latest ncrb 2016 data16. according to national family health survey report, about 34% of the women in haryana aged 15-49 years17 have experienced physical or sexual violence. of this, only 14% have ever sought any help regarding the abuse17. india’s first hospital-based crisis center was established in 2001 by the center for enquiry into health and allied themes (cehat) at the kb bhabha hospital, bandra. it is named dilaasa, which means ‘reassurance’, and is broadly accepted as the dilaasa model18,19. the success of the dilaasa model laid the foundation for developing ‘one stop crisis centres’ in india by the ministry of women and child development20 in 2013-2014. in haryana, the hospitalbased ‘one stop crisis centre’ was named sukoon. its aim was to offer shelter along with police, legal, medical and counseling services to victims of violence under one roof— incorporated with a 24-hours operational, public, police and sukoon helpline20. after screening victims of violence, further help is given only after the victim provides consent. if the victim complains of sexual assault or attempted rape, screening of the victims is done according to the ‘safe kit’ developed by cehat21. the formally trained counselors by cehat play a key role in coordinating and managing all the activities of sukoon. they instill confidence and support victims, provide assistance in seeking justice and coordinate between victim, hospital, police and legal cell at each step. families of the victims are also called to sukoon, and discussions are held by the staff to identify the reasons leading to violence. trained counselors hold sessions with victims and their families for various time periods. if families give some positive response, and no further violence is reported by the victim in follow up sessions up to one year later and no legal help of any kind was sought by the case, then the case is deemed as resolved. in cases where families were not cooperative, police have to be contacted by the sukoon staff to intervene in the matter. as per the policy of the sukoon, for cases which are considered to be resolved, victims are still contacted by the counselors at frequent intervals to check for further acts of violence up to one year. after this, if required, victims can approach sukoon anytime for further assistance. to study the role of sukoon in identifying and assisting the victims of violence, this study was conducted with three objectives. first, to identify the various categories of assaults experienced by the victims. second, to find out the various ways through which victims were approaching sukoon, and third, to identify type and status of help received by the victims through sukoon. methods sukoon maintains regular computerized records of victims. all registered victims approached sukoon through helpline numbers, were identified from the local district hospital, or brought to sukoon by police. we obtained the records of the center for a period of 2.5 years from august 1, 2014 to january 31, 2017 for this study. during the above period, 430 victims were registered with the center to use the oscc services. while collecting data from the records of sukoon, adequate confidentiality was maintained and accordingly, identities of the victims were not disclosed to the public. this study was approved by the hospital ethics committee. for study purposes, the categorization of victims has been explained under various headings, as given below. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx verma this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.297 | http://cajgh.pitt.edu domestic violence: it is the physical abuse of females within a domestic setting. it may involve physical beating or verbal, emotional, economic and religious abuse. sexual assault: this is an act in which a female is physically abused against her will in any environment. it may include sexual touching, kissing, fondling or attempted rape. physical assault: any physical attack on a female outside the domestic setting is termed as physical assault. it may be done by an individual or a group of people. it may include pushing, stalking, threatening or harming with a weapon. poisoning: a condition where the victim has been given poison as a result of any type of assault with the intention to kill her. burn: where an attempt has been made to burn the victim using any flammable substance by the abusing person. attempted suicide: a situation where a victim tries to end her life by consuming poison or any other means but has survived. others: this category includes any other type of violence which is not included above but present in the society, e.g. acid attack, trafficking, etc. statistical analysis victims were categorized in 5 major categories: type of violence experienced, age, marital status, source of entry into the sukoon centre and agency involved in resolving the violence-case. the collected data was then analyzed using statistical software spss 20. as the data is categorical, pearson’s chi square test was used to look at the relationship between two pairs of variables. the analysis focused on identifying major types of assaults, studying the role of variables, and investigating the agencies involved in resolving a violence case. significance of association of studied factors with type of assault was investigated using χ2 test due to large sample size. yates has suggested a correction for continuity in χ2 value in case of 2x2 tables, preferably when cell frequencies are smaller than 5; this is popularly known as the yates correction. thus, to apply the χ2 test at places where cell frequencies were less than 5, either the required number of rows and columns were clubbed together or the well-known yates correction for 2x2 contingency tables was employed to the test. because 18 is the cut off point for categorizing an individual as a minor or major, victims were divided into 2 groups: below 18 years (as a minor) and above 18 years for studying the association of age with the types of violence. results victims (n=430) were first categorized into different groups, based on the type of violence. on further analysis (table 1), it was found that a large number of victims, had experienced domestic violence (46.51%), followed by sexual assault (21.86%), poisoning (16.28%), burn (1.63%), other miscellaneous type of violence (1.16%) and suicide (0.70%). violence type violence cases studied percentage cumulative percentage domestic violence 200 46.51 46.51 sexual violence 94 21.86 68.37 physical assault 51 11.86 80.23 poisoning 70 16.28 96.51 suicide 3 0.70 97.21 burn 7 1.63 98.84 miscellaneous 5 1.16 100.00 total 430 100.0 table 1. types of violence against women (vaw) amongst women approaching sukoon centre http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx verma this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.297 | http://cajgh.pitt.edu age and marital status were hypothesized to be associated with the type of assault, and they were investigated using χ2 test (tables 2 and 3). age of studyvictims ranged from 4 to 75 years with a median age of 26 years and mean age of 27.61 years with standard deviation of 10.56 years; the age-frequency curve was found to be asymmetrical. the majority (92.72%) of victims were adults (over the age of 18). in this category, most cases of assaults were of domestic violence (49.63%), followed by sexual assault (17.87%), poisoning (16.87%) and physical assault (12.41%). minors (below 18 years of age) in the sample studied were the minority (6.28%) and a great majority of them had suffered from sexual assault (81.48%), followed by poisoning (7.42%) and then other assaults (table 2). analysis further revealed that the types of violence that occurred to women were significantly associated with their age (χ2=5.76, d.f.=1, p<0.05). violence type minors (below 18 years old) n (%) adults (18 years and older) n (%) domestic violence 0 (0) 200 (49.63) sexual violence 22 (81.48) 72 (17.87) physical assault 1 (3.70) 50 (12.41) poisoning 2 (7.42) 68 (16.87) suicide 0 (0) 3 (0.74) burn 1 (3.70) 6 (1.49) miscellaneous 1 (3.70) 4 (0.99) total 27 (100.0) 403 (100.0) table 2. violence against women (vaw) by age amongst women approaching sukoon centre out of 430 victims, 70.23% were married and the remainder (29.77%) were unmarried (table 3). among the married victims, domestic violence was the most common type of assault (58.94%), followed by physical assault (13.24%) and then poisoning (10.60%). among the unmarried victims, sexual assault was the main type of assault (48.44%), followed by poisoning (19.53%) and then domestic violence (17.19%). the women’s marital status was found to be significantly associated with their types of assaults (χ2=98.23, d.f.=4, p<0.001). violence type married n (%) unmarried n (%) domestic violence 178 (58.94) 22 (17.19) sexual violence 32 (10.60) 62 (48.44) physical assault 40 (13.24) 11 (8.59) poisoning 45 (14.91) 25 (19.53) suicide 2 (0.66) 1 (0.78) burn 3 (0.99) 4 (3.13) miscellaneous 2 (0.66) 3 (2.34) total 302 (100.0) 128 (100.0) table 3. violence against women (vaw) by marital status among women approaching sukoon centre http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx verma this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.297 | http://cajgh.pitt.edu table 4 shows that out of 430 violence cases, a great majority of the cases (69.30%) were resolved either by sukoon directly (35.58%) or with police intervention (33.72%). in some cases, sukoon also helped victims by providing legal aid. there were 8.61% of victims who received justice through legal courts under the guidance of sukoon. despite all this, a considerable number of violence cases were still pending in the courts of law (22.09%) at the time of the end of the study. of the 430 victims, 334 (77.67%) were identified by the doctors from hospitals and referred to sukoon after examining them. fifty-six cases (13.02%) approached sukoon through the available helpline numbers, and 40 cases (9.30%) were referred to sukoon as medico-legal cases (table 4). when the status of the association between sources of victims and intervening agencies for resolving violence cases was tested, it was found to be statistically significant (χ2=58.74, d.f.=6, p<0.001). intervening agencies sources of victims sukoon got as a medico-legal case n (%) by sukoon directly n (%) through screening & counseling by sukoon n (%) total n (%) resolved through sukoon 1 (2.50) 17 (30.36) 135 (40.42) 153 (35.58) resolved through court of law 9 (22.50) 8 (14.28) 20 (5.99) 37 (8.60) resolved through police 8 (20.00) 14 (25.00) 123 (36.83) 145 (33.72) cases still pending 22 (55.00) 17 (30.36) 56 (16.76) 95 (22.09) total 40 (100.0) 56 (100.0) 334 (100.0) 430 (100.0) table 4. intervening agencies in resolving cases of violence against women (vaw) vis-à-vis their sources of information discussion continuous efforts are made by the central and the state governments to empower women, but violence still remains one of the most pressing problems in india. victims are often uneducated women from low socioeconomic status, which increases their possibility of visiting a public hospital. dealing with cases of violence is a part of healthcare services, and screening of victims should be a routine practice. in already overcrowded indian hospitals this may often prove challenging. screening procedures in a hospital increase the possibility of identifying victims of domestic violence,22 and it is already accepted by women in indian healthcare settings23. in cases of injury, victims often report to hospitals for medical aid, however, violence resulting in minor injuries often go unreported. a health care system can be a safe and secure environment for women suffering from violence, where they can disclose their experience with confidentiality. the results of the present paper further support the idea of institutional screening and providing support to victims, thus proving that health care systems (hospitals) play a crucial role in response to vaw24. doctors often play a leading role in early identification of vaw, supportive responses, clinical care, and referrals as per the need of the victim25. the victims of intimate partner violence trust healthcare specialists in disclosure of abuse26. however, the lack of knowledge, practices and support services on the issue makes this challenging27. proper training of health care providers can create a change in their attitude and practices in addressing cases of assault28. the large number of cases identified through sukoon further support the presence of oscc in hospitals for screening and counseling of victims. the dilaasa model also proved that the presence of an oscc along with active screening has helped in early detection of domestic violence19. in this study, age and marital status were found to be the possible risk factors of the types of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.297 | http://cajgh.pitt.edu violence seen, which is similar to the results reported by babu and kar29. paul studied the role of socioeconomic factors which were responsible for seeking help by women victims of violence emphasized the role of age, education and religion in seeking formal or informal help against violence30. in india, victims while seeking help preferred informal sources like family, neighbors or friends as compared to seeking help from formal sources like police, doctors or lawyers. contrary to this, most cases (77.7%) came to sukoon through counseling and screening of the victims from the hospital, which further highlights hesitation of victims in reporting cases of violence. researchers have proved that victims receiving institutional support reported less violence by their husbands in their follow up visits31. this emphasizes the need for counseling and awareness among the victims of violence for proper help and advice to fight against violence. further, a considerable number of cases were provided help by the police (33.7%). dealing with violence is a teamwork which requires proper coordination at various levels, and every case needs a different approach to help the victim to fight against violence. the delay in the settlement of cases shows that justice to the victims at the level of judiciary in india is still quite slow. the high number of court cases still pending demonstrate a delay in the judicial process due to various reasons. the sukoon crisis centre also faces some challenges in meeting the needs of victims. there is a need for separate counseling rooms at the centre to attend different victims at the same time and maintain their privacy. counselors face a major problem if repeated calls have to be made to the police for any type of intervention. sometimes, doctors do not refer victims to the oscc due to a huge rush of patients. many times, victims of violence do not want to go back to their homes. in such situations, provisions should be made for temporary stay-arrangements at shelter homes. some initial financial aid should be provided to the victims until the case is taken up or transferred to some other authority. this study has helped in highlighting the relevance of osccs in assisting the victims of violence along with the problems associated with the functioning of these centers. but the study has certain limitations also, as the results of this study are based on the data from only one hospital of haryana and do not represent the success of all osccs in general. however, the success of other osccs will differ according to the availability of services and experts in each hospital. also, the time taken to solve each case is not included in the study, and thus, it is not possible to comment upon this aspect. further studies with wider samples and demographics are required along with the feedback from the victims so as to ascertain problems they face at various levels, which would help in effective functioning of the osccs. sukoon provides support to the victim at various levels, which includes providing emergency treatment, followed by treatment to mitigate potentially long-lasting effects of the violence in later stages of life and educating the victims on violence and how to advocate for themselves against any type of violence. to address the problem of domestic violence more efficiently, concrete changes are required in education and clinical systems. measures to deal with violence cases ought to be formally included in the study curriculum of medicine and to make screening and reporting cases of violence a part of their responsibility. domestic violence cannot be curbed by a single specialty of experts— it is a teamwork requiring the skills of different fields, including government policies, hospitals, non-government organizations, police, lawyers and judges. they should be trained in their respective domains to address cases of violence. to help the doctors in the screening of vaw, a representative of sukoon (counselor) should be posted in the outpatient door area (opd) to facilitate referral of victims to sukoon. along with doctors, nurses can also play a significant role in dealing with domestic violence cases within hospitals, as they are the people who are in http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx verma this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.297 | http://cajgh.pitt.edu direct contact with patients for the longest period of time, especially in the hospital area. helping a victim of violence at sukoon needs coordination between various agencies like police, doctors and lawyers. this often leads to unnecessary delay of the process at various steps. thus, a time limit should be decided for helping all cases of violence. any delay at a certain point should be documented with valid reasons. a strong partnership between a non-government organizations and healthcare workers is required for osccs29. victims should be motivated during follow up to make other females aware of such centers and bring any female there if she is experiencing any kind of violence. results of this study justify that hospitals can be an ideal place to identify victims of violence and as such, there is a need to establish more osccs at hospitals of various levels with their regular monitoring and evaluation. screening and attending to the victims within the hospital can be a positive approach in identifying and helping them. a regular teaching and training program, along with spreading awareness regarding violence, should be an important activity of every oscc for women. references 1. kimuna sr, djamba yk, ciciurkaite g, and cherukuri s. domestic violence in the 2005-2006 national family health survey. journal of interpersonal violence. 2013; 28:773-807. 2. women un facts and figures: ending violence against women. http;//www.unwomen.org updated august 2017.accessed june 8,2018. 3. simister jg. gender-based violence is a growing problem in india. medical research archives. 2018; 6(1):1-21. 4. jeyaseelan l, kumar s, neelakantan n, peedicayil , pillai r, and duvvury n. physical spousal violence against women in india: some risk factors. journal of biosocial science. 2007;39:657-670. 5. vijayendra rao. wife-beating in rural south india: a qualitative and econometric analysis. social science & medicine. 1997;44:1169-1180. 6. koenig ma, stephenson r, ahmed s, jejeebhoy sj, and campbell j. individual and contextual determinants of domestic violence in north india. american journal of public health. 2006; 96:132-138. 7. rocca ch, rathod s, falle t, pande rp and krishnan s. challenging assumptions about women's empowerment: social and economic resources and domestic violence among young married women in urban south india. international journal of epidemiology. 2008 38:577-585. 8. yee a. reforms urged to tackle violence against women in india. the lancet. 2013;381(9876):14451446. 9. hackett mt. domestic violence against women: statistical analysis of crimes across india. . journal of comparative family studies. 2011; 42: 267-288. 10. naved rt, azim s, bhuiya a and persson lå. physical violence by husbands: magnitude, disclosure and help-seeking behavior of women in bangladesh. social science & medicine. 2006;62:2917-2929. 11. djikanović b, lo fo wong s, jansen ha et al. help-seeking behaviour of serbian women who experienced intimate partner violence. family practice. 2011;29:189-195. 13. fugate m, landis l, riordan k, naureckas s and engel b. barriers to domestic violence help seeking: implications for intervention. violence against women. 2005;11:290-310. 14. decker mr, nair s, saggurti n et al. violencerelated coping, help-seeking and health care–based intervention preferences among perinatal women in mumbai, india. journal of interpersonal violence. 2013;28 :1924-1947. 15. snell-rood c. informal support for women and intimate partner violence: the crucial yet ambivalent role of neighbors in urban india. culture, health & sexuality. 2015;17: 63-77. 16. national crime records bureau. crime in india:2016.ministry of home affairs, government of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.297 | http://cajgh.pitt.edu india, national highway-8, mahipalpur, new delhi; 2017. 17. international institute of population sciences. national family health survey (nfhs-4), haryana, govandi station road, deonar, mumbai; 2017. 18. bhate-deosthali p, duggal r. rethinking genderbased violence and public health policies in india. gender based violence and public health. new delhi, routledge; 2013:184-196. 19. bhate-deosthali padma, ravindran ts and vindhya u. addressing domestic violence within health care settings: the dilaasa model. economic and political weekly. 2012;47:66-75. 20. ministry of women and child development. one stop centre scheme implementation guidelines for state governments / ut administrations. government of india, new delhi; 2016 21. pitre a. sexual assault care and forensic evidence kit: strengthening the case for use of the kit. paper presented at: 10th international women and health meeting, new delhi; 2005:21-25 (unpublished). 22. ramsay j, richardson j, carter, yh, davidson ll, and feder, g. should health professionals screen women for domestic violence? brit med j. 2002;325(7359):314. 23. suryavanshi n, naik s, waghmare s et al. genderbased violence screening methods preferred by women visiting a public hospital in pune, india. bmc women's health. 2018;18:19 24. garcía-moreno c, hegarty k, d'oliveira afl, koziol-mclain, j, colombini m, and feder g. the health-system's response to violence against women. the lancet. 2015; 385 (9977): 1567-1579. 25. allen ne, lerner a, mattison e, miles t, and russel a. promoting system's change in the health care response to domestic violence. journal of community psychology. 2007;35:103-120. 26. feder gs, hutson m, ramsay j, and taket ar. women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. archives of internal medicine. 2006;166:22-37. 27. taket a, nurse j, smith k, watson j, shakespeare j, lavis, v and feder g. routinely asking women about domestic violence in health settings. british medical journal. 2003;327 (7416): 673 28. donohoe j. uncovering sexual abuse: evaluation of the effectiveness of the victims of violence and abuse prevention programme. journal of psychiatric and mental health nursing. 2010;17:9-18. 29. babu bv, and kar sk. domestic violence in eastern india: factors associated with victimization and perpetration. public health. 2010; 124:136-148 30. ragavan m, iyengar k and wurtz r. perceptions of options available for victims of physical intimate partner violence in northern india. violence against women. 2015;21:652-675. 31. akhter r and wilson jk. using an ecological framework to understand men’s reasons for spousal abuse: an investigation of the bangladesh demographic and health survey 2007. journal of family violence. 2016; 31:27-38. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. hiv risks, testing, and treatment in the former soviet union: challenges and future directions in research and methodology victoria m. saadat department of health research and policy, stanford university of medicine, stanford, ca vol. 4, no. 2 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu abstract background. the dissolution of the ussr resulted in independence for constituent republics but left them battling an unstable economic environment and healthcare. increases in injection drug use, prostitution, and migration were all widespread responses to this transition and have contributed to the emergence of an hiv epidemic in the countries of former soviet union. researchers have begun to identify the risks of hiv infection as well as the barriers to hiv testing and treatment in the former soviet union. significant methodological challenges have arisen and need to be addressed. the objective of this review is to determine common threads in hiv research in the former soviet union and provide useful recommendations for future research studies. methods. in this systematic review of the literature, pubmed was searched for english-language studies using the key search terms “hiv”, “aids”, “human immunodeficiency virus”, “acquired immune deficiency syndrome”, “central asia”, “kazakhstan”, “kyrgyzstan”, “uzbekistan”, “tajikistan”, “turkmenistan”, “russia”, “ukraine”, “armenia”, “azerbaijan”, and “georgia”. studies were evaluated against eligibility criteria for inclusion. results. thirty-nine studies were identified across the two main topic areas of hiv risk and barriers to testing and treatment, themes subsequently referred to as “risk” and “barriers”. study design was predominantly cross-sectional. the most frequently used sampling methods were peer-to-peer and non-probabilistic sampling. the most frequently reported risks were condom misuse, risky intercourse, and unsafe practices among injection drug users. common barriers to testing included that testing was inconvenient, and that results would not remain confidential. frequent barriers to treatment were based on a distrust in the treatment system. conclusion. the findings of this review reveal methodological limitations that span the existing studies. small sample size, crosssectional design, and non-probabilistic sampling methods were frequently reported limitations. future work is needed to examine barriers to testing and treatment as well as longitudinal studies on hiv risk over time in most-at-risk populations. keywords: hiv, hiv treatment, hiv testing, barriers, sex workers, literature review, central asia, russia hiv risks, testing, and treatment in the former soviet union: challenges and future directions in research and methodology victoria m. saadat department of health research and policy, stanford university of medicine, stanford, ca research historical overview the former soviet union (fsu)—a group of countries and republics spread out across a vast area spanning europe and asia—is harboring one of the fastest growing epidemics of human immunodeficiency virus/acquired immune deficiency syndrome (hiv/aids) in the world.1 little attention, however, was paid to the epidemic during its early years. the epidemic’s growth was masked by low infection rates throughout the region and the pressure felt by each newly formed nation to establish new and independent political and economic infrastructures before addressing public health issues. what remains today is a low-profile, yet alarming, spread of hiv that necessitates a strategic response. large parts of the fsu, especially central asia, have been experiencing one of the fastest-growing epidemics of hiv in the world.2 some areas have recorded infection rates doubling every year since 2000, when steady record keeping began.3 another study demonstrated a 13% increase in new hiv infections in central asia and eastern europe between 2006 to 2012.4 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu research into the causes of the epidemic and the barriers to its alleviation is the crux of an effective strategy. when the soviet union collapsed in 1991, the constituent republics (russian federation, ukraine, uzbekistan, kazakhstan, belarus, azerbaijan, georgia, armenia, tajikistan, moldova, kyrgyzstan, lithuania, turkmenistan, latvia, and estonia) were left to transition to independence with limited resources and guidance. during the transition period, economic collapse and political turmoil catalyzed many societal changes.5 economic transition severely weakened public health infrastructure due to loss of funding from state subsidies, widespread unemployment, and an increase in private practice—where fee-for-service and hidden payments became the norm.6 after the healthcare infrastructure became stagnated and devoid of necessary funding, physicians and researchers began to notice a rise in hiv prevalence. the spread of hiv also coincided with a decline in life expectancy, higher levels of alcohol and injection drug use (idu), and increased rates of coinfection with tuberculosis (tb), hepatitis c virus (hcv), and syphilis among other sexually transmitted infections (sti).7,8 driving forces behind the epidemic efficacy of hiv testing and access to treatment have been evaluated at both the individual and societal levels in many regions of the world, but studies of how vulnerable populations—especially idu—access these services in the fsu have been limited.9 in recent years, approaches to hiv/aids worldwide have broadened to focus not only on individual risk-taking behavior, but also on the environmental and societal factors that influence risky behavior and use of health services.10,11 most-at-risk populations—idu, migrant workers, and commercial sex workers (csw)—are particularly vulnerable without access to hiv testing, treatment, and prevention resources. they also are among the fsu’s least studied groups.10 initiating public health research around highly stigmatized populations, however, has proven to be especially challenging in the fsu.12 in the most extreme case, this stigma has resulted in little to no research on hiv in turkmenistan, where it is unlawful to diagnose or report a patient with hiv.13,14 this review makes little reference to the hiv situation in turkmenistan, where there is limited national data. furthermore, the body of literature on hiv in the fsu is just beginning to take shape. however, the eventual goal of building a substantive body of literature around the causes of and barriers to reduction of hiv is to identify why at-risk populations are more vulnerable to hiv, as well as the barriers underlying suboptimal access to testing and treatment.15 knowing these barriers, programs can be redirected and new initiatives prepared. furthermore, in order to conduct more effective research, challenges and limitations of past studies must be discussed. the primary aim of this review is to systematically evaluate the literature and provide a concise review of research and methodological challenges to-date on the hiv epidemic in the fsu. a second goal of this analysis is to provide guiding factors for the planning and implementation of future studies for the design of more effective testing and treatment programs in the region. methods search methods search terms used on pubmed included “hiv”, “aids”, “human immunodeficiency virus”, “acquired immune deficiency syndrome”, “central asia”, “kazakhstan”, “kyrgyzstan” “uzbekistan”, “tajikistan”, “turkmenistan”, “russia”, “ukraine”, “armenia”, “azerbaijan”, and “georgia” (countries were chosen on the basis of availability of research literature). bibliographies of relevant articles and reviews were scanned for further studies. to be eligible, studies had to be published in english, contain primary data, and identify hiv risk factors and/or barriers to hiv testing or treatment as http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu primary outcomes. these overarching themes are subsequently referred to as “risk” and “barriers”. studies highlighting risks and barriers were chosen for review because hiv prevention and treatment efforts cannot be realized unless the underlying risks are understood.16 the flow of study selection is illustrated in figure 1. the search engine pubmed was used in the collection of studies for this review. studies deemed irrelevant were either only tangentially related to hiv in the former soviet union or contained the key words but were not answering a research question that contributed to the aims of the review. figure 1. flow chart depicting the review process of selecting studies for inclusion and analysis of manuscripts examining risks of hiv infection, barriers to hiv treatment and challenges in hiv prevention data extraction table 1 shows the main features of each study; tables 2a, 2b, and 2c summarize the most frequently reported risks, barriers to testing, and barriers to treatment, respectively. table 1. summary of studies examining risks of hiv infection, barriers to hiv treatment and challenges in hiv prevention. pertinent characteristics include location, study aim, design, population, sampling method(s), and sample size results study location the literature collected was sorted into geographical categories by country. the number of studies from each are as follows: armenia (n=3)17-19; azerbaijan (n=2)20,21; georgia (n=2)22,23; kazakhstan (n=6)24-29; kyrgyzstan (n=3)30-32; russia (n=13)33-45; tajikistan (n=5)46-50; ukraine (n=3)32,51,52; and uzbekistan (n=2)53,54. studies were most heavily represented in russia (33% of studies), kazakhstan (15%), and tajikistan (13%). study design the majority of studies employed a crosssectional design (n=36). of these studies, 10 also obtained biological samples to determine hiv status of participants. the only longitudinal study was from georgia where investigators and implemented both hiv testing and biobehavioral surveys at two different time points, three years apart from each other.23 however, the study reported that the sample size was insufficient to power a comparison between the two time points. therefore, small sample size among a marginalized population was a key limiting factor. study population idu were the target population in 17 studies (44%) and were conducted in each country except turkmenistan. other major populations were migrant workers (n=8), female and csw (n=7). sampling methods the most common sampling methods were purposive sampling (n=19), convenience sampling (n=6), and respondent-driven sampling (includes snowball sampling) (n=5). study limitations the most frequently reported methodological challenges were cross-sectional study design (n=12), inability to obtain a representative sample (n=11), use of self-report (n=11), sub-optimal participant recruiting procedures (n=8), and/or a small sample size (n=6). further methodological limitations included: data were found not to be generalizable outside of the country in which the research was conducted (n=5), specifically having used purposive or snowball sampling to recruit participants (n=5), low participation rates (including not http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu having obtained data on specific groups that declined to participate) (n=4), translation issues and cultural misunderstanding of qualitative data (n=4), and likely underreporting of risky, illegal, and/or stigmatized behaviors in surveys and interviews (n=4). risk factors for hiv infection the most frequently reported categories of risks were condom misuse (n=9), risky intercourse (n=9), unsafe injection practices among idu (n=8), and spread of infection through people who inject drugs (n=8) (table 2). additional groups of risk factors included migration challenges (n=6), low hiv/aids knowledge (n=4), and a history of sti (n=4). table 2. risk factors for infection with hiv as determined by the reviewed studies with detailed aspects as well as the supporting studies barriers to hiv testing the most prominent barriers to testing for hiv status included the perception that it was shameful to test for hiv (n=2), that testing was inconvenient (n=2), and that test results would not be held confidential (n=2) (table 3). table 3. barriers to hiv testing as determined by the reviewed studies detailed aspects of each category and supporting studies barriers to hiv treatment the most frequently reported barriers to obtaining treatment for hiv were based on a distrust in the treatment system and experience with the lack of efficiency in the structure of the treatment system (table 4). specifically, the barriers included a fear of disclosure of treatment status (n=6), an inefficient and ineffective treatment structure (n=6), difficulty in registering for and/or being accepted into a treatment facility (n=5), and difficulty in accessing treatment facilities (n=5). table 4. barriers to hiv treatment as determined by the reviewed studies with detailed aspects of each and a list of the supporting studies for each category discussion this is, to our knowledge, the first systematic review of the current body of research spanning the stages of hiv infection in the fsu, from risk/infection through testing and treatment. the results reveal several important areas in which the current state of research and knowledge is incomplete due to methodological limitations of many studies. as shown in tables 3 and 4, barriers to testing and treatment remain strong among atrisk populations (idu, csw, and migrant workers) but remain inadequately researched when compared to the number of studies examining risk factors for hiv infection. among the reasons for this include sample recruitment challenges, and other methodological challenges, which are further discussed below. most-at-risk populations csw, men who have sex with men (msm), idu, and migrant workers have been found to be key players in the spread of hiv.1,4,7 however, they are the most stigmatized and marginalized groups and have very little access to hiv treatment.55 further, economic, social, and institutional factors in the region can be linked to the spread of hiv among these groups. migrant workers migration between russia, the caucuses, and central asia has been observed as a driver of the epidemic.1,11,56 many tajik and kyrgyz migrants travel through kazakhstan and into russia to find work. as http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu might be expected, extensive travel often puts them at risk.56 often, financially compromised and separated from family, migrants have been shown to engage in behaviors that increase the risk of hiv transmission.57 their financial and legal status in the host country make it extremely difficult to access medical care should hiv be suspected or treatment needed.9 injection drug users throughout the fsu, the idu population has been growing and is associated with harmful drug use and co-infections of tb and hcv.4 the example of central asia demonstrates both behavioral, economic, and geographical factors, among others, at play in the concentration of hiv among idu.58-60 the trafficking of opium out of afghanistan results in large amounts of the drug being transported through kazakhstan, fueling rapid growth of the nation’s population of idu. additionally, kazakhstan and other central asian nations’ location at the centers of labor migration routes compound the effect of drug trafficking: when migratory patterns considerably overlapped with drug trafficking routes, the number of cases among idu increased five-fold in the 13 years following kazakhstan’s independence.61 commercial sex workers this group consists of both men and women who engage in sex work for compensation and suffer tremendously from the stigma that accompanies their work. among this group, female sex workers are more stigmatized than their male counterparts. those who also inject drugs experience a form of double jeopardy.62 methodological challenges one, studies have been conducted in many, but not all, of the countries of the fsu. research in the field of hiv/aids is particularly limited in ukraine and georgia, along with being severely limited in turkmenistan. while the number of studies from russia and kazakhstan, for instance, are relatively numerous, they cannot necessarily be generalized to other fsu countries. this could be explained by the simultaneous similar-and-different nature of the countries: on one hand, they shared some common elements of their political, social, and economic history for most of the 20th century. on the other hand, each country has its own history and ethno-cultural fabric, which is likely to uniquely affect the mentality and psychology of its people. therefore, studying the risks and barriers within every fsu country is necessary in order to help each one best prepare and implement an approach to ameliorate the hiv/aids epidemic. two, many of the studies used a cross-sectional design in collecting their data. it is difficult to make statements of causation from such designs. more longitudinal designs are needed to study the range of factors for any given at-risk group. for example, migrant workers may need to be studied throughout the migration process to evaluate the stage of the migration experience that introduces the most vulnerability to exhibit hiv risk behaviors. three, many of the studies employed nonprobabilistic sampling. it is difficult to know the probability with which the target population has been represented in the sample when using a non-probabilistic method of sampling. such methods that have been employed in this review’s studies include convenience sampling, purposive sampling, and snowball sampling. the studies required participation by individuals who exhibit illicit, illegal, or stigmatized behaviors and are, therefore, socially marginalized. convenience sampling, purposive sampling, and snowball sampling were used to gain access to such populations. although migrant workers, idu and csw are understandably difficult to access and representatively sample, studies could be designed in a more rigorous way that takes into account these limitations of working with hard-to-sample populations that are hidden and lack most formal forms of rosters or lists of documentation, from which probabilistic samples could be obtained. in a separate search of the literature about hiv risk behavior studies in http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu other parts of the world, including thailand and australia, it was interesting to find that many of the studies did not demonstrate a need for purposive or respondent-driven sampling techniques, for instance. instead, the researchers often approached csw, in many cases, in testing or treatment facilities.63,64 this may likely indicate a difference in the difficulties inherent in recruiting marginalized populations in the fsu, when compared to the same task in other parts of the world.65 four, many of the studies reported that it was likely that subjects may have underreported stigmatized, illegal, or risky behaviors in self-report questionnaires and interviews. although not verified, it was an observation made by researchers who were likely aware of the stigmatized nature of most-at-risk populations. for this reason, it was thought to be likely, given that study participants may have distrusted the researchers and feared that the interview results deemed confidential would be released to the police.66 furthermore, data obtained from self-report can be subject to the “socialdesirability bias,” by which a participant may answer questions in a certain manner in order to portray themselves as lawful and socially acceptable. while this insight is helpful in interpreting the data, it sill reveals that the data acquired are not thoroughly accounting for the range and prevalence of behaviors that put subjects at risk for hiv infection or pose barriers to testing and treatment. limitations there are several limitations of the review that must be noted. first, while most of the studies were generally accessible in english, several studies were available only in russian (n=8) or full-text was inaccessible. without the ability to identify and retrieve all relevant studies, the review’s scope may diminish from the ideal. second, the study of hiv is a relatively new area of epidemiologic and public health focus in the fsu, and thus the number of relevant studies is limited, resulting in 39 eligible studies for review. third, the methodological limitations that were extracted from the study manuscripts and tabulated above were based on what the authors had listed in their own evaluation of study limitations and/or from what was available in the methodological descriptions of the studies. for instance, purposive sampling—as a methodological limitation in a study—was determined from the methodological descriptions and/or from the discussion of limitations provided by the study’s authors. this means that certain methodological limitations deemed infrequent in this review—especially “distrust of researchers” (3% of studies reviewed)—should not be viewed as certainly infrequent. many of the studies may have suffered from participant distrust, which may have either gone unnoticed and had an effect on data or sampling outcomes or have been noticed but not reported in the manuscript. participant distrust of the researchers can have an effect on many parts of a study that involve mostat-risk populations: participation rate, sample size, and underreporting can all be affected, but it is important to note in fsu-based studies when distrust occurs in order to help determine ways to improve the relationship between most-at-risk populations and researchers. conclusion hiv research in the former soviet union today, the epidemic grows as risky behavior continues, and prevention and treatment programs face difficulties gaining a foothold in the still-transitioning atmosphere of the fsu. however, the findings of this review reveal a few particular ways in which the current state of knowledge is incomplete as a result of methodological limitations of many of the existing studies. for instance, while 20 studies reported risk factors for hiv infection, only seven of the 39 studies reported barriers to hiv testing, and 9 studies reported barriers to treatment. these numbers illustrate where the bulk of the research has been conducted in the hiv infection pathway (risks factors and infection, testing, and treatment) in the fsu. one reason for this finding http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu may be that there are many more individuals at risk for or infected with hiv than there are individuals who have sought testing and/or treatment. given that small sample size has been a limitation and concern among many of the reviewed studies, it may be a reason for the relative scarcity of studies on barriers to testing and treatment when compared to studies on the risk factors for hiv infection. recommendations for future studies going forward, energy and resources would be best spent on research to study the barriers to getting tested and treated for hiv. of the studies included, the number of which that looked barriers to testing and treatment was minimal compared to what was aimed at studying the risks of hiv infection. future research would include a combination of studies that address the described methodological challenges and one or more attempts at meta-analysis of the data from thematically aligned studies. efforts to apply the results from the above-mentioned research would assist in improving existing hiv programs and advising the development of new ones in the fsu.67,68 references 1. donoghoe mc, lazarus jv, matic s. hiv/aids in the transitional countries of eastern europe and central asia. clin med. 2005;5(5):487-490. 2. thorne c, ferencic n, malyuta r, mimica j, niemiec t. central asia: hotspot in the worldwide hiv epidemic. lancet infect dis. 2010;10(7):479-488. 3. parfitt t. drug addiction and hiv infection on rise in tajikistan. lancet. 2003;362(9391):1206. 4. dehovitz j, uuskula a, el-bassel n. the hiv epidemic in eastern europe and central asia. curr hiv/aids rep. 2014;11(2):168-176. 5. atlani l, caraël m, brunet jb, frasca t, chaika n. social change and hiv in the former ussr: the making of a new epidemic. soc sci med. 2000;50(11):1547-1556. 6. balabanova d, mckee m, pomerleau j, rose r, haerpfer c. health service utilization in the former soviet union: evidence from eight countries. health serv res. 2004;39(6 pt 2):19271950. 7. walsh n, maher l. hiv and hcv among people who inject drugs in central asia. drug alcohol depend. 2013;132(suppl 1):s37-s40. 8. atun r, olynik i. resistance to implementing policy change: the case of ukraine. bull world health organ. 2008;86(2):147-154. 9. terlikbayeva a, zhussupov b, primbetova s, et al. access to hiv counseling and testing among people who inject drugs in central asia: strategies for improving access and linkages to treatment and care. drug alcohol depend. 2013;132(suppl 1):s61-s64. 10. godinho j, renton a, vinogradov v, novotny t, rivers mj. reversing the tide: priorities for hiv/aids prevention in central asia. world bank working papers2005. 11. rhodes t, simic m. transition and the hiv risk environment. bmj. 2005;331(7510):220-223. 12. link bg, phelan jc. stigma and its public health implications. lancet. 2006;367(9509):528-529. 13. rechel b, sikorskaya i, mckee m. hope for health in turkmenistan? lancet. 2009;373(9681):2093-2095. 14. rechel b, mckee m. the effects of dictatorship on health: the case of turkmenistan. bmc med. 2007;5:21. 15. boltaev aa, el-bassel n, deryabina ap, et al. scaling up hiv prevention efforts targeting people who inject drugs in central asia: a review of key challenges and ways forward. drug alcohol depend. 2013;132(suppl 1):s41-s47. 16. gupta gr, parkhurst jo, ogden ja, aggleton p, mahal a. structural approaches to hiv prevention. lancet. 2008;372(9640):764-775. 17. markosyan km, babikian t, diclemente rj, hirsch js, grigoryan s, del rio c. correlates of hiv risk and preventive behaviors in armenian female sex workers. aids behav. 2007;11(2):325-334. 18. lang dl, salazar lf, diclemente rj, markosyan k. gender based violence as a risk factor for hiv-associated risk behaviors among female sex workers in armenia. aids behav. 2013;17(2):551-558. 19. johnston l, grigoryan s, papoyan a, grigoryan t, balayan t, zohrabyan l. high hiv and hcv and the unmet needs of people who inject drugs in yerevan, armenia. int j drug policy. 2014;25(4):740-743. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu 20. nassibov r, abdukkayev a. rapid assessment on spread of injection drug use related hiv/aids in azerbaijan. int j drug policy. 2005;16(6):432-435. 21. botros ba, aliyev qm, saad md, et al. hiv infection and associated risk factors among long-distance truck drivers travelling through azerbaijan. int j std aids. 2009;20(7):477482. 22. otiashvili d, kirtadze i, o'grady ke, et al. access to treatment for substance-using women in the republic of georgia: socio-cultural and structural barriers. int j drug policy. 2013;24(6):566-572. 23. tsereteli n, chikovani i, chkhaidze n, goguadze k, shengelia n, rukhadze n. hiv testing uptake among female sex workers and men who have sex with men in tbilisi, georgia. hiv med. 2013;14(suppl 3):29-32. 24. viale bn. how perceived barriers to voluntary counseling & testing impact actual hiv testing among injection drug users in kazakhstan. 2010; http://hdl.handle.net/10211.10/624. 25. el-bassel n, gilbert l, terlikbayeva a, et al. hiv risks among injecting and non-injecting female partners of men who inject drugs in almaty, kazakhstan: implications for hiv prevention, research, and policy. int j drug policy. 2014;25(6):1195-1203. 26. el-bassel n, gilbert l, terlikbayeva a, et al. implications of mobility patterns and hiv risks for hiv prevention among migrant market vendors in kazakhstan. am j public health. 2011;101(6):1075-1081. 27. el-bassel n, gilbert l, terlikbayeva a, et al. hiv among injection drug users and their intimate partners in almaty, kazakhstan. aids behav. 2013;17(7):2490-2500. 28. berry m, wirtz al, janayeva a, et al. risk factors for hiv and unprotected anal intercourse among men who have sex with men (msm) in almaty, kazakhstan. plos one. 2012;7(8):e43071. 29. boltaev aa, deryabina ap, kusainov a, howard aa. evaluation of a pilot medication-assisted therapy program in kazakhstan: successes, challenges, and opportunities for scaleup. adv prev med. 2012:308793. 30. deryabina a. mapping of key hiv services, assessment of their quality, and analysis of gaps and needs of most-at-risk populations in chui oblast and bishkek city, kyrgyzstan. 2011; http://pdf.usaid.gov/pdf_docs/pnaea608.pdf. accessed oct. 20, 2015. 31. messner l, kazantseva t. gender assessment: access to hiv services by key populationis in kyrgyzstan. 2013; https://www.encompassworld.com/sites/default/files/aidstaron e_report_gender_assessment_web.pdf. accessed oct. 20, 2015. 32. spicer n, bogdan d, brugha r, harmer a, murzalieva g, semigina t. 'it's risky to walk in the city with syringes': understanding access to hiv/aids services for injecting drug users in the former soviet union countries of ukraine and kyrgyzstan. global health. 2011;7:22. 33. tkatchenko-schmidt e, renton a, gevorgyan r, davydenko l, atun r. prevention of hiv/aids among injecting drug users in russia: opportunities and barriers to scaling-up of harm reduction programmes. health policy. 2008;85(2):162171. 34. bobrova n, rhodes t, power r, et al. barriers to accessing drug treatment in russia: a qualitative study among injecting drug users in two cities. drug alcohol depend. 2006;82(suppl 1):s57-s63. 35. sarang a, rhodes t, platt l. access to syringes in three russian cities: implications for syringe distribution and coverage. int j drug policy. 2008;19(suppl 1):s25-s36. 36. king ej, maman s. structural barriers to receiving health care services for female sex workers in russia. qual health res. 2013;23(8):1079-1088. 37. king ej, maman s, bowling jm, moracco ke, dudina v. the influence of stigma and discrimination on female sex workers' access to hiv services in st. petersburg, russia. aids behav. 2013;17(8):2597-2603. 38. vasquez c, lioznov d, nikolaenko s, et al. gender disparities in hiv risk behavior and access to health care in st. petersburg, russia. aids patient care stds. 2013;27(5):304310. 39. sarang a, rhodes t, sheon n. systemic barriers accessing hiv treatment among people who inject drugs in russia: a qualitative study. health policy plan. 2013;28(7):681-691. 40. zabrocki c, weine s, chen s, et al. socio-structural barriers, protective factors, and hiv risk among central-asian female migrants in moscow. cent asian j glob health. 2013;2(1). 41. niccolai lm, toussova ov, verevochkin sv, barbour r, heimer r, kozlov ap. high hiv prevalence, suboptimal hiv testing, and low knowledge of hiv-positive serostatus among injection drug users in st. petersburg, russia. aids behav. 2010;14(4):932-941. 42. kruse gr, barbour r, heimer r, et al. drug choice, spatial distribution, hiv risk, and hiv prevalence among injection drug users in st. petersburg, russia. harm reduct j. 2009;6:22. 43. amirkhanian ya, kelly ja, mcauliffe tl. psychosocial needs, mental health, and hiv transmission risk behavior among http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu people living with hiv/aids in st petersburg, russia. aids. 2003;17(16):2367-2374. 44. amirkhanian ya, kuznetsova av, kelly ja, et al. male labor migrants in russia: hiv risk behavior levels, contextual factors, and prevention needs. j immigr minor health. 2011;13(5):919928. 45. weine s, bahromov m, mirzoev a. unprotected tajik male migrant workers in moscow at risk for hiv/aids. j immigr minor health. 2008;10(5):461-468. 46. stachowiak ja, tishkova fk, strathdee sa, et al. marked ethnic differences in hiv prevalence and risk behaviors among injection drug users in dushanbe, tajikistan, 2004. drug alcohol depend. 2006;82(suppl 1):s7-s14. 47. beyrer c, patel z, stachowiak ja, et al. characterization of the emerging hiv type 1 and hcv epidemics among injecting drug users in dushanbe, tajikistan. aids res hum retroviruses. 2009;25(9):853-860. 48. weine s, bahromov m, loue s, owens l. trauma exposure, ptsd, and hiv sexual risk behaviors among labor migrants from tajikistan. aids behav. 2012;16(6):1659-1669. 49. golobof a, weine s, bahromov m, luo j. the roles of labor migrants' wives in hiv/aids risk and prevention in tajikistan. aids care. 2011;23(1):91-97. 50. jing l, weine s, bahromov m, golobof a. does powerlessness explain elevated hiv risk amongst tajik labor migrants? an ethnographic study. j hiv aids soc serv. 2012;11(2):105-124. 51. mimiaga mj, safren sa, dvoryak s, reisner sl, needle r, woody g. "we fear the police, and the police fear us": structural and individual barriers and facilitators to hiv medication adherence among injection drug users in kiev, ukraine. aids care. 2010;22(11):1305-1313. 52. booth re, dvoryak s, sung-joon m, et al. law enforcement practices associated with hiv infection among injection drug users in odessa, ukraine. aids behav. 2013;17(8):2604-2614. 53. todd cs, alibayeva g, khakimov mm, sanchez jl, bautista ct, earhart kc. prevalence and correlates of condom use and hiv testing among female sex workers in tashkent, uzbekistan: implications for hiv transmission. aids behav. 2007;11(3):435442. 54. sanchez jl, todd cs, bautista ct, et al. high hiv prevalence and risk factors among injection drug users in tashkent, uzbekistan, 2003-2004. drug alcohol depend. 2006;82(suppl 1):s15-s22. 55. rechel b. hiv/aids in the countries of the former soviet union: societal and attitudinal challenges. cent eur j public health. 2010;18(2):110-115. 56. smolak a. contextual factors influencing hiv risk behaviour in central asia. cult health sex. 2010;12(5):515-527. 57. todrys kw, amon jj. within but without: human rights and access to hiv prevention and treatment for internal migrants. global health. 2009;5:17. 58. dershem l, tabatadze m, sirbiladze t, tavzarashvili l, tsagareli t, todadze k. characteristics, high‐risk behaviors and knowledge of sti/hiv/aids, and prevalence of hiv, syphilis and hepatitis among injecting drug users in batumi, georgia: 2004 – 2006. 2007; http://pdf.usaid.gov/pdf_docs/pnadk406.pdf. 59. renton a, gzirishvilli d, gotsadze g, godinho j. epidemics of hiv and sexually transmitted infections in central asia: trends, drivers and priorities for control. int j drug policy. 2006;17(6):494-503. 60. zabransky t, mravcik v, talu a, jasaitis e. post-soviet central asia: a summary of the drug situation. int j drug policy. 2014;25(6):1186-1194. 61. bobrova n, sarang a, stuikyte r, lezhentsev k. obstacles in provision of anti-retroviral treatment to drug users in central and eastern europe and central asia: a regional overview. int j drug policy. 2007;18(4):313-318. 62. el-bassel n, strathdee sa, el sadr wm. hiv and people who use drugs in central asia: confronting the perfect storm. drug alcohol depend. 2013;132(suppl 1):s2-s6. 63. estcourt cs, marks c, rohrsheim r, johnson am, donovan b, mindel a. hiv, sexually transmitted infections, and risk behaviours in male commercial sex workers in sydney. sex transm infect. 2000;76(4):294-298. 64. kilmarx ph, limpakarnjanarat k, mastro td, et al. hiv-1 seroconversion in a prospective study of female sex workers in northern thailand: continued high incidence among brothelbased women. aids. 1998;12(14):1889-1898. 65. hamama l, tartakovsky e, eroshina k, et al. nurses' job satisfaction and attitudes towards people living with hiv/aids in russia. int nurs rev. 2014;61(1):131-139. 66. smolak a, el-bassel n. multilevel stigma as a barrier to hiv testing in central asia: a context quantified. aids behav. 2013;17(8):2742-2755. 67. wolfe d, carrieri mp, shepard d. treatment and care for injecting drug users with hiv infection: a review of barriers and ways forward. lancet. 2010;376(9738):355-366. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu 68. wolfe d. paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in asia and the former soviet union. int j drug policy. 2007;18(4):246-254. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu table 1: summary of studies examining risks of hiv infection, barriers to hiv treatment and challenges in hiv prevention. pertinent characteristics include location, study aim, design, population, sampling method(s), and sample size reference location aims outcome methods population sampling method sample markosyan et al. (2007) armenia describe hiv risk/preventive behaviors and correlates among armenian fsw questionnaire, focus groups, interviews armenian fsw convenience sample 98 lang et al. (2013) armenia identify the association of gender-based violence with sexual risk among fsw survey armenian fsw convenience and snowball sampling 120 johnston et al., (2014) armenia present risk behavior associations for hiv and hcv infection among pwid interview and testing for hiv and hcv pwid injecting drugs within the past three months rds 270 nassibov et al., (2005) azerbaijan examine the prevalence and context of injection drug use and hiv-risk behaviors and trends in hiv transmission survey and focus groups idu and key informants (medical staff, police, and legal experts) not described 400 botros et al., (2009) azerbaijan assess hiv prevalence and associated risk behaviors among truck drivers questionnaire and sero-surveillance blood testing truck drivers traveling through azerbaijan convenience sampling 3,763 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu otiashvili et al. (2013) georgia investigate the factors that may facilitate or hinder substance-using women’s help-seeking behavior or access to treatment services secondary analysis of in-depth interviews substance-using women and providers of health-related services word-of-mouth 89 tsereteli et al. (2013) georgia investigate hiv testing practice among fsw and msm and to identify determinants of never testing behavior among msm bio-behavioral surveys fsw and msm in tbilisi, georgia fsws were recruited through time-location sampling; recruitment of msm was carried out through rds 278 viale, bn (2010) kazakhstan assess perceived barriers to seeking and accessing voluntary testing survey idu in kazakhstan rds 1,071 el-bassel et al. (2014) kazakhstan compare fwid and females who do not inject drugs, examining associations between history of idu and hiv and hcv risk behaviors reanalysis of data from prior rct with self-reported responses and biological assays female partners of mwid: both fwid and non-injecting female partners trained research assistants recruited potential study participants from neighborhoods where idu gather as well as hiv clinics and needle exchange programs (for more detail see elbassel et al.,2013) 364 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu el-bassel et al. (2011) kazakhstan examine associations between mobility patterns and hiv risks among male and female migrant market vendors structured interview male and female migrant market vendors in almaty randomized sampling using gis (mapping of stalls at barakholka) 422 el-bassel et al. (2013) kazakhstan examine associations between hiv serostatus, socio-demographic factors, and sexual and drug risk behaviors self-report data and biological assays for hiv serostatus idu and their heterosexual intimate partners word-of-mouth and targeted outreach in known neighborhood locations where idu gather 728 berry et al. (2012) kazakhstan measure hiv risk factors and hiv prevalence among msm questionnaire and hiv test msm in almaty rds 400 boltaev et al. (2012) kazakhstan evaluate the quality and effectiveness of the mat pilot in kazakhstan and review implementation in-depth qualitative interview mat patients in kazakhstan not specified 93 deryabina, a. (2011) kyrgyzstan understand the current status of hiv services for most-at-risk populations (marp), access to, and quality of services provided semi-structured interviews and focus groups idu, csw, former prisoners, and leaders of various hiv/aids groups in chui oblast and bishkek city marp representatives who participated in fgds or individual interviews were recruited through ngo representatives (outreach 243 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu workers) and thus only included clients of hiv-related services messner et al. (2013) kyrgyzstan identify gender-based constraints to accessing hiv/aids programs and services interviews individuals from various governmental organizations a list of key informants was developed in collaboration with usaid/kyrgyzstan and additional interviewees were identified during the in-country data collection 60 spicer et al. (2011) kyrgyzstan explore access barriers to hiv/aids services experienced by a key risk group of idu semi-structured interviews idu and stakeholders in ukraine and kyrgyzstan purposive sampling 228 tkatchenkoschmidt, et al. (2008) russia examine attitudes of russian policy-makers and hiv stakeholders towards hr scale up semi-structured interviews hiv-focused governmental organizations and ngos in volgograd purposive and chain sampling 58 bobrova et al. (2006) russia assess factors that impact idu access to treatment qualitative interviews idu purposive sampling 86 sarang et al. (2008) russia investigate idu access to needles and syringes qualitative interviews idu in moscow, volgograd, barnaul targeted and snowball sampling 209 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu king et al. (2013) russia determine facilitators of and barriers to accessing hiv services in-depth qualitative interviews fsw in st. petersburg purposive sampling 29 king et al. (2013) russia better understand how stigma and discrimination influence hiv service utilization questionnaire fsw purposive sampling 139 vasquez et al. (2013) russia define characteristics and barriers to hiv care questionnaire people receiving hiv treatment in st. petersburg convenience sampling 152 sarang et al. (2013) russia explore barriers to accessing art among pwid in-depth qualitative interviews pwid in yekaterinburg purposive sampling 42 zabrocki et al. (2013) russia understand socio-structural barriers, protective factors, and hiv sexual risk interviews unmarried female migrants in moscow purposive sampling 30 niccolai et al. (2010) russia estimate hiv prevalence and testing patterns among idus hiv and sti testing; survey idu in st. petersburg rds 387 kruse et al. (2009) russia examine behaviors associated with hiv risk questionnaire and hiv testing idu purposive sampling 900 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu among idus amirkhanian et al. (2011) russia explore health service access of persons living with hiv questionnaire individuals with hiv/aids from 5 st. petersburg health care and social service agencies convenience sampling 470 amirkhanian et al. (2011) russia determine how well migrant workers understand hiv risk factors and behaviors that increase hiv risk questionnaire and survey male labor migrants in st. petersburg convenience sampling 499 weine et al. (2008) russia characterize hiv/aids risk; identify contextual factors that could impede or facilitate a preventive intervention ethnographic interview and survey tajik male migrant workers in moscow purposive sampling at work sites 30 stachowiak et al. (2006) tajikistan examine differences by ethnicity of hiv prevalence and correlates among idu questionnaire and hiv testing active adult idus purposive sampling 489 beyrer et al. tajikistan determine hiv, hcv, and survey; hiv, hcv, active adult idus purposive sampling 491 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu (2009) syphilis prevalence and correlates and syphilis testing weine et al. (2012) tajikistan determine the role of trauma and ptsd symptoms in the context of migrationassociated hiv risk behaviors survey tajik married male labor migrants in moscow probabilities proportionate to size (pps) methods; simple random sampling (srs) 400 golobof et al. (2011) tajikistan understand labor migrants' wives' knowledge, attitudes, and behaviors regarding hiv/aids risk and protection minimally structured interviews and field observations tajik wives in dushanbe married to male migrant workers in moscow purposive sampling 30 jing et al. (2012) tajikistan investigate powerlessness in hiv risk among internal and external male labor migrant workers from tajikistan minimally structured interviews and field observations migrants working in regar; migrants working in moscow purposive sampling 60 mimiaga et al. (2010) ukraine examine barriers and facilitators to haart adherence semi-structured focus groups hiv-infected idu seeking treatment at the city aids center, kiev purposive/convenience sampling: participants recruited from those attending treatment the aids center 16 booth et al. ukraine learn how experiences with the legal system (police and semi-structured idu; police and not specified 19 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu (2013) courts) correlate with hiv among idu interviews members of the court spicer et al. (2011) ukraine explore multiple access barriers to hiv/aids services experienced by a key risk group of idu semi-structured interviews idu (current and former) and national and sub-national stakeholders in ukraine and kyrgyzstan purposive sampling: client interviewees were recruited with the agreement of hiv/aids service providers who introduced potential interviewees to the researchers 391 todd et al. (2007) uzbekistan examine condom use and hiv testing use among fsw questionnaire, interview, and hiv testing fsw in tashkent purposive sampling by outreach workers affiliated with istiqbolli avlod, a ngo in tashkent 448 sanchez et al. (2006) uzbekistan determine hiv prevalence and potential associations with sociodemographic and behavioral factors among idu survey and hiv biosurveillance idu in tashkent purposive sampling by the center for aids prevention and control and in idu gathering locations 701 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu table 2. risk factors for infection with hiv as determined by the reviewed studies with detailed aspects as well as the supporting studies risk factor reported details supporting studies condom use irregular, inconsistent, and incorrect use of condoms beyrer et al. (2009), botros et al. (2009), lang et al. (2013), amirkhanian et al. (2011), sanchez et al. (2006), markosyan et al. (2007), vasquez et al. (2013), zabrocki et al. (2013), jing et al. (2012) risky intercourse sex with idu clients, msm status, unprotected sex, unprotected sex with csw, earlier age of initiation of sex work, transactional sex, multiple female partners in last 3 months, having unprotected anal intercourse with male partners, unprotected receptive anal sex markosyan et al. (2007), amirkhanian et al. (2011), lang et al. (2013), weine et al. (2008), lang et al. (2013), berry et al. (2012), amirkhanian et al. (2011), berry et al. (2012), berry et al. (2012) unsafe injection practices daily injecting, injecting alone, starting injecting at a younger age of initiation of illegal drug use, longer history of drug abuse, rushed injections due to fear of the police, idu status, being female idu stachowiak et al. (2006), beyrer et al. (2009), vasquez et al. (2013), booth et al. (2013), vasquez et al. (2013), amirkhanian et al. (2011), el-bassel et al. (2014), el-bassel et al. (2011) migration challenges being tajik or uzbek nationality, frequent travel outside of current place of residence, harsh living and working conditions, lack of legal protection from the government, poor social support beyrer et al. (2009), el-bassel et al. (2013), el-bassel et al. (2013), weine et al. (2008), el-bassel et al. (2013), amirkhanian et al. (2003) threats from police police planting drugs, idu paying police to avoid arrest, prior confiscation of pre-filled syringes, history of incarceration booth et al. (2013), booth et al. (2013), booth et al. (2013), booth et al. (2013), el-bassel et al. (2014) low hiv/aids knowledge incomplete or vague knowledge of hiv transmission jing et al. (2012), markosyan et al. (2007), zabrocki et al. (2013), amirkhanian et al. (2011) history of sti current sti symptoms, history of sti, prior history of hepatitis berry et al. (2012), botros et al. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu (2009), sanchez et al. (2006), lang et al. (2013) concurrent alcohol and drug use drinking alcohol, non-injection drug use jing et al. (2012), markosyan et al. (2007), berry et al. (2012) pressure not to use condom fear of sexual partners’ reaction to condom use lang et al. (2013), golobof et al. (2011) history of drug abuse treatment history of undergoing drug abuse treatment multiple times stachowiak et al. (2006), beyrer et al. (2009) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu table 3. barriers to hiv testing as determined by the reviewed studies detailed aspects of each category and supporting studies barrier to testing reported details supporting studies shame thoughts that testing is shameful, hiv stigma golobof et al. (2011), king et al. (2013) convenience of testing low access and hard to find testing locations, inconvenient clinic hours tsereteli et al. (2013), viale, bn (2010) confidentiality of testing fear of being disclosed as an idu, fear that testing results would not remain confidential nassibov et al. (2005), tkatchenko-schmidt, et al. (2008) fear of result fear of a positive test result viale, bn (2010) priorities perception that more immediate problems take priority viale, bn (2010) self-perception of hiv risk considering self at low or no risk for hiv tsereteli et al. (2013) lack of experience in sex work engaging in sex work less than 2 years, younger than 21, initiated sex work at the age of 18 or younger todd et al. (2007) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu table 4. barriers to hiv treatment as determined by the reviewed studies with detailed aspects of each and a list of the supporting studies for each category barriers to treatment reported details supporting studies fear of disclosure lack of anonymity/confidentiality of treatment, fear of registration as idu, fear of police around treatment centers, criminalization of drug use at treatment centers, harassment and discrimination by police king et al. (2013), bobrova et al. (2006), otiashvili et al. (2013), sarang et al. (2008), spicer et al. (2011), mimiaga et al. (2010) inefficient and ineffective treatment structure shortages of commodities and human resources, low knowledge and skills of service providers, insufficient drug policies, limited opportunities for staff development, complexity of drug treatment regimen, services and entitlements spicer et al. (2011), otiashvili et al. (2013), otiashvili et al. (2013), boltaev et al. (2012), mimiaga et al. (2010), spicer et al. (2011) difficult to register for or be accepted into treatment bureaucracy, tough registration system, organizational barriers, lack of legal status while being a migrant worker sarang et al. (2008), king et al. (2013), spicer et al. (2011), zabrocki et al. (2013), king et al. (2013) difficult to access treatment facilities scarce infrastructure of narcological facilities, inadequate access and coverage, insufficient supply management, geographic proximity and access, lack of availability of comprehensive treatment programs, restrictive methadone dispensing policies boltaev et al. (2012), boltaev et al. (2012), boltaev et al. (2012), otiashvili et al. (2013), boltaev et al. (2012) unable to afford treatment financial constraints (especially for migrant workers) zabrocki et al. (2013), bobrova et al. (2006), otiashvili et al. (2013), king et al. (2013) stigma stigmatization of hiv/aids and drug use, discrimination among government service providers spicer et al. (2011), mimiaga et al. (2010), spicer et al. (2011), bobrova et al. (2006) distrust in treatment lack of belief in treatment effectiveness, perceived low efficacy, feeling that harm reduction programs are forced on them from outside tkatchenko-schmidt, et al. (2008), bobrova et al. (2006), tkatchenko-schmidt, et al. (2008) drug use policies in treatment opioid dependence, fear of treatment being withheld b/c drug use mimiaga et al. (2010), sarang et al. (2008) limited knowledge limited knowledge of hiv/aids risk factors spicer et al. (2011) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saadat this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu mental health problems co-morbid mental health problems mimiaga et al. (2010) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.225 | http://cajgh.pitt.edu figure 1. flow chart depicting the review process of selecting studies for inclusion and analysis of manuscripts examining risks of hiv infection, barriers to hiv treatment and challenges in hiv prevention http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. track implementation: a bangladesh scenario abdul kader mohiuddin1 1dr. m. nasirullah memorial trust, tejgaon, dhaka, bangladesh vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.416 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ mohiuddin this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.416|http://cajgh.pitt.edu abstract with the increasing burden of non-communicable diseases in low-income and middle-income countries (lmics), biological risk factors, such as hyperglycemia, are a major public health concern in bangladesh. optimization of diabetes management by positive lifestyle changes is urgently required for prevention of comorbidities and complications, which in turn will reduce the cost. diabetes had 2 times more days of inpatient treatment, 1.3 times more outpatient visits, and nearly 10 times more medications than non diabetes patients, as reported by british medical journal. and surprisingly, 80% of people with this so called “rich man's disease” live in lowand middle-income countries. according to a recent study of american medical association, china and india collectively are home of nearly 110 million diabetic patients. the prevalence of diabetes in this region is projected to increase by 71% by 2035. bangladesh was ranked as the 8th highest diabetic populous country in the time period of 2010-2011. in bangladesh, the estimated prevalence of diabetes among adults was 9.7% in 2011 and the number is projected to be 13.7 million by 2045. the cost of diabetes care is considerably high in bangladesh, and it is primarily driven by the medicine and hospitalization costs. according to bangladesh bureau of statistics, in 2017 the annual average cost per t2dm was $864.7, which is 52% of per capita gdp of bangladesh and 9.8 times higher than the general health care cost. medicine is the highest source of direct cost (around 85%) for patients without hospitalization. the private and public financing of diabetes treatment will be severely constrained in near future, representing a health threat for the bangladeshi population. keywords: blood sugar screening; compliance; overweight; lifestyle; regular health checkup; ramadan fasting; climate issue of diabetes track (by nehep) implementation: a bangladesh scenario abdul kader mohiuddin1 1dr. m. nasirullah memorial trust, tejgaon, dhaka, bangladesh news: research and practice bangladesh was ranked as the 8th highest diabetic populous country in the time period of 20102011 [1]. in bangladesh, the estimated prevalence of diabetes among adults was 9.7% in 2011 and the number is projected to be 13.7 million by 2045. the cost of diabetes care is considerably high in bangladesh, and it is primarily driven by the medicine and hospitalization costs. according to bangladesh bureau of statistics, in 2017 the annual average cost per t2dm was $864.7, which is 52% of per capita gdp of bangladesh and 9.8 times higher than the general health care cost [2]. in bangladesh, specifically, the idf projects the prevalence of diabetes will increase to more than 50% in the next 15 years [3,4]. about 129,000 deaths were attributed to diabetes in bangladesh in 2015, as reported by leading research organization icddr, b [5]. according to the who-diabetes country profile of bangladesh in 2016, the physical inactivity was prevailing among 25.1% of population [6]. around 85% population of age group 25-65 never checks for diabetes [7]. a recent study by british medical journal says, 1 in 10 bangladeshi adults aged ≥18 years have hyperglycemia (among urban residents) [8]. even in rural bangladeshi community, undiagnosed diabetes was high, 7.2% found in a 2016 and 10% in 2019 [9,10]. roughly 20%–30% of adults in rural areas of bangladesh have abnormal fasting glucose or impaired glucose tolerance, with the prevalence of diabetes (mostly type 2 diabetes) expected to reach 24%–34% by 2030 [10-12]. and idf says, there are 7.1 million people with undetected diabetes in bangladesh and this number will be double http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.416|http://cajgh.pitt.edu figure 1. track, a program of national institute of health (nih), england to memorize the factors that can contribute to health while living with diabetes [14]. by 2025 [13]. prevalence of dyslipidemia was over 70% to both male and female subjects, which indicates the urgency of lifestyle intervention strategies to prevent and manage this important health problem and risk factor [15]. among 8400 stroke patients from different hospitals in bangladesh over a period of sixteen years, diabetic patients were nearly 25% [16]. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mohiuddin this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.416|http://cajgh.pitt.edu risk factors prevalence physical inactivity (overall) 25.1% physical inactivity (among adults) 35% to 38% young adults among capital who unmet recommended physical activity 80% adults who never checks diabetes 85% undiagnosed diabetes among rural population 7.2% adults with hyperglycemia 10% abnormal fasting glucose among rural population 20%-30% people over the age of 35 having diabetes under control 12% people over 35 had abnormal fasting glucose 25% stroke among diabetic patients 25% non-compliance with medication 87% prevalence of dyslipidemia more than 70% obesity among young adults 22% to 27% obesity among school going children 40% mothers unaware of consequences of childhood obesity 70% obesity among urban women 34% obesity among married women 30% obesity increase among women in 15 years study 17.5% higher prevalence of diabetes among males 7.4% overall consumption of fast food consumption among youth and children around 54% prevalence of self-reported depression 47% smokers (male) 37% gdm 15% adulterated food in daily consumption 50% child marriage 30% undernourished women 33% underweight among children aged less than five years 40% low health literacy (among urban people) 60% table 1. summary of diabetic risk factors in bangladesh icddr, b, estimated 150 food items in the country. more than 50% of the food samples they tested were adulterated reported by the institute of public health (iph) [17]. undoubtedly human health is now under the domination of formalin, in bangladesh about 400 tons of formalin is being imported which are goes to human stomach, creates deadly mistreats on long term exposure [18]. several studies highlighted formaldehyde-induced neurodegeneration, diabetes risk and diabetes-associated cognitive impairments [19-21]. even more unfortunate is the fact that nefarious practice of food adulteration increases exponentially during the month of ramadan in bangladesh [22]. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.416|http://cajgh.pitt.edu a netherlands based study in cnn health says, "a 1-degree celsius rise in environmental temperature could account for more than 100,000 new diabetes cases per year in the usa alone" [23]. a similar study says bangladesh will exceed 35-degree celsius before the end of the century [24]. consuming arsenic contaminated food grains could be another reason of high diabetes prevalence [25]. in sex-stratified analyses with 641 subjects from rural bangladesh, a study reported arsenic exposure (50.01-150 μg/l) showed a clearer pattern of dose-dependent risk for hyperglycemia in females than males [26]. again, 15% of expecting women are diagnosed with gestational diabetes among these 60% contribute to permanent diabetes within 10 years, says dr samsad jahan (professor of obstetrics and gynecology, birdem) [27]. according to a 2018 bbc record, insulin availability found supplies were low in six countries bangladesh, brazil, malawi, nepal, pakistan and sri lanka [28,29]. also, huge gap between the number of diabetic patients and doctors are well-known [30]. the diabetic association of bangladesh (dab) record shows, except dhaka and chittagong, there are no tertiary facilities in bangladesh to preventing blindness due to diabetic retinopathy. children with diabetes are still managed by adult physicians or occasionally by adult diabetologists, except in institutions like birdem, and dhaka shishu hospital [31]. around 22% to 27% bangladeshi youth were recorded as obese with different stages of obesity [32]. another study says nearly 40% bangladeshi youth, taking fast foods were recognized as overweight where 32% were noted as obese with different phases of obesity and overall prevalence of fast food consumption was about 53.8% [33]. in a newspaper interview, professor ak azad khan, president, diabetic association of bangladesh said 40% school going children of dhaka city were either obese or overweight [34]. “children with type 2 diabetes is rising “alarmingly” in bangladesh. a 300% raise in the last five years”, according to the changing diabetes in children program of the birdem hospital [35]. a community level study shows 35% of mothers perceived that childhood overweight/obesity could be a health problem and nearly 70% were not aware of any health consequences of childhood obesity [36]. another study shows 97.4% students consume fast food contain monosodium glutamate which causes obesity and other body discomforts [37]. in a similar study among students of 4 private universities of dhaka, 98% of the students were well informed about the negative effects associated with excessive fast food consumption, they were still profoundly addicted to it [38]. prevalence rates of overweight and obesity are higher in urban peoples compared to rural peoples living in bangladesh [39]. according to the who-diabetes country profile of bangladesh in 2016, the physical inactivity was prevailing more than 25% of population. bangladeshi women more at health risk than men due to inactivity. two big reasons to diabetes among bangladeshi people are carbohydrate-dependent food pattern and sedentary lifestyle [40-42]. evidence shows that prevalence of physical inactivity 35% to 38% in bangladeshi adults aged 25 years and older [43]. despite the high levels of diabetes and intermediate hyperglycemia, awareness and control of the condition is low [44]. in a crosssectional study in urban population of bangladesh, more than 60% of the diabetic patients had inadequate functional health literacy of them and nearly 90% had inadequate glycemic control (hba1c>8%) [45]. also, another study says that diabetes-related health literacy in rural bangladesh is a major factor associated with diabetic retinopathy (dr) screening [46]. the idf atlas estimated the incidence of type 1 diabetes in bangladesh as 4.2 new cases of t1dm/100,000 children (0–14 years)/year, in 2013 [31]. the social challenges faced by t1dm children are numerous. many of them are poor, with little access to education. they are often considered a burden on the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mohiuddin this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.416|http://cajgh.pitt.edu family, especially girls; they have little prospect of getting married or being employed. according to unicef, bangladesh has the fourth highest prevalence rate of child marriage in the world, and the second highest number of absolute child brides – 4.5 million. around 30% of girls in bangladesh married before the age of 15 and nearly 80% got married before the age of 18 [47-49]. the prevalence of nutritional deficiency was relatively higher among rural, illiterate and early married women and among those with a low standard of living. child marriage, low-birthweight, mother nutrition and diabetes closely related to each other [50]. recently, telenor health and dab have launched the firstever diabetes management service, dia360, to help people with diabetes manage their blood sugar levels and reduce risks of complications. people can enroll in three dab centers in dhaka—bangladesh institute of health and sciences, bangladesh institute of research and rehabilitation in diabetes, endocrine and metabolic disorders (birdem) general hospital, and the national health network hospital. it has more than 400,000 diabetics registered at its tertiary center, birdem in dhaka. however, the most important thing is patient education, that the modern world is giving the highest priorities. rich or poor, privileged or unprivileged, all segment of population should be brought under the arena of compliance through patient education, at least by health campaign. both government, profit taking ngos and pharmaceutical companies should take initiatives in this regard. abbreviations lowand middle-income countries (lmics); international diabetes federation (idf); national eye health education program (nehep); bangladesh demographic and health survey (bdhs); bangladesh institute of research and rehabilitation in diabetes, endocrine and metabolic disorders (birdem); institute of public health (iph). references 1. bhowmik b, binte munir s, ara hossain i, siddiquee t, diep lm, mahmood s, mahtab h, khan ak, hussain a. prevalence of type 2 diabetes and impaired glucose regulation with associated cardiometabolic risk factors and depression in an urbanizing rural community in bangladesh: a population-based cross-sectional study. diabetes metab j. 2012 dec;36(6):42232. doi: 10.4093/dmj.2012.36.6.422. 2. afroz a, alam k, ali l, et al. type 2 diabetes mellitus in bangladesh: a prevalence based cost-of-illness study. bmc health serv res. 2019;19(1):601. published 2019 aug 27. doi:10.1186/s12913-019-4440-3 3. islam jy, zaman mm, bhuiyan mr, haq sa, ahmed s, al-qadir az. prevalence and determinants of hyperglycaemia among adults in bangladesh: results from a population-based national survey. bmj open. 2019;9(7):e029674. published 2019 jul 24. doi:10.1136/bmjopen-2019-029674 4. rawal lb, biswas t, khandker nn, et al. non-communicable disease (ncd) risk factors and diabetes among adults living in slum areas of dhaka, bangladesh. plos one. 2017;12(10):e0184967. published 2017 oct 3. doi:10.1371/journal.pone.0184967 5. mohiuddin ak. diabetes fact: bangladesh perspective. international journal of diabetes research. 2019;2(1):14-20. doi:10.17554/j.issn.2414-2409.2019.02.12. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.416|http://cajgh.pitt.edu 6. salahuddin t. obesity is increasing among the younger generation in bangladesh. the daily star, bangladesh, september 23, 2018 7. star online report. 80 lakh bangladeshis suffering from diabetes: state minister. the daily star, april 06, 2016. 8. asaduzzaman m, chowdhury s, shahed jh, et al. prevalence of type 2 diabetes mellitus among urban bihari communities in dhaka, bangladesh: a cross-sectional study in a minor ethnic group. cureus. 2018;10(1):e2116. published 2018 jan 26. doi:10.7759/cureus.2116 9. islam fm, chakrabarti r, islam mt, wahab m, lamoureux e, finger rp, shaw je. prediabetes, diagnosed and undiagnosed diabetes, their risk factors and association with knowledge of diabetes in rural bangladesh: the bangladesh population-based diabetes and eye study. j diabetes. 2016 mar;8(2):2608. doi: 10.1111/1753-0407.12294. 10. fottrell e, ahmed n, morrison j, et al. community groups or mobile phone messaging to prevent and control type 2 diabetes and intermediate hyperglycaemia in bangladesh (dmagic): a cluster-randomised controlled trial. lancet diabetes endocrinol. 2019;7(3):200–212. doi:10.1016/s22138587(19)30001-4 11. fottrell e, ahmed n, shaha sk, et al. distribution of diabetes, hypertension and noncommunicable disease risk factors among adults in rural bangladesh: a cross-sectional survey. bmj glob health. 2018;3(6):e000787. published 2018 nov 12. doi:10.1136/bmjgh2018-000787 12. hasan mm, tasnim f, tariqujjaman m, ahmed s. socioeconomic inequalities of undiagnosed diabetes in a resource-poor setting: insights from the cross-sectional bangladesh demographic and health survey 2011. int j environ res public health. 2019;16(1):115. published 2019 jan 3. doi:10.3390/ijerph16010115 13. shariful islam sm, lechner a, ferrari u, laxy m, seissler j, brown j, niessen lw, holle r. healthcare use and expenditure for diabetes in bangladesh. bmj glob health. 2017 jan 3;2(1):e000033. doi: 10.1136/bmjgh-2016000033. 14. wisconsin council of the blind & visually impaired. stay on track of your diabetes. wp-content, may 28, 2019. available in: https://wcblind.org/wpcontent/uploads/2019/06/nycu-june-2019pdf.pdf 15. das h, banik s. prevalence of dyslipidemia among the diabetic patients in southern bangladesh: a cross-sectional study. diabetes metab syndr. 2019 jan feb;13(1):252-257. doi: 10.1016/j.dsx.2018.09.006. 16. mohammad qd, habib m, mondal ba, chowdhury rn, hasan mh, hoque ma, rahman km, khan su, chowdhury ah, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mohiuddin this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.416|http://cajgh.pitt.edu haque b. stroke in bangladeshi patients and risk factor. mymensingh med j. 2014 jul;23(3):520-9. 17. mohiuddin ak. the mysterious domination of food contaminants and adulterants in bangladesh. journal of environmental science and public health. 2018;03(01):34-56. doi:10.26502/jesph.96120046. 18. tulpule k, dringen r. formaldehyde in brain: an overlooked player in neurodegeneration? j neurochem. 2013 oct;127(1):7-21. doi: 10.1111/jnc.12356. 19. tan t, zhang y, luo w, lv j, han c, hamlin jnr, luo h, li h, wan y, yang x, song w, tong z. formaldehyde induces diabetesassociated cognitive impairments. faseb j. 2018 jul;32(7):3669-3679. doi: 10.1096/fj.201701239r. 20. hipkiss ar. depression, diabetes and dementia: formaldehyde may be a common causal agent; could carnosine, a pluripotent peptide, be protective?. aging dis. 2017;8(2):128–130. published 2017 apr 1. doi:10.14336/ad.2017.0120 21. ai l, tan t, tang y, et al. endogenous formaldehyde is a memory-related molecule in mice and humans. commun biol. 2019;2:446. published 2019 nov 29. doi:10.1038/s42003019-0694-x 22. mohiuddin ak. chemical contaminants and pollutants in the measurable life of dhaka city. european journal of sustainable development research. 2019;3(2), em0083. https://doi.org/10.29333/ejosdr/5727 23. azad a. how climate change will affect your health. cnn health, october 12, 2018. 24. tribune desk. temperature in bangladesh to raise to deadly heights by end of century. dhaka tribune, bangladesh, august 03, 2017. 25. mohiuddin ak. domination of pollutant residues among food products of south-east asian countries. global journal of nutrition & food science. 2019;2(3):1-4. doi:10.33552/gjnfs.2019.02.000536. 26. paul sk, islam ms, hasibuzzaman mm, hossain f, anjum a, saud za, haque mm, sultana p, haque a, andric kb, rahman a, karim mr, siddique ae, karim y, rahman m, miyataka h, xin l, himeno s, hossain k. higher risk of hyperglycemia with greater susceptibility in females in chronic arsenicexposed individuals in bangladesh. sci total environ. 2019 jun 10;668:1004-1012. doi: 10.1016/j.scitotenv.2019.03.029. 27. chaity aj. 15% pregnant women diagnosed with diabetes. dhakatribune, november 14th, 2017. 28. biswas s. is the world heading for an insulin shortage? bbc news, asia/india, 30 november 2018. 29. beran d, ewen m, laing r. constraints and challenges in access to insulin: a global perspective. the lancet diabetes & http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://doi.org/10.29333/ejosdr/5727 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.416|http://cajgh.pitt.edu endocrinology. 2016;4(3):275-285. doi:10.1016/s2213-8587(15)00521-5. 30. rahman ms, akter s, abe sk, et al. awareness, treatment, and control of diabetes in bangladesh: a nationwide population-based study. plos one. 2015;10(2):e0118365. published 2015 feb 18. doi:10.1371/journal.pone.0118365 31. azad k. type 1 diabetes: the bangladesh perspective. indian journal of endocrinology and metabolism. 2015;19(7):9-11. doi:10.4103/2230-8210.155344. 32. al muktadir mh, islam ma, amin mn, ghosh s, siddiqui sa, debnath d, islam mm, ahmed t, sultana f. nutrition transition pattern iv: leads bangladeshi youth to the increasing prevalence of overweight and obesity. diabetes metab syndr. 2019 may jun;13(3):1943-1947. doi: 10.1016/j.dsx.2019.04.034. 33. goon s, bipasha ms, islam ms. fast food consumption and obesity risk among university students of bangladesh. european journal of preventive medicine. 2014;2(6):99104. doi: 10.11648/j.ejpm.20140206.14 34. the daily star. “access to insulin is a human right”. world diabetes day 2018, november 14, 2018. 35. hasib ni. children getting type 2 diabetes alarmingly in bangladesh. bdnews 24.com, bangladesh, 06 april, 2016. 36. hossain ms, siddiqee mh, ferdous s, faruki m, jahan r, shahik sm, raheem e, okely ad. is childhood overweight/obesity perceived as a health problem by mothers of preschool aged children in bangladesh? a community level cross-sectional study. int j environ res public health. 2019 jan 12;16(2). pii: e202. doi: 10.3390/ijerph16020202. 37. chaity aj. obesity blamed for alarming rise in childhood diabetes. dhaka tribune, bangladesh, november 13, 2017. 38. bipasha ms, goon s. fast food preferences and food habits among students of private universities in bangladesh . south east asia journal of public health . 2014;3(1):61-64. https://doi.org/10.3329/seajph.v3i1.17713 39. hoque me, long kz, niessen lw, al mamun a. rapid shift toward overweight from double burden of underweight and overweight among bangladeshi women: a systematic review and pooled analysis. nutr rev. 2015 jul;73(7):43847. doi: 10.1093/nutrit/nuv003. 40. guthold r, stevens ga, riley lm, bull fc. worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants. lancet glob health. 2018 oct;6(10):e1077-e1086. doi: 10.1016/s2214109x(18)30357-7. 41. mahbub i. why is diabetes on the rise in bangladesh? future startup october 25, 2016. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://doi.org/10.3329/seajph.v3i1.17713 mohiuddin this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.416|http://cajgh.pitt.edu 42. tareq s. obesity is increasing among the younger generation in bangladesh. the daily star, bangladesh, september 23, 2018. 43. vancampfort d, firth j, schuch f, rosenbaum s, de hert m, mugisha j, probst m, stubbs b. physical activity and sedentary behavior in people with bipolar disorder: a systematic review and meta-analysis. j affect disord. 2016 sep 1;201:145-52. doi: 10.1016/j.jad.2016.05.020. 44. who/ country office for bangladesh. double trouble: diabetes and depression. available in: http://www.searo.who.int/bangladesh/depressio ndoubletrouble/en/ 45. mehzabin r, hossain kj, moniruzzaman m, sayeed skjb. association of functional health literacy with glycemic control: a cross sectional study in urban population of bangladesh. journal of medicine. 2019;20(1):19-24. doi:10.3329/jom.v20i1.38816. 46. islam fma, kawasaki r, finger rp. factors associated with participation in a diabetic retinopathy screening program in a rural district in bangladesh. diabetes res clin pract. 2018 oct;144:111-117. doi: 10.1016/j.diabres.2018.08.012. 47. marry before your house is swept away child marriage in bangladesh. human rights documents online. doi:10.1163/2210-7975_hrd-2156-2015030. 48. kamal sm, hassan ch, alam gm, ying y. child marriage in bangladesh: trends and determinants. j biosoc sci. 2015 jan;47(1):120-39. doi: 10.1017/s0021932013000746. 49. hossain mg, mahumud ra, saw a. prevalence of child marriage among bangladeshi women and trend of change over time. j biosoc sci. 2016 aug;48(4):530-8. doi: 10.1017/s0021932015000279. 50. zahangir ms, hasan mm, richardson a, tabassum s. malnutrition and noncommunicable diseases among bangladeshi women: an urban-rural comparison. nutr diabetes. 2017 mar 20;7(3):e250. doi: 10.1038/nutd.2017.2. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.searo.who.int/bangladesh/depressiondoubletrouble/en/ http://www.searo.who.int/bangladesh/depressiondoubletrouble/en/ cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. challenges of ngo-to-state referral in the delivery of hiv prevention programs in ukraine supported by the global fund svetlana mcgill queen margaret university, edinburgh, united kingdom vol. 4, no. 2 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.213 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ mcgill this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu abstract background: ukraine has one of the world’s fastest growing hiv rates and was one of the largest recipients of funding from the global fund to fight aids, tuberculosis and malaria (gf). the objective of this study was to close the gaps in the literature on the delivery of hiv prevention services by ngos and the perceptions of ngo delivered services, using as an example hiv prevention programs in ukraine funded by the gf. methods: the aim of this qualitative study was to determine how ngo-based services were implemented in the context of a stateowned healthcare system of ukraine. an ethnographic study, which included 50 participant interviews, was conducted in three oblasts in ukraine and in the capital, kyiv, between 2011 and 2013. this article presents some of the findings that emerged from the analysis. results: participants reported that ngos were focused more on reporting numbers of rapid tests, and less on motivating clients to continue onto treatment. the role division between ngos and the state in hiv services was largely perceived by participants as unclear and challenging. overall, lack of clarity on the role of government healthcare providers and ngos in providing hiv services compromised the process of finding, referring, and retaining hiv patients in care. conclusions: gaps in linking hiv patients to the hiv care continuum have been identified as a potentially problematic issue in delivery of hiv prevention services by gf funded ngos. with an anticipated gf exit from ukraine, the lack of clearly defined ngo-to-state referrals of hiv patients complicates the transition of ngo run services into state funding. further steps to improve referral systems are necessary to ensure a smooth transition and enable ukraine to fight its hiv epidemic effectively. keywords: hiv care continuum, global fund, linkage to care, ngos challenges of ngo-to-state referral in the delivery of hiv prevention programs in ukraine supported by the global fund svetlana mcgill queen margaret university, edinburgh, united kingdom research since 2008, hiv rates have steadily increased in eastern europe and central asia.1 russia and ukraine account for over 90% of diagnosed hiv cases; however, ukraine has the most severe increase among the eastern european and central asian countries, with an estimated 440,000 cases of people living with hiv2 and an estimated hiv prevalence of 1.63% at the end of 2007.3 as of february 11, 2014, there were 247,101 registered cases of hiv infection, over 66,607 registered cases of aids, and 32,283 aids deaths.4 recent political turmoil has led to claims that the ukraine's aids program is "breaking down" and international organizations are concerned that hiv rates are beginning to rise for the first time since 2002.5 ukraine has been among the top ten recipient countries of the global fund (gf) to fight aids, tuberculosis, and malaria. in 2003, ukraine received a gf round 1 (r1) hiv grant of 95 million usd. the principal recipients were the ministry of health (moh), united nations development programme, and the ukrainian fund against hiv/aids. utilization of the grant funds quickly stalled primarily due to inefficient http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu governance and slow program implementation.6 as a result, in 2004, gf suspended the funding to all recipients and transferred the r1 grant to an international nongovernmental organization, international hiv/aids alliance, based in the united kingdom. in 2012, a grant was awarded to two ngo principal recipients. an anticipated outcome of the gf decision to transfer funding to an international nongovernmental organization was the creation of robust and effective delivery of hiv services. with the moh as an original implementer, the services were perceived to be delivered by state healthcare, the backbone of which was the network of specialized regional aids clinics. ukraine’s healthcare is often viewed as a "hybrid semashko” system7 because many elements of the previous soviet healthcare system are still present. a network of aids clinics, known as aids centers, represents one such element. after control of gf funds was transferred to an international nongovernmental organization, the perceived division of roles between state healthcare and ngos ceased to exist, bringing implementation challenges to ukraine’s original gf program, which was geared to state healthcare. hiv care continuum and perceived ngo delivery roles in ukraine for individuals with hiv infection to fully benefit from antiretroviral therapy, they need to know that they are hiv infected, be engaged in regular hiv care, and receive and adhere to effective antiretroviral therapy.8 ‘the hiv care continuum’ -also known as ‘the hiv treatment cascade’ -is a model used to describe the delivery of hiv services to people living with hiv across the entire continuum of care. figure 1. a model of hiv treatment cascade (gardner et al.2011) in ukraine, a distinction is made between “testing to identify hiv” typically done through rapid hiv tests at a variety of settings – and “making an hiv diagnosis” (or confirmatory test) – that includes other assessments/testing and can be performed only at healthcare facilities.9 importantly, administration of antiretroviral therapy and other free hiv continuum healthcare services associated with an hiv positive test begin when a patient presents with a positive hiv result obtained from confirmatory testing for antibodies to hiv and antigen р24 hiv-1.10 the patient is then put on a dispensary list, which requires registration and submission of individual passport data to the aids center. thus, confirmatory hiv testing is important to link the patient to ukraine’s hiv healthcare continuum. ukraine implements the combined voluntary counseling and testing model, administered through an extensive, tiered hiv laboratory system in state-funded hospitals, sexually-transmitted disease (std) clinics, narcological and tuberculosis dispensaries, family planning, and antenatal clinics.11 virologic and immunologic testing is performed at over 27 regional aids center laboratories, as well as at a central hiv reference laboratory. some 761 state-funded dovira (trust) centers, located in residential areas in all oblasts (or states) in ukraine,12 conduct express testing and counseling. rapid tests are also administered by hiv-service ngos.11 an evaluation of the gf implementers in ukraine by australian aids projects management group underlined that “successful referral from testing to treatment is key to controlling the epidemic,” but noted that “the division between the sectors and lack of government resources means that many people who test positive do not get treatment” and that the linkages between relevant ngos and government services were “highly variable.”13 eight years after the gf began supporting ngo provision of hiv services, a usaid funded publication found that a “licensing and accreditation system has not actually been developed or implemented.”14 lack of a legal framework carried the risk that many ngo-based health services would have to http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcgill this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu be provided ad hoc and, as such, might not be recognised by the state. while the hiv care continuum model appears to be well-established in many countries across the world, research into practices bringing people living with hiv into the healthcare continuum is insufficient in ukraine. the objective of this study was to close the gaps in the literature on the delivery of hiv prevention services by ngos and the perceptions of ngo delivered services, using as an example hiv prevention programs in ukraine funded by the gf. methods consistent with a significant body of research of aid programs in post-communist countries,15-19 an ethnographic study design was chosen as the most appropriate research approach in this setting. data collection primary data were collected between 2011 and 2013 through 50 in-depth, open-ended, face-to-face interviews with purposively selected participants with experience in gf programs, based in kyiv, and in three oblasts of ukraine. an interview guide was developed for use in conducting the interviews. the interview guide structured inquiry into the following open-ended questions: 1. principal recipient ngos roles and relations with other healthcare actors in gf programs; 2. linkage of hiv services provided by gf funded ngos with state healthcare; and 3. focus on gf funded hiv prevention services. in addition, literature and documents were searched about hiv services provided by ngos using pubmed and google scholar. conceptualizations from the literature were synthesized with the findings that emerged from the interview data analysis. secondary data analysis included review of gf program documents such as principal recipient annual reports, minutes of country coordinating mechanism (ccm) and stakeholder meetings, pr and government press releases, documents on the web-sites of the gf, state service of ukraine for aids and other infectious diseases, the ukrainian center for disease control, and two principal recipients. respondents’ sampling criteria and setting a key criterion for inclusion into this research was the respondent’s experience of engagement with gf program implementation. following a review by the queen margaret university ethics research panel, ethical approval was obtained in order to conduct the interviews. respondents were primarily national and regional government stakeholders, ngo service providers, and state healthcare service providers, purposively selected to have an experience of previous or current engagement with the global fund to fight aids, tuberculosis and malaria program implementation. at the oblast level, key informant interviews were conducted with local government and health officials and staff of gf sub-recipient ngos. the respondents were also categorised into three geographical levels according to their location: sub-national (region), national, and international. the choice of oblasts was meant to reflect on the regional balance of ukraine, diffusion of its hiv epidemic, and the perceived depth of penetration by the the global fund to fight aids, tuberculosis and malaria programs. figure 2 represents the locations of the sampling points. figure 2. location of the sampling points twenty-seven interviews were conducted in oblasts, and 23 interviews were conducted with national and international stakeholders. respondent’s sector identification was determined through self-assessment http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu (figure 3). the majority of the participants (72%) had five or more years of experience with gf programs, and only 8% of participants had less than 2 years of experience. figure 3. self-identification of participants data analysis the interviews were transcribed verbatim, then coded and analyzed using thematic content analysis. the steps included matrix-based categorization of data from the interviews and theoretical coding in which open codes and categories were compared to generate an analytic schema to interpret the findings. in line with an ethnographic inquiry paradigm, the analysis attempted to capture as many accounts as possible within the chosen thematic categories, yielding broad accounts of various aspects of gf implementation. following social science practices of data representation,20 verbatim quotations from participant interviews are used widely in this paper as evidence for the author’s interpretations, and for illustration purposes. quotations are presented using the numbers rather than sector or regional identities in order to protect participants’ anonymity. results the sections below outline the results that emerged from the analysis based on the interview data collected from 50 respondents. (1) linkage of hiv services with state healthcare following features characterized hiv services provided by ngos: (1a) a ‘broken link’ in the chain of hiv services participants reported that ngos were focused more on reporting numbers of rapid tests, and less on motivating clients to continue onto treatment (to illustrate, participant verbatim quotations are provided in appendix 1). (1b) inconsistent referral practices among participants overall, there was no uniform view of what constituted a successful referral. while some participants understood a successful referral as linking a patient to an official registration, others believed that only the retention of a patient in care constituted a full referral (see section 1b in appendix 1). as to the reasons for inconsistent referral, respondents noted the following: (1) the absence of referral protocols, (2) ineffective client management, and (3) lack of patients. some respondents doubted the existence of referrals and suggested there were no client referral services in ukraine at all. (1c) use of coupons to regulate referral respondents identified the following problems about the coupon system: scarcity of coupons, number of coupons limited per day, and overburdened staff at aids clinics (see section 1c of appendix 1). (2) gaps in gf funded hiv prevention services a lack of focus on a confirmatory hiv testing was demonstrated by primary data analysis. study participants reported that gf funded activities appeared to be more concentrated on the early ‘field stage’ of finding a client and providing a rapid test, rather than on follow-up to care. participants reported that the focus on rapid tests conducted by ngos led to services not being seen as part of state healthcare, nor being counted in state statistics (see section 2b in appendix 1). (3) role division between ngos and state and sustainability in gf programs the role division between ngos and state in hiv services was largely perceived by participants as unclear and challenging, and it affected the division of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcgill this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu labor between them as actors in service delivery. the ngos’ role as gf implementers was also described as contradictory. unclear role division between gf funded ngos and state could be a reflection of different views between gf and state on hiv prevention (see section 3 in appendix 1). appendix 1. participants’ view on ngo-to-state linkage practices in gf-funded programs discussion this study is one of the first qualitative studies examining the delivery of ngo hiv services in gf funded programs in ukraine. the study results suggest disconnect in the delivery of hiv services by gf funded ngos, and identified gaps in linking hiv patients to the hiv care continuum. literature suggests that the linkage between gf funded services and state healthcare in ukraine should be comprised of providing services to vulnerable communities and to link clients to needed services.21 when ngo referral practices to aids centers were reviewed, there was no follow-up conducted to ensure that the client engaged with the state services, indicating that hiv positive clients may be lost to follow-up.22 in addition, several publications noted a lack of consistent referral practices between ngos and government services.13,23 these studies analyzed hiv services provided to the people who inject drugs, concluding that client referrals were “inconsistently applied and frequently consisted of informal sign posting rather than formalised referral across government and ngo providers.”13 these findings are consistent with the data collected from the interviews. participants reported that the ngos spent little effort on ensuring clients continued treatment, developing consistent referral protocols, and effectively transitioning clients from one stage of hiv care to the next. an analysis of published pr documents demonstrated that in round 6 (r6), in response to concerns about the referral process, the principal recipients established a system of referring people who tested hiv positive using rapid tests by ngos by providing them with talony -appointment coupons to undergo confirmatory testing with an aids clinic. this procedure was also mentioned by varban et al.11 interview respondents attested to a scarcity of coupons and daily limits on coupons, which may indicate a need to ration access to confimatory testing due to the number of rapid hiv tests conducted by ngos generating more potential hiv carriers than the state sector’s screening capacity was prepared to handle. confirmatory hiv testing, and not rapid hiv screening, is deemed important for the purpose of linking patients with appropriate care canters in ukraine. recent publications have identified three major gaps associated with rapid hiv screening: (1) failure of clients from high-risk groups to be identified at an early, rapid hiv screening stage “to return to the aids center to receive their confirmatory test results;”13 (2) sub-recipients “not providing incentives to clients to pick up the results of the tests” from the aids center;13 (3) legal constraints – by ukrainian law, hiv screening by rapid tests can only be executed by the medical staff of state institutions, who also have the exclusive right to communicate test results to the patients.11 similarly, judice et al.14 noted regulatory gaps remaining in ngo run mobile units, also funded by the gf, such as the requirement to sub-contract a doctor to inform the patient of the hiv screening results, and the inability of ngos to provide clients with official certification – spravka – of the test results. in addition, the delivery of hiv prevention services between governmental and non-governmental service providers appear to remain poorly coordinated, which presents “a risk to the sustainability of prevention programs currently supported by the global fund grants and the viability of overall national prevention efforts.”24 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu participant responses and analyzes of published data both suggest that gf funded hiv programs only partially fulfilled the objective of improving the national aids prevention, treatment and support program. while gf funded hiv services appeared to be more focused on outreach, field-based (polevye) activities, such as distribution of commodities (syringes, condoms, or information brochures) and on preliminary, rapid hiv screening, linkage to the next stages of hiv care continuum appeared weak, with no traceable follow-up for a confirmatory screening with state aids clinics, or entry and registration into antiretroviral therapy and other treatment. ngo referral systems varied among different ngos and were mostly ad hoc with no referral protocol or coordination to track entities that provided services to clients. lack of effective referrals meant that fewer patients could enter the hiv care continuum or receive antiretroviral therapy. the lack of clearly defined referral standards to facilitate referral of hiv patients from ngo services into the state care may impair ukraine’s ability to fight its hiv epidemic effectively. there is an urgent need to balance the numbers of hiv positive individuals identified by ngos with the ability of aids centers to provide hiv care that requires better defined referral standards, effective strategy of ngo-to-state referral, and an increased ownership of oblasts over local re-programming of gf funding. with an anticipated gf exit from ukraine in 2017, ngo run hiv services would need to transit into state funding. further steps to improve referral systems are necessary in order to enable ukraine to assume full ownership of its health programs and to manage its hiv epidemic effectively. results of this study question some of the existing views of civil society organizations as central in providing hiv services in conditions of insufficient, scattered, or even non-existent state healthcare settings that is typical in many regions where hiv is highly prevalent. role division between state healthcare providers and ngos in provision of hiv health services resulted in an accountability gap.25 while the ngos received large funding from gf, they were not legally obligated to bring clients into care, while government providers had an obligation to provide care but did not have the funding, as reported by participants. as a result, the capacity of ukraine’s post-semashko healthcare to provide treatment for hiv patients appeared compromised by unclear boundaries between ngo run prevention services and state aids clinics, resulting in gaps in the process of finding, referring, and retaining hiv patients in care. study strengths and limitations while this is one of the first studies conducted to evaluate hiv gf programs in ukraine, it should be noted that this ethnographic study is limited in scope and does not evaluate the impact of such programs on the national level. the sample size and location of data collection points, while in line with qualitative research standards, may not be sufficient to generate generalized conclusions on the impact of gf programs to the whole country. this study has important implications for future research in this area, as it raises a number of problems and gaps in existing publications that may fuel further interest in researching gf programs in ukraine. the analysis and the discussion presented in this paper are based on the research that was completed prior to later changes in the gf grant systems in 2012 and before the 2014 economic and political crisis in ukraine occurred. the major strengths of this study include analyzing a very important under-investigated problem in ukraine and conducting interviews in multiple locations, thus improving generalizability of research findings. references 1. unaids. unaids world aids day report. geneva: unaids;2011. 2. kruglov yv, kobyshcha yv, salyuk t, varetska o, shakarishvili a, saldanha vp. the most severe hiv epidemic in europe: ukraine's national hiv prevalence estimates for 2007. sex transm infect. 2008;84 suppl 1:i37-i41. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcgill this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu 3. unaids. second independent evaluation 2002-2008. country visit to ukraine. summary report. 2008; http://data.unaids.org/pub/basedocument/2009/20090417_sie _countrysummaryreport_ukraine_en.pdf. accessed november 20, 2012. 4. ucdc. ukrainian center for socially dangerous disease control of the ministry of health of ukraine. operatyvna informaciya. in ukrainian. 2014; http://ucdc.gov.ua/attachments/article/972/%d0%a1%d1%96 %d1%87%d0%b5%d0%bd%d1%8c%202014.pdf. accessed april 30, 2015. 5. martin n. war-torn ukraine facing aids care 'disaster' sky news. february 6, 2015. 6. oig. the office of the inspector general. review of the suspension/termination processes for global fund grants. the global fund;2008. audit report no: tgf-oig-08-003 7. lekhan v. rv, richardson e. ukraine: health system review. health systems in transition. geneva: who;2010. 8. gardner em, mclees mp, steiner jf, del rio c, burman wj. the spectrum of engagement in hiv care and its relevance to test-and-treat strategies for prevention of hiv infection. clin infect dis. 2011;52(6):793-800. 9. who. providing integrated services at healthcare facilities for people who use drugs in ukraine. guidelines. 2012; http://www.euro.who.int/__data/assets/pdf_file/0005/167315/ e96608-update.pdf. 10. the complex plan of scaling up population access to hiv prevention, diagnostics, treatment and care in q2-q4 of 2012, and q1 of 2013. kyiv: the ministry of health of ukraine;2012. 11. varban m, grishaeva, i., zhitkova, y., parkhomenko, zh.,sidorenko, o. counselling and testing for hiv using quick tests in prevention projects for groups of high risk to hiv. in russian. kyiv: international hiv/aids alliance in ukraine;2012. 12. perehinets i. hiv testing and counselling services in ukraine: what else should be done? . paper presented at: who 'hiv in europe' conference2012; copenhagen. 13. apmg. from beyond boutique to epidemic control evaluation report of hiv prevention activities by international hiv/aids alliance ukraine funded by the global fund to fight aids, tb and malaria. aids projects management group. 2009; http://www.aidsprojects.com/wpcontent/uploads/2011/05/apmg-eval-ukr-alliance-finalreport.pdf. accessed september 20, 2012. 14. judice n, zaglada, o., mbuya-brown, r. hiv policy assessment: ukraine. washington, dc: futures group, health policy project;2011. 15. atlani-duault l. humanitarian aid in post-soviet countries: an anthropological perspective. new york: routledge; 2007. 16. hrycak a. from global to local feminisms: transnationalism, foreign aid and the women's movement in ukraine. sustainable feminisms. advances in gender research 2007;11:75-93. 17. kichorowska-kebalo m. personal narratives of women's leadership and community activism. ann arbor, mi: proquest llc, the city university of new york; 2011. 18. owczarzak j. defining hiv risk and determining responsibility in postsocialist poland. medical anthropology quarterly. 2009;23(4):417-435. 19. wedel j. collision and collusion: the strange case of western aid to eastern europe. new york: palgrave;2001. 20. corden a, sainsbury, r. using verbatim quotations in reporting qualitative social research: researchers’ views – spru. 2006; https://www.york.ac.uk/inst/spru/pubs/pdf/verbquotresearch.p df. accessed june 18, 2015. 21. semigina t. tracking global hiv/aids initiatives and their impact on the health system in ukraine final report. kyiv: global hiv/aids initiatives network;2009. 22. who. systematic screening for active tuberculosis principles and recommendations. 2013; http://apps.who.int/iris/bitstream/10665/84971/1/9789241548 601_eng.pdf?ua=1. accessed december 12, 2014. 23. spicer n, bogdan, d., brugha, r., harmer, a., murzalieva, g. and semigina, t. 'it's risky to walk in the city with syringes': understanding access to hiv/aids services for injecting drug users in the former soviet union countries of ukraine and kyrgyzstan. globalisation and health. 2011;7:22. 24. unaids. comprehensive external evaluation of the national aids response in ukraine: consolidated report (english original, january 2009). geneva: unaids;2009. 25. mcgill s. ngo hybridisation as an outcome of hiv services delivery in global fund-supported programmes in ukraine. voluntas: international journal of voluntary and nonprofit organizations. june 2015. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://data.unaids.org/pub/basedocument/2009/20090417_sie_countrysummaryreport_ukraine_en.pdf http://data.unaids.org/pub/basedocument/2009/20090417_sie_countrysummaryreport_ukraine_en.pdf http://ucdc.gov.ua/attachments/article/972/%d0%a1%d1%96%d1%87%d0%b5%d0%bd%d1%8c%202014.pdf http://ucdc.gov.ua/attachments/article/972/%d0%a1%d1%96%d1%87%d0%b5%d0%bd%d1%8c%202014.pdf http://www.euro.who.int/__data/assets/pdf_file/0005/167315/e96608-update.pdf http://www.euro.who.int/__data/assets/pdf_file/0005/167315/e96608-update.pdf http://www.aidsprojects.com/wp-content/uploads/2011/05/apmg-eval-ukr-alliance-final-report.pdf http://www.aidsprojects.com/wp-content/uploads/2011/05/apmg-eval-ukr-alliance-final-report.pdf http://www.aidsprojects.com/wp-content/uploads/2011/05/apmg-eval-ukr-alliance-final-report.pdf https://www.york.ac.uk/inst/spru/pubs/pdf/verbquotresearch.pdf https://www.york.ac.uk/inst/spru/pubs/pdf/verbquotresearch.pdf http://apps.who.int/iris/bitstream/10665/84971/1/9789241548601_eng.pdf?ua=1 http://apps.who.int/iris/bitstream/10665/84971/1/9789241548601_eng.pdf?ua=1 mcgill this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.207|http://cajgh.pitt.edu table 1. a model of hiv treatment cascade8 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcgill this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu figure 2. location of the sampling points (mapinfo 7.0) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu figure 3. self-identification of participants* *note. country coordinating mechanism (ccm) membership was reported in addition to the main respondent category. therefore, the total number of respondents is above 50. 16 2 7 14 5 6 21 0 5 10 15 20 25 state medical sector state non-medical sector national ngo regional ngo international organisation independent expert government/ccm/regionccm number of respondents in each category http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcgill this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu appendix 1. participants’ views on ngo-to-state linkage practices in gf-funded programs emerging themes participant characterizations verbatim illustrative quotes (1): linkage of hiv services with state healthcare (1a) a ‘broken link’ in the chain of hiv services (1b) referral practices: inconsistent successful referral means: linking a patient to official registration: only when patient is retained in care ngos report numbers… but how to get people to start going to... get tested, how to stop them from being afraid of testing, and how to help those people who are found to have hiv become less afraid of getting treatment (009: 92-94) “[during] referral to confirmatory tests, coverage sharply falls.” (040: 299) there is a need to work continuously with a person who has received a positive result until he or she gets registered (028: 223). here they found a drug user, took him to [get] methadone…there they provided him with information and counselling. but the final goal is not just finding a person, or even bringing him for treatment. it is retaining him there (020: 441443). you not only need to count services…you need to take the patient to the logical end. (019: 100) reasons for inconsistent referrals: absence of referral protocols “there are many ngos around the aids center, but no referral protocol” (013: 329-330); http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu ineffective client management lack of patients “there is no client base. clients may enter programme several times” (019: 571-586); “client management is not well developed, there is lots of subjectivity” (018: 125-127); “in 2012, the government and the gf doubled the number of patients – to have twice as much more patients on antiretroviral therapy... but suddenly they realised that they could not find the people. first, there were not enough drugs, now there were enough drugs, but they could not get the people”. (050: 35-40) client referral did not happen ‘no client referral services in ukraine at all’ (012: 377), (014:24). (1c) practices of using coupons to regulate referral the coupon appointment system overburdened the aids center staff “the coupons were “scarce, hard to get” (019: 344-345) “the number of coupons was limited per day” (032: 342-343). our oblast aids center is suffocating. our ngo takes 7 out of 20 coupons that are for an aids center visit. the remaining 13 coupons go to other ngos. it means that an aids center can only receive 20 people per day, which means 100 people per week. they are suffocating... staffing is a problem (019:286-288). (2) gaps in gf-funded hiv prevention services 2(a) services concentrated more on early ‘field’ stage of finding a client, less on linking him or her to care: “the lion’s share of the money is being spent on finding clients… when instead, it should be spent on retaining [them] in healthcare…they [ngos] are fixated on field work… they spend so much money in the field… but their work ends there. clients do not reach the treatment stage” (020: http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcgill this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu 2(b)‘rapid hiv tests by ngos are neither viewed as part of state healthcare, nor counted in state statistics 443-446). “a quick test is not confirmatory…people need to go to an aids centre to have the second test.” (028: 216-217) “the moh does not report quick screening by ngos. it only reports on the tests they have done.” (029: 232-233) “you can pass a quick test a million times, but you are nobody for the [health] system. you only become a patient after a confirmatory screening” (040: 299-300). (3) role division between ngo and state services unclear, challenging contradictory based on different views between gf and state on hiv prevention: there is no clear division of roles…what is state doing? what are ngos doing?... we need to define this division clearly... and then we won’t interfere in their work and they won’t interfere in ours (020: 352-358). we do not want to take over the roles that the state should fulfil treatment, or prevention... we cannot substitute the state. (036: 158-180) there is a discrepancy in that the government is responsible for prevention, but implementation rests with ngos... there is a contradiction here... (049: 60-66). there is a big contradiction that large funds are concentrated with ngo but government is responsible for healthcare. the risk is that money will not be spent for the purpose it needs to be spent, because gf priorities in funding [hiv] prevention may not coincide with state policy or even run counter to it. (025: 267-270) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.213|http://cajgh.pitt.edu ngo services are unsustainable the state is used to ngos doing prevention. but if [gf] funding stops, the state is not ready to support this work. it is only loyal to ngos because they receive grants. if the state has to fund this, it will not. it has other priorities. (036: 204-231) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. external quality assessment of sputum smear microscopy in tuberculosis laboratories in sughd, tajikistan eva chang1, fabio luelmo2, zamira baydulloeva3, marija joncevska4, guljamol kasymova5, oktam bobokhojaev5, tom mohr6 1harvard medical school, boston, ma, usa; 2tb control programmes, geneva, switzerland; 3quality health care project tajikistan; 4project hope; 5republican centre of population protection from tuberculosis tajikistan; 6quality health care project kazakhstan vol. 4, no. 2 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.230 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ chang this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu abstract introduction: tajikistan has a laboratory network with three levels of tuberculosis (tb) laboratories. the external quality assessment (eqa) of sputum smear microscopy was implemented in 2007. the objective of this study was to evaluate the eqa system and identify potential performance improvement strategies in tb microscopic laboratories in sughd, tajikistan. methods: this is a cross-sectional study based on retrospective record review and secondary data analyses on acid-fast bacilli (afb) microscopy data and eqa reading results collected between the first quarter of 2011 and the fourth quarter of 2013. descriptive analyses were conducted to examine the overview of microscopy laboratories activities, eqa results, and laboratory performance. result: of the 123,874 smears examined between 2011 and 2013, 11,522 (9.30%) were re-checked by the eqa system. the population tb screening rate rose from 0.46% in 2011 to 0.57% in 2013, and the case positivity rate decreased from 6.98% to 4.80%. the regional eqa results showed a reduction in high false-positive, high false-negative, and low false-negative errors. false-positive errors had decreased from 0.13% in 2011 to 0.07% in 2013, and false-negative errors from 0.91% in 2011 to 0.15% in 2013. regional sensitivity of smear microscopy, when compared to re-checking controller, increased from 88.2% in 2011 to 97.2% in 2013. the regional specificity level remained relatively stable at above 99%. conclusion: our study found that a decreasing trend of case positivity rate from 2011 to 2013 in sughd, though the overall laboratory workload was on the rise. in addition, eqa results showed an overall error reduction and an improved sensitivity of smear microscopy in the region. the overview of microscopic laboratory activities and the actual evaluation of the eqa system on sputum smear microscopy complement each other in providing a better picture on the progress of tb laboratory strengthening. we recommend similar approaches to be adapted by future evaluations on tb microscopic laboratories, particularly among countries of high burden. interactive training and feedback loops are crucial to improving tb surveillance in tajikistan. keywords: external quality assessment, tuberculosis, sputum smeal microscopy, tajikistan external quality assessment of sputum smear microscopy in tuberculosis laboratories in sughd, tajikistan eva chang1, fabio luelmo2, zamira baydulloeva3, marija joncevska4, guljamol kasymova5, oktam bobokhojaev5, tom mohr6 1harvard medical school, boston, ma, usa; 2tb control programmes, geneva, switzerland; 3quality health care project tajikistan; 4project hope; 5republican centre of population protection from tuberculosis tajikistan; 6quality health care project kazakhstan research tuberculosis (tb), an air-borne disease caused by mycobacterium tuberculosis, is the second leading cause of death from an infectious agent in the world.1 in 2013, there was an estimated nine million new tb cases globally, and the burden of the disease has hit the low http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu and middle-income countries most heavily.1 early and accurate tb detection is crucial to effective tb control and care.2 despite the substantial advancement in tb diagnostic and monitoring tools in the past two decades, sputum smear microscopy remains the most common and economical method in the most affected countries.1,2 classical smear microscopy, an antiquated test of 130 years, directly identifies acid-fast bacilli (afb) in ziehl-neelsen (zn) stained sputum under a light microscope.3 simple and inexpensive to adopt, microscopy of sputum smears is particularly suitable for peripheral laboratories based at primary health clinics or district hospitals to quickly detect infectious pulmonary tb cases.3 patients suspected of having pulmonary tb are recommended to have at least two sputum specimens for microscopic examination.4 as a result, strengthening laboratory capacity and network to promote good-quality microscopy-based case detection and management has been gaining high priority in the global tb agenda.5 the need to establish comprehensive laboratory external quality assessment (eqa) programs under the national tb programs (ntp) in order to evaluate laboratory performance on afb microscopy were fully recognized by the global health community. the international union against tuberculosis and lung disease (iuatld) published the guidebook of eqa for afb microscopy in 2002.3 yet, little research on the evaluation of eqa systems in tb microscopic laboratories has been conducted in resource-limited countries.5 tajikistan is a landlocked central asian country that used to be a member of the former soviet union. the collapse of the soviet union and a half-decade civil war (1992-1998) shortly after the independence of the country heavily damaged both its economy and health infrastructure,6,7 giving rise to a re-emergence of a tb epidemic that peaked around 2001.8 in a population of 8.2 million people, tajikistan had an estimated prevalence of 12,000 tb cases in 2013.8 the country is also one of the 27 high burden countries of multiple drugresistant tb (mdr-tb); 1 approximately 13% of new patients and 56% of the retreatment tb patients were reportedly mdr-tb cases.8 tajikistan has a wellorganized government laboratory network since its formative years (refer to supplement figure s1).5 three levels of tb laboratories operate under the umbrella of the republican tb center (rtbc) at the central level.5 provincial tb centers form the intermediate level of the laboratory network in the three administrative “oblasts” of the republic: sughd, khalton, and gorno-badakhsan autonomous oblast (gbao).5 districts of republican subordination, a fourth oblast in tajikistan is centrally managed by the rtbc. the microscopic laboratories are on the peripheral level at the city/district tb dispensaries and primary healthcare clinics. the sughd oblast (sughd) is located in the northwest of tajikistan with a population of 2.2 million people in 2012.9 sughd has the largest network of tb laboratories in the country with one oblast-level and 22 peripheral laboratories. the oblast first launched the eqa system for afb microscopy in march 2004 with a grant awarded by the global fund. although outputs of the eqa strengthening work had been consistently monitored and evaluated in funded projects, no operational research was conducted to investigate the actual performance of the eqa system. our study aimed to evaluate the eqa system and identify potential performance improvements strategies in tb microscopic laboratories in sughd, tajikistan. methods description of eqa strategy in tajikistan, the government tb laboratories follow the who guidelines and grading system of microscopic diagnosis for all afb smear microscopy readings (refer to supplement table s1 and table s2).10 as of 2014, directly observed treatment short course (dots) program operates in all 84 microscopic laboratories in tajikistan. appropriate quality control procedures are in place in all three levels of tb laboratory service. the staff had been trained in conventional and advanced methods of tb diagnosis and http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx chang this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu had successfully completed two rounds of eqa provided by project hope. currently, the rtbc is responsible for coordinating the afb microscopy network. quality assurance of smear microscopy services has been implemented with donor assistance since 2007. the collected eqa results are analyzed annually and reported to the ntp management where corrective measures for quality improvement are planned. figure 1 shows the algorithm of smear evaluation and blinded re-checking of eqa system in the tb microscopic laboratories in sughd. tajikistan adopted the lot quality assurance system (lqas) for its slide sampling strategy with a pre-specified relative sensitivity of 80% and zero acceptance number of errors. figure 1: algorithm of stepwise rechecking of the eqa system in sughd10 each year, the national coordinator at rtbc calculates the needed sampling size for each laboratory based on reported slide positivity rate from the previous year. oblast and peripheral laboratory staff are notified of the needed number of slides to be submitted for blinded re-checking for each laboratory. peripheral laboratory staff are responsible of the initial slide preparation, proper slide storage, and physical delivery of all collected slides to the oblast laboratory coordinator during the quarterly re-training sessions. in sughd, the oblast laboratory coordinator then conducts blinded, random sampling of the afb smears. the selected afb smears are blindedly re-examined by the first re-checker at the oblast laboratory using the same technique and number of fields as used in the peripheral laboratories. slides yielding discrepant results between the peripheral and oblast laboratories are blindedly re-read by a different re-checker at the oblast laboratory or at rtbc, if necessary. the implementation of blinded re-checking is monitored closely by the national coordinator. the final reading result is reached by the two agreed readings out of the three blinded readings. eqa reading results are forwarded to the national coordinator for data compilation, entry into the eqa database, and reporting. the national coordinator conducts quarterly oblast visits to provide feedback to the oblast and peripheral laboratories as well as the original technicians. table 1 lists the classification of reading errors as defined by the eqa system.3 table1: classification of errors3 study design we conducted a cross-sectional study on the eqa system of afb smear microscopy among the government tb laboratories in sughd, tajikistan based on retrospective record review and secondary data analyses. due to resource constraints, the evaluation was not expanded to the national scale. this study did not require ethics review as no human subjects were involved. quarterly afb smear microscopy data and the corresponding eqa reading results, collected from the 26 tb laboratories in sughd (two were in operation for shorter than one year), between the first quarter of 2011 and the fourth quarter of 2013 were extracted from the nrl microscopic laboratory and afb smear microscopy eqa databases. database entries were verified against the paper-based eqa reports submitted by the laboratories. entries missing source documentation were excluded from the analyses. the population served by each laboratory was estimated by the residential population of each corresponding district/municipality as reported by the agency of statistics under president of the republic of tajikistan.9 for districts/municipalities that had more than one peripheral laboratory, annual service population was estimated by dividing the total district/municipal population by the number of active laboratories in each specific year period. data analyses http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu descriptive analyses, including t-based confidence interval computation, were performed to examine the overview of microscopic laboratories activities in sughd in terms of case positivity rate and laboratory workload. both regional and laboratoryspecific measures were calculated. the oblast laboratory (no. 1), due to its distinctive role in the eqa system, and the two peripheral laboratories (no. 24 and 25) that operated shorter than one year, due to their lack of yearly trend, were excluded from the laboratory-specific analyses. nonetheless, we included data from all these laboratories in the regional-level analyses. the results of the eqa blinded re-checking system were evaluated based on the proportion of high false-positive (hfp), high false-negative (hfn), low false-positive (lfp), low false-negative (lfn), and quantification errors. sensitivity and specificity were calculated, along with respective t-based confidence intervals, to demonstrate the afb smear reading performance of the peripheral laboratories relative to the final eqa re-checking (controller) results. data were analyzed using microsoft excel (microsoft office excel xp) and stata 12 software (statacorp lp, college station, tx). results out of the 264 expected quarterly eqa reports, 11 were missing from nine peripheral laboratories. these 11 missing reports could possibly be archived in other district files by error. due to the lack of source documentation and verification failure, their associated quarterly data were excluded from our analyses. from the first quarter of 2011 to the fourth quarter of 2013, tb microscopic laboratories in sughd examined a total of 123,874 smears, among which, 11,522 (9.30%) were rechecked by the eqa system. the proportion of the population screened had increased from 0.46% in 2011 to 0.57% in 2013. table 2 gives an overview of the regional and laboratory-specific activities during the study period. while the population in sughd was steadily on the rise, its case positivity rate had gradually decreased from 6.98% (95% ci: 6.50-7.49%) in 2011 to 4.80% (95% ci: 4.44-5.17%) in 2013, possibly signifying the reduced incidence or prevalence of tb as reflected in who global reports. nonetheless, the overall laboratory workload, reflected by the number of smears examined, grew by 19.5%. on the laboratory level, no. 2, 16 and 23 showed the highest case positivity rates in sughd while no. 10, 8 and 5 had the heaviest workloads. table 2: overview of annual service population, case positivity rate, total number of smears and total number of slide rechecking from 2011 to 2013 among tb microscopic laboratories in sughd, by laboratory annual eqa rechecking results, as shown in table 3, reported regional reduction in hfp, hfn and lfn errors. the lowest number of errors was achieved in 2012. overall, the percentage of fp errors had decreased from 0.13 in 2011 to 0.07 in 2013, though zero fp error was achieved in 2012. the region also saw a reduction of fn errors from 0.91% in 2011 to 0.15% in 2013. on the individual laboratory level, only ten laboratories (45.5%) achieved the nrl’s zero-error standard in 2011. this measure was improved with eighteen laboratories (81.8%) in 2012 and sixteen laboratories (72.7%) in 2013 achieving zero-error. no.18 had the highest number of errors in 2013 (one hfn, two lfp and one qe). only no. 3 and 7 displayed small rising trends of errors (from zero to one and from zero to two, respectively). no. 11, 10, 13 and 20 showed the most improvement in error elimination. table 3: annual eqa rechecking results by laboratory the performance of tb smear microscopy in sughd is shown in table 4. based on the eqa rechecking http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx chang this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu results, we reported an increased regional sensitivity from 88.2% (95% ci: 83.4-92.0%) in 2011 to 97.2% (95% ci: 94.3-98.9%) in 2013 (highest at 97.4% (95% ci: 94.7-98.9%) in 2012). the regional specificity level remained relatively stable: 99.9% (95% ci: 99.6-100%) in 2011, 100% (95% ci: 99.9-100%) in 2012 and 99.9% (95% ci: 99.8-100%) in 2013. the positive predictive values and negative predictive values remained stable through the three years (table 4). among all low performers in sensitivity were no. 7 (71.4%), 14 (80%), 3 (85.7%), and 21 (90%). they all displayed deteriorating trends in sensitivity over the three years. no. 23 (98.9%) and 18 (99.0%) were the only two laboratories which scored less than perfect in specificity in 2013, though both remained high. table 4: percentage of sensitivity and specificity of smear microscopy, by laboratory discussion in their review on the roles of laboratories and laboratory systems in effective tb programs, ridderhof et al., called for more operational research to be done in tb laboratories in the field in resource-limited settings to support evidence-based laboratory practice.5 evaluations of eqa systems and/or blinded random re-checking strategies in tb microscopic laboratories had been conducted in various countries with high tb burden.6-8 our study performed the first evaluation on the eqa system and the performance of the tb microscopic laboratories in sughd, tajikistan since system implementation. our study found a descending trend of case positivity rates from 2011 to 2013 in sughd, which suggested a regional decline of tb prevalence, while the proportion of population being screened for active tb expanded. this finding is consistent with the stable, national trend of decline in tb prevalence and incidence since 20028, as published by who. this could possibly be attributed to higher community awareness of tb and more proactive contact tracing strategies over the past decade. although earlier a knowledge, attitude and practice (kap) survey conducted jointly by project hope, who tajikistan, and sino project/swiss center for international health in 2005 and 2008 indicated room for improvement in raising public awareness of tb, the two surveys showed improved knowledge of tb symptoms among respondents over a 3-year period.6 a qualitative study in 2006, consisting of 13 focus group discussions among 43 community members, echoed that overall knowledge of tb symptoms was accurate among community members.11 since then, the country has implemented various initiatives of patient support groups and community leaders training in expansive scales. such joint efforts of the ntp and non-governmental organizations might contribute to the climbing case notification rate from 2004 to 2010.8 however, since 2010, tajikistan started to see declining trends in both case notification and incidence rates.8 as systematic screening for active tb has been gaining momentum in central asia, we anticipate the rising tb screening rate, accompanied by the steadily declining tb incidence and prevalence, to persist with extended local effort in advocacy, communication, and social mobilization activities. our study also showed that sputum smear microscopic laboratories in sughd had achieved total error reduction over these three years, in spite of mounting laboratory workload. effective reduction in microscopist workload was named the top priority in improving reading quality in previous studies.7,8 although our study did not include direct measures of laboratory workforce, we noted that high staff turn-over and emigration of skilled workers continued to challenge local programs in maintaining human resource capacity. as a significant increase in microscopist workforce in the region remained unlikely during the study period, the observed error reduction might be an outcome of stronger interactive training and feedback loop established as part http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu of the eqa system in sughd. overall, the peripheral laboratories in this region saw substantial improvement in the sensitivity of afb smears in tb detection while maintaining high specificity levels. hfn was the most frequent error type found in peripheral laboratories in sughd, followed by lfp being the second most common error type. one limitation of our study was that many pieces of eqa data entries in the nrl database were excluded due to missing source documents. coordinators at rtbc confirmed that all entries were made based on the paper-based reports; however, misfiling of 11 original quarterly reports was possible. corrective actions that aim to enhance the local filing system for the eqa reports will not only promote data accuracy but also allow future evaluations on other tajik regions and/or time periods to be completed more efficiently. with who’s recent recommendations on systematic screening for active tb,12 continuous monitoring, through laboratory data, on the population tb screening rate, case positivity rate, and number of smears performed gives crucial information on the progress of systematic screening, the trend of tb prevalence, and the status of laboratory workload both at the individual laboratory level and the regional level. our study computed these three indicators along with the eqa errors and afb microscopy performance analyses. we believe that the overview of microscopic laboratory activities and the actual evaluation of the eqa system on sputum smear microscopy complement each other in providing a better picture on the progress of tb laboratory strengthening. we recommend similar approaches to be adapted by future evaluations on tb microscopic laboratories, particularly among countries of high burden. acknowledgements the authors are grateful to the staff of the usaid quality health care project for their support. the assistance provided by the project hope office and the national tb program in tajikistan is gratefully acknowledged. authors’ contributions eva chang contributed to the concept, protocol, analysis, and writing of the manuscript. fabio luelmo contributed to the study concept and protocol development. zamira baydulloeva, gulfamol kasymova, and oktam bobokhojaev contributed to the data collection. marija joncevska critically revised the article. tom mohr contributed to the protocol, implementation, and supervision of the study. competing interests none of the authors has any conflict of interest to declare. funding the study was funded by the usaid quality health care project tajikistan and project hope. the quality health care project is funded by the u.s. agency for international development under contract no. aid176-c-10-00001, beginning september 2010. the quality project is implemented by abt associates inc. and its subcontractor, namely, project hope. references 1. who. global tuberculosis report 2014. 2014. 2. new diagnostics working group of the stop tb partnership. pathways to better diagnostics for tuberculosis. 2009; http://www.finddiagnostics.org/export/sites/default/resourcecentre/reports_brochures/docs/blueprinttb_annex_web.pdf. accessed december 12, 2014. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.finddiagnostics.org/export/sites/default/resource-centre/reports_brochures/docs/blueprinttb_annex_web.pdf http://www.finddiagnostics.org/export/sites/default/resource-centre/reports_brochures/docs/blueprinttb_annex_web.pdf chang this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu 3. the global laboratory initiative. a roadmap for ensuring quality tuberculosis diagnostics services within national laboratory strategic plans. 2010. 4. tb care i. international standards for tuberculosis care. 2014. 5. ridderhof j, van deun, a, kam, m, abdul, m. roles of laboratories and laboratory systems in effective tuberculosis programmes. bull. world health organ. 2007(039081):354– 359. 6. korobitsyn a, mohr, t, ismoilova, ., trusov, a, mohr, t. tb case detection in tajikistan analysis of existing obstacles. cent. 2013;2. 7. edwards p, wyss, k. management of pulmonary tuberculosis in tajikistan : which factors determine hospitalization ? trop. med. int. health 2008;13:1364–1371. 8. who. tuberculosis country profiles. http://www.who.int/tb/country/data/profiles/en/. accessed december 12, 2014. 9. agency on statistics under president of the republic of tajikistan. the population of the republic of tajikistan on 1 january 2013. 2013; http://stat.tj/en/img/36a268df28cfe07c2098351a71bb2773_13 72996986.pdf. accessed december 12, 2014. 10. aziz m, ba, f, becx-bleumink, m, britzel, g. external quality assessment for afb smear microscopy. 2002; http://stacks.cdc.gov/view/cdc/11440. accessed december 12, 2014. 11. ayé r, wyss, k, abdualimova, h, saidaliev, s. . illness costs to households are a key barrier to access diagnostic and treatment services for tuberculosis in tajikistan. bmc res. notes. 2010;3:340. 12. who. systematic screening for active tuberculosis principles and recommendations. 2013; http://apps.who.int/iris/bitstream/10665/84971/1/9789241548 601_eng.pdf?ua=1. accessed december 12, 2014. 13. national program for tuberculosis protection of the population of the republic of tajikistan for 2010-2015. 2009. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu table 1: classification of errors3 result of technician result of controllers negative 1-9 afb/100f 1+ 2+ 3+ negative correct lfn hfn hfn hfn 1-9 afb/100f lfp correct correct qe qe 1+ hfp correct correct correct qe 2+ hfp qe correct correct correct 3+ hfp qe qe correct correct *note. lfp = low false-positive, hfp = high false-positive, lfn = low false-negative, hfn = high false-negative, qe = quantification error http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx chang this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu table 2: overview of the annual service population, case positivity rate, total number of smears, and total number of slide rechecking from 2011 to 2013 among tb microscopic laboratories in sughd, by laboratory laboratory number service population case positivity rate (%) number of smears examined number of slides rechecked 2011 2012 2013 2011 2012 2013 2011 2012 2013 2011 2012 2013 2 54333 55100 55877 15.03 12.78 13.62 2226 2232 873 58 112 25 3 54333 55100 55877 1.60 3.73 2.30 1683 1838 1782 201 73 150 4 54333 55100 55877 1.43 3.17 1.45 727 686 1129 90 92 166 5 102000 104600 107266 6.35 5.94 6.40 4211 3602 3859 145 201 165 6 135400 138000 140650 5.41 4.39 5.01 2926 2280 3473 141 201 208 7 46500 47300 48114 0.87 1.33 1.10 691 1266 1659 104 304 309 8 232200 236900 120848 4.88 3.47 2.82 4277 3926 4602 141 284 248 9 224100 229700 235440 8.99 9.97 4.45 1104 1266 1782 96 118 73 10 251000 257900 264990 8.58 5.62 5.50 3812 4503 5273 102 78 105 11 40600 41500 42420 7.14 3.57 2.29 490 480 635 88 132 191 12 28400 29400 30432 3.68 4.85 5.37 498 588 1106 129 129 293 13 136300 140000 143800 9.27 7.67 5.18 510 888 633 155 123 140 14 139500 143300 147204 3.73 2.33 0.30 1073 1572 3135 170 225 172 15 60800 62500 64248 2.83 6.79 1.97 1452 1113 964 95 252 130 16 21100 21600 22112 17.79 3.13 8.33 552 128 52 40 81 28 17 116600 119400 122267 5.30 3.73 2.25 2648 2664 3507 209 193 198 18 114000 116700 119464 2.71 2.33 2.90 2373 2081 2514 206 156 213 19 34900 35800 36723 2.82 1.26 1.63 739 1051 818 135 239 277 20 159050 162550 110751 4.47 2.14 2.23 1691 2815 2502 365 298 319 21 159050 162550 110751 3.50 0.47 4.35 680 724 561 244 306 444 22 72000 73100 74217 4.90 6.06 5.22 394 394 500 83 162 283 23 14400 14700 15006 17.97 12.14 13.71 572 650 693 44 76 99 regional (95% ci) 2251700 2302700 2354855 6.98 (6.50-7.49) 5.64 (5.22-6.09) 4.80 (4.44-5.17) 38437 39452 45985 3063 3866 4593 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu table 3: annual eqa rechecking results, by laboratory laboratory number type of errors hfp hfn lfp lfn qe 2011 2012 2013 2011 2012 2013 2011 2012 2013 2011 2012 2013 2011 2012 2013 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 6 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 7 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 10 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 11 0 0 0 5 1 0 0 0 0 0 0 0 1 0 0 12 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 14 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 16 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18 0 0 0 3 0 1 0 0 2 2 0 0 0 0 1 19 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 21 0 0 0 0 2 0 1 0 0 0 0 1 0 0 0 22 0 0 0 2 3 0 0 0 0 0 0 0 0 0 0 23 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 regional 2 0 0 21 6 6 2 0 3 7 1 1 1 0 1 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx chang this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu table 4: percentage of sensitivity and specificity of smear microscopy, by laboratory laboratory number sensitivity (%) specificity (%) positive predictive value (%) negative predictive value (%) 2011 2012 2013 2011 2012 2013 2011 2012 2013 2011 2012 2013 2 100 100 100 100 100 100 100 100 100 100 100 100 3 100 100 85.7 100 100 100 100 100 100 100 100 9903 4 100 100 100 100 100 100 100 100 100 100 100 100 5 94.4 96.2 100 99.2 100 100 94.4 100 100 99.2 99.3 100 6 89.5 100 100 100 100 100 100 100 100 98.4 100 100 7 na 100 71.4 100 100 100 na 100 100 100 100 99.3 8 100 100 100 100 100 100 100 100 100 100 100 100 9 96.2 100 100 100 100 100 100 100 100 98.6 100 100 10 78.6 100 100 100 100 100 100 100 100 96.7 100 100 11 58.3 88.9 100 100 100 100 100 100 100 93.8 99.2 100 12 100 100 100 100 100 100 100 100 100 100 100 100 13 80.0 100 100 100 100 100 100 100 100 97.9 100 100 14 87.5 100 80.0 99.4 100 100 87.5 100 100 99.4 100 99.4 15 100 100 100 100 100 100 100 100 100 100 100 100 16 na 100 na 100 100 100 na 100 na 100 100 100 17 100 100 100 100 100 100 100 100 100 100 100 100 18 58.3 100 92.3 100 100 99.0 100 100 85.7 97.5 100 99.5 19 100 100 100 100 100 100 100 100 100 100 100 100 20 89.7 100 100 100 100 100 100 100 100 99.1 100 100 21 100 66.7 90.0 99.6 100 100 85.7 100 100 100 99.3 99.8 22 50.0 82.4 100 100 100 100 100 100 100 97.5 98.0 100 23 100 100 100 97.4 100 98.9 83.3 100 85.7 100 100 100 regional (95% ci) 88.2 (83.492.0) 97.4 (94.798.9) 97.2 (94.398.9) 99.9 (99.6100) 100 (99.9100) 99.9 (99.8100) 98.1 (95.399.5) 100 (98.6100) 98.8 (96.599.7) 99.0 (98.699.3) 99.8 (99.699.9) 99.8 (99.799.9) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx chang this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu figure 1: algorithm of stepwise rechecking of the eqa system in sughd10 feedback feedback peripheral laboratory slide preparation afb microscopy slide storage intermediate laboratory random sampling blinded rechecking (first and second recheckers, if needed) republican tb center report/interpretation eqa database maintenance blinded slide transporting rechecked eqa results eqa report http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx chang this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu supplement figure s1: the structure of government tb microscopic laboratory network in tajikistan13 national tb reference center central level republican tb center intermediate level khujand oblast tb center lab sughd oblast intermediate level kurgan-tube oblast tb center lab no.1 khalton oblast intermediate level kulob oblast tb center lab no.2 khalton oblast intermediate level khorog oblast tb center lab gbao peripheral level soghd oblast 22 peripheral level khalton oblast kurgan-tube 15 peripheral level khalton oblast kulob 11 peripheral level gorno badakhshan autonomous oblast 8 peripheral level dushanbe city 10 peripheral level districts of republican subordination 13 republican tb center republican microscopy surveillance center peripheral level disciplinary department ministry of justice 5 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu table s1: afb smear microscopy grading system findings grade no acid-fast bacilli found in at least 100 fields negative 1-9 acid-fast bacilli per 100 fields scanty (report exact figure/100) 10-99 acid-fast bacilli per 100 fields 1+ 1-10 acid-fast bacilli per field in at least 50 fields 2+ more than 10 acid-fast bacilli per field in at least 20 fields 3+ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx chang this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.230|http://cajgh.pitt.edu table s2: laboratory numbers and corresponding laboratory names laboratory number laboratory name 1 deqmoy 2 khujand g 3 khujand phc 1 4 khujand phc 5 5 mastchoq 6 konibodom phc 7 konibodom sub 8 isfara 9 istaravshan 10 panchakent 11 kairokkum 12 chkalovsk 13 asht 14 gonchi 15 zafarobod 16 mastchoqi kuqi 17 spitаmen 18 rasulob 19 shaqriston 20 gafurov phc 21 gafurov 22 aini 23 taboshar 24 isfara chorku 25 gafurov eva http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. diabetes mellitus among adults in herat, afghanistan: a crosssectional study khwaja mir islam saeed1 1grant and service contract management unit, ministry of public health, kabul, afghanistan vol. 6, no. 1 (2017) | issn 2166-7403 (online) doi 10.5195/cajgh.2017.271 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.271|http://cajgh.pitt.edu abstract introduction: diabetes is reaching epidemic levels in afghanistan. this study identifies the risk factors associated with diabetes in herat city, afghanistan, and explores the prevalence of previously undiagnosed diabetes. methods: a cross-sectional study was conducted using multistage cluster sampling by adopting the world health organization’s (who) stepwise approach to surveillance (steps). we enrolled 1129 participants aged 25-70 years between may and june of 2015 (47.4% males, 52.6% females). a structured questionnaire was used for data collection of demographic, socioeconomic, and behavioral factors. investigators collected anthropometric measurements and blood samples from study participants. a multivariable logistic regression model was used to identify factors associated with diabetes prevalence. results: we found that the prevalence of diabetes in herat city was 9.9% (9.8% in males and 10.1% in females). of the 1129 respondents, only 3.3% were previously diagnosed with diabetes or were under treatment, whereas 6.6% of respondents were previously undiagnosed. the multivariable analyses showed that age, frequency of rice consumption, type of cooking oil, and systolic blood pressure were associated with diabetes. conclusions: this is one of the first studies to discuss the high prevalence of undiagnosed diabetes in herat, afghanistan. this study found several modifiable factors that were associated with diabetes in herat, afghanistan. future reduction of disease burden should focus on these factors in the development of the most optimal diabetes prevention programs. keywords: risk factors; diabetes; chronic disease; afghanistan diabetes mellitus among adults in herat, afghanistan: a crosssectional study khwaja mir islam saeed1 1grant and service contract management unit, ministry of public health, kabul, afghanistan research diabetes mellitus (dm) is a global public health problem and is listed as a priority noncommunicable disease (ncd) by the world health organization (who).1 the rising prevalence of diabetes is reaching epidemic proportions worldwide.2 genetics, environmental factors, and lifestyle choices are contributing to the development of this chronic metabolic disorder.3 diabetes was ranked as the sixth leading cause of death in 2015, with 1.6 million deaths attributed to this disease.4 the global prevalence of diabetes increased from 4.7% in 1980 to 8.5% in 2014, resulting in 422 million people in the world living with diabetes in 2014.5 according to a study of diabetes in kuwait, the crude prevalence of total diabetes cases in this country was 21.4%, and almost one-fifth of these cases were previously undiagnosed.6 in oman, the overall http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.271|http://cajgh.pitt.edu figure 1. location of study setting in western province of herat, afghanistan prevalence of diabetes appears to be on the rise with risk factors such as urban residence, obesity, age, and systolic blood pressure being significantly associated with diabetes.7 the study from iran demonstrated that diabetes was more prevalent among older age groups, females, and urban dwellers.8 in china, the prevalence of diabetes in the 35–74 age group was 5.5%, with 5.8% of females and 5.2% of males being diagnosed with diabetes.9 a study in pakistan found that central obesity, hypertension, and family history of the disease were risk factors for diabetes.10 in afghanistan, due to years of war and conflict, few studies were conducted to estimate the burden of diabetes in the country. however, the afghanistan mortality survey (ams) in 2010 reported that one third of all deaths were attributed to ncds.11 the prevalence of diabetes in the 20-79 year age group in afghanistan was estimated to be 8.6% in 2010, whereas by 2030 it is projected to reach 9.9%.12 moreover, studies reported that the prevalence of diabetes was 13.2% in kabul (age group of ≥40 years), 11.8% in jalalabad, and 22.4% in kandahar in the early 2010s.13-16 we also previously reported an overall diabetes prevalence of 9.9% in a cohort of adults from herat.15 however, the risk factors associated with diabetes in this population have not yet been explored. the aim of this study was to determine risk factors associated with diabetes among adults living in herat, afghanistan and to explore the prevalence of previously undiagnosed diabetes in this geographic region. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.271|http://cajgh.pitt.edu methods the institutional review board of the ministry of public health, afghanistan, provided ethical approval of the study protocol. the study design was a crosssectional survey of permanent residents of herat, afghanistan, using the stepwise approach to surveillance (steps) tool,17 which inludes demographic, physical, and biochemical measurements. herat is the largest city in the herat province of afghanistan. the location of the study setting in herat is shown in figure 1. the urban population of herat is estimated to be 491,967, (242,102 females and 249,865 males.18) permanent residents of herat between the ages of 25 and 70 were enrolled in this study. participants signed informed consents prior to face-to-face interviews. for illiterate participants, the informed consent was read by the interviewer and the fingerprint of the respondent was taken to confirm agreement to participate. sampling strategy the statistical software program epi info v. 7 was used to calculate the sample size for this study. although the national burden of diabetes is not well known in afghanistan, a who report estimated the prevalence of diabetes at 8.6%.12 although information on diabetes risk factors is scarce for afghanistan, epidemiological research from other developing countries has reported that physical activity, blood pressure, dietary factors, obesity, age, level of education, smoking status, and other factors were associated with diabetes. the sample size was calculated to be 1200 based on the proportion of these risk factors and the cluster sampling technique. inclusion criteria were as follows: adult population aged 25-70 (as outlined in who survey tool), must be herat residents during the study period, and must consent to participate. exclusion criteria included: temporary residents (less than six months in the city) and those living in the institutionalized settings or unsafe areas. study variables and data collection the primary outcome variable was the presence of diabetes (yes/no). participants with a fasting blood sugar (fbs) of ≥126mg/dl or undergoing diabetes treatment during the data collection appointment were considered as diabetic.19 main factors such as age, sex, ethnicity, educational status, income, job type, proxy for physical activity (vigorous or moderate physical activity), dietary factors, tobacco use, obesity, hypertension, and blood lipid levels were assessed and analyzed. a structured (standardized) steps questionnaire was adopted and translated into the dari language, the official language of afghanistan. the answer options in the questionnaire were previously coded to facilitate the data entry and data analysis. training and field testing was conducted ahead of time, and the questionnaire was adjusted accordingly before the actual data collection period of may-june 2015. a household was defined as a group of people who are cooking together in same kitchen, sharing the same food pot but no necessarily the same roof. in each household, the interviewer counted all persons eligible for the study based on the inclusion and exclusion criteria. in the households with more than one eligible person, a lottery system was used to select the respondent for the survey. if that individual refused to participate, the interviewers approached the next household on the list. anthropometric measurements (height and weight) were used to calculate body mass index (bmi). a bmi of >30 kg/m2 was considered as obese, 25–30 kg/m2 as overweight, and 18.5–25 kg/m2 as normal weight.20 a waist circumference of 94 cm for men and 80 cm for women was considered as central obesity.21 systolic blood pressure of 140 mmhg and diastolic blood pressure of 90 mmhg were considered as hypertensive.22 blood samples were collected and processed by lab technicians under supervision of the lab coordinator. after samples were shipped to the central public health laboratory (cphl) in kabul, they were stored at -80°c until glucose http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.271|http://cajgh.pitt.edu figure 2. prevalence of diagnosed and undiagnosed diabetes by age group measurements were completed. to enhance the quality of the data, close monitoring of all procedures was carried out throughout the study. statistical analysis data entry was done using epi info v. 7 and data analysis was done using spss version 20. participants with missing data and specimens were excluded from the final analysis. our final sample size for statistical analysis was 1,129 participants. central tendencies, proportions, and frequencies were calculated and tabulated. the prevalence of diabetes was calculated in all subgroups, and different tables were developed including tables of demographic, socio-economic, and behavioral data using descriptive analyses. statistical analyses were conducted using student t-test, chi-square, univariate, and multivariable logistic regression. in the univariate model, the relationship between the variables and the outcome was analyzed individually. then, based on the level of significance and biological plausibility, a multivariable analysis was conducted to address confounding and to find independent associations of factors with the outcome. statistical significance was based on an α level of <0.05 and 95% confidence interval. results table 1 summarizes all of the participant characteristics. out of 1129 participants included in this analysis, 594 (52.6%) were females and 535 (47.4%) were males. the participants had a mean age of 41.7±13.1 years, and 60% were aged less than 45 years. about 48% of study respondents were overweight or obese and 52.3% had central obesity. high blood pressure was recorded in 35.6% of the participants. approximately 28.4% had high cholesterol and 45% had high triglycerides. furthermore, high levels of low density lipoprotein (ldl) and high levels of high density lipoprotein (hdl) were observed in 47% of the study participants. more than half of the respondents (54%) were illiterate, and 82.7% of the participants had a monthly income lower than 10,000 afghanis (usd 146). 3.50% 6.90% 7.70% 10.80% 6.60% 0.80% 1.80% 5.00% 8.10% 3.30% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 25-35 35-45 45-55 55+ total undiagnosed diagnosed http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.271|http://cajgh.pitt.edu variables categories no diabetes diabetes odds ratio ci 95% lower limit ci 95% upper limit n % n % age in years 25 34 382 37.6 17 15.2 1.00 reference 35 44 263 25.9 25 22.3 2.14 1.13 4.03 45 54 192 18.9 28 25.0 3.28 1.75 6.14 55 + 180 17.7 42 37.5 5.24 2.91 9.46 gender female 536 52.7 58 51.8 1.00 reference male 481 47.3 54 48.2 1.84 1.15 2.95 fruit serving days per week ≤3 days 793 84.0 77 74.0 1.00 reference > 3 days 151 16.0 27 26.0 0.96 0.72 1.27 vegetable serving days per week ≤ 3 days 692 71.9 70 66.7 1.00 reference >3 days 270 28.1 35 33.3 1.28 0.83 1.97 cooking oil in kitchen liquid 491 60.1 37 40.7 1.00 reference solid 326 39.9 54 59.3 2.20 1.41 3.42 obesity based on bmi no 858 84.6 90 81.1 1.00 reference yes 156 15.4 21 18.9 1.28 0.78 2.13 high blood pressure no 687 67.6 40 35.7 1.00 reference yes 330 32.4 72 64.3 3.75 2.49 5.64 triglycerides <150 mg/dl 574 56.4 47 42.0 1.00 reference http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.271|http://cajgh.pitt.edu ≥150 mg/dl 443 43.6 65 58.0 1.79 1.21 2.66 rice consumption in days per week ≤3 days 290 29.1 53 48.2 1.00 reference > 3 days 708 70.9 57 51.8 0.44 0.30 0.66 vigorous physical activity no 903 89.5 101 91.0 1.00 reference yes 106 10.5 10 9.0 0.84 0.43 1.67 moderate physical activity no 781 77.6 96 85.7 1.00 reference yes 225 22.4 16 14.3 0.58 0.33 1.00 table 1. univariate analysis of demographic, socio-economic and behavioral factors associated with diabetes among study participants in herat, afghanistan as previously reported, the overall prevalence of diabetes was 9.9%.15 when stratified by sex, we found that 9.8% of males and 10.1% of females had diabetes. we found that 6.6% of the participants were previously undiagnosed with diabetes, while 3.3% had been previously diagnosed and were undergoing treatment (figure 2). the mean level of fasting blood sugar was 96.20 mg/dl, with a range of 22-388 mg/dl. the main diabetes management modalities reported by the participant were insulin (28%), oral drugs (74%), dietary restriction (68%), and weight loss recommendation (38%). identification of diabetes type (type i vs. type ii) was not the objective of the study and is not reported. table 1 shows the results of univariate analysis of risk factors and diabetes among study participants. odds of having diabetes were 2.14 (95% ci: 1.13 – 4.03) times higher in the 35-45 year age group, 3.28 (95% ci: 1.75 – 6.14) times higher in the 45-55 year age group, and 5.24 (95% ci: 2.91 – 9.46) times higher in the ≥55 year age group as compared to 25-35 age category. gender, level of education, marital status, income, and other socioeconomic factors were not significantly associated with diabetes in this study. there was a statistically significant association between type of cooking oil used (liquid that was assumed to be unsaturated oil and solid that was assumed to be saturated oil) and diabetes with an or=2.20 (95% ci: 1.41 – 3.42) (table 1). greater frequency of rice consumption was significantly associated with reduced odds of diabetes with an or = 0.44 (95% ci: 0.30-0.66). other dietary habits such as frequency of consuming vegetables, fruits, chicken, red meat, and table salt were not significantly associated with diabetes. high blood pressure and high levels of triglycerides were associated with diabetes with or=3.75 (95% ci: 2.49 – 5.64) and or=1.79 (95% ci: 1.21 – 2.66) respectively. furthermore, blood lipids (except triglycerides) and proxies for physical activity as defined by who stepwise approach to surveillance were not associated with diabetes (table 1). in the multivariable analysis, only the variables of biological and statistical significance (table 1) were included in the model. table 2 summarizes the variables http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.271|http://cajgh.pitt.edu variables categories b odds ratio ci 95% lower limit ci 95% upper limit p value age groups 25-35 1 reference 35-45 0.90 2.45 1.17 5.15 0.02 45-55 0.94 2.56 1.20 5.48 0.02 55+ 1.43 4.17 2.02 8.61 <0.01 high blood pressure no 1 reference yes -0.88 0.42 0.26 0.67 <0.01 triglyceride <150 mg/dl 1 reference ≥150 mg/dl -0.57 0.56 0.36 0.90 0.02 cooking oil liquid 1 reference solid -0.75 0.47 0.30 0.75 <0.01 consuming rice three times per week ≤3 per week 1 reference >3 per week 0.63 1.53 1.03 2.26 0.01 table 2. multivariable analysis of risk factors and diabetes among study participants in herat, afghanistan that were significantly associated with diabetes, including age group, blood pressure, triglyceride, type of cooking oil, and rice consumption. the multivariate model was run with all variables in one model to identify the independent associations in logistic regression. increasing age group was associated with greater odds of having diabetes, with the 55+ age group having the greatest odds (or = 4.17, 95% ci: 2.02-8.61). greater rice consumption was significantly associated with increased odds of having diabetes with an or = 1.53 (95% ci: 1.03-2.26). high blood pressure, high triglycerides, and solid cooking oil were all associated with lower odds of having diabetes (all p < 0.05). discussion the prevalence of diabetes in herat city was found to be 9.9%, which was lower than reported in similar studies from kabul13 and jalalabad14; and it is less than half of the rate recorded in kandahar, in southern afghanistan.16 this may be due to age differences and/or cultural variations. although blood samples were collected after fasting for 10-12 hours, outliers could be present due to non-fasting status of some of the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.271|http://cajgh.pitt.edu participants (noncompliance to fasting requirement) or higher level of diabetes. however, our findings are consistent with similar reports from india, pakistan, and china.10,23-25 global studies reported that lowand middle-income countries have a greater burden of diabetes.5 countries from the eastern mediterranean region including the uae, saudi arabia, bahrain, kuwait, and oman have reported a higher prevalence of diabetes ranging from 13.4-18.7% among wider age ranges.11 in a multivariatable analysis, age was a significant non-modifiable risk factor for diabetes, similar to results reported by other studies.12 our findings show a higher prevalence of diabetes in women (10.1%) as compared to men (9.8%); however, gender was not statistically significant in both the univariate and multivariable analyses. other studies have supported the statistical significance of gender at the national level in kabul13 and in other countries.25 significant increases in the global age-standardized prevalence of diabetes was observed in both men and women, with the greatest increase and highest prevalence reported in men. this increase could be due to the factors such as global population aging and sex differences in prevalence of risk factors, such as smoking and bmi.5 analysis of dietary habits showed that consuming rice more frequently is associated with higher levels of diabetes. systolic blood pressure was significantly associated with diabetes. hypertension, frequency of vegetable consumption, and obesity was associated with diabetes in other studies conducted in jalalabad, kabul, and kandahar cities.13,14,16,26 triglycerides were found to be significant risk factors for diabetes, which may be due to their association with obesity as supported by published research.14,27 there were several limitations to our study. the main limitation was the inability to do follow-up visits. in addition, offering blood tests and blood pressure checks could have encouraged those with pre-existing diabetes or hypertension to be over enrolled. physical activity levels were not significantly associated with diabetes; however, this association has been supported by other studies.8,14,28,29 our future studies may need to assess physical activity using standardized data collection tools. afghanistan is traditionally viewed as a conflict zone, with health issues receiving inadequate attention. the design, implementation, and reporting of scientific studies, particularly epidemiological research in health, is an essential step in improving healthcare and the public health system of afghanistan. to our knowledge, the current study was the first epidemiological crosssectional investigation with the objective to identify the risk factors associated with diabetes among herat residents in afghanistan. the high prevalence of diabetes among the adult population and the presence of modifiable risk factors are of importance for planning and implementing effective public health interventions. the findings of this study could be used as a baseline or starting point to design and implement nationwide studies to reflect the national burden of diseases and risk factors in afghanistan. references 1. global report on diabetes. who press: world health organization; 2016. 2. idf atlas. brussels, belgium: international diabetes federation; 2015. 3. american diabetes association. clinical practice recommendations 2003. diabetes care. 2003;26 (suppl 1). 4. who mortality database. http://www.who.int/mediacentre/factsheets/fs3 10/en/. accessed 29 july 2017. 5. ncd risk factor collaboration (ncd-risc). worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4.4 million participants. lancet (london, england). 2016;387(10027):1513-1530. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saeed this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.271|http://cajgh.pitt.edu 6. al khalaf mm, eid mm, najjar ha, alhajry km, doi sa, thalib l. screening for diabetes in kuwait and evaluation of risk scores. eastern mediterranean health journal = la revue de sante de la mediterranee orientale = almajallah al-sihhiyah li-sharq al-mutawassit. 2010;16(7):725-731. 7. al-moosa s, allin s, jemiai n, al-lawati j, mossialos e. diabetes and urbanization in the omani population: an analysis of national survey data. population health metrics. 2006;4:5. 8. esteghamati a, gouya mm, abbasi m, et al. prevalence of diabetes and impaired fasting glucose in the adult population of iran: national survey of risk factors for non-communicable diseases of iran. diabetes care. 2008;31(1):9698. 9. gu d, reynolds k, duan x, et al. prevalence of diabetes and impaired fasting glucose in the chinese adult population: international collaborative study of cardiovascular disease in asia (interasia). diabetologia. 2003;46(9):1190-1198. 10. shera as, basit a, fawwad a, et al. pakistan national diabetes survey: prevalence of glucose intolerance and associated factors in the punjab province of pakistan. primary care diabetes. 2010;4(2):79-83. 11. afghan public health institute at the ministry of public health aphi/moph cso-ca, icf macro, indian institute of health management research iihmr, and world health organization regional office for the eastern mediterranean who/emro. afghanistan mortality survey 2010. calverton, maryland, usa: aphi/moph, cso, icf macro, iihmr and who/emro; 2011. 12. shaw je, sicree ra, zimmet pz. global estimates of the prevalence of diabetes for 2010 and 2030. diabetes research and clinical practice. 2010;87(1):4-14. 13. saeed kmi, asghar rj, sahak mn, ansari j. prevalence and risk factors associated with diabetes mellitus among kabul citizens— afghanistan, 2012. international journal of diabetes in developing countries. 2015;35(3):297-303. 14. mir islam sk. prevalence and predictors of diabetes mellitus in jalalabad city, afghanistan-2013. iranian journal of diabetes and obesity. 2014;6(1):1-8. 15. saeed kmi, rasooly m. prevalence of risk factors for non-communicable diseases (ncd) using who step-wise approach in herat city afghanistan. iosr journal of pharmacy. 2016;6(10):34-40. 16. saeed kmi. prevalence of diabetes and its risk factors in urban setting of kandahar city, afghanistan-2015. iosr journal of pharmacy. 2016;6(11):53-60. 17. bonita r, winkelmann r, douglas ka, de courten m. the who stepwise approach to surveillance (steps) of non-communicable disease risk factors. in: mcqueen dv, puska p, eds. global behavioral risk factor surveillance. boston, ma: springer us; 2003:9-22. 18. central statistics of afghanistan (cso). population: estimated settled population by civil division, urban, rural and sex-2015-16. http://www.cso.gov.af/en/page/demographyand-socile-statistics/demographstatistics/3897111. accessed 29 july 2017. 19. diabetes. fact sheet no. 312. 2015; http://www.who.int/mediacentre/factsheets/fs3 12/en/. accessed 29 july 2017. 20. obesity: preventing and managing the global epidemic. geneva: world health organization; 2000. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.271|http://cajgh.pitt.edu 21. the idf consensus worldwide definitions of the metabolic syndrome. 2006; https://www.idf.org/e-library/consensusstatements/60-idfconsensus-worldwidedefinitionof-the-metabolic-syndrome. accessed 29 july 2017. 22. whitworth ja. 2003 world health organization (who)/international society of hypertension (ish) statement on management of hypertension. journal of hypertension. 2003;21(11):1983-1992. 23. aekplakorn w, abbott-klafter j, premgamone a, et al. prevalence and management of diabetes and associated risk factors by regions of thailand: third national health examination survey 2004. diabetes care. 2007;30(8):20072012. 24. zafar j, bhatti f, akhtar n, et al. prevalence and risk factors for diabetes mellitus in a selected urban population of a city in punjab. jpma the journal of the pakistan medical association. 2011;61(1):40-47. 25. ning f, pang zc, dong yh, et al. risk factors associated with the dramatic increase in the prevalence of diabetes in the adult chinese population in qingdao, china. diabetic medicine : a journal of the british diabetic association. 2009;26(9):855-863. 26. khawaldeh a. hyperlipidemia in non-insulindependent diabetes mellitus. bahrain medical bulletin. 1999;21(4). 27. seftel ad, sun p, swindle r. the prevalence of hypertension, hyperlipidemia, diabetes mellitus and depression in men with erectile dysfunction. the journal of urology. 2004;171(6 pt 1):23412345. 28. asgari f, agajani h, haghazali m, heidarian h. non-communicable diseases risk factors surveillance in iran. iranian journal of public health. 2009;38(suppl 1):119-122. 29. bener a, zirie m, janahi im, al-hamaq ao, musallam m, wareham nj. prevalence of diagnosed and undiagnosed diabetes mellitus and its risk factors in a population-based study of qatar. diabetes research and clinical practice. 2009;84(1):99-106. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx diabetes mellitus among adults in herat, afghanistan: a cross-sectional study abstract keywords: risk factors; diabetes; chronic disease; afghanistan diabetes mellitus among adults in herat, afghanistan: a cross-sectional study research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. prep in india’s hiv prevention policy in the era of social media and sex positivity anindya kar1*, dinesh bhugra2, shuvankar mukherjee3, agnibho mondal4, aaditya suresh kumar5 1department of psychiatry, advanced neuropsychiatry institute, kolkata, india; 2health service and population research department, institute of psychiatry, psychology & neuroscience, king’s college london, london, uk; 3department of community medicine, calcutta national medical college, kolkata, india; 4department of tropical medicine, school of tropical medicine, kolkata, india; 5department of neurology, institute of neurosciences, kolkata, india *corresponding author vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kar this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu abstract introduction: the global revolution of online social media and connectivity had a tremendous effect on sexual behavior in both developed and developing countries. this global change is influencing the societal structure and existing social principles. moreover, it has a significant impact on the epidemiology of different infectious diseases, especially hiv. discussion: india is one of the most diverse democratic countries that has undergone a social-cultural transition in the last decade. however, having the second-highest hiv infection rate in the world, india does not have any other new prevention tools in their national hiv prevention strategy. pre-exposure prophylaxis (prep), a boon of hiv prevention widely used in different countries, is still not implemented in india. the concept of “digital india” by the government of india is giving wide access of internet to the people of india. furthermore, people are exposed to social media, and that is impacting their sex seeking behavior. interestingly, recent legal changes in india promotes sex positivity. it also calls for introspection on existing hiv preventive strategies. conclusion: given the current scenario of prep and other existing preventive measurements of hiv, further research is needed to determine the acceptance and efficacy of prep and improve engagement in care for individuals in india. various international studies recommend effective implication of prep to reduce the rate and economic burden of hiv infection. keywords: hiv; prep; social media; india; sex positivity prep in india’s hiv prevention policy in the era of social media and sex positivity anindya kar1, dinesh bhugra2, shuvankar mukherjee3, agnibho mondal4, aaditya suresh kumar5 1department of psychiatry, advanced neuropsychiatry institute, kolkata, india; 2health service and population research department, institute of psychiatry, psychology & neuroscience, king’s college london, london, uk; 3department of community medicine, calcutta national medical college, kolkata, india; 4department of tropical medicine, school of tropical medicine, kolkata, india; 5department of neurology, institute of neurosciences, kolkata, india research india’s socio-cultural transition in the last decade has been impactful on the demography of hiv1. the recent explosion in social media usage and the digital india campaign are remarkably changing human interaction on many levels. the giants of social media like facebook and twitter, along with dating apps like tinder and grindr, are not restricted to a particular group of people in india but cater to wide and diverse populations. this heterogeneous distribution of social media users has an impact on sexual behavior and its risks. furthermore, it appears that the incidence and prevalence of hiv varies among people of different cultural backgrounds due to an interplay of psychological and social factors. the provision of healthcare in any democratic country, such as india, is influenced by the demands of its people of many different cultural identities and relies on social, political and economic factors to achieve an optimal prevention policy. the recent changes in hiv prevention policy of india where every individual with hiv positive status are being treated with free antiretroviral therapy (art) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu irrespective of their cd4 count are definitely1 benefitting the people living with hiv (plhiv). however, hiv infection is a significant public health burden in india, and pre-exposure prophylaxis (prep) is still an alien concept. the global sexual renaissance2 has changed societal attitude towards consensual online sex. in india, online dating applications and websites are also widely used, and the pattern of sex-seeking behavior has drastically changed in the last few years3. policy makers need to take into consideration behavioral responses to changes in the cost of disease and implement strategies that are holistic and long-sighted. this paper will review these changes and how they impinge upon and, by so doing, help the policy makers and clinicians to identify the need of prep and address these issues in a culturally sensitive way. discussion global perspective of prep behavioral interventions and barrier methods, such as the use of condoms, slowed down the hiv epidemic in past4, but as long as no vaccine is available, new intervention strategies are still urgently needed. the two drug fixed-dose combination therapy with emtricitabine/tenofovir disoproxil fumarate (ftc/tdf) became the first to be used as prep, known as truvada, and was approved by usa food and drug administration (fda) in july 2012 for high risk groups5. both tdf and ftc are nucleos(t)ide analogue reverse transcriptase inhibitors (nrtis). they have longer halflives, which allow for less frequent dosing6. in fact, the half-lives of tdf/ftc are the longest for the nrti class, a potentially favorable pharmacological characteristic for prep from an adherence perspective3. prior to the fda licensure there was a series of meta-analyses of studies on prep that had been done on high risk groups, i.e. those who are vulnerable to hiv infections. a sub-analysis of the men who have sex with men (msm) study (known as the pre-exposure prophylaxis initiative [iprex]) showed that with optimal adherence, efficacy was more than 90%, and incidence of hiv infection was reduced by 92%7,8. other trials, including one among serodiscordant heterosexual couples in kenya and uganda and another among sexually active young men and women in botswana, have also demonstrated promising results for the use9 of prep as a prevention strategy. as clinical trials continue to establish efficacy, researchers have been increasingly interested in awareness and acceptability among potential candidates of prep. studies have found that overall knowledge of prep is low to modest, with concerns relating to potential side effects, costs, drug resistance and accessibility10. on a recent study amongst hiv-negative individuals, some men suggested that the reason for the likely future adoption of prep was the opportunity to engage in sex without condom use, either with their serodiscordant partner or casual partners. other participants equated prep adoption with greater sexual freedom11. in july 2014, the world health organization (who) suggested that all msm should consider taking prep in conjunction with other risk reduction strategies12. countries like south africa, australia, united kingdom, germany and other european countries have considered prep as an emerging strategy and an important addition to the toolbox of hiv prevention13. understanding the cultural context of prep provision is vital for implementation, with factors such as sexual practice, age and gender playing important roles in hiv acquisition risk and acceptability of interventions. pressure has increased globally for countries to submit to regulatory authorities and include prep in national policies. hiv in india—current scenario and challenges the most prevalent mode of hiv transmission in india is sexual route14. according to the recent data of 2018, the new hiv infections increased to 88,000 from 80,000 and aids-related new deaths increased to 69,000 from 62,000 in india15. the unaids data suggests almost 79% of plhiv are aware of their status and on effective art. the treatment efforts, primarily through http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kar this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu region adult hiv prevalence (%) india 0.22 mizoram 2.04 manipur 1.43 nagaland 1.15 telangana 0.7 andhra pradesh 0.63 karnataka 0.47 goa 0.42 maharashtra 0.33 delhi 0.3 tamil nadu 0.22 table 1. states with adult (15-49 years) hiv prevalence about the national average, 2017 art, helped to manage their infection. most importantly, the introduction of indian government’s ‘test-and-treat’ policy, irrespective of the cd4 counts and clinical stage of the disease, catalyzed the process of “treatment as prevention” (tasp)11 moreover, the rate of new infections and deaths is not falling rapidly enough in meeting the 90–90–90 ambitious treatment target to help end the aids epidemic given by the joint united nations programme on hiv/aids (unaids)16. the state wise prevalence of hiv infections in india given by national aids control organization (naco) in 2017 is elaborated in table 1 and figure 1. a recent study says prep with a biannual testing program has the potential to improve average per-person survival by nearly one year and block more than 270,000 hiv transmissions in india17. prep drug costs18 are lower than hiv treatment costs, both per-dose and for the duration of use. moreover, prep is prescribed to be taken consistently, but only when someone is at heightened risk of hiv, whereas, should someone acquire hiv, they will need to be on art for their entire life in order to stay healthy18,19. in may 2018, drug maker cipla received regulatory approval in india to sell its version of truvada as tenvir em20. however, this highly expensive monthly drug remains out of reach for many people who want and need it. there are no studies from india that can establish the efficacy or acceptance of prep in india. the only trial that has ever been done on prep in india focused on female sex workers, led by the sonagachi project in kolkata15. the trial was designed to assess prep feasibility in that particular population but did not provide sufficient evidence to recommend that prep be made routinely available by the national or state aids control programs for high risk individuals. social media and the change in sex-seeking behavior with the development of the internet and mobile technology, the ways of socializing and seeking sexual partners have changed dramatically21. mobile online dating applications like grindr and tinder along with other social media sites are widely used to seek potential sexual partners among both heterosexual and homosexual people22. seal et al. suggest that because the internet can accommodate a variety of sexual http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu expressions, as well as allow anonymity for the user, it provides an ideal environment to explore sexuality23. online partner seeking also allows people to more precisely delineate specific partner characteristics, such as hiv serostatus or a desire to engage in certain types of sexual behaviours20. however, there is no literature on sex-seeking behavior in india, especially on the use of social media. most of the current literature on the use of the social media has focused on msm. in contrast, relatively little research, especially qualitative research, has focused on heterosexual individuals. this is potentially due to the large burden that hiv infection has on msm populations or that msm use the internet more actively to find sex than heterosexual men and women24. it was estimated that in the beginning of 2018, there were almost 3 million users on one of the most popular heterosexual dating apps in india25. on the other hand, various gay dating apps also have a significant number of users, one example being grindr, which boasts around 4.5 million users worldwide as of 202026. gay dating apps often give reminders of hiv testing, ask if the person is on prep and whether the person has an undetectable viral load if the person is seropositive27. these dating apps also spread the message that ‘undetectable equals untransmittable’28. undetectable equals untransmittable is the message of the unaids campaign that shows the evidence demonstrating that hiv treatment is highly effective in reducing the transmission of hiv29,30. apart from this, facebook is also used for no strings attached sexual encounters31. another popular application, instagram, is also quite popular among the youth to find casual partners for physical intimacy32. there were around 201 million and 35 million indian users on facebook and instagram respectively in 201733. source: national aids control organization of india, 2017 figure 1. people living with hiv, percent distribution among states, 2017 18 15 13 12 10 7 7 6 4 4 4 remaining states/ut maharashtra andhra pradesh karnataka telangana tamil nadu west bengal uttar pradesh bihar gujarat rajasthan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kar this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu sex positivity and legal changes sex positivity is defined as “a positive attitude to sexual activity that is seen as a healthy relationship and form of self-expression”34. sexual pleasure is a valuable attribute in itself even without the context of marriage, procreation or an intimate relationship. it is, in itself, an important and positive part of human existence. “hookups” or uncommitted sexual encounters, are becoming progressively more engrained in popular culture, reflecting both evolved sexual predilections and changing social and sexual scripts35. this particular trend has been catalyzed by emerging online dating apps coming into the mainstream and challenged the existing ideas of monogamous relationships, prioritizing consensual sex36. social change influences laws37,38. in 2014, the supreme court of india recognized the transgender persons as members of a third gender alongside male and female39. in january of 2018, the supreme court in its judgment on privacy, said that right to privacy and the protection of sexual orientation lie at the core of the fundamental rights guaranteed by articles 14, 15 and 21 of the indian constitution40. on september 06, 2018, in a historic judgment, the supreme court of india removed consensual adult sex as a crime under section 377, saying sexual orientation is natural and people have no control over it41. before this, the law particularly affected the lesbian, gay, bisexual, transgender (lgbt) community and violated the right to form association under article 19 of the indian constitution42. on september 27, 2018, the apex court also ruled that adultery is no longer a crime under law, recognizing that the colonial-era law was unconstitutional and had some gender based discriminatory elements43. empowering with prep prep empowers the susceptible people including women to hiv infection44. prep also reduces the stigma of hiv infection and hence acts as an emancipator of people living with hiv by reducing the risk of acquiring hiv infection amongst serodiscordant couples39. prep is considered as an option for hivnegative women who want to have a baby with their partner living with hiv45. it is also considered as a mature and empowering approach for a person who is in a relationship with a partner who is not willing to use preventive measures. furthermore, it is a valuable method that allows women to protect themselves from hiv infection without dependence on their male sex partners to use condoms. on the other hand, there is a wide range of stigma and stereotyping regarding certain sexual positions within the gay community46. the bottom, or receptive partner during sexual intercourse, is 13 times more likely to get infected with hiv than the top, who is the insertive partner47. furthermore, bottom shaming is highly prevalent due to the gender roles related stigma, as the receptive partner is associated with femininity48. prep is the first opportunity bottoms have ever had to be in full control of their risk of hiv transmission. moreover, it allows both partners, regardless of sexual position, to be responsible for their own protection49. in a country like india, where almost 90%50 of transgender people are involved in sex work, prep, if implemented, will be added to the arsenal of measures they can employ to protect themselves51. recommendations implementation of prep is a long time constructive work. a few recommendations that can be considered are a) policy makers should be sensitive to cultural backgrounds and aware of social changes. b) there should be further studies on acceptance, efficacy and side effects of prep in india. c) the medical curriculum needs to be gender sensitive and it is important to discourage moral http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu judgement in clinical practices. the new updates of hiv medicine like effectiveness of art to reduce transmissibility, usefulness of prep, etc. should be taught to the primary health care physicians. d) the first step in implementing prep is identifying persons at high risk of hiv acquisition. however, identifying such persons can be challenging due to perceived fear of stigma and social discrimination. the lack of a trusting relationship between the patient and the clinician may also make it harder. hence it is important that clinicians routinely take a sexual and injection drug use history for all their patients in an open and nonjudgmental manner. prep is only fully effective when it is adhered to exactly as prescribed. furthermore, it does not protect against other sexually transmitted infections (stis). hence, it needs to be delivered as part of a comprehensive package of hiv/sti prevention services based on an individual's circumstances. references 1. jayanta bhattacharya. hiv prevention & treatment strategies current challenges & future prospects. ijmr. 2018 : 148(6). 671-674. doi: 10.4103/0971-5916.252150 2. techasrivichien, t., darawuttimaprakorn, n., punpuing, s. et al. changes in sexual behavior and attitudes across generations and gender among a population-based probability sample from an urbanizing province in thailand. arch sex behav 45, 367–382 (2016). https://doi.org/10.1007/s10508-014-0429-5 3. angelina mao and ahalya raguram. online infidelity: the new challenge to marriages. indian j psychiatry. 2009 oct-dec; 51(4): 302–304. doi: 10.4103/0019-5545.58299 4. vissers dc, voeten ha, nagelkerke nj, habbema jd, de vlas sj. the impact of pre-exposure prophylaxis (prep) on hiv epidemics in africa and india: a simulation study. plos one. 2008 may 7;3(5):e2077. doi: 10.1371/journal.pone.0002077. 5. hoff cc, chakravarty d, bircher ae, campbell ck, grisham k, et al. attitudes towards prep and anticipated condom use among concordant hiv-negative and hivdiscordant male couples. aids patient care stds. 2015 jul;29(7):408-17. doi: 10.1089/apc.2014.0315. 6. blumenthal, j., & haubrich, r. (2013). pre-exposure prophylaxis for hiv infection: how antiretroviral pharmacology helps to monitor and improve adherence. expert opinion on pharmacotherapy. 2013. 14(13). 1777– 1785. doi:10.1517/14656566.2013.812072 7. grant rm, lama jr, anderson pl, mcmahan v, liu ay, vargas l, et al. preexposure chemoprophylaxis for hiv prevention in men who have sex with men. n engl j med. 2010 dec 30;363(27):2587-99. doi: 10.1056/nejmoa1011205. 8. smriti naswa, y. s. marfatia. pre-exposure prophylaxis of hiv. indian j sex transm dis aids. 2011 jan-jun; 32(1): 1–8. doi:10.4103/2589-0557.81246 9. golub sa, gamarel ke, rendina hj, surace a, lelutiuweinberger cl. from efficacy to effectiveness: facilitators and barriers to prep acceptability and motivations for adherence among msm and transgender women in new york city. aids patient care stds. 2013 apr.27(4):24854. doi: 10.1089/apc.2012.0419. 10. saberi p, gamarel ke, neilands tb, comfort m, sheon n, darbes la, et al. ambiguity, ambivalence, and apprehensions of taking hiv-1 pre-exposure prophylaxis among male couples in san francisco: a mixed methods study. plos one. 2012;7(11):e50061. doi: 10.1371/journal.pone.0050061. 11. brooks ra, landovitz rj, kaplan rl, lieber e, lee sj, barkley tw. sexual risk behaviors and acceptability of hiv pre-exposure prophylaxis among hiv-negative gay and bisexual men in serodiscordant relationships: a mixed methods study. aids patient care stds. 2012 feb;26(2):87-94. doi: 10.1089/apc.2011.0283 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kar this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu 12. world health organization. people most at risk of hiv are not getting the health services they need. world health organization. http://www.who.int/mediacentre/news/releases/2014/keypopulations-to-hiv/en/. published july 11, 2014. accessed april 8, 2020. 13. prep in europe. the prep situation in europe, european prep: a history. http://www.prepineurope.org/en/who-is-the-prep-ineurope-initiative/the-prep-situation-in-europe/. accessed april 8, 2020 14. bhattacharya j. hiv prevention & treatment strategies current challenges & future prospects. indian j med res. 2018 dec.148(6):671-674. doi: 10.4103/09715916.252150. 15. puneeta vohra, kahamnuk jamatia, b subhada, rahul vinay chandra tiwari, ms nabeel althaf and chayan jain. correlation of cd4 counts with oral and systemic manifestations in hiv patients. j family med prim care. 2019 oct; 8(10): 3247–3252. doi: 10.4103/jfmpc.jfmpc_767_19 16. world health organization. consolidated guidelines on the use of antiretroviral drugs for treating and preventing hiv infection: recommendations for a public health approach. 2nd ed. geneva: world health organization; 2016. https://www.who.int/hiv/pub/arv/arv-2016/en/. accessed april 8, 2020 17. kazemian, p., costantini, s., kumarasamy, n., paltiel, ad., mayer, kh., chandhiok, n., walensky, rp., freedberg, ka. the cost-effectiveness of human immunodeficiency virus (hiv) preexposure prophylaxis and hiv testing strategies in high-risk groups in india. clin infect dis. 2020 feb 3;70(4):633-642. doi: 10.1093/cid/ciz249. 18. unaids . on the fast-track to end aids by 2030: focus on location and population. unaids, 2015, https://www.unaids.org/sites/default/files/media_asset/wa d2015_report_en_part01.pdf, accessed april 8, 2020 19. mayer kh, chandhiok n, thomas b. antiretroviral pre-exposure prophylaxis: a new opportunity to slow hiv spread in india. indian j med res. 2016 feb; 143(2): 125– 128. doi: 10.4103/0971-5916.180194 20. pt jyothi datta. cipla gets approval to sell its version of truvada in india. mumbai. the hindu business line. https://www.thehindubusinessline.com/companies/ciplagets-approval-to-sell-its-version-of-truvada-inindia/article8637483.ece. published may 23, 2016. updated january 20, 2018. accessed april 8, 2020 21. seal dw, benotsch eg, green m, snipes dj, bull ss, cejka a, et al. the use of the internet to meet sexual partners: a comparison of non-heterosexually-identified men with heterosexually-identified men and women. int j sex health. 2015; 27(1): 1–15. doi: 10.1080/19317611.2014.918921 22. lutz c, ranzini g. where dating meets data: investigating social and institutional privacy concerns on tinder. social media + society. 2017. 3(1) 1-12. http://journals.sagepub.com/doi/10.1177/20563051176977 35 23. seal dw, ehrhardt aa. masculinity and urban men: perceived scripts for courtship, romantic, and sexual interactions with women. culture, health, and sexuality. 2003.5(4).295–319. 24. rietmeijer ca, bull ss, mcfarlane m. sex and the internet. aids. 2001 jul 27;15(11):1433-4. 25. georgia w, wellman e. tinder is big in india-at least with men. the wall street journal; 2018 june 24. https://www.wsj.com/articles/india-has-lots-of-singlewomen-but-good-luck-finding-them-on-tinder1529869656. published june 24, 2018. accessed april 8, 2020 26. deccan chronicle. grindr lite comes to india, for users on slower phones, poor data network. deccan chronicle. chennai. https://www.deccanchronicle.com/technology/inother-news/120320/grindr-lite-comes-to-india-for-usershttp://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/mediacentre/news/releases/2014/key-populations-to-hiv/en/ http://www.who.int/mediacentre/news/releases/2014/key-populations-to-hiv/en/ http://www.prepineurope.org/en/who-is-the-prep-in-europe-initiative/the-prep-situation-in-europe/ http://www.prepineurope.org/en/who-is-the-prep-in-europe-initiative/the-prep-situation-in-europe/ https://www.who.int/hiv/pub/arv/arv-2016/en/ http://www.unaids.org/sites/default/files/media_asset/wad2015_report_en_part01.pdf http://www.unaids.org/sites/default/files/media_asset/wad2015_report_en_part01.pdf https://www.unaids.org/sites/default/files/media_asset/wad2015_report_en_part01.pdf https://www.unaids.org/sites/default/files/media_asset/wad2015_report_en_part01.pdf https://www.thehindubusinessline.com/companies/cipla-gets-approval-to-sell-its-version-of-truvada-in-india/article8637483.ece https://www.thehindubusinessline.com/companies/cipla-gets-approval-to-sell-its-version-of-truvada-in-india/article8637483.ece https://www.thehindubusinessline.com/companies/cipla-gets-approval-to-sell-its-version-of-truvada-in-india/article8637483.ece http://journals.sagepub.com/doi/10.1177/2056305117697735 http://journals.sagepub.com/doi/10.1177/2056305117697735 https://www.wsj.com/articles/india-has-lots-of-single-women-but-good-luck-finding-them-on-tinder-1529869656 https://www.wsj.com/articles/india-has-lots-of-single-women-but-good-luck-finding-them-on-tinder-1529869656 https://www.wsj.com/articles/india-has-lots-of-single-women-but-good-luck-finding-them-on-tinder-1529869656 https://www.deccanchronicle.com/technology/in-other-news/120320/grindr-lite-comes-to-india-for-users-on-slower-phones-poor-data-netw.html https://www.deccanchronicle.com/technology/in-other-news/120320/grindr-lite-comes-to-india-for-users-on-slower-phones-poor-data-netw.html central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu on-slower-phones-poor-data-netw.html. published march 12, 2020. accessed april 22, 2020. 27. mcneil jr. dg. grindr app to offer h.i.v. test reminders. the new york times. https://www.nytimes.com/2018/03/26/health/grindr-hivtest-reminder.html. published march 26, 2018. accessed april 8, 2020 28. hornet user. this pride season, ‘undetectable = untransmittable’ needs to be your mantra. https://hornet.com/stories/undetectable-untransmittablepride. published july 10, 2018. accessed april 8, 2020 29. unaids explainer. undetectable=untransmittable public health and hiv viral load suppression. available from: http://www.unaids.org/en/resources/presscentre/featurestor ies/2018/july/undetectable-untransmittable. published july 20, 2018. accessed april 8, 2020 30. prof alison j rodger, frcp valentina cambiano, phd tina bruun, rn prof pietro vernazza, md simon collins olaf degen, md et al. risk of hiv transmission through condomless sex in serodifferent gay couples with the hivpositive partner taking suppressive antiretroviral therapy (partner): final results of a multicentre, prospective, observational study. the lancet. 2019. 393(10189): 24282438. doi: 10.1016/s0140-6736(19)30418-0 31. gayle d. new facebook hook-up app shows which of your friends want to 'bang' you (so long as you don't mind your other friends knowing too). daily mail; 2013 jan 25. available from: http://www.dailymail.co.uk/sciencetech/article2268201/facebook-hook-app-shows-friends-want-bangyou.html. published january 25, 2013. accessed april 8, 2020 32. safronova v. instagram is now a dating platform, too. here’s how it works. the new york times. https://www.nytimes.com/2017/12/21/style/instagramthirst-traps-dating-breakups.html. december 21 2017. accessed april 8, 2020 33. arora k. india has the most fb users: report. the times of india; 2017 july 15. https://timesofindia.indiatimes.com/india/india-has-themost-fb-users-report/articleshow/59603509.cms. published july 15, 2017. accessed april 8, 2020 34. ivanski c, kohut t. exploring definitions of sex positivity through thematic analysis. the canadian journal of human sexuality. 2017 dec; 26(3):216-225. doi: 10.3138/cjhs.2017-0017 35. garcia jr, reiber c, massey sg, merriwether am. sexual hookup culture: a review. rev gen psychol. 2012 jun 1; 16(2): 161–176. doi: 10.1037/a0027911 36. bhatta dn, liabsuetraku t. social self-value intervention for empowerment of hiv infected people using antiretroviral treatment: a randomized controlled trial. bmc infect dis. 2016; 16: 272. doi: 10.1186/s12879-016-1634-8. 37. mandelker dr. the role of law in social change. osgoode hall law journal. 1970 nov; 8(2). 38. abel rl. law and society: project and practice. annual review of law and social science. 2010 dec; 6:123. https://doi.org/10.1146/annurev-lawsocsci-102209152851 39. venkatesan j. supreme court recognises transgenders as third gender. the hindu. https://www.thehindu.com/news/national/supreme-courtrecognises-transgenders-as-thirdgender/article5914572.ece. published april 15, 2014. accessed april 8, 2020 40. india today. section 377: supreme court's right to privacy judgment sparked fresh debate on decriminalising gay sex. india today. https://www.indiatoday.in/india/story/section-377supreme-court-right-to-privacy-judgment-sparked-freshdebate-on-decriminalising-gay-sex-1129699-2018-01-08. published january 8, 2018. accessed april 8, 2020 41. the times of india. ‘gay sex is not a crime,’ says supreme court in historic judgement. new delhi: the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.deccanchronicle.com/technology/in-other-news/120320/grindr-lite-comes-to-india-for-users-on-slower-phones-poor-data-netw.html https://www.nytimes.com/2018/03/26/health/grindr-hiv-test-reminder.html https://www.nytimes.com/2018/03/26/health/grindr-hiv-test-reminder.html https://hornet.com/stories/undetectable-untransmittable-pride https://hornet.com/stories/undetectable-untransmittable-pride http://www.unaids.org/en/resources/presscentre/featurestories/2018/july/undetectable-untransmittable http://www.unaids.org/en/resources/presscentre/featurestories/2018/july/undetectable-untransmittable http://www.dailymail.co.uk/sciencetech/article-2268201/facebook-hook-app-shows-friends-want-bang-you.html http://www.dailymail.co.uk/sciencetech/article-2268201/facebook-hook-app-shows-friends-want-bang-you.html http://www.dailymail.co.uk/sciencetech/article-2268201/facebook-hook-app-shows-friends-want-bang-you.html https://www.nytimes.com/2017/12/21/style/instagram-thirst-traps-dating-breakups.html https://www.nytimes.com/2017/12/21/style/instagram-thirst-traps-dating-breakups.html https://timesofindia.indiatimes.com/india/india-has-the-most-fb-users-report/articleshow/59603509.cms https://timesofindia.indiatimes.com/india/india-has-the-most-fb-users-report/articleshow/59603509.cms https://doi.org/10.1146/annurev-lawsocsci-102209-152851 https://doi.org/10.1146/annurev-lawsocsci-102209-152851 https://www.thehindu.com/news/national/supreme-court-recognises-transgenders-as-third-gender/article5914572.ece https://www.thehindu.com/news/national/supreme-court-recognises-transgenders-as-third-gender/article5914572.ece https://www.thehindu.com/news/national/supreme-court-recognises-transgenders-as-third-gender/article5914572.ece https://www.indiatoday.in/india/story/section-377-supreme-court-right-to-privacy-judgment-sparked-fresh-debate-on-decriminalising-gay-sex-1129699-2018-01-08 https://www.indiatoday.in/india/story/section-377-supreme-court-right-to-privacy-judgment-sparked-fresh-debate-on-decriminalising-gay-sex-1129699-2018-01-08 https://www.indiatoday.in/india/story/section-377-supreme-court-right-to-privacy-judgment-sparked-fresh-debate-on-decriminalising-gay-sex-1129699-2018-01-08 kar this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu times of india. https://timesofindia.indiatimes.com/india/gay-sex-is-not-acrime-says-supreme-court-in-historicjudgement/articleshow/65695172.cms. published september 6, 2018. accessed april 8, 2020 42. express web desk. sc hearing on section 377 highlights: law violates right to form association under article 19, say petitioners. the india express. https://indianexpress.com/article/india/supreme-courthearing-section-377-live-updates-decriminalisation-ofhomosexuality-5253008/. published july 11, 2018. accessed april 8, 2020 43. the hindu. ‘not a crime: on supreme court's adultery ruling’. the hindu. https://www.thehindu.com/opinion/editorial/not-acrime/article25061715.ece. published september 28, 2018. accessed april 8, 2020 44. sheth an, rolle cp, gandhi m. hiv pre-exposure prophylaxis for women. j virus erad. 2016 jul; 2(3): 149– 155. 45. goparaju l, experton ls, praschan nc et al. women want pre-exposure prophylaxis but are advised against it by their hiv-positive counterparts. j aids clin res. 2015 november; 6(11): 1–10. doi:10.4172/21556113.1000522. 46. rodriguez-jimenez j. op-ed: it is time to end bottomshaming. the advocate. https://www.advocate.com/31days-prep/2014/10/31/op-ed-it-time-end-bottom-shaming. published october 31, 2014. accessed april 8, 2020 47. centers for disease control and prevention. anal sex and hiv risk. centers for disease control and prevention. https://www.cdc.gov/hiv/risk/analsex.html. published october 27, 2016. accessed april 8, 2020 48. moskowitz, da., rieger, g, roloff, me. tops, bottoms and versatiles. sexual and relationship therapy; 2008; 23(3): 191-202. 49. curry t. how prep empowers bottoms. the advocate. https://www.advocate.com/hivaids/2015/9/25/how-prep-empowers-bottoms. published september 25, 2015. accessed april 8, 2020 50. avert. transgender people, hiv and aids. avert. https://www.avert.org/professionals/hiv-social-issues/keyaffected-populations/transgender updated: october 10, 2019. accessed on: april 22, 2020. 51. sevelius jm, deutsch mb, grant. r. the future of prep among transgender women: the critical role of gender affirmation in research and clinical practices. j int aids soc. 2016; 19(7suppl 6): 21105. doi: 10.7448/ias.19.7.21105 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://timesofindia.indiatimes.com/india/gay-sex-is-not-a-crime-says-supreme-court-in-historic-judgement/articleshow/65695172.cms https://timesofindia.indiatimes.com/india/gay-sex-is-not-a-crime-says-supreme-court-in-historic-judgement/articleshow/65695172.cms https://timesofindia.indiatimes.com/india/gay-sex-is-not-a-crime-says-supreme-court-in-historic-judgement/articleshow/65695172.cms https://indianexpress.com/article/india/supreme-court-hearing-section-377-live-updates-decriminalisation-of-homosexuality-5253008/ https://indianexpress.com/article/india/supreme-court-hearing-section-377-live-updates-decriminalisation-of-homosexuality-5253008/ https://indianexpress.com/article/india/supreme-court-hearing-section-377-live-updates-decriminalisation-of-homosexuality-5253008/ https://www.thehindu.com/opinion/editorial/not-a-crime/article25061715.ece https://www.thehindu.com/opinion/editorial/not-a-crime/article25061715.ece https://www.advocate.com/31-days-prep/2014/10/31/op-ed-it-time-end-bottom-shaming https://www.advocate.com/31-days-prep/2014/10/31/op-ed-it-time-end-bottom-shaming https://www.cdc.gov/hiv/risk/analsex.html https://www.advocate.com/hiv-aids/2015/9/25/how-prep-empowers-bottoms https://www.advocate.com/hiv-aids/2015/9/25/how-prep-empowers-bottoms https://www.avert.org/professionals/hiv-social-issues/key-affected-populations/transgender https://www.avert.org/professionals/hiv-social-issues/key-affected-populations/transgender cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. screening procedure for hemihypertrophy: preliminary results of international multicenter prospective study michael vaiman1, phillip shilco2,9, yulia roitblat3, nicolas padilla-raygoza4, aidan leit5, aaron kavin6, edan schonberger6, liliia nehuliaieva7, noa buchris8,9, michael shterenshis9 1department of otolaryngology, assaf harofeh medical center, affiliated with sackler faculty of medicine, tel aviv university, telaviv, israel; 2“briut hashen” dental health clinic, jerusalem, israel 3department of sciences, belkind school for special education, rishon-lezion, israel; 4department of nursing and obstetrics, division of health sciences and engineering, campus celaya-salvatierra, university of guanajuato, mexico; 5department of sciences, the harley school, rochester, ny, usa; 6department of anatomy, mount moriah college, sydney, australia; 7department of pediatrics, danylo halytsky lviv national medical university, lviv, ukraine; 8dept. of sciences, el camino real charter high school, woodland hills, ca, usa; 9science research department, alexander muss high school in israel (amhsi) affiliated with alexander muss institute for israel education (amiie), hod hasharon, israel vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.336 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.336|http://cajgh.pitt.edu abstract introduction: isolated or congenital hemihypertrophy is a rare disorder characterized by asymmetric overgrowth of one side of the body. this article describes the protocol and preliminary results of a lateral body asymmetry (hemihypertrophy) screening procedure performed in healthy adolescents in a multicenter study. the reported incidence of hemihypertrophy varies between different publications and standardized protocols are needed to improve research in this area. methods: our screening program is taking place in australia, israel, mexico, ukraine and usa. procedure includes two steps: (1) “three measurements – three questions” screening, or assessment of face, palms, and shins; (2) in-depth assessment of selected cases in order to exclude localized, lesional, and syndrome-related cases as well as body asymmetry within normative range and to select suspected cases of isolated hemihypertrophy. this step includes measurements of various anatomical regions and a detailed questionnaire. results: at this stage, the screening procedure is completed and the selected participants are advised to refer to medical institutions for further clinical and genetic follow up to exclude possible tumors and other accompanying disorders. conclusion: we present an easy-to-use selection tool to identify children with suspected ih, which results in the selection of the risk group that may benefit from referral to a pediatrician and a clinical geneticist. keywords: hemihypertrophy; hemihyperplasia; asymmetric regional body overgrowth; body asymmetry; adolescents screening procedure for hemihypertrophy: preliminary results of international multicenter prospective study michael vaiman1, phillip shilco2,9, yulia roitblat3, nicolas padilla-raygoza4, aidan leit5, aaron kavin6, edan schonberger6, liliia nehuliaieva7, noa buchris8,9, michael shterenshis9 1department of otolaryngology, assaf harofeh medical center, affiliated with sackler faculty of medicine, tel aviv university, tel-aviv, israel; 2“briut hashen” dental health clinic, jerusalem, israel 3department of sciences, belkind school for special education, rishonlezion, israel; 4department of nursing and obstetrics, division of health sciences and engineering, campus celaya-salvatierra, university of guanajuato, mexico; 5department of sciences, the harley school, rochester, ny, usa; 6department of anatomy, mount moriah college, sydney, australia; 7department of pediatrics, danylo halytsky lviv national medical university, lviv, ukraine; 8dept. of sciences, el camino real charter high school, woodland hills, ca, usa; 9science research department, alexander muss high school in israel (amhsi) affiliated with alexander muss institute for israel education (amiie), hod hasharon, israel research introduction isolated or congenital hemihypertrophy (ih, isolated hemihyperplasia, human genetic disorders code: omim 23500; lateralized overgrowth) is a rare disorder characterized by asymmetric overgrowth of one side of the body. statistics vary on how many people actually have this pathology because the incidence of ih has been reported to range from 1:13,000 to 1:86,000 live births.1 such estimation may be inaccurate, as the age of onset of ih can vary between the cases. numerous case reports describe patients who were first referred to a pediatrician between 10 and18 years of age.2-4 in general, patients with ih are at an increased risk for medullary sponge kidneys, arteriovenous abnormalities, and tumors in the abdomen. therefore, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.336|http://cajgh.pitt.edu having a standardized screening procedure for such cases is desirable.5,6 adolescents are not usually at risk for tumor development, yet some internal abnormalities may accompany visible body asymmetry, which may severely affect quality of adolescents’ life.1,2,7 diagnosing ih is complicated by similar conditions, including beckwithwiedemann syndrome, proteus syndrome, klippeltrenaunay syndrome, and sotos syndrome, which have symptoms similar to ih. most of these disorders are presented at birth or identified in early childhood, thus the main purpose of the screening is to detect ih in older children. this study describes a screening procedure and the selection tool for adolescent ih cases. recently published article by mark et al. describes in detail how a practitioner should assess and investigate a patient with suspected ih and what surveillance strategy should be applied to such patients.8 our screening procedure may help to select potential ih cases that may benefit from such fifteen-minute consultation. this article describes the protocol and preliminary results of a lateral body asymmetry (hemihypertrophy) screening procedure performed in healthy adolescents in a multicenter study. screening procedure study population our screening is currently taking place in several countries including usa, australia, israel, mexico, and ukraine, aiming to screen at least 5000 participants in each country. institutional review board approvals were acquired for each respective institution that conducts this research. inclusion criteria were the following: healthy individuals, aged 15-18, of both sexes. exclusion criteria were the following: individuals with known disorders such as beckwith-wiedemann syndrome, mosaic trisomy 8, proteus syndrome, russellsilver syndrome (hemihypotrophy), klippel-trenaunay syndrome, sotos syndrome, neurofibromatosis type 1, and bannayan-riley syndrome. prospective participants were excluded from the study if their body asymmetry was a result of known trauma, lymphatic malformation/lymphedema, and vascular malformations. initial screening the screening procedure includes two steps. the initial step is “three measurements – three questions” screening, or “face – palms – shins survey”. the three measurements are: http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu 1. the measurement of the fullest part of the calf below the knee with a difference of circumference ˃1.5 cm between the two legs reported as significant, 2. comparison of palms (figure 1a), with a difference of length ˃1 cm between the two hands reported as significant, 3. assessing face asymmetry by measuring the distance between philtrum (below the nose) and the angle of a lower jaw (figure 1b) with a difference of width ˃1.5 cm as significant. each participant is asked the following three questions: 1. is he/she bothered with his/her body asymmetry? 2. has he/she ever had dental braces, orthodontic treatment, lower jaw repositioning, etc. 3. has he/she ever visited a podiatrist, had orthopedic treatment, or worn shoes of different sizes? the total score for a participant after all measurements and answers ranges from 0 to 9. each positive answer to the question adds 1 point; each asymmetrical measurement adds 1 point if the asymmetry does not psychologically bother a participant, and 2 points if the asymmetry is reported as bothersome to a participant. the selection for the second step is based on the assessment of the score: score 0 to 2 – definitely not selected, score 4 to 9 – definitely selected, score 3– selected if all three points were gained from the measurements data. about five minutes per participant are needed to complete this stage of assessment. follow-up screening the subsequent step is in-depth assessment of selected cases to select suspected cases of ih and exclude localized or lesional cases, in which initial findings are not supported by anatomical changes in other parts of the body or the history of trauma is present. this step includes measurements of various anatomical regions (length of the soles, legs and arms, the circumference of the thigh 10 cm above the upper edge of the patella, theleft and right half-circumferences from the navel to the spinous process of l4, presence/absence of scoliosis). each additional asymmetrical measurement (˃1.5 cm as significant) adds 1 point to the score. an additional question is asked: “are there any other members of your family with any kind of body asymmetry?” a positive answer adds 3 points to the score. the subsequent questions concern the type of malignancy in the family (yes/no, which type, if yes – 1 point is added; if wilms tumor (nephroblastoma that is usually diagnosed in children under the age of 6) – 3 points are added), and ultrasonography of the abdomen (performed: yes/no, if no 1 point is added). if three or more points are added to the initial score that a participant obtained at the first stage, the participant is assigned to the risk group. about 10-15 minutes per participant are needed for these measurements and questions. at this stage, the screening procedure ends and the selected participants, “the risk group”, are advised to refer to medical institutions for further investigations to confirm/disprove ih, for differential diagnosis between hemihypertrophy and hemihypotrophy, that may involve further investigations, and to exclude possible accompanying disorders. results and discussion the preliminary findings as for december 2018 are presented in table 1. these findings indicate the incidence of ih as 1:5000 that is significantly higher than previous 1:13,000 to 1:86,000 estimates. while the initial genetic mutation that leads to ih and the subsequent syndromes appeared in europe in the 19th century, it was rapidly spreading over the planet in the20th century and became a global phenomenon in the 21st century.1,4,6-8 the above-described screening procedure is taking place using the protocol described above in several http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.336|http://cajgh.pitt.edu country goal # of participants selected for selected for diagnosis was screened stage 2 “risk group” confirmed australia 5000 478 2 1 0 israel 5000 5000 185 41 1 mexico 5000 370 0 0 0 ukraine 5000 1834 4 2 0 usa 5000 2384 76 29 1 total 25,000 10,066 267 73 2 table 1. preliminary results of the research (for december 2018) country by country included in the survey. countries across various continents. we would like to suggest that a higher number of children and adolescents with suspected ih need to be referred to pediatricians for consultation to confirm or rule out the disorder in order to improve quality of life of the patients and to ensure that no internal anatomical changes, such as possible accompanying hyperplasia/hypertrophy of the abdominal organs, are evolving. recently published preliminary results based on 6000 participants9 estimate the incidence of ih ranging from 1:13,000 to 1:86,0001 is an underestimation. our goal, therefore, is to screen 25,000 participants internationally to estimate global prevalence of the disorder. our preliminary assessment corroborates the findings of schook et al.10 these authors investigated 170 children with a referral diagnosis of lower extremity lymphedema. they confirmed this diagnosis in only 72.9 percent of patients and found ih in 8.7 percent of the initial cohort. these important findings indicate that ih can be overlooked or misdiagnosed which may lead to incorrect management of some patients. the rationale for selecting the first step measurements was based on the fact that ih most often reveals itself through facial hemihypertrophy and hypertrophy of the limbs. the 1.5 cm difference was chosen as significant because most study participants had left-right face and shins asymmetry between 0.5 and 1.5 cm.9 the length of the palms, however, was symmetrical in most of the cases. the first question was chosen to assess the quality of life and psychological issues. the second question probes further into the facial asymmetry. misdevelopment of the lower jaw is a significant indicator of ih. ih is associated with dental and oral abnormalities, including dental arch asymmetry and differences of dental development in the right and left jaws.11,12 maxillo-facial surgeons may approach the case as an isolated pathology and ih can be overlooked. the same is true for the feet. for abnormal limb size, orthopedic treatment and corrective shoes can be recommended as palliative measures, but podiatrists may overlook ih. the subsequent steps will aim to collect more data within the survey frame. while numerous reports on genetic abnormalities in ih cases were published, additional assessment of other family members to rule out any kind of body asymmetry may be highly informative because hereditary basis of the disorder, the instability of the 11p15.5 chromosomal region, is very well established.1-5,8-10 a close connection between ih and wilms tumor (nephroblastoma, a common pediatric neoplasm of the kidney) was postulated already in the 1950s and was confirmed in more recent publications.13,14 while the overall median age for wilms tumor is 3.5 years, adolescents and even adults also can be affected.15,16 that is why the question about wilms http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx vaiman this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.227|http://cajgh.pitt.edu tumor is one of the key questions in the questionnaire, despite the fact that tumor risk for adolescents is low. we present an easy-to-use selection tool to identify subjects with suspected ih who may benefit from further clinical investigation and genetic counseling. the selection tool involves anthropological measurements and questions concerning family history, quality of life, and details of the lateral body asymmetry, which results in the selection of the risk group that may benefit from referral to a pediatrician and a clinical geneticist. acknowledgements the authors thank mordechai cohen, orit rome, leor sinai, and rachelle sevitt for assistance with this research in israel; ryan cleminson and caleb crossley for assistance with this research in australia; xóchitl sofía ramírez gómez, cuauhtémoc sandoval salazar, marissa padilla morales for assistance with this research in mexico; and jacob ilani, jacob burger, jacob hanai, and sari rosenberg for assistance with this research in the usa. references 1. hoyme he, seaver lh, jones kl, procopio f, crooks w, feingold m. isolated hemihyperplasia (hemihypertrophy): report of a prospective multicenter study of the incidence of neoplasia and review. am j med genet. 1998;79:274-8. 2. urban pp, bruening r. congenital isolated hemifacial hyperplasia. j neurol. 2009;256(9):1566-9. doi: 10.1007/s00415-0095148-9. 3. van der velpen i, schendelaar p, van pinxterennagler e, mouës-vink cm. a 15-year-old girl with an asymmetric hemitruncal fat distribution: hemihypertrophy or hemiatrophy? plast reconstr surg glob open. 2016;4(4):e684. doi: 10.1097/gox.0000000000000653. ecollection 2016 apr. 4. nyati a, kalwaniya s, agarwal p. idiopathic hemihypertrophy with multiple fibroadenoma. indian dermatol online j. 2016;7(4):316-7. doi: 10.4103/2229-5178.185481 5. brioude f, kalish jm, mussa a, foster ac, bliek j, ferrero gb, et al. expert consensus document: clinical and molecular diagnosis, screening and management of beckwithwiedemann syndrome: an international consensus statement. nat rev endocrinol. 2018;14(4):229-249. doi: 10.1038/nrendo.2017.166. 6. suri m. approach to the diagnosis of overgrowth syndromes. indian j pediatr. 2016;83(10):1175-87. doi: 10.1007/s12098015-1958-1. 7. nuzzi lc, cerrato fe, webb ml, et al. psychological impact of breast asymmetry on adolescents: a prospective cohort study. plast reconstr surg. 2014;134(6):1116-23. doi: 10.1097/prs.0000000000000736. 8. mark c, hart c, mccarthy a, thompson a. fifteen-minute consultation: assessment, surveillance and management of hemihypertrophy. arch dis child educ pract ed. 2017 aug 26. pii: edpract-2017-312645. doi: 10.1136/archdischild-2017-312645 9. vaiman m, shilco p, roitblat y, nehuliaieva l, rosenberg s, leit a, cleminson r, shterenshis m. hemihyperplasia/hemihypertrophy in adolescents: prospective international study. int j adolesc med health, 2018, in print. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.ncbi.nlm.nih.gov/pubmed/?term=urban%20pp%5bauthor%5d&cauthor=true&cauthor_uid=19424770 https://www.ncbi.nlm.nih.gov/pubmed/?term=bruening%20r%5bauthor%5d&cauthor=true&cauthor_uid=19424770 https://www.ncbi.nlm.nih.gov/pubmed/19424770 https://www.ncbi.nlm.nih.gov/pubmed/?term=van%20der%20velpen%20i%5bauthor%5d&cauthor=true&cauthor_uid=27200246 https://www.ncbi.nlm.nih.gov/pubmed/?term=schendelaar%20p%5bauthor%5d&cauthor=true&cauthor_uid=27200246 https://www.ncbi.nlm.nih.gov/pubmed/?term=van%20pinxteren-nagler%20e%5bauthor%5d&cauthor=true&cauthor_uid=27200246 https://www.ncbi.nlm.nih.gov/pubmed/?term=van%20pinxteren-nagler%20e%5bauthor%5d&cauthor=true&cauthor_uid=27200246 https://www.ncbi.nlm.nih.gov/pubmed/?term=mou%c3%abs-vink%20cm%5bauthor%5d&cauthor=true&cauthor_uid=27200246 https://www.ncbi.nlm.nih.gov/pubmed/27200246 https://www.ncbi.nlm.nih.gov/pubmed/27559513 https://www.ncbi.nlm.nih.gov/pubmed/27559513 https://www.ncbi.nlm.nih.gov/pubmed/?term=brioude%20f%5bauthor%5d&cauthor=true&cauthor_uid=29377879 https://www.ncbi.nlm.nih.gov/pubmed/?term=kalish%20jm%5bauthor%5d&cauthor=true&cauthor_uid=29377879 https://www.ncbi.nlm.nih.gov/pubmed/?term=mussa%20a%5bauthor%5d&cauthor=true&cauthor_uid=29377879 https://www.ncbi.nlm.nih.gov/pubmed/?term=foster%20ac%5bauthor%5d&cauthor=true&cauthor_uid=29377879 https://www.ncbi.nlm.nih.gov/pubmed/?term=bliek%20j%5bauthor%5d&cauthor=true&cauthor_uid=29377879 https://www.ncbi.nlm.nih.gov/pubmed/?term=ferrero%20gb%5bauthor%5d&cauthor=true&cauthor_uid=29377879 https://www.ncbi.nlm.nih.gov/pubmed/?term=brioude+f%2c+kalish+jm%2c+mussa+a%2c+foster+ac%2c+bliek+j%2c+ferrero+gb https://www.ncbi.nlm.nih.gov/pubmed/?term=suri%20m%5bauthor%5d&cauthor=true&cauthor_uid=26680784 https://www.ncbi.nlm.nih.gov/pubmed/26680784 https://www.ncbi.nlm.nih.gov/pubmed/25415081 https://www.ncbi.nlm.nih.gov/pubmed/25415081 https://www.ncbi.nlm.nih.gov/pubmed/28844056 https://www.ncbi.nlm.nih.gov/pubmed/28844056 https://www.ncbi.nlm.nih.gov/pubmed/28844056 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.336|http://cajgh.pitt.edu 10. schook cc, mulliken jb, fishman sj, alomari ai, grant fd, greene ak. differential diagnosis of lower extremity enlargement in pediatric patients referred with a diagnosis of lymphedema. plast reconstr surg. 2011;127(4):1571-81. doi: 10.1097/prs.0b013e31820a64f3. 11. orbak z, orbak r, kara c, kavrut f. differences in dental and bone maturation in regions with or without hemihypertrophy in two patients with russell-silver syndrome. j pediatr endocrinol metab. 2005;18(7):701-10. 12. jia hc, sun xh. dental arch characteristics of the facial asymmetry. hua xi kou qiang yi xue za zhi. 2005;23(5):412-4, 437. 13. bjorklund si. hemihypertrophy and wilms's tumour. acta paediatr. 1955;44(3):287-92. 14. dumoucel s, gauthier-villars m, stoppalyonnet d, et al. malformations, genetic abnormalities, and wilms tumor. pediatr blood cancer. 2014;61(1):140-4. doi: 10.1002/pbc.24709. 15. arrigo s, beckwith jb, sharples k, d'angio g, haase g. better survival after combined modality care for adults with wilms' tumor. a report from the national wilms' tumor study. cancer. 1990;66:827-30. 16. breslow n, beckwith jb, ciol m, sharples k. age distribution of wilms' tumor: report from the national wilms' tumor study. cancer res. 1988;48:1653-5 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.ncbi.nlm.nih.gov/pubmed/?term=schook%20cc%5bauthor%5d&cauthor=true&cauthor_uid=21187804 https://www.ncbi.nlm.nih.gov/pubmed/?term=mulliken%20jb%5bauthor%5d&cauthor=true&cauthor_uid=21187804 https://www.ncbi.nlm.nih.gov/pubmed/?term=fishman%20sj%5bauthor%5d&cauthor=true&cauthor_uid=21187804 https://www.ncbi.nlm.nih.gov/pubmed/?term=alomari%20ai%5bauthor%5d&cauthor=true&cauthor_uid=21187804 https://www.ncbi.nlm.nih.gov/pubmed/?term=alomari%20ai%5bauthor%5d&cauthor=true&cauthor_uid=21187804 https://www.ncbi.nlm.nih.gov/pubmed/?term=grant%20fd%5bauthor%5d&cauthor=true&cauthor_uid=21187804 https://www.ncbi.nlm.nih.gov/pubmed/?term=greene%20ak%5bauthor%5d&cauthor=true&cauthor_uid=21187804 https://www.ncbi.nlm.nih.gov/pubmed/21187804 https://www.ncbi.nlm.nih.gov/pubmed/?term=orbak%20z%5bauthor%5d&cauthor=true&cauthor_uid=16128247 https://www.ncbi.nlm.nih.gov/pubmed/?term=orbak%20r%5bauthor%5d&cauthor=true&cauthor_uid=16128247 https://www.ncbi.nlm.nih.gov/pubmed/?term=kara%20c%5bauthor%5d&cauthor=true&cauthor_uid=16128247 https://www.ncbi.nlm.nih.gov/pubmed/?term=kavrut%20f%5bauthor%5d&cauthor=true&cauthor_uid=16128247 https://www.ncbi.nlm.nih.gov/pubmed/16128247 https://www.ncbi.nlm.nih.gov/pubmed/16128247 https://www.ncbi.nlm.nih.gov/pubmed/?term=jia%20hc%5bauthor%5d&cauthor=true&cauthor_uid=16285549 https://www.ncbi.nlm.nih.gov/pubmed/?term=sun%20xh%5bauthor%5d&cauthor=true&cauthor_uid=16285549 https://www.ncbi.nlm.nih.gov/pubmed/16285549 https://www.ncbi.nlm.nih.gov/pubmed/16285549 https://www.ncbi.nlm.nih.gov/pubmed/13292237 https://www.ncbi.nlm.nih.gov/pubmed/13292237 https://www.ncbi.nlm.nih.gov/pubmed/23970395 https://www.ncbi.nlm.nih.gov/pubmed/23970395 abstract keywords: hemihypertrophy; hemihyperplasia; asymmetric regional body overgrowth; body asymmetry; adolescents research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. alcohol and tobacco use among undergraduate and postgraduate medical students in india: a multicentric cross-sectional study nidhi goel, vivek khandelwal, kapil pandya, atul kotwal armed forces medical services, india vol. 4, no. 1 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.187 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/4.0/ goel this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.187 | http://cajgh.pitt.edu abstract background: substance use among medical fraternity is a well-known phenomenon among both undergraduate (ug) and postgraduate (pg) medical students. yet, there have been very few multi-centric studies to estimate the actual burden of this problem in this important population group in india. this study was conducted to estimate the prevalence of alcohol and tobacco use, assess the knowledge and attitudes towards this issue, and identify factors associated with substance use among ug and pg medical students in india. methods: a pre-tested, self-report, anonymous questionnaire was administered to medical undergraduates and post graduate medical residents of eight medical colleges across india. this study used a convenience sample of medical colleges with random selection of study participants within each college for each group, ug and pg. results: prevalence of alcohol and tobacco use among ug students was 16.6%, 95% ci [14.5, 18.9] and 8.0%, 95% ci [6.4, 9.6], respectively, whereas prevalence was 31.5%, 95% ci [26.3, 37.0] and 14.5%, 95% ci [10.7, 18.9], respectively for pgs. for both substances, males had a higher prevalence of use compared to females in both groups (p < 0.001). positive family history of substance use (p < 0.001 for both groups) and early age of initiation (p = 0.011 for tobacco; p > 0.05 for alcohol) were associated with a greater difficulty to quit the habit. over 90% of study participants felt that substance use adversely affected their skills and reported not using substances prior to managing their patients. conclusions: since substance use is a relatively common phenomenon among ug and pg medical students in india, future prospective studies and interventions are required to better understand the pattern of substance use and reduce its prevalence. keywords: alcohol, tobacco, undergraduate medical students, postgraduate medical students, cross-sectional alcohol and tobacco use among undergraduate and postgraduate medical students in india: a multicentric cross-sectional study nidhi goel, vivek khandelwal, kapil pandya, atul kotwal armed forces medical services, india research undergraduate (ug), as well as postgraduate (pg), medical students are exposed to daily stressors, which can lead to substance use and abuse. substance abuse remains a covert yet well-known phenomenon among medical students and medical practitioners globally.1,2 substances that have been documented as being used recreationally among medical students in india include alcohol, tranquillizers, and psychedelics.3 recreational drug use has become more popular and may be representative behavior of the youth lifestyle; thus, increasing the need to monitor drug use trends, especially among ug and pg medical students.1 substance abuse is any maladaptive pattern of substance use leading to clinically significant impairment or distress. impairment in social and occupational functioning is often associated with substance use, which includes the inability to control use of or to discontinue use of the substance. additionally, substance use may be associated with the development of serious withdrawal http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.187 | http://cajgh.pitt.edu symptoms after cessation of or reduction in use for recreational or medical purposes.4 in the developed countries, studies have shown that alcohol impairment is one of the leading reasons for disciplinary action against physicians.5 however, this problem and effective interventions to reduce substance use among physicians have not been sufficiently explored in published research studies. numerous studies conducted in the field of substance use around the world have focused mainly on the general population and adult age groups.6,7 most of the indian studies in this field are regional in nature, representing a large research gap which our study is aiming to address. there is a dearth of large multi-centric efforts in india to evaluate this important public health concern.8-11 global prevalence rates of alcohol abuse disorders among adults were estimated to range from 016.0% with highest prevalence rates in eastern europe.12 tobacco consumption and nicotine addiction is a major global concern, popularly known as the “brown epidemic.”13 the prevalence of smoking is as high as 51.0% in men (who western pacific region) and 22.0% in women (who european region) with an increasing trend in adolescent girls and boys globally.13 in india, alcohol use figures vary widely from 3.8% to 21.0%, with men 9.7 times more likely to regularly use alcohol as compared to women.8,9,14 prevalence of smoking has been estimated as 26.0% in males and 4.0% in females. for youth, the prevalence is 19.0% and 8.3%, respectively.15 in previous studies, men were 25.5 times more likely than women to report regular smoking and 3.7 times more likely to regularly chew tobacco.13 there are few studies to date that have examined the prevalence of tobacco and alcohol use among ugs and pgs. out of the available studies, tobacco and alcohol use prevalence was 9.0% in ugs and 7.1 in pgs.10,11,16 young physicians had a prevalence of 16.7% for alcohol use.17 thus, geographic variation and changing trends in substance use around the globe warrant new epidemiologic investigations that can be used to inform policy changes. medical fraternity (ug as well as pg) is no different from the general population when it comes to substance use; however, they may be at a higher risk of substance use problems due to higher stress levels. this study was conducted to estimate the prevalence of alcohol and tobacco use, to assess the knowledge and attitudes towards this issue, and to explore possible risk factors associated with substance use among ug and pg medical students in india. an effort was also made to gather suggestions from the fraternity for tackling this problem. use of illegal drugs and psychoactive substances were not studied due to ethical concerns as well as the potential lack of willingness to participate in the study. methods participants and settings twelve medical colleges were recruited for participation in the study; however, four colleges did not have a sufficient sample of students for participation. the resulting 8 medical colleges participated in a multicentric, cross-sectional survey. there were four medical colleges from maharashtra and one each from new delhi, west bengal, madhya pradesh, and kerala. the selection of medical colleges was convenience based, as per logistics and staff availability. for each selected college, a sample size was calculated using an estimated alcohol use prevalence of 25.0%. with alpha as 0.05 and an error margin as 7.5%, the appropriate sample size was 128. a sample of 150 final year bachelor of medicine, bachelor of surgery (mbbs) degree students and 55 pg residents was drawn from each college by simple random sampling. ethical clearance for the study was obtained from institutional ethical committee of armed forces http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goel this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.187 | http://cajgh.pitt.edu medical college, pune, india. informed consent was obtained from each participant. a self-report, anonymous, pretested questionnaire covering multiple domains of substance use was used for data collection. statistical analysis was performed using spss (version 14.0). data analysis descriptive statistics were obtained to describe basic characteristics of the study participants. descriptive statistics were also used to estimate the prevalence of alcohol and tobacco use. inferential statistics were used to compare male and female substance use and for differences between ug and pg for age of initiation of substance use. age of initiation was compared amongst two groups, greater than 16 years of age and 16 years of age or younger at initiation, and then further analyzed to assess impact on difficulty in quitting the habit. chisquare test was used to measure the risk associated with family history of substance use and current substance use and to assess the knowledge and attitudes towards substance use. p-values lower than 0.05 were considered significant. results the mean age of the participating ugs was 21.5 ± 1.6 years and pgs was 29.0 ± 3.7 years. 46.2% of ug students and 72.7% of pg students were male. table 1 shows the distribution of participant characteristics and prevalence of substance usage in each college. table 1. distribution of alcohol and tobacco use among participants stratified by college and student group out of the 1,455 participants, males were significantly more involved in substance use as compared to females (p < 0.001 for alcohol as well as tobacco). age of initiation was significantly lower in ugs as compared to pgs (p = 0.003) for alcohol as well as tobacco. when this age was dichotomized into 16 years or less and greater than 16 years, younger age of initiation was significantly associated with more difficulty in quitting tobacco (p = 0.011) but not alcohol. positive family history was significantly associated with increased prevalence of substance use, as shown in table 2. those who had a positive family history also found it more difficult to quit (p < 0.001). table 3 shows the percentages of participants who attempted to quit. table 2. association of a positive family history with consumption of substances among ugs and pgs table 3. proportion of participants who tried to quit the habit ‘feeling psychologically upset’ (30.8% alcohol; 45.2% tobacco) and ‘pressure by friends’ (41.0% alcohol; 19.0% tobacco) were the most common reasons reported for resumption of the habit in those who quit but relapsed. a significant association between respondents’ “thinking substance abuse was a growing problem” and their “thinking that something should be done about it” (p = 0.003) was also found. alcohol use affecting overall performance as a physician was mentioned by 65.6% of pgs. beverage preferences associated with alcohol and mode of tobacco consumption are depicted in table 4. when questioned about the description of occasions when they consumed alcohol or tobacco, the highest number of participants answered ‘with close friends’ followed by ‘during parties.’ however, for the occasion ‘during exams,’ frequency of tobacco use increased more than that of alcohol. “batch-mates” (or classmates), which refers to a cohort of students of the same entrance http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.187 | http://cajgh.pitt.edu year in medical school, were the most common people to encourage the participants use either of the substances, followed by “seniors.” table 4. alcohol types and tobacco modes used for consumption discussion our study was conducted in 8 medical colleges across india. it revealed that prevalence of alcohol consumption for ug students and pg students was 16.6%, 95% ci [14.5, 18.9] and 31.5%, 95% ci [26.3, 37.0], respectively. tobacco usage for ug students and pg students was found to be 8.0%, 95% ci [6.0, 9.6] and 14.5%, 95% ci [10.7, 18.9], respectively. the former are thought to be especially vulnerable to prescription drug use due to greater access and the professional culture that favors pharmacological approaches to the management of occupational stress.3,9 studies have shown an alarming increase in drug, alcohol, and tobacco consumption among doctors in the latter half of 20th century globally.11 personal use of addictive substances by doctors has the potential to jeopardize their professional performance, as well as care of patients with addictions,18 thus, it is important to investigate this area of concern. 82.5% medical students in previously published irish study were current alcohol consumers,18 whereas the prevalence was only 16.6% in our study. for resident doctors, the prevalence of 31.5% in our sample was higher than 16.7% as brought out in previous studies on young indian physicians.17 the prevalence of alcohol use among our study participants is higher when compared with prevalence among adult indian general population, which ranges between 3.8% to 4.5%.8,12 for medical students, the prevalence of current tobacco usage has been previously reported to be 10% in the indian population17 and 15.3% in western populations.18 in our study, the prevalence of current tobacco usage is 8% and 14.5% among medical students and doctors, respectively, which is almost equal to the national medical fraternity figures. the prevalence of tobacco use in any form is much lower in medical students (17.5%) as compared to students in general (21.6%).19 tobacco was consumed in smoking form by the majority of its users, which is consistent with national as well as global trends. our study highlights the finding that for medical fraternity, the overall prevalence of tobacco usage is lower than the national figures. this is true in some other countries, including china.20 in countries like the united states of america, greece, japan, and australia, the trends of substance use in medical fraternity follows the national prevalence rates.20 the overall low prevalence of tobacco usage may be attributed to bans on smoking in campuses in the government medical colleges. for both substances, males had a higher prevalence of consumption compared to females. this was true for medical students, as well as resident doctors (p = 0.001). this trend is similar to other published studies conducted in india and across the world.1,20 though alcohol use rates have been increasing in females according to some studies,18 no such trends were found in this study due to its cross sectional design. future prospective studies may be able to more thoroughly examine temporal trends in substance use. one of the interesting findings of this study is that medical students and doctors who had a positive family history of substance use had higher prevalence of substance use. though this factor is not commonly analyzed in previously published investigations, this finding is very important for india, where family values greatly influence the behaviors of younger people as reported in previous indian study.3 thus, families can potentially play a role in reducing substance consumption in the medical community. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goel this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.187 | http://cajgh.pitt.edu another factor which is scarcely reported in the literature on substance use among medical professionals is the age of initiation of substance usage. in our study, we found that current ug students are beginning the usage of alcohol or tobacco much earlier than current pg students (p = 0.01). also, for tobacco, earlier age of initiation (less than 16 years) was associated with difficulty in quitting. this means that the efforts to educate and counsel the medical students on problems associated with substance use must start much earlier than previously thought, preferably at the very beginning of their medical curriculum. among the reasons for initiation, “curiosity” was the most common reason reported by the respondents in our study. this response is consistent with most studies on this subject.8-11 the implication is that if the concepts of neuro-physiological mechanisms involved in substance use and addiction are explained to the students at the time of entry into the medical colleges, the curiosity factor and the experimentation tendency might be reduced. other reasons for initiation of alcohol use were ‘pleasure’ and ‘stress/anxiety relief.’1 the individuals most commonly encouraging or influencing initiation of substance use were ‘batchmates.’ also, for most of those who tried to quit, it was their friends that pressured them to relapse. thus, if we are able to reduce substance use rate in a small group of students, they potentially would be able to influence others to change their behaviors and reduce substance use. however, a large number of students reported that no one encouraged them, indicating that a significant group of students were self-motivated to initiate the habit. thus, this group can particularly benefit from behavior change communication (bcc) activities. an interesting finding is that among doctors using any substance, 92.0% 95.0% had never consumed the respective substance prior to managing their patients or conducting a medical/ surgical procedure, suggests that respondents understand that substance use may influence their professional performance. strengths and limitations the main limitation of this study was the convenience sampling method used to select the medical colleges. the other limitation was a low response rate in a few of the medical colleges or lack of willingness to answer questions related to alcohol consumption. additionally, cross-sectional nature of this study did not allow us to make conclusions about substance use trends over time, limitation that will be addressed by future research studies. the key strength of this study was its multicentric approach, since medical colleges from different parts of the country were involved. also, this study examines various risk factors and correlates for substance use in ugs as well as pgs, which can potentially guide counseling efforts or other interventions. this study provides a foundation for future prospective studies can be conducted regarding the role of bcc approach targeted at specific points in a medical student’s career. references 1. newbury-birch d, walshaw d, kamali f. drink and drugs: from medical students to doctors. drug alcohol depend. 2001;64(3):265-270. 2. domenighetti g, tomamichel m, gutzwiller f, berthoud s, casabianca a. psychoactive drug use among medical doctors is higher than in the general population. soc sci med. 1991;33(3):269-274. 3. kumar p, basu d. substance abuse by medical students and doctors. j indian med assoc. 2000;98(8):447-452. 4. american psychiatric association. diagnostic and statistical manual of mental disorders: dsm-iv. washington d. c.: american psychiatric association; 1994. 5. holtman mc. disciplinary careers of drugimpaired physicians. soc sci med. 2007;64(3):543-553. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.187 | http://cajgh.pitt.edu 6. baptista t, uzcàtegui e. substance use among resident doctors in venezuela. drug alcohol depend. 1993;32(2):127-132. 7. ghosh s, samanta a, mukherjee s. patterns of alcohol consumption among male adults at a slum in kolkata, india. j health popul nutr. 2012;30(1):73-81. 8. neufeld kj, peters dh, rani m, bonu s, brooner rk. regular use of alcohol and tobacco in india and its association with age, gender, and poverty. drug alcohol depend. 2005;77(3):283-291. 9. murthy p, manjunatha n, subodh bn, chand pk, benegal v. substance use and addiction research in india. indian j psychiatry. 2010;52(5):189-199. 10. ramakrishna gs, sankara sarma p, thankappan kr. tobacco use among medical students in orissa. natl med j india. 2005;18(6):285-289. 11. seshadri s. substance abuse among medical students and doctors: a call for action. natl med j india. 2008;21(2):57-59. 12. world health organization (who). global health observatory: prevalence of alcohol use disorders. 2012; www.who.int/gho/substance_abuse/burden/alc ohol_prevalence/en/index.html. accessed july 8, 2012. 13. agrawal a, lynskey mt. tobacco and cannabis co-occurance: does route of administration matter. drug alcohol depend. 2009;99(1-3):240-247. 14. deepa m, pradeepa r, anjana rm, mohan v. noncommunicable diseases risk factor surveillance: experience and challenge from india. indian j community med. 2011;36(suppl 1):s50-s56. 15. world health organization (who). global health observatory: prevalence of tobacco use. 2012; www.who.int/gho/tobacco/use/en/. accessed july 10, 2012. 16. british medical association. the misuse of alcohol and other drugs by doctors. london: british medical association; 1998. 17. ray r. the extent, pattern and trends of drug abuse in india: national survey. ministry of social justice and empowerment, government of india & united nations office on drugs and crime, regional office for south asia; 2004. 18. boland m, fitzpatrick p, scallan e, et al. trends in medical student use of tobacco, alcohol and drugs in an irish university, 1973-2002. drug alcohol depend. 2006;85(2):123-128. 19. reddy ks, shah b, varghese c, ramadoss a. responding to the threat of chronic diseases in india. lancet. 2005;366(9498):1744-1749. 20. smith dr, leggat pa. an international review of tobacco smoking among medical students. j postgrad med. 2007;53(1):55-62. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/gho/substance_abuse/burden/alcohol_prevalence/en/index.html http://www.who.int/gho/substance_abuse/burden/alcohol_prevalence/en/index.html http://www.who.int/gho/tobacco/use/en/ goel this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.187 | http://cajgh.pitt.edu table 1: distribution of alcohol and tobacco use among participants stratified by college and student group medical college ug students pg residents n prevalence (95% ci) n prevalence (95% ci) alcohol tobacco alcohol tobacco 1 100 16(9.4,24.6) 11(5.6,18.8) 41 29.3(16.1,45.5) 17.1(7.1,32) 2 151 38.4(30.6,46.6) 21.9(15.5,29.2) 35 40(23.8,57.8) 22.9(10.4,40.1) 3 151 17.2(11.5,24.2) 7.9(4.1,13.4) 35 40(23.8,57.8) 22.9(10.4,40.1) 4 148 4.1(1.5,8.6) 0 50 22(11.5,35.9) 0 5 150 7.3(3.7,12.7) 2.7(0.7,6.6) 50 30(17.8,44.6) 8(2.2,19.2) 6 151 17.2(11.5,24.2) 7.9(4.1,13.4) 0 0 0 7 148 4.1(1.5,8.6) 0 50 22(11.5,35.9) 0 8 145 28.3(21.1,36.3) 13.1(8.0,19.7) 50 42(28.1,56.8) 36(23,50.8) total 1,144 16.6(14.5,18.9) 8(6.,9.6) 311 31.5(26.3,37.0) 14.5(10.7,18.9) grand total n=1,455 total prevalence among med fraternity: alcohol – 19.8(17.8, 21.9); tobacco – 9.4(8.0, 11.0) note. * indicates that the number of participants enrolled were less than the required sample size http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.187 | http://cajgh.pitt.edu table 2: association of a positive family history with consumption of substances among ugs and pgs family history self-consumption p-value* yes no alcohol + 156 245 < 0.001 132 922 tobacco + 52 171 < 0.001 84 1,148 note. *based off chi-square analyses. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx goel this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.187 | http://cajgh.pitt.edu table 3: proportion of participants who tried to quit the habit alcohol tobacco no answer 11 (3.8%) 12 (8.8%) no 237 (82.3%) 82 (60.3%) yes 40 (13.8%) 42 (30.9%) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.187 | http://cajgh.pitt.edu table 4: alcohol types and tobacco modes used for consumption type of substance n alcohol beer 226 vodka 175 whisky 162 rum 100 other 146 total 288 (19.8%) tobacco smoking 120 chewing 3 sniffing 1 total 136 (9.3%) note. discrepancy in totals is due to multiple responses for some options and no response by some users. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. estimating maternal mortality in remote rural regions: an application of the sisterhood method in tajikistan kylea laina liese1, heather pauls2, sarah robinson3, crystal patil1 1department of women, children, and family health sciences, university of illinois, chicago, usa; 2office of research facilitation, university of illinois, chicago, usa; 3department of psychology and educational sciences, university of geneva, switzerland vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.341 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ liese this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.341|http://cajgh.pitt.edu abstract introduction: the sisterhood method of maternal mortality data collection and analysis provides a validated framework for estimating maternal mortality ratios in situations of limited infrastructure. the aim of this study is to assess sub-national maternal mortality in the badakhshan region of tajikistan using the sisterhood method as part of a larger ethnographic study on maternal risk. methods: in 2006-2007, 1004 married women of reproductive age in gorno-badakhshan autonomous oblast, tajikistan were surveyed using the sisterhood method. respondents were asked eleven questions about the sex, age and survivorship of all children born to the respondent’s mother. results: using a national total fertility rate (tfr) estimate of 4.88, the maternal mortality ratio (mmr) in tajik badakhshan was 141 maternal deaths per 100,000 live births (95% ci 49-235). the lifetime risk of maternal death was 1 in 141 (95% ci 34-103). conclusion: given the inherent time-lag of the sisterhood method, precise estimates of maternal mortality are dependent on accurate tfrs, which may vary based upon regional experiences of demographic transitions. socio-political instability and the dismantling of soviet welfare programs and civil war following tajikistan’s independence from the soviet union in 1991 likely impacted tfr in tajik badakhshan. socio-political trends influencing tfr in rural regions compared to urban, and the investigation of factors associated with maternal mortality, require additional investigation. keywords: maternal mortality, sisterhood method, tajikistan, gorno-badakhshan autonomous oblast estimating maternal mortality in remote rural regions: an application of the sisterhood method in tajikistan kylea laina liese1, heather pauls2, sarah robinson3, crystal patil1 1department of women, children, and family health sciences, university of illinois, chicago, usa; 2office of research facilitation, university of illinois, chicago, usa; 3department of psychology and educational sciences, university of geneva, switzerland research introduction countries with the highest rates of maternal mortality typically do not have strong health information systems. these systems are vital to generate accurate maternal mortality ratio (mmr), the statistical backbone on which millions of dollars are spent through research, programming, monitoring, and evaluation. however, maternal mortality ratios are complex indicators with estimation requiring both the accurate identification of cause of death and large sample sizes.1-2 the sisterhood method of maternal mortality data collection and analysis provides a validated framework for estimating maternal mortality ratios in situations of limited infrastructure.2-3 the sisterhood method embedded in demographic and health surveys (dhs) produce maternal mortality ratios for at least 28 countries, comprising 16% of global births.3 with better estimates of maternal mortality at the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.341|http://cajgh.pitt.edu subnational level, health care spending could be tailored to address the specific needs of rural populations. maternal mortality rates in post-soviet central asia are lower than those in countries with similar income levels, likely due to comprehensive social and economic development programs of the soviet era (e.g., paved roads, compulsory education, access to healthcare and minimum marriage age). in tajikistan, the poorest of the post-soviet countries, health care in the mountainous region of gorno-badakhshan autonomous oblast (administrative region) (gbao) is limited compared to urban centers. although gbao makes up 45% of the land of tajikistan, it is scarcely populated with only 218,000 residents (3% of the national population).5 villages in gbao are situated along tributaries leading into and along the pyanj river, the border between tajikistan and afghanistan. as citizens of a former soviet republic (1929-1991), tajik women in gbao had greater access to quality obstetric care and were rewarded for having upwards of ten offspring to grow “the fatherland.” however, with the breakdown of soviet union in 1991, women were encouraged to curb their fertility.6-7 the dismantling of soviet welfare programs and the socio-political instability associated with independence contributed to a civil war between 19921997, which further destabilized the country’s health and social infrastructure. this transition directly and indirectly impacted maternal risk as women’s access to high quality obstetric care declined, and funding for maintaining roads, schools, and hospitals was reduced. the data presented here come from a maternal mortality survey using the sisterhood method2 conducted in the darwaz district of gbao tajikistan in 2006. this survey was part of a larger anthropological study that used mixed-methodologies to explore the underlying biosocial context of maternal risk in the badakhshan regions shared between tajikistan and afghanistan. in 2001, afghan badakhshan was reported to have the highest maternal mortality ratio ever recorded (6507 deaths per 100,000 live births) in a maternal mortality survey that utilized the sisterhood method.8 although national estimates suggested that maternal mortality was much lower in tajik badakhshan, situated directly across the pyanj river, no subnational data existed. since these regions share important ethnic and geopolitical features (e.g., poor roads, mountainous terrain, and histories of civil war and drug trade), investigating gbao maternal mortality rates is very important. the purpose of this study was to obtain an estimate of maternal mortality in the badakhshan region of tajikistan and to compare it with afghan badakhshan, harnessing previously collected comparative ethnographic data. materials and methods this study was carried out in 2006-2007 in gbao. with a population of 23,600, darwaz district was selected because of a bridge connecting villages on either side of the border, permitting the lead researcher a unique regular access to otherwise isolated afghan and tajik villages. the population of darwaz is predominantly ethnically tajik and religiously muslim. in addition to the survey, the study included semistructured interviews (n=184) with married women of reproductive age, which collected observations on birth and reproductive health care in local clinics and hospitals. also included were key informant interviews with community and religious leaders and healthcare providers in tajik and afghan villages situated opposite each other along the border. after training, three local female field assistants fluent in tajiki language conducted household surveys, recording the data using the standardized validated forms. over the course of 7 months, every third household in 24 villages in tajik badakhshan was selected and visited. the villages were selected based on population (< 300 households, > 300 households), geographic location (road access, along a river/tributary, on a mountainside), and distance from the district http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx liese this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.341http://cajgh.pitt.edu hospital in kalai-khumb. all women present in the household who were 18 and older and who were not sisters were invited to participate. a total of 820 participants answered the minimum four interview questions necessary for the analysis. this short survey was also embedded in a longer semi-structured interview for another 184 participants, resulting in a total of 1004 participants. the longer ethnographic interview instrument elicited a complete reproductive history, including onset of sexual activity, contraceptive use, details on each pregnancy and birth, and personal perspectives on the issues of gender, marriage, and childbearing risk in their village. no males were interviewed. three subjects with unknown ages were excluded from the long interview group, resulting in the final sample size of 1001 research participants. this study was approved by the stanford university irb, and all respondents verbally consented to participating in the study. by interviewing women about the survival of their adult sisters, the sisterhood method allows for retrospective maternal mortality estimates in remote regions like gbao because it reduces sample size requirements and costs. the who has relied on maternal mortality estimates collected via the sisterhood method to provide crucial maternal health programming in the absence of vital registration systems since the 1980’s.4 according to the procedure for the direct sisterhood method (s1),2 respondents were asked eleven questions about the sex, age and survivorship of all children born to the respondent’s mother. for all sisters reported to be deceased who were married, respondents were asked for the year of death, age at death, and whether the sister died while pregnant, in childbirth, or within the 42 days following pregnancy or childbirth. answers to these questions were used to obtain data on four indicators: 1) the number of sisters born to the same mother who reached the age of 15 years or older; 2) how many of these sisters were still alive; 3) how many of these sisters died; and 4) of those who died, how many died during pregnancy or within 42 days of birth. undergraduate research assistants from the university of central asia in dushanbe entered the data into an excel database. data were cleaned prior to analysis by reviewing and comparing the data in the excel spreadshees and the paper forms. erroneous values and missing data were coded as missing (less than 2%). although the legal age of marriage in tajikistan is 17, women regularly married at younger ages.7 to consider these cultural factors, we followed the method of smith et al9 and counted every female sibling over the age of 15 as married. siblings under the age of 15 were excluded, but their data were used to compute total reported siblings. polygyny is illegal in tajikistan and not routinely practiced. no homes with multiple wives were visited. for the 820 participants who completed the short survey, the respondent’s exact age was not collected. respondent age was estimated, and age categories were assigned using birth order and reported sibling ages. to estimate respondent age, the population mean interbirth interval, the total age range of siblings divided by total number of siblings (ibi = 2.78), was added to the age of the sibling born just prior to the respondent. for the 181 women who received more indepth interviews as part of the larger ethnographic study, year of birth was collected, and we therefore used exact age. five groups were used to produce age category estimates. we used r (2018) version “joy in playing” for calculations based on the methodology suggested by graham [table 1].2 confidence intervals (95%) were calculated for lifetime risk [table 2] and mmr [figure 1] using the method published by hanley.6 the lifetime risk of maternal death was calculated by dividing the number of maternal deaths by the sister units of risk exposure, q(w) = ri bi⁄ , where the sister units of risk exposure was given by the number of ever-married sisters multiplied by an adjustment factor, bi = niai . adjustment factors are corrections based on a found age-distributed pattern between the proportion of sisters dying of maternity related causes http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx liese this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.341|http://cajgh.pitt.edu table 1. estimation of maternal mortality using the sisterhood method for gbao tajikistan, 2006. and the probability of dying from those causes.2 we also applied a correction to the number of sisters at risk in the younger respondent group by multiplying the number of respondents by the average number of sisters reported by older respondents (25 and older). this adjusts for underestimation of the number of total lifetime sisters for young respondents.3 finally, because sample size was too small to rely on age group estimates, the data were aggregated over all age groups to give the total lifetime risk of maternal death, q = ∑ ri ∑ bi⁄ [table 1 and table 2]. to reduce the impact of potential reporting biases, we also followed graham et al2 in restricting respondent age to 49 and under, however, a maternal death of a sister is a very memorable event,7 and we had no reason to believe that the memories of these older respondents were impaired. the maternal mortality ratio (mmr), is a function of the lifetime mortality risk and the total fertility rate, mmr = 1 p1 tfr⁄ , where p = 1 q , the lifetime probability of avoiding death from maternal causes, and tfr is the total fertility rate, the total number of children born per woman in her lifetime, or likely to be, if exposed to current rates of age-specific fertility. when lifetime cumulative risk, q, remains constant or increases in tandem with lower tfrs, the mmr increases, showing an increased risk of dying per pregnancy. standard errors for q were calculated as seq = √(r b) ∗ 1 − (r b)⁄⁄ b⁄ . upper and lower confidence limits of 95%, q ±1.96(se), were then substituted into the mmr equation to give upper and lower bounds on these estimates.6 time-lags using this method2 also place age group of respondents, 𝒊 (a) number of respondents (b) sisters evermarried, 𝑵𝒊 (c) maternal deaths, 𝒓𝒊 (d) adjustment factor, 𝑨𝒊 (e) sister-units of risk exposure, 𝑩𝒊 (f = ce) life-time risk of maternal death, 𝒒(𝒘) (g = d/f) proportion of dead sisters dying of maternal causes (h) 18-24 173 593 * 2 0.151 90 0.0222 0.4000 25-34 254 807 4 0.421 340 0.0118 0.2222 35-44 208 798 2 0.737 588 0.0034 0.1429 45-54 188 659 1 0.934 616 0.0016 0.0500 55+ 178 572 6 0.992 567 0.0106 0.1304 total 1001 429 15 -2201 0.0068 ** (1 in 147) - * derived for age 18-24 by multiplying the # of respondents 18-24 (n=173) by the average number of ever married sisters per respondent for age groups 25+ (3.425). this corrects for under-estimation of the number of total sisters for young respondents (graham, 1989). reported number of ever married for respondents 18-24 is 358. ** lifetime risk of maternal death for respondents under 54 years of age = 9/1634 = 0.0055 (1 in 182) n = 823. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx liese this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.341http://cajgh.pitt.edu aggregated estimates of mmr for ≤49 about 12 years before data collection. for our sample, the mmr then refers to the post-soviet transitional period, approximately 1994 – 1995. results the average number of siblings (brothers and sisters) reported was m = 6.5 (sd = 3.0) with a maximum of 23, however 93% of respondents reported 10 or less siblings. an average of m = 4.95 (sd = 2.26) sisters with a maximum of 11 was found. results for each age group are reported in table 1. for all respondents, the evermarried number of sisters was n = 3429, with 103 reported as deceased (15/103 mortality events attributed to maternal causes). we report both the total lifetime risk, q, for population age groups ≤ 49 and for ≤ 54 [table 2]. for tajik badkhstan using all respondents, q = 0.0068, 95% ci [0.0034, 0.0103], or a lifetime risk of maternal death of 1 in 147. lifetime risk of maternal death for age 49 and under is q = 0.0069, 95% ci [0.0024, 0.0114], or 1 in 145. the lifetime risk for those 54 and under is 0.0055, 95% ci [0.0019, 0.0091], or 1 in 182. the national tfr estimate for 1994-1995 is 4.88.8 using this tfr, our estimate of the maternal mortality ratio (mmr) in tajik badakhshan is 141 maternal deaths per 100,000 live births, 95% ci [49, 235]. this figure is congruent with the mmr national estimate for that time frame, mmr = 129, ci [112, 149]9 represented in figure 1 by the grey shaded region, matching the spike in mmr experienced nationally in tajikistan in the immediate post-soviet transition. this confirms the usability of mmr best estimates using the sisterhood method, despite small sample sizes and large confidence intervals. our research also suggests the need for local estimates of tfr and the need for repeated studies to track mmr trends in rural areas. as can be seen in figure 1, mmr is highly dependent on tfr. urban areas typically have lower fertility compared to rural regions, and the fertility transition is typically slower in these areas. while fast rates of fertility transition are similar across urban contexts, the diffusion to non-urban areas is, in contrast, characterized by large heterogeneity.10 in this study, 62% of respondents reported using some form of birth control, but given the limited ability to estimate tfr directly using the current data, we relied on the national tfr point estimate. for comparison, we also computed the mmr using the national tfr for the three following five-year periods (1995-2000, 2000-2005, 2005-2010), and contrasted these results with those given by who, unicef, unfpa, world bank group, and the united nations population division.9 [figure 1] discussion we used the sisterhood method to produce a sub-national estimate of maternal mortality, mmr, for an isolated region in tajikistan. the estimates we provide (using a range of national tfr estimates for four-time periods) refer to a period about 12 years before the q, lifetime risk [ci] all women 0.0068 [0.0034 0.0103] 1 in 147 [1/294 to 1/97] ≤49 years 0.0069 [0.0024 0.0114] 1 in 145 [1/417 to 1/88] ≤54 years 0.0055 [0.0019 0.0091] 1 in 182 [1/526 to 1/110] table 2. lifetime risk of maternal death http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx liese this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.341|http://cajgh.pitt.edu figure 1. gbao tajikistan sisterhood estimated mmr (per 100,000) with 95% confidence intervals mmr estimates using the national tfr (4.88) for the same period based on time-lag (1990-1995) are congruent with the spike shown for national levels in 1995. mmr estimates using dropping tfr values during the post-soviet fertility transition illustrate the stability or potential increase in mmr in this region compared to the national estimates for the same time period if urban improvements in maternal mortality outpace rural. survey, approximately 1994 – 1995. who, unicef, unfpa, world bank group, and the united nations population division (2015) found an mmr 129, ci [112, 149] for this timeframe, demonstrating a spike in maternal mortality during the post-soviet transition.12 this estimate is higher than maternal mortality ratios in neighboring post-soviet countries such as uzbekistan (mmr 54) and kazakhshan (mmr 91), though similar to kyrgyzstan (mmr 120).12 our result for gbao is congruent with the national tajikistan estimate, mmr = 141, ci [49, 235]. we suspected that the mmr for gbao would be higher than the national mmr given its isolation as a semiautonomous region in the pamir mountains along the border with afghanistan. despite the stabilizing power of socialized health care during the soviet era, emergency obstetric care was not always available in the region, though skilled midwives did attend most births.7 the post-soviet transition involved dismantling key socialist welfare programs that contributed to conditions that increased maternal mortality risk nationwide. there are multiple limitations to consider in this study. though recall bias may be unlikely because a sister’s death is a significant and memorable sociocultural event, it is possible some respondents failed to report maternal deaths of sisters who may have moved out of the area, resulting in an underestimation of maternal deaths. recall bias may have also produced an overestimation of maternal deaths if some respondents incorrectly attributed deaths of sisters to maternal factors. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx liese this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.341http://cajgh.pitt.edu it is possible that sisters living in the same village produced duplicated accounts. however, in this patrilineal society, women move to their husband’s village when they are married, making this limitation unlikely or uncommon. the results are also potentially impacted by the lack of a local estimate of tfr during a period of dropping fertility nationwide. figure 1 shows the effect of tfr estimates on estimates of the mmr. tfr decreases after the soviet period ended (approximately 1991), yet the mmr spikes nationwide before quickly dropping. this is likely a reflection of the dramatic socio-political instability which followed independence from the soviet union. tajikistan was not only cut off from soviet benefits such as nutritional supplies, roads, and hospital supplies, but also plummeted into a lengthy civil war between 1992 and 1997, making it unique among the former soviet countries of central asia. cut off from the capital and bordering afghanistan, gbao was particularly impacted by the upheaval of the civil war and its aftermath. however, a lower tfr is likely applicable to respondents in our study, rather than the tfr of their parents during the decades when the soviets enforced pro-natal agendas in gbao, which increased fertility substantially. the tajikistan demographic and health survey suggests that the region-specific tfr is 3.30, close to the 2005-2010 united nations (2015) estimate (3.48). a lower tfr increases the mmr if individuals continue to be exposed to the 1994-1995 risk profile. this problem could be exacerbated as inequality between urban and rural areas often widens in periods of economic transition; maternal mortality may improve in urban areas but worsen in rural, requiring further investigation. these aspects of fertility and mortality require investigation. for this population, using national tfrs based on model life tables (as we do) may be a more reliable approach due to small sample sizes, but fertility transitions make applicability to rural areas uncertain. therefore, estimating tfr locally while incorporating the uncertainty in this calculation could improve our grasp of region specific needs in these contexts. discussion of important trends in tfr in rural regions compared to urban and the investigation of associated impacts on maternal mortality requires repeated studies of both local tfr and maternal mortality risk. this point is especially important to consider in similar post-soviet countries of central asia where the collapse of the soviet union heightened health and social disparities between rural and urban populations. regional variation in maternal mortality may be as high as variation across international borders, necessitating targeted interventions to improve maternal outcomes at the local level.9 global health efforts to reach developed countries’ standards may have greater impact when subnational variation in maternal mortality is addressed. our results indicate that where social, political, and economic conditions contribute to rapidly changing mortality and fertility rates in small subnational populations, it is crucial that researchers use effective and accessible methods to estimate local tfr in order to better understand variation in maternal health outcomes at the local level. for example, the fall of the soviet union changed women’s lives in gbao in ways that directly impact maternal risk, including education, marriage age, medical education, availability of medical supplies and contraceptives, hospital infrastructure, and accessibility.7 understanding trends in maternal mortality in subnational areas in relation to those found using national metrics will require repeated studies. references 1. blencowe, h., calvert, c., lawn, j. e., cousens, s., & campbell, o. m. measuring maternal, foetal and neonatal mortality: challenges and solutions. best practice & research clinical obstetrics & gynaecology. 2016; 36: 14-29. 2. graham, w., brass, w., & snow, r. w. estimating maternal mortality: the sisterhood http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.341|http://cajgh.pitt.edu method. studies in family planning. 1989;20(3):125-135 3. hill, kenneth, et al. estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. the lancet 370.9595. 2007: 1311-1319. 4. shiffman, jeremy. "can poor countries surmount high maternal mortality?." studies in family planning. 2000; 31.4: 274-289. 5. population of the republic of tajikistan as of 1 january 2008, state statistical committee, dushanbe, 2008. 6. khalid, a. islam after communism: religion and politics in central asia. berkeley: university of california press. 2007. 7. liese, k. l. motherdeath in childbirth: explaining maternal mortality on the roof of the world. stanford: stanford university. 2009. 8. bartlett, l. a., mawji, s., whitehead, s., crouse, c., dalil, s., ionete, d., ... & afghan maternal mortality study team. where giving birth is a forecast of death: maternal mortality in four districts of afghanistan, 1999– 2002. the lancet, 2005; 365(9462), 864-870. 9. smith, j. b., fortney, j. a., wong, e., amatya, r., coleman, n. a., & johnson, j. d. g. estimates of the maternal mortality ratio in two districts of the brong-ahafo region, ghana. bulletin of the world health organization. 2001;79(5): 400-408. 10. hanley, j. a., hagen, c. a., & shiferaw, t. confidence intervals and sample-size calculations for the sisterhood method of estimating maternal mortality. studies in family planning. 1996; 220-227. 11. graham, w. j., foster, l. b., davidson, l., hauke, e., & campbell, o. m. measuring progress in reducing maternal mortality. best practice & research clinical obstetrics & gynaecology. 2008;22(3): 425-445. 12. united nations, department of economic and social affairs, population division. world population prospects: the 2015 revision, dvd edition. 2015. 13. world health organization. trends in maternal mortality: 1990 to 2015 estimates by who, unicef, unfpa, world bank group and the united nations population division. who: switzerland; 2015. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. sero-occurrence of hbv/hcv coinfection and levels of liver enzymes among patients at a tertiary care hospital in central india: a pilot study prabha desikan1, aseem rangnekar1, zeba khan1, nikita panwalkar1, protiti bose1, hanni vasudev gulwani2, sukhpreet kaur2 1department of microbiology, bhopal memorial hospital and research centre, india; 2department of pathology, bhopal memorial hospital and research centre, india vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.313 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ desikan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.313|http://cajgh.pitt.edu abstract introduction: hepatitis b and c viral infections share common modes of transmission and account for a large proportion of liver disease burden across the globe. patients with hepatitis b (hbv) and hepatitis c virus (hcv) co-infection may have more severe liver disease and are potentially at higher risk for developing hepatocellular carcinoma. the aim of this study was to assess the sero-occurrence of hbv/hcv co-infection by examining the medical records of tertiary care hospital patients in central india and determine the extent of liver damage based on liver function tests (lfts). methods: patients with a positive test for hbv surface antigen (hbsag) over a period of 10 years were identified from laboratory records in a tertiary care facility in central india. records of 51,075 consecutive non-duplicate blood samples were then screened for a positive hbv and hcv tests. lft, liver enzymes, and bilirubin data were also extracted. means and standard deviations were determined for continuous variables, and the difference in means was compared using a independent samples t-test. associations between hbv/hcv co-infection status and demographic variables were calculated using pearson’s chi-squared test. a p-value less than 0.05 was considered statistically significant. results: in this study, 1674 (3.27%) screened patients were positive for hbsag and the sero-occurrence of co-infection with hcv in hbsag positive patients was reported in 28 individuals (1.67%). there was no significant gender difference for hbv/hcv coinfection (p>0.05). hbv/hcv co-infection was observed more frequently in the 31-60 year old age group (p=0.001). hbv/hcv co-infected patients had significantly higher levels of liver enzymes and bilirubin than those with hbsag mono-infection (p=0.001). conclusion: liver function tests are potentially important predictors for hbv/hcv coinfection. screening for hcv co-infection in hbsag-positive patients is recommended in india. detection of co-infection may enable timely preventive/therapeutic interventions aimed at preventing progression to hepatocellular carcinoma. keywords: hepatitis b; hepatitis c; co-infection; india sero-occurrence of hbv/hcv coinfection and levels of liver enzymes among patients at a tertiary care hospital in central india: a pilot study prabha desikan1, aseem rangnekar1, zeba khan1, nikita panwalkar1, protiti bose1, hanni vasudev gulwani2, sukhpreet kaur2 1department of microbiology, bhopal memorial hospital and research centre, india; 2department of pathology, bhopal memorial hospital and research centre, india research introduction chronic liver disease (cld) results from an inflammatory injury to the liver, persisting for six or more months without complete resolution. cld can result from a spectrum of diseases including chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma (hcc)1. chronic hepatitis b virus (hbv) and hepatitis c virus (hcv) infections are significant public health issues globally. compared to hbv mono-infected patients, hbv/hcv co-infected patients have higher rates of cirrhosis (44% vs. 21%) and decompensated liver disease (24% vs. 6%). similarly, hbv/hcv co-infected patients compared to hcv mono-infected patients, have a higher rate of cirrhosis (95% vs. 49%) and more advanced decompensated liver disease (child-pugh class http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.313|http://cajgh.pitt.edu c 37% vs. 0%)2. epidemiologic studies in patients with dual hbv/hcv infection demonstrated an increased risk of hcc, which has been confirmed by three published meta-analyses3-5. evidence suggests that hbv is capable of initiating the neoplastic process, while hcv can act as a promoter, and that the two conditions may be synergistic in leading to hcc development3. the estimated global prevalence of hbv/hcv co-infection is approximately 5-20% in hbsag positive patients and 2-10% in hcv positive patients6. in india, the prevalence of hbv and hcv coinfection ranges from 1.89% to 56% depending on the region7,8, which may be related to a lack of awareness of hbv vaccine availability by the general public9. hbv/hcv co-infection is more frequent in high-risk populations of various ages, including intravenous drug users, patients receiving hemodialysis, patients undergoing organ transplantation, hiv-positive patients, and β-thalassemia patients10. previous studies reported that age below 40, asian race, injection drug use, a greater number of lifetime sexual partners, inadequate sterilization of medical equipment, unprotected sex, and the use of unscreened blood and blood products are independent risk factors for hbv/hcv dual infection10,11. in india, the most commonly reported modes of transmission of hbv and hcv are sexual transmission, blood transfusion, and intravenous drug use12. moreover, because of the shared modes of transmission, hbv/hcv co-infections are common in endemic areas and among subjects with a high risk of parenteral transmission13,14 study findings report a greater likelihood of the progression from chronic hepatitis to cirrhosis and hcc in patients with hbv/hcv co-infection compared to infection by hbv or hcv alone; this combination of cirrhosis and hcc is particularly difficult to clinically manage15. measurement of liver enzymes function (i.e. alanine transaminase (alt), aspartate transaminase (ast), and alkaline phosphatase (alp)) is an inexpensive and non-invasive method of assessing liver disease. measurement of liver enzymes reflect the activity of hepatotropic viruses and the degree of damage to the liver during therapy with various hepatotoxic drugs16. to our knowledge, very limited data about the sero-occurrence of hbv/hcv coinfection are available from central india. the objectives of this study are to (1) identify the prevalence of sero-occurrence of hbv/hcv coinfection in a large tertiary care facility, and (2) determine the extent of liver damage in patients with hbv/hcv co-infection. methods study design and data collection: the study was carried out in the department of microbiology, bhopal memorial hospital & research centre (bmhrc), bhopal, and madhya pradesh, india. bmhrc is a tertiary care hospital and serves a population of more than two million residents. records of patients and test results were maintained in lab registers as well as a hospital information system (his) of the bmhrc. laboratory records from january 2006 to december 2016 were reviewed retrospectively for demographic and hbsag data. lab records were also reviewed for anti-hcv sero-positivity among hbsag positive samples. this study was limited to samples from patients who visited either outpatient (opd) or inpatient departments (ipd) of bmhrc, and who were diagnosed as hbsag and anti-hcv positive. samples with incomplete liver function panel or demographic data were excluded. all the investigations for hbsag and anti-hcv were completed by enzyme linked immunosorbent assay (elisa) as part of routine laboratory work flow, in accordance with the manufacturer’s instructions. liver enzyme tests were done by biochemical assays, and included alanine transaminase (alt), aspartate transaminase (ast), alkaline phosphatase (alp), bilirubin total (bt), bilirubin indirect (bi), and bilirubin direct (bd). the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx desikan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.313|http://cajgh.pitt.edu study was approved by the institutional ethical committee of bmhrc. statistical analysis data were analyzed using openepi online software17. differences in variable distribution were evaluated by pearson’s chi-squared test, and a p-value of less than 0.05 was considered statistically significant. means and standard deviations were reported for continuous variables, and differences in means were compared with an independent samples t-test. we defined abnormal liver enzyme cut-offs according to the national health and nutrition examination survey (nhanes) criteria iii18. abnormal values of liver enzymes and bilirubin levels were defined as alt/ast≥50 iu/ml, alp≥129 iu/ml.bt/bi ≥1.1 mg/dl, and bd≥ 0.3 mg/dl. results a total of 51,075 consecutive non-duplicate blood samples were collected over a period of ten years for hbsag testing. out of these samples, 1674 (3.27%) were positive for hbsag, and 295 (0.57%) were found to be positive for anti-hcv. among individuals positive for hbsag or anti-hcv, 28 (1.67%) samples were identified as positive for both, hbsag and anti-hcv. serooccurrence rates are summarized in table 1. ages of patients positive for hbv ranged from 12-75 years of age (median=54 years, iqr: 15), and 29-74 years of age (median=45 years, iqr: 26) for hbv/hcv co-infected individuals. hbv/hcv co-infection was more frequent in males at 78.5% (n=22) than in females at 21.4% (n=6), but the difference was not statistically significant (p=0.80). a significantly higher prevalence of hbv/hcv co-infection was observed in the 31-60 years (46.4%) age group compared to the 1-30 years (25.0%) and >60 years (28.6%) age groups (p=0.001) (table 1). the proportion of sero-occurrence of hbv/hcv coinfection fluctuates between 2006 and 2016 with the highest prevalence in 2013 (figure 1). out of 1674 hbsag positive samples, lft results were available for 773 samples. the mean values of serum levels of alanine transaminase (alt), aspartate figure 1. trends of sero-positivity of hbsag, anti-hcv, and hbv/hcv co-infection at bhopal memorial hospital and research center in central india 2006 – 2016. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx desikan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.313|http://cajgh.pitt.edu table 1. demographic data on hbv/hcv distribution in the study population. transaminase (ast), alkaline phosphatase (alp), bilirubin total (bt), bilirubin indirect (bi), and bilirubin direct (bd) were 114.4±403.8 iu/l, 94.7±344.8 iu/l, 101.4±71.6 iu/ml, 1.4±2.9mg/dl, 0.7±2.7mg/dl, and 0.7±1.7mg/dl respectively in hbsag positive patients, and 100.25±201.4 iu/l, 106.3±265.7 iu/l, 114.7±65.9 iu/ml, 1.7±2.7mg/dl, 1.05±2.7mg/dl, and 0.7±0.7mg/dl respectively in hbv/hcv co-infected patients. levels of alt, ast, alp, and bilirubin were significantly different between hbv/hcv co-infected patients and hbsag mono-infected patients (p <0.001) (table2). discussion in this study, sero-occurrence of hcv coinfection in hbv patients was found to be low (1.67%) compared to global data, but higher than reported in other parts of india7,12,19. a large multicenter study from the united states assessed the prevalence of hbv/hcv coinfection and found anti-hcv was present in 7% of chronic hbv carriers10. tesfa et.al. reported a 6.39% prevalence of hbv/hcv co-infection in a hospital-based study conducted in ethiopia20. studies conducted in different regions of india have reported diverse prevalence rates of hbv/hcv co-infection in drug abusers having chronic liver disease (1.5 %), patients on hemodialysis (0.8%), and in patients with hiv infection (3.0%)7,21-22. while not statistically significant, we found that the seropositivity rate of hbv/hcv co-infection among males was higher than in females. this is an interesting finding, as it corroborates a previous report that male subjects are at a higher risk of developing hbv/hcv coinfection compared to females23-24. the reason for a higher frequency of hbv/hcv co-infection among male patients could be a result of a higher level of exposure to risk factors associated with co-infection, including drug abuse, unprotected sex, and having more than one sexual partner25. our study showed that hbv/hcv co-infection rates were highest among individuals in the age group of 31-60 (46.4%), followed by the age group of 60 years and over (28.57%), which was similar to a previously published study in the united states10. a higher prevalence in the 31-60 years age group may be associated with increased exposure to risk factors for hbv/hcv co-infection. hbv/hcv co-infected patients in this study had significantly higher levels of alt, ast, and alp compared to hbsag and anti-hcv mono-infected patients. higher levels of liver enzymes have been demographic variables hbsag positive (%) anti-hcv positive (%) hbv/hcv co-infection (%) p-value* sex male 1,364 (81.4) 201 (68.1) 22 (78.5) p = 0.8 female 310 (18.5) 94 (31.8) 6 (21.4) age 1-30 257 (15.35) 75 (25.4) 7 (25) p = 0.001 31-60 754 (45.04) 105 (35.5) 13 (46.4) >60 663 (39.60) 115 (38.93) 8 (28.6) *based on chi-squared test http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx desikan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.313|http://cajgh.pitt.edu table 2. liver function profile in hbv mono-infected patients and those with hbv/hcv co-infected patients. reported in hbv/hcv co-infected patients compared to those having hbv and hcv mono-infection26. bilirubin concentrations were found to be highest in co-infected patients in this study. a study conducted in tribal populations of central india also found an elevated level of bilirubin in hbv/hcv co-infected patients27-28. it is documented that elevated levels of liver enzymes in hbv infected patients are associated with higher risk of liver cirrhosis and hcc29. once hbv infection is detected during a diagnostic workup of hepatitis, it is possible that hepatitis may be attributed to hbv infection alone and further etiological diagnoses may not be carried out. this may lead to underreporting of co-infection with hcv. therefore, detection of co-infection may enable timely intervention to prevent progression to hcc. this pilot investigation is the first study to show sero-occurrence of hbv/hcv coinfection within the central zone of india, along with the comparison of liver enzymes data among these patients. our findings indicate that there is a potentially higher level of liver damage in patients with hbv/hcv co-infection, warranting that those diagnosed with either hbv or hcv should also be tested for the other hepatitis virus. screening of hbv infection can be made more widespread through molecular testing of hbv dna by polymerase chain reaction to detect occult hepatitis b infection. there were several limitations to our study. there were no available data on occult hbv infection since hbv dna assays were not performed. this might underestimate the real burden of hbv in this study population. the hbv immunization status of patients was also unknown, which is something we can address in our future investigations. in this study, the majority of hbsag and anti-hcv cases were initially diagnosed by clinical suspicion of an underlying disease, which is likely to underestimate the total number of viral hepatitis infections in our population, due to the presence of subclinical or asymptomatic infections. this study is limited to the review of medical records; no information was gathered directly from the patients. variables hbsag mono infection hbv/hcv coinfection p value* alt, mean±sd 114.4±403.8 100.25±201.4 0.001 alt abnormal high (n%) 156 (20.1%) 14 (50.0%) ast, mean±sd 94.7±344.8 106.3±265.7 0.001 ast abnormal high (n%) 140 (18.1%) 8 (28.5%) alp mean±sd 101.4 ± 71.6 114.7±65.9 0.001 alp abnormal high (n%) 132 (17.7%) 11 (39.2%) bilirubin total mean±sd 1.4±2.9 1.7±2.7 0.001 bilirubin total abnormal high (n%) 151 (19.5%) 11 (39.2%) bilirubin direct mean±sd 0.7±2.7 1.05±2.7 0.001 bilirubin direct abnormal high (n%) 368 (47.6%) 15 (53.3%) bilirubin indirect mean±sd 0.7±1.7 0.7±1.7 0.001 bilirubin indirect abnormal high (n%) 110 (14.2%) 7 (25.0%) *student’s t-test http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.313|http://cajgh.pitt.edu our results may be useful for making estimates and projections about future liver disease burden. a recently developed mathematical model by el-bouzedi30, that uses available epidemiological data on viral hepatitis to estimate future consequences of hepatitis infection, can be incorporated in our future research. such models will help to inform health policy, resource distribution, and healthcare delivery in india, as well as other countries. these types of studies can also lead to improved management of patients with viral hepatitis and inform health policy. references 1. laraba a, wadzali g, sunday b, et al., hepatitis c virus infection innigerianswith chronic liver disease. internet j gastroenterol 2009; 9(1):1-3. 2. konstantinou d, deutsch m. the spectrum of hbv/hcv coinfection: epidemiology, clinical characteristics, viralinteractions and management. annals of gastroenterology: quarterly publication of the hellenic society of gastroenterology. 2015;28(2):221-228. 3. donato f, boffetta p, puoti m. a meta-analysis of epidemiological studies on the combined effect of hepatitis b and c virus infections in causing hepatocellular carcinoma. int j cancer. 1998;75:347–354. 4. shi j, zhu l, liu s, xie wf. a meta-analysis of case-control studies on the combined effect of hepatitis b and c virus infections in causing hepatocellular carcinoma in china. br j cancer. 2005;92:607–612. 5. cho ly, yang jj, ko kp, et al. coinfection of hepatitis b and c viruses and risk of hepatocellular carcinoma: systematic review and meta-analysis. int j cancer. 2011;128:176– 184. 6. caccamo g, saffioti f, raimondo g. hepatitis b virus and hepatitis c virus dual infection. world journal of gastroenterology : wjg. 2014;20(40):14559-14567. 7. malhotra r, soin d, grover p, galhotra s, khutan h, kaur n. hepatitis b virus and hepatitis c virus co-infection in hemodialysis patients: a retrospective study from a tertiary care hospital of north india. journal of natural science, biology, and medicine. 2016;7(1):7274. 8. desikan p, khan z. prevalence of hepatitis b and hepatitis c virus co-infection in india: a systematic review and meta-analysis. indian j med microbiol. 2017;35:332-9 9. lahariya c, subramanya b p, sosler s. an assessment of hepatitis b vaccine introduction in india: lessons for roll out and scale up of new vaccines in immunization programs. indian j public health 2013;57:8-14. 10. bini ej, perumalswami pv. hepatitis b virus infection among american patients with chronic hepatitis c virus infection: prevalence, racial/ethnic differences, and viral interactions. hepatology. 2010;51:759–766. 11. gaeta gb, stornaiuolo g, precone df, et al. epidemiological and clinical burden of chronic hepatitis b virus/hepatitis c virus infection. a multicenter italian study. j hepatol. 2003;39:1036–1041. 12. tripathi ak, khanna m, gupta n, chandra m.low prevalence of hepatitis b virus and hepatitis c virus co-infection in patients with human immunodeficiency virus in northern india.jassoc physicians india. 2007 jun;55:429-31. 13. sagnelli e, coppola n, pisaturo m, masiello a, tonziello g, sagnelli c, messina v, filippini p. hbv superinfection in hcv chronic carriers: a disease that is frequently severe but associated with the eradication of hcv. hepatology. 2009 apr;49(4):1090-7. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx desikan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.313|http://cajgh.pitt.edu 14. yang s, wang d, zhang y, et al. transmission of hepatitis b and c virus infection through body piercing: a systematic review and metaanalysis. martin. s, ed. medicine. 2015;94(47):e1893. 15. ringehan m, mckeating ja, protzer u. viral hepatitis and liver cancer. philosophical transactions of the royal society b: biological sciences.2017;372(1732):20160274. 16. sama lf, nganoudjinou oi, wam ec, bamou r, ali im, et al. (2017) sero-prevalence of hepatitis b and c virus and high risk of hepatotoxicity amongtb/hiv positive and hiv negative population in western cameroon. glob j infect dis clin res 3(1): 001-008 17. dean ag, sullivan km, soe mm. openepi: open source epidemiologic statistics for public health, version. www.openepi.com). accessed on march 29, 2019 18. national health and nutrition examination survey (nhanes) iii. https://wwwn.cdc.gov/nchs/nhanes/20072008/biopro_e.htm. accessed on march 29, 2019 19. jamil m, bhattacharya pk, yunus m, lyngdoh cj, roy a, talukdar kk. prevalence of hepatitis b and hepatitis c in haemodialysis population in atertiary care centre in north eastern india. international journal of biomedical and advance research 2016;7(6): 267-269. 20. tesfa h, biadgo b, getachew f, tegegne k, yismaw g and muluye d. seroprevalence of hepatitis b and c virus infection among patients attending serology laboratory of gondar university hospital. bmc research notes 2013, 6:164. 21. ray saraswati l, sarna a, sebastian mp, et al. hiv, hepatitis b and c among people who inject drugs: high prevalence of hiv and hepatitis c rna positive infections observed in delhi, india. bmc public health. 2015;15:726. 22. arora u and mann a. prevalence of hepatitis b virus, hepatitis c virus, and hiv in patients of chronic liver disease in amritsar. jiacm 2007; 8(1): 29-3. 23. chowdhury a, santra a, chaudhuri s, ghosh a, banerjee p, mazumder dn. prevalence of hepatitis b infection in the general population: a rural community based study. trop gastroenterol. 1999 apr-jun;20(2):75-7. 24. anbazhagan gk, ks, and thiyagarajan t seroprevalence of hcv and its co-infection with hbv and hiv among liver disease patients of south tamil nadu. world j hepatol. 2010 jan 27; 2(1): 42–48. 25. halim m.d, offor e, ajayi o.i (1992). epidemiologic study of the seroprevalence of hepatitis b surface antigen and hiv-1 in blood donors. niger. j. clin. pract.: 2; 45-55. 26. wondimeneh y, alem m, asfaw f, belyhun y. hbv and hcv seroprevalence and their correlation with cd4 cells and liver enzymes among hiv positive individuals at university of gondar teaching hospital, northwest ethiopia. virology journal. 2013;10:171. 27. khuntep,khare rl, beck p, kumar s. prevalence of hepatitis b virus and hepatitis c virus co-infection in human immunodeficiency virus positive patients: a study from tribal area of central india. int j res med sci. 2015 sep;3(9):2311-2315. 28. ionita g, malviya a,rajbhandaricr, william w, schluter g,sharmae s,kakchapatic s. rijalf s, dixit s. seroprevalence of hepatitis b virus and hepatitis c virus co-infection among people living with hiv/aids visiting antiretroviral therapy centres in nepal: a first nationally representative study. international journal of infectious diseases. 2017,60:64-69. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.openepi.com/ https://wwwn.cdc.gov/nchs/nhanes/2007-2008/biopro_e.htm https://wwwn.cdc.gov/nchs/nhanes/2007-2008/biopro_e.htm central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.313|http://cajgh.pitt.edu 29. hann h-w, wan s, myers re, et al. comprehensive analysis of common serum liver enzymes as prospective predictors of hepatocellular carcinoma in hbv patients. camerondw, ed. plos one. 2012;7(10):e47687. 30. el-bouzedi a. investigation and modeling the epidemiology of hepatitis c virus in libya, phd thesis. united kingdom: university of glamorgan, faculty of advanced technology; 2012. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx sero-occurrence of hbv/hcv co-infection and levels of liver enzymes among patients at a tertiary care hospital in central india: a pilot study abstract keywords: hepatitis b; hepatitis c; co-infection; india sero-occurrence of hbv/hcv co-infection and levels of liver enzymes among patients at a tertiary care hospital in central india: a pilot study research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. prevalence of tobacco smoking and factors associated with the initiation of smoking among university students in dhaka, bangladesh sahadat hossain1, shakhaoat hossain1, fahad ahmed2, rabiul islam1, tajuddin sikder1, abdur rahman1 1department of public health and informatics, jahangirnagar university, dhaka, bangladesh; 2department of environmental sciences, jahangirnagar university, dhaka, bangladesh vol. 6, no. 1 (2017) | issn 2166-7403 (online) doi 10.5195/cajgh.2017.244 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu abstract introuduction: tobacco smoking is considered to be the key preventable risk factor for morbidity and mortality at the global level. the aim of this study was to determine the prevalence of tobacco smoking and factors associated with the initiation of smoking among university students in dhaka, bangladesh. methods: a cross-sectional survey study was conducted with 264 students of jahangirnagar university, dhaka, bangladesh in 2015. a standard, self-administered questionnaire consisting of questions on socio-demographic variables, tobacco smoking status, family and peer tobacco smoking history, attitudes and beliefs about tobacco smoking, as well as knowledge about the negative health consequences of tobacco smoking was administered to participants. data were analyzed using logistic regression models, chi square, and fisher exact tests. results: the overall prevalence of tobacco smoking was 60.2%, where males smoked at higher rates than females (68.81% and 19.56%, respectively). the influence of friends was the most significant reason for initiating tobacco smoking (or: 0.862; ci: 0.810-0.917). perception regarding tobacco smoking was significantly related to continuing tobacco use. logistic regression models identified that smoking-related attitudes, potential health problems, and family members dying from cardiovascular disease and cancer were significantly associated with tobacco smoking. conclusion: the current tobacco smoking prevalence among university students in bangladesh is over 60%. we suggest adopting who framework convention on tobacco control (fctc) policies, especially for university students. keywords: student health, tobacco smoking, public health, bangladesh prevalence of tobacco smoking and factors associated with the initiation of smoking among university students in dhaka, bangladesh sahadat hossain1, shakhaoat hossain1, fahad ahmed2, rabiul islam1, tajuddin sikder1, abdur rahman1 1department of public health and informatics, jahangirnagar university, dhaka, bangladesh; 2department of environmental sciences, jahangirnagar university, dhaka, bangladesh research tobacco smoking has been associated with multiple health problems and is considered to be a preventable risk factor for six of the eight leading causes of morbidity and mortality at the global level.1 smoking is a serious and growing public health problem globally, with a large number of tobacco-associated deaths occurring in lowand middle-income countries.2 future projections suggest that tobacco smoking will kill more than 8 million people each year worldwide by the year 2030, with 80% of these premature deaths occurring in lowand middle-income countries.3 according to the world health organization, there are about 1 billion smokers in the world, 80% of whom are in developing countries.2 tobacco smoking has many detrimental effects on health in general and it is has been estimated that tobacco smokers die 10 years earlier than non-smokers.4,5 tobacco smoking leads to lung cancer, chronic obstructive lung disease, atherosclerotic http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu cardiovascular diseases, peptic ulcer disease, intrauterine growth retardation, spontaneous abortion, antepartum hemorrhage, female infertility, sexual dysfunction in men, and many other diseases.6 it has been calculated that nearly a third of the world’s population, aged 15 years above, are smokers7 and smoking prevalence is on the rise, especially in the developing countries.8 large number of young people are initiating smoking at earlier ages, which is a major public health concern.9 university students constitute a high risk group for engaging in risky behaviors, such as smoking and illicit substance use.10,11 these students are at high risk of initiating and continuing smoking as they are likely to be exposed to peers who smoke. at the same time, they face social, emotional, and educational challenges when they enter the university settings.12-15 this predilection toward risk taking behaviors has been associated with the underdevelopment of the orbitalfrontal cortex.16 moreover, identity development is a major concern for the youth, and young people are more susceptible to peer pressure.14 the global youth tobacco survey (gyts), conducted in 131 countries surveyed 750,000 college students, demonstrated that smoking starts as early as at 13–15 years of age. this survey found that approximately 9% of students were current cigarette smokers, while 11% currently used tobacco products other than cigarettes.17 another survey among undergraduate medical students at addis ababa university reported a lifetime smoking prevalence of 9% and a current smoking prevalence of 1.8%.18 a survey conducted among university students in southwest nigeria showed that the prevalence of ever smokers was 22.0%, while the prevalence of current smokers was 13.7%.19 similarly, a study conducted among university students in cameroon reported an ever smoking prevalence of 30.1% and with a current smoking prevalence of 6.3%.20 another study among young adults in nepal showed that 84.3% of smokers believed that tobacco use is harmful to their health.21 in bangladesh, the numbers of tobacco smokers are increasing rapidly because of the availability of cheap tobacco products, lack of strong tobacco control regulations, and weak enforcement of existing regulations. the global adult tobacco survey conducted by who reported that bangladesh is one of the top ten countries in the world with high tobacco use (both smoking and smokeless forms) with a prevalence of 43.3% among adults (41.3 million), with 44.7% of men and 1.5% of women engaging in tobacco smoking.22 a study based on demographic and health survey data reported that the prevalence of tobacco smoking among men in bangladesh is 60%.23 another study among male university students in 2009 stated that 36.1% students smoked tobacco.24 among fourthyear dental students, the prevalence of cigarette smoking was reported to be 49.5% and 1.7% in males and females, respectively.25 an increasing trend of tobacco smoking is anticipated to occur among university students and this could be related to perceived alleviation of stress, life problems, peer pressure, social acceptance, class history of smoking, lower educational level of parents, and the desire to attain higher societal class.26-28 smoking among students in bangladesh has been poorly investigated and our initial hypothesis was that it is possible that university students may be lacking knowledge on the link between smoking and adverse health effects. the aim of this study was to estimate the prevalence of tobacco smoking among university students and to identify factors that may be related to both initiation and prevalence of tobacco smoking. methods participants all of the participants involved in this study have read and signed a written consent form. this study was approved by the bio-safety, bio-security & ethical committee of jahangirnagar university. participants http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu were informed that the information collected would be kept anonymous and participation was totally voluntary. a cross-sectional study was undertaken in jahangirnagar university, located approximately 30 km from the downtown area of dhaka, bangladesh (figure 1). approximately 14,500 students are enrolled in this university at the undergraduate and postgraduate programs in different faculties or departments. the inclusion criteria for the study included full-time student status, enrolment in one of the university’s undergraduate or postgraduate programs, and age between 18 and 27 years. figure 1. location map of the study area data collection study questionnaire was distributed to a random sample of 346 students, with 264 students completing the questionnaire. each participant completed a questionnaire consisting of 5 sections. the questionnaire was developed in our university and pretested in a pilot study of 50 students. minor phrasing modifications were made on the original questionnaire after the pretest. the self-administered questionnaire included demographic data (age, sex, class, and family background, including paternal and maternal education levels, employment, and income levels), tobacco smoking patterns (type of smoking, frequency, age of initiation, and duration), risk factors for tobacco smoking initiation and retention, smoking status (current smoker, ever smoker and non-smoker), average number of cigarettes/self-rolled cigarettes smoked daily, socio-demographic status, and place of living. in order to maximize the response rate, trained researchers checked the questionnaires and if data were missing, the questionnaire was immediately returned to the respective respondent for completion. we applied the standard of gyts for calculating the prevalence of tobacco smoking.29 our estimates of tobacco smoking were derived from three questions resulting in two measures: ever smoker and current smoker. a smoker was defined as someone who was currently using ≥1 tobacco product (cigarettes (commercial), bidis (self-rolled), cigars etc.). current smoking included daily and occasional smoking in the past 30 days preceding the survey. ever smoker refers to a person who smoked at least 1 tobacco product (cigarettes, bidis, cigars, etc.) during their lifetime.30,31 statistical analysis data analysis included descriptive statistics as well as inferential statistics approaches. descriptive statistics for categorical variables included frequencies and proportions; means and standard deviations were utilized for continuous variables. differences between categorical variables were assessed for significance using the chi-square or fisher’s exact test, as appropriate. variables that were found to be significantly associated with tobacco smoking were further analyzed using logistic regression. in simple regression analysis, we adjusted for several relevant factors including: age, sex, smoking status, second-hand exposure to smoking, knowledge, attitude and practices among the tobacco smokers, and smoking associated diseases that caused fatality among family members. adjusted odds ratios (ors) and 95% confidence intervals were reported. the level of significance was p<0.05. data were first entered into microsoft excel and then transferred to spss software for windows, version 22.0 (chicago, il, usa) for analyses. results among the respondents, 46 (17.4%) were female and 218 (82.6%) were male, which was found to be a statistically significant difference (p < 0.001) (table 1). a total of 82 individuals did not complete the survey; therefore, the response rate was 76.30%. respondents ranged in age from 18-27 years, with a mean of 21.55 (± 1.98) years (table 2). among tobacco smokers, 94.34% were males and 5.66% were females. forty-three percent of the respondents were first year http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu students, and 26%, 11%, and 4% were from 2nd year, 3rd year, and 4th year respectively. the remaining 16% of the respondents were from masters level programs. out of 264 respondents, 206 (78%) mentioned their department of studies. thirty-three percent were in the biological sciences, 31% were in the arts and humanities, 17% were in the mathematical & physical sciences, 13% were in the social sciences, and 6% were in business studies. table 1. demographic characteristics of study population and proportion of students using tobacco (n=264) table 2. age comparison of the study population the average age of initiating tobacco smoking for both males and females was 17.91 years (sd: 2.1). age of initiation of tobacco smoking for females was 20.22 years (sd: 1.4) and for males it was 17.8 years (sd: 2.02). the 95% confidence interval for these means was 19.15 – 21.29 and 17.44 – 18.09 for female and male respondents, respectively. some students reported initiation of tobacco smoking as early as 12 years of age and nearly one third (30%) of ever smokers initiated it before they were 17 years of age. initiation of tobacco smoking was found to be dramatically increased after 17 years of age until 21 years, and then smoking decreases (figure 2). the most significant factor for initiating tobacco smoking was the influence of a friend (p < 0.001) (table 3). family history of tobacco smoking was also a significant factor for smoking initiation. a large proportion (69.62%) of students reported that at least one family member smoked tobacco. of these respondents, 64.30 % reported that the father smoked tobacco, and 51.80 % reported that a brother smoked tobacco. among tobacco smokers, almost 62% attempted to give up tobacco smoking at any stage after initiation; however, most were unable to successfully quit. students were asked which factors influenced smoking continuation. majority of the respondents (54.18%) reported depression as the reason they continued to smoke tobacco (table 3). other reasons for continued smoking/use of other tobacco products were difficulties in a relationship with a girlfriend (41.51%) and educational problems (14%). less than 2% of respondents refused to answer this question. figure 2. percent of age of initiating tobacco smoking by gender table 3. factors for initiating tobacco use the knowledge and perceptions about tobacco smoking were measured with both open-ended questions and multiple choice questions. students were asked if they were aware of the harmful effects of tobacco smoking. of the total respondents, 253 (95.83%) students claimed to have knowledge about the hazards of tobacco smoking (table 4). among the students who reported to have knowledge about the health hazards of tobacco smoking, 218 (86.16%) have ever used tobacco products (mainly cigarettes) and 35 (13.83%) never used. approximately 78.4% of the participants agreed with the statement that students should not smoke; however, 35.8% of smokers did not agree with this statement. among them, 81.30% reported that use of tobacco, especially cigarette smoking, makes them mentally alert or brings mental tranquility. table 4. proportion of students by knowledge and perception about hazardous tobacco smoking smokers were asked if they had health problems typically associated with tobacco smoking during the last three months, with 46% reporting that they were suffering from smoking associated diseases. almost 63% reported that they experienced coughing. other health problems that have been reported included breathing problems (46.7%), asthma (9.3%), chest pain (37.3%), lack of appetite (41.3%), and other problems (5.3%) (figure 3). figure 3. self-reported health problems of smokers http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu among the tobacco smokers, 37.7% smoked 1 to 5 cigarettes, 47.8% smoked 6 to 10 cigarettes, and 14.5% smoked more than 10 cigarettes per day. on average, the smokers in this study consumed 6.94 (sd: 3.1) cigarettes daily. we estimated that the total yearly expenditure for tobacco smoking was 2.7 million bd taka ($33,920) for the smokers enrolled in this study. on average, 37.1% tobacco smokers were spending more than 50 taka (>$ 0.63) per day for smoking. thirty four percent of the smokers were spending 30-50 taka ($ 0.38 0.63) per day and the remaining 29% spent up to 30 taka (≤ $ 0.38) in a day. table 5 reports the results of the logistic regression. the most important independent predictors of tobacco smoking among the students were the perceptions– looking smart (or = 1.642; 95% ci = 1.48 – 1.908), and looking modern (or = 1.40; 95% ci = 1.02 – 2.847). the findings of the logistic regression analysis also demonstrated the strongest relationship between tobacco smoking and coronary heart diseases and cancer among the family members of the respondents (e.g., father, uncle, or grandfather) who have had a long history of tobacco use (or = 0.327; 95% ci = 0.161 – 0.665). another significant finding was the association of second-hand tobacco smoke with the study population (or: 0.20; 95% ci: 0.094-0.425 for male and or: 0.509; 95% ci: 0.253-1.025 for smokers). table 5. logistic regression analyses for smokingrelated factors among the students discussion this study demonstrated that perception of social appearance is a very important predictor for tobacco smoking initiation. this finding is consistent with the idea that culture plays a key role in determining behavior. in bangladesh, tobacco use is widely practiced, especially among adults. adolescents and young adults are the most vulnerable groups for smoking initiation. in this study, we have found that almost 60% of students were involved in tobacco smoking, with the majority of smokers being males. this finding is in agreement with previously published literature from the kingdom of saudi arabia (ksa) and for muslim countries where culture and norms play an important role in female behaviors and customs.14,33,34 our estimate of tobacco smoking prevalence among females is low compared with the estimate from other studies.35-37 though smoking among females (5.7%) was lower than for males, estimates show that this rate is approximately 3.8 times higher than previously reported who findings.22 from a public health standpoint, the increase in the number of female tobacco smokers in bangladesh is of concern. our study suggests that age was an important factor related to tobacco smoking among university students, with older students being at a higher risk for smoking.27 the differences between the age of smokers and non-smokers were statistically significant (p = 0.042), which was also observed in a study in china.32 according to the world health organization, most of the students start using tobacco early, often beginning in their high school years.22 among respondents, most of the students started tobacco smoking during adolescence. the finding of our study is similar to that reported by the world health organization. 22 the majority of the students reported that they initiated tobacco smoking due to the influence of friends (62.26%) and by the imitation of family members. smoking among friends and their influence may indicate a link between peer pressure and the development of smoking habits.15,38-40 family association also has an influence on tobacco smoking; the smoking habits of family members (father’s use: or = 0.308; 95% ci: 0.158-0.603, brother’s use: or = 0.288; 95% ci: 0.141-0.588, and grandfather’s use: or = 2.151; 95% ci: 1.0-4.624) are statistically significant factors relating to the smoking habits of their offspring or siblings. this is consistent with findings from http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu previous tobacco studies among students.14,15 almost 37.20% of tobacco smokers in our study reported that they had started tobacco smoking because of curiosity. unstable relationships among family members were also a factor for continuing to smoke tobacco. majority of the students who participated in this study (95.83%) were knowledgeable about the link between smoking cigarettes and chronic diseases, which is encouraging for future programs targeting smoking cessation. the findings of the present study are similar to that reported in the united states, great britain, and australia among adults where the proportion of respondents knowledgeable on cigarette smoking as cause of heart disease and lung cancer were (85.8%, 94.4%), (92.3%, 98.2%), and (94%, 91%) respectively.41-43 however, the proportion of adolescents in denmark who were knowledgeable on lung and heart diseases was lower, 46.3% and 49.3%, respectively.44 the perception of smokers about tobacco smoking is also an important predictor of the retention of tobacco smoking habit. we found a significant association between smoking and the personal perception; in our study smokers believe that smoking makes them look smarter, or more modern compared to those who do not smoke. previously published studies have also shown a significant association between these variables.34,39,40,45 there are some limitations of this study. first, the information is self-reported, which is subject to recall bias. second, we had a relatively small sample area and sample size, the results of our study may not be fully representative of other parts of the country. third, the study focused only on smoking tobacco, no information was collected about illicit drug use or other non-smoking tobacco use, which needs to be explored in the future studies. conclusion the findings of our study reveal that tobacco smoking is initiated by students during the early adolescent years and continues throughout the university years. smoking was more prevalent among males, possibly due to fewer opportunities to smoke due to cultural and social restrictions among females. curiosity, peer pressure, and psychological stress were the main causes of initiating tobacco smoking, with family members of the tobacco smokers playing a vital role indirectly to initiate tobacco use. public awareness measures, such as anti-smoking campaigns must be implemented to create awareness, reduce smoking levels, and avoid negative health consequences in bangladesh. this study provides justification for the implementation of the who framework convention on tobacco control (fctc) policies for students. our findings also contribute to a knowledge base from which to develop targeted tobacco control policies for university students. if we can establish a holistic approach for tobacco control in university level, the overall tobacco control movement in bangladesh will be accelerated. besides, a smoke free campus policy will encourage other universities to create a healthy environment for education in future. the government of bangladesh should take steps to eradicate tobacco smoking, and smoking control laws and policies should be strongly enforced by the tobacco control agencies. tobacco education should start at the grade school level to educate children about harmful effects of tobacco smoking. these measures, along with the legislative control, will go a long way in creating a tobacco smoking free society in bangladesh and globally. references 1. who report on the global tobacco epidemic, 2008: the empower package. world health organization; 2008. available at: http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu http://www.who.int/tobacco/mpower/2008/en/. access date: december 21, 2016 2. who updated fact sheet on tobacco. world health organization; 2016. available at: http://www.who.int/mediacentre/factsheets/fs3 39/en/. access date: december 21, 2016 3. who report on the global tobacco epidemic, 2011: warning about the dangers of tobacco. world health organization; 2011. available at: http://www.who.int/tobacco/global_report/201 1/en/. access date: december 21, 2016 4. cdc fact sheet. health effects of cigarette smoking; 2016. available at: https://www.cdc.gov/tobacco/data_statistics/fa ct_sheets/health_effects/effects_cig_smoking/. access date: december 21, 2016 5. jha p, ramasundarahettige c, landsman v, et al. 21st-century hazards of smoking and benefits of cessation in the united states. new england journal of medicine. 2013; 368(4):341-50. doi:10.1056/nejmsa1211128. 6. kebede y, abula t, ayele b, feleke a, degu g, kifle a et al. substances abuse for the ethiopian health center team. ethiop public health train initiative. 2005; 81. 7. fawibe ae, shittu ao. prevalence and characteristics of cigarette smokers among undergraduates of the university of ilorin, nigeria. niger j clin pract. 2011; 14: 201–205. 8. cdc. global smoking: gateway to health communication & social marketing practice. centers for disease control and prevention. 2011. available at: https://www.cdc.gov/healthcommunication/too lstemplates/entertainmented/tips/globalsmokin g.html. access date: december 21, 2016 9. koushki pa, & bustan m. smoking, belt use, and road accidents of youth in kuwait. safety science. 2006; 44(8): 733–746. 10. m farajat, c hoving, and h de vries. psychosocial determinants of cigarette smoking among university students in jordan. journal of developmentalorigins of health and disease. 2011; 2(3):152–161. 11. poscia a, parente p, frisicale em, teleman aa, de waure c, pietro mld. risky behaviours among university students in italy. ann. ist. super. sanità . 2015; 51( 2 ): 111115. 12. wangeri t, kimani e, mutweleli sm. transitional challenges facing university first year students in kenyan public universities: a case of kenyatta university. interdisciplinary review of economics and management. 2012; 2(1):41-50. 13. nassar h. the economics of tobacco in egypt: a new analysis of demand, health, nutrition and population discussion paper. international bank for reconstruction and development/world bank; 2003. available at: http://siteresources.worldbank.org/healthn utritionandpopulation/resources/28 1627-1095698140167/nassar-theeconomicswhole.pdf. access date: december 21, 2016 14. mandil a, a hussein, h omer, g turki and i gaber. characteristics and risk factors of tabacco consumption among university of sharjah students: 2005. eastern mediterranean health journal. 2007; 13(6):1449–1458. 15. almutairi k. tobacco prevalence among health sciences college students (hsc): riyadh, saudi arabia. middle east journal of family medicine. 2010; 8( 7) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/tobacco/mpower/2008/en/ http://www.who.int/mediacentre/factsheets/fs339/en/ http://www.who.int/mediacentre/factsheets/fs339/en/ http://www.who.int/tobacco/global_report/2011/en/ http://www.who.int/tobacco/global_report/2011/en/ https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/ https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/ https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/globalsmoking.html https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/globalsmoking.html https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/globalsmoking.html http://siteresources.worldbank.org/healthnutritionandpopulation/resources/281627-1095698140167/nassar-theeconomics-whole.pdf http://siteresources.worldbank.org/healthnutritionandpopulation/resources/281627-1095698140167/nassar-theeconomics-whole.pdf http://siteresources.worldbank.org/healthnutritionandpopulation/resources/281627-1095698140167/nassar-theeconomics-whole.pdf http://siteresources.worldbank.org/healthnutritionandpopulation/resources/281627-1095698140167/nassar-theeconomics-whole.pdf central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu 16. farajat m, hoving c, de vries h. psychosocial determinants of cigarette smoking among university students in jordan. journal of developmental origins of health and disease. 2011; 2(3):152–161. 17. warren c w, jones n r, eriksen m p, asma s. patterns of global tobacco use in young people and implications for chronic disease burden in adults. lancet. 2006; 367: 749–753. 18. deressa w, azazh a. substance use and its predictors among undergraduate medical students of addis ababa university in ethiopia. bmc public health. 2011; 11: 660. 19. babatunde oa, elegbede oe, ayodele lm, atoyebi oa, ibirongbe do. cigarette smoking practices and its determinants among university students in southwest, nigeria. j asian sci res. 2012; 2(2): 62–69. 20. ngahane bhm, luma h, mapoure yn, fotso zm, ze ea. (2013) correlates of cigarette smoking among university students in cameroon. int j tuberc lung dis. 2013; 17(2): 270–274. 21. aryal ur, bhatta dn. perceived benefits and health risks of cigarette smoking among young adults: insights from a cross-sectional study. tobacco induced diseases. 2015; 13:22, doi: 10.1186/s12971-015-0044-9. 22. who. global adult tobacco survey (gats): bangladesh. world health organization 2009. available at: http://www.who.int/tobacco/surveillance/surve y/gats/en/. access date: december 22, 2016 23. sreeramareddy ct, pradhan pms, mir ia, sin s. smoking and smokeless tobacco use in nine south and southeast asian countries: prevalence estimates and social determinants from demographic and health surveys. population health metrics. 2014; 12:22. doi:10.1186/s12963-014-0022-0. 24. kamal sm, islam ma, rahman ma. sociopsychological correlates of smoking among male university students in bangladesh. asia pac j public health. 2011; 23(4):555-67. doi: 10.1177/1010539509350495. 25. chowdhury mth, croucher r. association between the tobacco cessation training and oral cancer knowledge level with tobacco use related behavior among the 4th year dental undergraduates: a cross sectional study in dhaka, bangladesh. j med. 2008; 9:31-36. 26. taheri e, ghorbani a, salehi m, sadeghnia hr. cigarette smoking behavior and the related factors among the students of mashhad university of medical sciences in iran. iranian red crescent medical journal. 2015;17(1):e16769. doi:10.5812/ircmj.16769. 27. al-kubaisy w, abdullah nn, al-nuaimy h, kahn sm, halawany g, kurdy s. factors associated with smoking behaviour among university students in syria. procedia social and behavioral sciences. 2012; 38:59 – 65. doi:10.1016/j.sbspro.2012.03.324. 28. öncel1 sy, gebizlioğlu ol, alioğlu fa. risk factors for smoking behavior among university students. turk j med sci. 2011; 41 (6): 10711080 29. cw warren, nr jones, a peruga, j chauvin, jp baptiste, vc silva et al. global youth tobacco surveillance:2000–2007.morbidity and mortalityweekly report, cdc. 2008; 57(1):1– 21. 30. sreeramareddy ct, suri s, menezes rg, et al. self-reported tobacco smoking practices among medical students and their perceptions towards training about tobacco smoking in http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/tobacco/surveillance/survey/gats/en/ http://www.who.int/tobacco/surveillance/survey/gats/en/ hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu medical curricula: a cross-sectional, questionnaire survey in malaysia, india, pakistan, nepal, and bangladesh. substance abuse treatment, prevention, and policy. 2010;5:29. doi:10.1186/1747-597x-5-29. 31. minaker lm, ahmed r, hammond d, et al. flavored tobacco use among canadian students in grades 9 through 12: prevalence and patterns from the 2010-2011 youth smoking survey. preventing chronic disease 2014;11:e102. doi: 10.5888/pcd11.140094 32. xianglongxu, doris yin ping leung, bing li, pengfei wang, yong zhao.smoking-related knowledge, attitude, social pressure, and environmental constraints among new undergraduates in chongqing, china. int j environ res public health. 2015; 12:895-909. 33. mm bassiony. smoking in saudi arabia. saudi medical journal. 2009; 30(7):876–881. 34. g el-sharkawy. cigarette smoking among university students: family—related & personal risk factors. journal of american science. 2011; 7(3):260–268. 35. mr koura, af al-dossary, aa bahnassy. smoking pattern among female college students in dammam, saudi arabia. journal of family and community medicine. 2011;18(2):63–68. 36. ng m, freeman mk, fleming td, robinson m, dwyer-lindgren l, thomson b, wollum a, sanman e, wulf s, lopez ad, murray cjl, gakidou e. smoking prevalence and cigarette consumption in 187 countries, 1980-2012. jama. 2014;311(2):183-192. doi:10.1001/jama.2013.284692 37. american cancer society. cancer facts & figures; 2007. available at: http://www.cancer.org/research/cancerfactsstati stics/cancerfactsfigures2007/index. access date: december 21, 2016 38. stramari lm, kurtz m, silva lc. prevalence of and variables related to smoking among medical students at a university in the city of passo fundo, brazil. j bras pneumol. 2009; 35: 442– 448. 39. mandil a, bin saeed a, ahmad s, aldabbagh r, alsaadi m, khan m. smoking among university students: a gender analysis. j infect public health. 2010; 3:179–187. 40. al-naggar ra, al-dubai sa, al-naggar th, chen r, al-jashamy k. prevalence and associated factors of smoking among malaysian university students. asian pac j cancer prev. 2011; 12:619–624. 41. siahpush m, mcneill a, hammond d, tong gt. socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: results from the 2002 international tobacco control (itc) four country surveys. tob control. 2006; 15:iii65 –iii70. doi:10.1136/tc.2005.013276. 42. terrades m, coulter wa, clarke h, mullally bh, stevenson m. patient’s knowledge and views about the effects of smoking on their mouths and the involvement of their dentists in smoking cessation activities. br dent j. 2009; 207:e22. 43. rikard–bell g, donnelly n, ward j. preventive dentistry: what do australian patients endorse and recall smoking cessation advice by dentists. br dent j. 2003; 194:159 64. 44. jensen ej, overgaard e. smoking patterns, knowledge of tobacco related health effects and desires to quit among 14-17yearhttp://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2007/index http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2007/index central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu old boarding school pupils in denmark, 198790. tob. control. 1993; 2:296-99. 45. stramari lm, kurtz m, silva lc. prevalence of and variables related to smoking among medical students at a university in the city of passo fundo, brazil. j bras pneumol. 2009; 35:442–448. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu table 1. demographic characteristics of study population and proportion of students using tobacco (n=264) demographic and personal characteristics of study participants smoker (%) n=159 non-smoker (%) n=105 p-value gender male 150 (94.34) 68 (64.76) 0.001a female 9 (5.66) 37 (35.24) age ≤ 19 years 20 – 23 years 24 – 27 years 10 (52.60) 117 (58.20) 32 (72.70) 9 (47.40) 84 (51.80) 12 (27.30) 0.042a academic year 1st 69 (61.06) 44 (38.94) 0.159b 2nd 34 (48.57) 36 (51.43) 3rd 20 (71.43) 8 (28.57) 4th 7 (63.64) 4 (36.36) masters 29 (69.04) 13 (30.96) departmentc business studies 7 (58.33) 5 (41.67) 0.004b social sciences 14 (56) 11 (44) mathematical & physical sciences 21 (56.76) 16 (43.24) arts & humanities 47 (73.44) 17 (26.56) biological sciences 28 (41.17) 40 (58.83) a p-values from chi-square tests. b p-values from fisher’s exact test conly 206 (78%) answered this question. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu table 2. age comparison of the study population male (±sd) female (±sd) p-valuea 95% ci lower uper smoker 21.55 (2.042) 23.78 (1.563) 0.002 3.601 0.862 non-smoker 21.54 (1.807) 21.00 (1.780) 0.141 0.184 1.272 ap-values from independent samples t test http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu table 3. factors for initiating tobacco use prevalence,% p-valuea odds ratio 95% ci influencing factors for starting cigarette smoking friend’s influence 62.26 < 0.001 0.862 0.810 0.917 father’s use 64.30 0.001 0.308 0.158 0.603 brother’s use 51.80 0.001 0.288 0.141 0.588 uncle’s use 53.60 0.914 0.964 0.4911.891 grandfather’s use 21.40 0.050 2.151 1.00 4.624 influencing factors for continuing cigarette smoking mental depression 54.18 0.628 0.642 0.107 3.848 bad family relations 6.92 0.999 0.000 0.00 educational problems 13.84 0.097 4.878 0.751 31.705 diifficulties in relationship with girlfriend 41.51 0.708 0.720 0.129 4.020 curiosity 36.48 0.846 0.826 0.119 5.709 ap-values from logistic regression analyses. [“no” is the reference category for each variable.] http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu table 4. proportion of students by knowledge and perception about hazardous tobacco smoking personal attitudes towards smoking smoker (n, %) non-smoker (n, %) p-value agreed disagreed agreed disagreed student should not smoke 102 (64.2) 57 (35.8) 105 0.216a tobacco brings mental tranquility 126 (81.30) 29 (18.70) 0.065 a use of tobacco is a cause of economic loss 109 (77.65) 50 (22.35) 96(91.43) 9 (8.57) <0.001a having knowledge of tobacco’s association with non-communicable diseases 218 (86.16) 35 (13.83) 0.009b ap-values from logistic regression analyses. bp-values from chi-square test http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu table 5. logistic regression analyses for smoking-related factors among the students category variable or 95% ci p-value smoker’s personal perceptions bad smart modern general 1 (ref) 1.642 1.40 2.497 1.48 – 1.908 1.02 – 2.847 1.868 – 5.688 <0.001a <0.001a <0.001a student should not smoke female male 1 (ref) 0.424 0.109 – 1.649 0.216b smoking due to peer pressure female male 1 (ref) 1.031 0.121 – 8.788 0.978b reported health problems due to tobacco smoking female male 1 (ref) 0.135 0.017 – 1.110 0.062b family members that died from chd and cancer died: person wasn’t smoker died: person was smoker 1 (ref) 0.327 0.161 – 0.665 0.002b exposure to environmental tobacco smoke female male 1 (ref) 0.20 0.094 – 0.425 <0.001b non-smoker smoker 1 (ref) 0.509 0.253 – 1.025 0.059b ap-values from multinomial logistic regression analyses bp-values from binary logistic regression analyses. abbreviation: ci = confidence intervals, or= odds ratio. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu figure 1. location map of the study area. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hossain this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu figure 2. percent of age of initiating tobacco smoking by gender http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.244|http://cajgh.pitt.edu figure 3. self-reported health problems of smokers 0 10 20 30 40 50 60 70 cough breathing problem asthma chest pain loss of appetite others cough breathing problem asthma chest pain loss of appetite others percent 62.7 46.7 9.3 37.3 41.3 5.3 frequency 47 35 7 28 31 4 health problems http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx prevalence of tobacco smoking and factors associated with the initiation of smoking among university students in dhaka, bangladesh abstract keywords: student health, tobacco smoking, public health, bangladesh prevalence of tobacco smoking and factors associated with the initiation of smoking among university students in dhaka, bangladesh research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. energy drink consumption practices of young people in bahrain maryam m. nassaif, ghufran j. j. alobed, noor a. a. alaam, abdulla n. alderrazi, muyssar s. awdhalla, asokan g. vaithinathan college of health sciences, university of bahrain, bahrain vol. 4, no. 2 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.216 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ nassaif this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.216|http://cajgh.pitt.edu abstract background: energy drink (ed) consumption is becoming increasingly popular among young bahrainis, who may be unaware of the health risks associated with ed consumption. to date, there have been few publications on the consumption of ed in bahrain, particularly among adolescents. this study seeks to fill a gap in the literature on energy drink consumption practices of bahraini adolescents. methods: data were collected using a previously established european food safety authority questionnaire. cross-sectional analyses were conducted on a convenience sample of 262 bahraini students aged 10 to 18 years. results: most participants consumed energy drinks 2 to 3 times per week and consumed two or more cans at a time. eighty percent of partcipants preferred energy drinks with sugar. participants in the older age group and higher educational level consumed more ed. the majority (57%) consumed ed at home with friends as part of socialization. notably, 60% of the parents of the respondents have not consumed energy drinks. prominent reasons for consumption of energy drinks included: taste (40%), energy (30%), stay awake (13%), augment concentration (4%), and enhance sports performance (6%). conclusion: energy drink consumption is a popular socialization activity among adolescents of bahrain. the potential health risks necessitates the need for novel health promotion strategies and advocacy efforts for healthy hydration practices. keywords: energy drinks, health effects, young people, health promotion energy drink consumption practices of young people in bahrain maryam m. nassaif, ghufran j. j. alobed, noor a. a. alaam, abdulla n. alderrazi, muyssar s. awdhalla, asokan g. vaithinathan college of health sciences, university of bahrain, bahrain research energy drink(s) (ed) refers to beverages that contain caffeine in combination with other ingredients such as taurine, guarana, and b vitamins, with claims to provide its consumers with extra energy.1 over 140 countries report ed consumption, with children, adolescents, and young adults representing half of the consumers of ed.2 the prevalence of ed consumption varies by age group and size. regionally, ed are largely consumed in the middle east and in the western world. for instance, 55% of male and 26% of female students in the university of dammam consumed ed,3 and saudi arabia was ranked among the top ten ed consuming countries.4 in 2013, the central information organization of bahrain reported that the consumption of ed in bahrain was 174 per 1,000 persons.5 in the usa, about 1 in 9 youths received counseling discouraging ed consumption from a health care professional.6 the prevalence of ed consumption in europe was 68%, varying from 48% in greece to 82% in the czech republic, and mostly observed in the age group of 15-18 years (73%).7 on average, adolescents consume 2.1 l of ed per month in europe.7 an australian report revealed that 48% of young adults consumed ed at least once a month with an average intake of 1-2 cans per day.8 eds act as non-nutritive stimulants with purported ergogenic or performance-enhancing effects. caffeine, taurine, d-glucorono-y-lactone, and sugar are the main ingredients. other products found in ed are http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.216|http://cajgh.pitt.edu vitamins, l-carnitine, and extracts such as guarana (1 gm of guarana equates 40 to 80 mg of caffeine), ginkgo biloba, bitter orange, and ginseng.2 the intended effects of ed are to provide sustenance, endurance, concentration, and enhanced performance. manufacturers of ed target their sales to students, athletes, and people in professions that warrant sustained alertness.9 popularity of ed among teenagers is associated with risk taking.10 studies have shown that moderate caffeine consumption (<400mg/ day) is not associated with the adverse effects of caffeine such as general toxicity, cardiovascular effects, effects on bone status, and calcium balance;11 however, the amounts of caffeine in ed far exceed that of safety limits.11 according to the world health organization (who) 2015 sugar intake for adults and children guidelines,12 the suggested limit of sugar consumption for adults of normal bmi is 25g/day (6 teaspoons). in general, sugar content in ed ranges from 21 g to 34 g per 8 oz. daily consumers of two or three cans of ed could be ingesting 4 to 6 times the maximum recommended daily intake of sugar, which poses a risk for obesity and dental problems. 13 common adverse effects of ed that have been documented are dizziness, inability to focus, nervousness, gastrointestinal upset, and insomnia.14 in rare situations, anxiety, seizure, increased heart rate, dehydration, acute mania, stroke, and behavioral problems like fighting and addiction have been observed.14 potential problems associated with ed consumption in children and adolescents include cardiovascular effects and eating disorders. a systematic review suggests using caution in consuming ed, even though long term studies with health effects follow up were lacking.14 the prevalence of non-communicable diseases is similar to other developed economies according to the national non-communicable diseases (nncd) risk factor survey carried out in bahrain,15 thus nutritional factors are important to investigate. as of 2016, no reports have been published on the consumption practices of ed in bahrain. therefore, this study was undertaken to explore energy drink consumption practices of bahraini adolescents. methods data collection for this cross-sectional study was carried out by study investigators using a convenience sampling approach from public places that students frequently visit (i.e. parks and malls of bahrain during the weekends). our study sample included bahraini adolescent students aged 10 to 18 years of both genders. to be 95% confident that the true value of the estimate will be within 5 percentage points of the prevalence of 17%,5 the required sample size was calculated to be 217 in order to achieve the desired level of accuracy. the final number of participants recruited was 262. in the initial phase of data collection, participants were asked whether they had ever consumed ed. those that answered yes were given a structured, self-report questionnaire. the questionnaire was modified from a previously established questionnaire for gathering consumption data on specific consumer groups of energy drinks by the european food safety authority (efsa).16 the modifications introduced were designed to make the questionnaire more suitable and compatible with the bahraini society regarding demographic, economic, and socio-cultural aspects. broadly, the questionnaire had two sections: 1) demographic data (i.e., age, gender, and current education level); 2) energy drink consumption data (i.e., consumption frequency, consumption amount, place of consumption, reasons for consumption, choice of sugar or sugar free, preferred brand, and parental consumption). for affirming face and content validity, the questionnaire was scrutinized by a panel of experts from the college of health sciences and nutrition in bahrain. the questionnaire was translated into arabic and back translated to english to ensure there http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx nassaif this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.216|http://cajgh.pitt.edu were no translation errors. before beginning the study, the questionnaire was piloted with 30 participants to determine feasibility. the study was approved by the institutional research committee of the college of health sciences, bahrain. after explaining the study purpose, a written informed consent was obtained from all of the participants. confidentiality of the participants and protection of data gathered was ensured by using study codes on data documents and removing all identifiable information. data analysis the data from the questionnaires were cleaned, coded, and entered in excel (microsoft, redmond, wa, usa) and then exported to spss version 21 (spss inc, chicago, illinois, usa) for analysis. descriptive statistics were used to analyze baseline participant characteristics. chi-square tests were used to compare the ed consumption patterns and baseline characteristics of the participants. results the median age of the participants was 16 years (range: 10-18), which was not normally distributed. the majority of participants were enrolled in secondary education institutions (grades 10 to 12) and 51% were male (table 1). table 1: qualitative demographic characteristics of participants analyzing the consumption practices, habitual consumption of ed was significantly higher in those aged 16 to 18 compared to those aged 10 to 12 or 13 to 15 (p<0.01), and a similar significant difference was observed in the group with higher levels of education compared to groups with two other levels of education (p<0.03). sixty one percent of participants had initiated ed consumption in the past year. fifty seven percent declared that they consumed ed at home and with friends as a part of socialization adjoining sedentary high screen media use such as watching tv or playing video games; less than 10% consumed ed during physical activities and sports or in public places. frequency of ed consumption varied in the sample (table 2). among the respondents, one third consumed ed two to three days a week, and one fifth consumed ed less than once per month. over 80% of respondants preferred a portion size of 250 ml more than any other available choice of portions. in an average month of the past year, 34% of the respondents had 2-4 cans and 23% of the respondents had 5-10 cans. in a single session of ed consumption over the last year 51% consumed either two or more cans. table 2: frequency and volume of energy drink consumption table 3 describes respondents’ key reasons for consumption of ed. among them, 40% liked the taste of the drink, and 30% thought that ed provides the needed energy. other reasons included: stay awake (13%), augment concentration (4%), and enhance sports performance (6%). the top three popular brands consumed by the participants of this study were red bull, boom boom, and bison. over 80% preferred ed with sugar over sugar free ed, and no difference in the preference between the age groups, gender or educational levels was found. among the parents of the respondents, 40% have consumed ed. table 3: reasons for energy drink consumption http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.216|http://cajgh.pitt.edu discussion most participants consumed ed 2 to 3 times per week, two or more cans at a time, and primarily preferred ed with sugar. older participants tended to consume more ed. many consumed ed as a part of socialization. this study supports the idea that ed marketing strategies have reached young people in bahrain, since the majority of the participants consumed two or more cans in a single session 2 to 3 times a week, which is similar to the frequency of ed consumption reported from italy.17 this study showed that in our sample, higher intake of ed was found in the older age group with a higher educational level, which may be due to independent money spending capacity and the ability to buy ed without parental supervision. the majority admitted to consuming ed at home and with friends as part of socialization. the primary reasons for consumption of ed were for the taste of the drink and the energy need. these findings corroborate the reasons adolescents consume ed given in a report18 from neighboring saudi arabia findings of our study contradict the belief that the intended effect of ed use is endurance and physical activity. less than 10% of the respondents reported that they consumed ed during physical activities or sports. the majority of the respondents were habitual consumers of ed and preferred ed with sugar, indicating that this practice may also be associated with higher consumption of other sugar-sweetened beverages. high consumption of sweetened ed without physical activity, along with sedentary high screen media use among young people, are risk factors for non-communicable diseases, such as cardiovascular disease and obesity. this finding can be cautiously corroborated by the nncd survey in bahrain. almost two thirds of adults in bahrain were reported to be consumers of high calorie sugar-sweetened beverages and less than 3% used artificial sweeteners instead of sugar.5 nncd has also revealed that the overall prevalence of overweight was 33%, obesity was 36%, diabetes mellitus was 14%, and hypercholesterolemia was 41%.15 considering that over 60% of parents did not consume ed, and generalizing the prevalence of non-communicable diseases by the nncd survey to our study, there is a trend of unhealthy consumption practices of ed by the current generation of young people in bahrain, and with the anticipated demographic shift of these young people to adults, the burden of non-communicable diseases in bahrain is expected to escalate over the reported nncd survey prevalence rates. at the same time, it is possible that ed consumption in various situations may serve as a marker for other unhealthy behaviors among young people.19 adolescents may not be fully capable of understanding complex concepts of behavior and health consequences, and their behavior patterns are different from children and adults. the successful transition period from childhood to adulthood of young people depends on the support of families, communities, schools, and health services. these support systems have the responsibility to promote their development and intervene effectively when problems arise.20 increasing popularity of ed, particularly with adolescents, has been observed since their introduction at the end of the last century. it has been suggested that some young adults consume ed for their perceived physiologic benefits, unaware of the ingredients in ed and the associated health risks.21 the american academy of pediatrics22 suggests that ed pose potential health risks to children and young adults primarily due to the stimulant content. often, young people do not distinguish ed from sports drinks. therefore, this exploratory study was conducted to investigate the consumption practices of ed among adolescents in bahrain. this preliminary study has a limitation. the convenience sampling method used in this study of over 200 individuals may not be representative of the general bahraini population. regardless of this limitation, our study employed an efsa validated survey tool with reliable measures to examine practices of ed consumption among young people of bahrain. we http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx nassaif this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.216|http://cajgh.pitt.edu recommend larger cross-sectional and logitudinal studies in the future to address this limitation. conclusion this study has shown that the ed consumption is a popular, high frequency socialization tool used among young people of bahrain. the potential health risks that high ed consumption may cause necessitates the need for novel health promotion strategies. to prevent consumption at home, where the majority reported consuming ed, parents should be educated about the potential consequences associated with ed consumption and promote healthy habits of hydration. fundamental to the health promotion campaign is instituting nutrition educational programs in educational institutions. the encouragement of the consumption of beverages with nutritive value, or water, and restricting the sale and use of ed on the institutional premises could curtail ed consumption. taking the experience from the health promotions of the saudi government23 and the active health promotion campaign in bahrain, health regulatory authorities may consider warning labels on the containers of ed, and regulation of advertisements of ed similar to alcohol and tobacco. conflicts of interests the author declares that they have no competing interests. acknowledgements we gratefully acknowledge all the participants in the study and the european food safety authority. we thank the following from college of health sciences, university of bahrain: dr. aneesa al sindi, dean, for the encouragement and support, and mr.hassan al basri for statistical analysis. references 1. nutrition and health info-sheet. some facts about energy drinks. http://nutrition.ucdavis.edu/content/infosheets/factpro-energydrinks.pdf. accessed december 24, 2014. 2. seifert sm, schaechter jl, hershorin er, lipshultz se. health effects of energy drinks on children, adolescents, and young adults. pediatrics. 2011;127(3):511-528. 3. alsunni aa ba. energy drinks consumption pattern, perceived benefits and associated adverse effects amongst students of university of dammam, saudi arabi. j ayub med coll abbottabad 2011;23:3-9. 4. chan m. return to alma-ata. lancet. 2008;372(9642):865-866. 5. devi s. reforming health care in kazakhstan. lancet. 2014;383(9936):2197-2198. 6. kumar gs ps, onufrak s. association between reported screening and counseling about energy drinks and energy drink intake among u.s. young people. patient educ couns. 2014;94:250-254. 7. knowledge @ warton. family physicians make a comeback in india. 2013; http://knowledge.wharton.upenn.edu/india/article.cfm?articleid =4719. accessed august 7, 2014. 8. trapp gs, allen kl, o'sullivan t, robinson m, jacoby p, oddy wh. energy drink consumption among young australian adults: associations with alcohol and illicit drug use. drug alcohol depend. 2014;134:30-37. 9. gunja n, brown ja. energy drinks: health risks and toxicity. med j aust. 2012;196(1):46-49. 10. marczinski ca, fillmore mt. dissociative antagonistic effects of caffeine on alcohol-induced impairment of behavioral control. exp clin psychopharmacol. 2003;11(3):228-236. 11. denoon d. how much caffeine is in your energy drink? . www.webmd.com/food-recipes/news/20121025/how-muchcaffeine-energy-drink. accessed december 24, 2014. 12. who. who opens public consultation on draft sugars guideline 2014. www.who.int/mediacentre/news/notes/2014/consultationsugar-guideline/en/ accessed february 11, 2015. 13. sifferlin a. what’s in your energy drink? . time2013. 14. burrows t, pursey k, neve m, stanwell p. what are the health implications associated with the consumption of energy drinks? a systematic review. nutr rev. 2013;71(3):135-148. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://nutrition.ucdavis.edu/content/infosheets/fact-pro-energydrinks.pdf http://nutrition.ucdavis.edu/content/infosheets/fact-pro-energydrinks.pdf http://knowledge.wharton.upenn.edu/india/article.cfm?articleid=4719 http://knowledge.wharton.upenn.edu/india/article.cfm?articleid=4719 http://www.webmd.com/food-recipes/news/20121025/how-much-caffeine-energy-drink http://www.webmd.com/food-recipes/news/20121025/how-much-caffeine-energy-drink http://www.who.int/mediacentre/news/notes/2014/consultation-sugar-guideline/en/ http://www.who.int/mediacentre/news/notes/2014/consultation-sugar-guideline/en/ central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.216|http://cajgh.pitt.edu 15. ministry of health, kingdom of bahrain. national noncommunicable diseases risk factors survey-undp. 2009; www.intranet.health.gov.bh/docs/reports%20%20studies/ncd %20survey%20report.pdf. accessed november 28, 2014. 16. zucconi s, volpato c, adinolfi f, et al. gathering consumption data on specific consumer groups of energy drinks. 2013; http://www.efsa.europa.eu/sites/default/files/scientific_output/ files/main_documents/394e.pdf. accessed march 10, 2015. 17. gallimberti l, buja a, chindamo s, et al. energy drink consumption in children and early adolescents. eur j pediatr. 2013;172(10):1335-1340. 18. musaiger a, zagzoog n. knowledge, attitudes and practices toward energy drinks among adolescents in saudi arabia. glob j health sci. 2014;6(2):42-46. 19. miller ke. energy drinks, race, and problem behaviors among college students. j adolesc health. 2008;43(5):490-497. 20. who. maternal, newborn, child and adolescent health. 2014; www.who.int/maternal_child_adolescent/topics/adolescence/de v/en/. accessed january 14, 2015. 21. o'dea ja. consumption of nutritional supplements among adolescents: usage and perceived benefits. health educ res. 2003;18(1):98-107. 22. sports drinks and energy drinks for children and adolescents: are they appropriate? pediatrics. 2011;127(6):1182-1189. 23. naeem z. health hazards of energy drinks and positive actions by saudi government. int j health sci (qassim). 2014;8(2):v-vi. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.intranet.health.gov.bh/docs/reports%20%20studies/ncd%20survey%20report.pdf http://www.intranet.health.gov.bh/docs/reports%20%20studies/ncd%20survey%20report.pdf http://www.efsa.europa.eu/sites/default/files/scientific_output/files/main_documents/394e.pdf http://www.efsa.europa.eu/sites/default/files/scientific_output/files/main_documents/394e.pdf http://www.who.int/maternal_child_adolescent/topics/adolescence/dev/en/ http://www.who.int/maternal_child_adolescent/topics/adolescence/dev/en/ nassaif this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.216|http://cajgh.pitt.edu table 1: qualitative demographic characteristics of participants variables n (%) age (in years) 10-12 38 (14.5) 13-15 90 (34.4) 16-18 134 (51.1) gender male 133 (50.8) female 129 (49.2) education primary (grades 1-6) 31 (11.8) intermediate (grades 7-9) 81 (30.9) secondary (grades 10-12) 150 (57.3) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.216|http://cajgh.pitt.edu table 2: frequency and volume of energy drink consumption n(%) frequency of energy drinks consumed per month rarely 42 (22.8) once-twice a month 28 (15.2) once per week 19 (10.3) 2-3 days per week 53 (28.8) 4-5 days per week 19 (10.3) everyday 23 (12.5) consumption of energy drinks by volume 250 ml can 149 (81.0) 355 ml can 28 (15.2) others 7 (3.8) frequency of energy drinks consumed per month 1 or less 40 (21.7) 2 to 4 cans 63 (34.2) 5 to 10 cans 42 (22.8) 11 to 20 cans 24 (13.0) >20 cans 15 (8.2) number of cans of energy drinks consumed in a single session 1 can 88 (47.8) 2 cans 59 (32.1) 3 cans 20 (10.9) 4 cans 7 (3.8) >4 cans 10 (5.4) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx nassaif this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 2 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.216|http://cajgh.pitt.edu table 3: reasons for energy drink consumption n(%) need energy (in general) 54 (30.0) stay awake 24 (13.3) i like their taste 72 (40.0) concentration augmenting (studying/working) 8 (4.4) enhance sport performance 11 (6.1) effect of promotions and advertisements 3 (1.7) stimulate my metabolism 1 (0.6) others 7 (3.9) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. kainar syndrome: history of the first epidemiological case-control study of the effect of radiation and malnutrition aidar atchabarov atchabarov institute for basic and applied biomedical research, asfeniyarov national medical university, almaty, kazakhstan vol. 4, no. 1 (2015) | issn 2166-7403 (online) doi 10.5195/cajgh.2015.221 | http://cajgh.pitt.edu http://creativecommons.org/licenses/by/3.0/us/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx atchabarov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.221 | http://cajgh.pitt.edu kainar syndrome: history of the first epidemiological casecontrol study of the effect of radiation and malnutrition aidar atchabarov atchabarov institute for basic and applied biomedical research, asfeniyarov national medical university, almaty, kazakhstan editorial kainar syndrome was originally described in the late 1950s as a health condition associated with increased bleeding, hair loss, fainting, and fatigue.1 the name “kainar” came from the village in kazakhstan where most of the affected patients resided. initial explorations of the etiology of kainar syndrome identified radiation exposure and insufficient levels of vitamin c as risk factors for the syndrome. an extensive study of the syndrome was conducted by the national academy of sciences of kazakh ssr from 1957 to 1960,1,2 which established the presence of harmful effects of nuclear tests in semipalatinsk nuclear test site (snts) on human and animal health.3 however, not all results were published, as authorities did not believe that such a condition existed. once the results of this research became known to the leaders of kazakhstan and the former soviet union, the military-industrial complex grew more concerned about the health effects of nuclear testing, and declared a moratorium on nuclear testing. since 1961, dangerous ground-level tests ceased; in 1962, testing was switched to high-altitude tests; and in 1963, only underground tests were allowed. on august 5, 1963, the limited test ban treaty was signed, banning nuclear weapon testing in the atmosphere, outer space, and underwater.4,5 the institute of regional pathology in almaata, the former capital of kazakhstan (currently, almaty), was founded due to the need to better understand the effects of penetrating radiation. this need arose due to the emergence of a new understanding that the early appearance of radiation sickness symptoms mimicked various other pathologies (e.g. infection, intoxication, burns, etc.). previous understanding of radiation sickness assumed that radiation sickness primarily manifested itself in genetic mutations at the cellular, tissue, and organ levels. the goal of this research program was to develop in-depth comprehensive studies of health outcomes impacted by radiation effects. a pilot study6 a group of researchers led by dr. bahia atchabarov, a renowned kazakh scientist, recruited 3,564 cases (individuals who lived in radiation exposed areas of the former semipalatinsk region) and 2,028 controls (individuals in areas without contamination) and examined their health status. cases were recruited from three radiation exposed areas of the former semipalatinsk region (abai, beskaragai, and shubartausky), and controls were recruited from four areas without contamination zhezkazgan (ulutausky district), karaganda (kounrad and kuvsky areas), and pavlodar (bayanaul area) regions. participants were matched based on key baseline health characteristics. in order to ensure the reliability of findings on health effects of radiation exposure, animal populations (farm animals) were also studied in addition to the human participants. to confirm the clinical data identified in humans and to clarify the severity of radiation influence http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.221 | http://cajgh.pitt.edu on health, the health status of farm animals (1,257 cows and 1,000 sheep) from the abai (case area) district and four control areas (800 cows and 605 sheep) were assessed. radiation in animals it was concluded that animals examined in the abai district suffered from hypochromic anemia, accelerated erythrocyte sedimentation rate, erythrocyte dysfunction, leucopenia, eosinophilia, stab and segmented neutrophilia, leukocytopenia, abnormality of redox processes of cellular respiration, decreased concentration of vitamin c in the blood, and abnormal liver function. extensive pathological changes in organs and tissues of animals in abai district were similar for all animals examined. the overall pattern of health deterioration was characterized by degenerative changes and sclerotic processes in parenchymal organs, tissue atrophy and hyperplasia of the respiratory and digestive tracts, pre-cancerous lesions in the lungs, degenerative changes in cortical neurons and the brain stem, a decrease in the islet apparatus of the pancreas, inhibition of germinal elements in the ovaries, and distinct changes in the thyroid gland. pronounced changes were also identified in the mucosa of the upper respiratory tract. there were areas of acute thinning and destruction of the epithelial lining, formation of dense cellular infiltrates beneath the epithelium, acute proliferation of smooth muscle, and abnormal intestinal wall elements, with an increasing number of nuclei in which amniotic division occurs. there were also pronounced inflammatory-degenerative changes in the thyroid gland. pathological changes in farm animals were more pronounced than changes in human participants. it was hypothesized that this may be due to the fact that animals were held in the fields during environmental radiation exposure without protective cover. animals also consumed forage contaminated with radioactive particles, and were in constant contact with the surface soil contaminated with radioactive fallout. radiation in participants human research participants examined in the semipalatinsk region (especially among the population of the abai district) had a higher number of clinical symptoms when compared to participants from control areas. these symptoms included: hemorrhages in the mucous membranes of the upper respiratory tract, mouth, and genitals, degenerative changes in the mucous membranes (e.g. erosion, leukoplakia, hyper pigmentation, and telangiectasia), abnormal changes in peripheral blood (e.g. leukopenia, lymphopenia, thrombocytopenia, lymphocytosis, anemia, and white blood cell stimulation), cataracts diagnosed at young age, increased fragility of blood vessels and capillaroscopic changes, changes in menstrual and ovarian cycles, abnormal liver function, atrophic rhinitis and pharyngitis, gingivitis, pathologies of the gastrointestinal tract (e.g. gastritis), skin changes particularly on skin surfaces not protected by clothing (e.g. hyperkeratosis and hyper pigmentation), nail dystrophy, asthenic and wasting syndromes, and hypotension. the frequency of detection of pathological changes in individuals who lived in areas with radioactive contamination was significantly higher than those from the control areas. pathological changes identified in human participants and animal subjects were not specifically attributed to any well-known common diseases characterized by inflammatory, degenerative, or sclerotic changes in the organs. in the evaluation of clinical samples, all participants were classified into four groups based on the number and severity of symptoms: a, b, c, and d. group a included individuals with the highest number of symptoms, many of which could be attributed to the nature and severity of the symptoms of chronic radiation sickness. group b had the second greatest number of symptoms, with greater than three clinical symptoms with the disease. group c consisted of individuals who had two or three clinical symptoms of the disease, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx atchabarov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.221 | http://cajgh.pitt.edu which (although they could occur in patients with chronic radiation sickness) more often were symptoms of well-known chronic somatic and infectious diseases. group d consisted of healthy individuals without any clinical symptoms of the disease or in the presence of one or two clinical symptoms within the normal range for residents of those areas. introduction of kainar syndrome later, the symptoms of the groups that exhibited clinical manifestations (a-c) were named "kainar syndrome," after the village where these clinical manifestations were most prevalent. kainar syndrome was very common among the symptomatic population in the surveyed regions, with a prevalence ranging from 48.2% to 62.6% in control areas, and ranging from 72.8% to 96.2% in areas with radiation contamination. in areas with radiation contamination and an increase in the disease frequency, the incidence of severe forms of disease also increased. kainar syndrome was divided into two groups based on the number of clinical symptoms and their severity: strongly pronounced rate "kainar a" (or "major kainar") and weakly pronounced rate "kainar c" (or "minor kainar"). major kainar includes the clinical manifestations of groups a and b, whereas minor kainar includes the clinical manifestations of the group c. major kainar encompasses the largest number of clearly defined clinical manifestations: vascular changes, hematopoietic system changes, functional changes in the nervous system (i.e. indicating the presence of wasting syndrome), and changes more specific to penetrating radiation exposure (e.g. changes in the eye lens at a young age and changes in exposed skin). minor kainar encompasses individuals with 2-3 clinical manifestations of mild severity, which have similar characteristics for chronic radiation sickness. individuals with minor kainar also develop infectious diseases or toxicities typically associated with age or with hypovitaminosis, in addition to mild radiation exposure. the prevalence of major kainar in the contaminated areas was 3 to 5 times greater than that of the control areas. this demonstrates the potential role of radiation in the development of this disease. the next question is “what is the cause, mechanism, and etiology of kainar syndrome, particularly minor kainar, which is found even in populations in control areas?” previous studies have found that lack of essential vitamins, such vitamins c, b, and a, are associated with an increased risk of developing kainar syndrome.1 based on the results of a previously published preliminary study,6 hypovitaminosis of vitamin c was associated with the development of kainar syndrome among the examined population in control areas. there was also a synergistic effect of radiation and hypovitaminosis of vitamin c in people residing in contaminated regions. according to the data, hypovitaminosis of vitamin c was identified as a very widespread condition among the examined population of central kazakhstan. chronic radiation sickness was found to be aggravated by hypovitaminosis of vitamin c.6 however, results were preliminary, and further studies are needed to examine the etiology of kainar syndrome in central asia. in conclusion, analysis of case-control data collected between 1957 and 1959 led to the assumption that pathological changes in humans and animals are directly related to radiation exposure. kainar syndrome was also found not to be specific for people living in areas with radioactive contamination, but is also found in people from control areas. while kainar syndrome, overall, has received significant attention in the literature, minor kainar syndrome remains an underpublished phenomenon. therefore, future research is needed to further investigate kainar syndrome in the geographic areas impacted by radiation exposure. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 4, no. 1 (2015) | issn 2166-7403 (online) | doi 10.5195/cajgh.2015.221 | http://cajgh.pitt.edu references 1. rozenson ri, apsalikov kn, zhumambayeva sm, masalimov et. the kainar syndrome: history and modern understanding. ipshu english research report series. 2012(28):144-150. 2. bailiff ik, stepanenko vf, göksu hy, et al. the application of retrospective luminescence dosimetry in areas affected by fallout from the semipalatinsk nuclear test site: an evaluation of potential. health phys. 2004;87(6):625-641. 3. grosche b, zhunussova t, apsalikov k, kesminiene a. studies of health effects from nuclear testing near the semipalatinsk nuclear test site, kazakhstan. cajgh. 2015;4(1). 4. gusev bi, abylkassimova zn, apsalikov kn. the semipalatinsk nuclear test site: a first assessment of the radiological situation and the test-related radiation doses in the surrounding territories. radiat environ biophys. 1997;36(3):201-204. 5. stephan g, pressl s, koshpessova g, gusev bi. analysis of fish-painted chromosomes in individuals living near the semipalatinsk nuclear test site. radiat res. 2001;155(6):796800. 6. atchabarov ba. the radioactivity of environment and the health of population and farm animals in central kazakhstan. paper presented at: the report of expedition 19571957; alma ata, kazakhstan. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx microsoft word babapour.docx new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. need for couple’s awareness about sexual health in covid-19 pandemic farzaneh babapour1, fatemeh hamidi1, zeinab hamzehgardeshi2* 1department of midwifery, nasibeh school of nursing and midwifery, mazandaran university of medical sciences, sari, iran; 2sexual and reproductive health research center, department of reproductive health and midwifery, school of nursing and midwifery, mazandaran university of medical sciences, sari, iran *corresponding author email: z.hamzehgardeshi@mazums.ac.ir vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.490 | http://cajgh.pitt.edu babapour this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.490 | http://cajgh.pitt.edu need for couple’s awareness about sexual health in covid-19 pandemic farzaneh babapour1, fatemeh hamidi1, zeinab hamzehgardeshi2* 1department of midwifery, nasibeh school of nursing and midwifery, mazandaran university of medical sciences, sari, iran; 2sexual and reproductive health research center, department of reproductive health and midwifery, school of nursing and midwifery, mazandaran university of medical sciences, sari, iran *corresponding author email: z.hamzehgardeshi@mazums.ac.ir editorial in december 2019, an outbreak of pneumonia was identified in wuhan, china. this novel viral outbreak, now named coronavirus disease 2019 (covid-19), has since quickly spread around the world. it is recognized as a major public health concern and was declared a pandemic disease by the world health organization (who) on 11 march 2020.1 there are similarities to the severe acute respiratory syndrome (sars) outbreak in 2003 and the middle east respiratory syndrome (mers) outbreak in 2012, suggesting that the sars-cov-2 virus primarily targets the respiratory system and is transmitted via air droplets and physical contact. patients were evaluated for viral pneumonia through the special testing utilizing wholegenome sequencing, cell cultures, and polymerase chain reaction (pcr). the virus was recognized as genus beta coronavirus and isolated from biologic samples, placing it alongside sars and mers.2 the lives of millions of people around the world are currently being affected by the crisis caused by the outbreak of covid-19. a less obvious repercussion of this pandemic is the potential implications for sexual health among those affected by the pandemic. according to the who definition, “sexual health is the state of physical, mental and social well-being in regard to sexuality. it requires a positive and respectful approach to sexuality and sexual relationships, in addition because the possibility of getting pleasurable and safe sexual experiences, freed from coercion, discrimination and violence.”3 in developing countries in particular, the provision of sexual and reproductive healthcare services may be negatively impacted during the pandemic.4 the covid-19 pandemic can pose a threat to sexual and reproductive health in both men and women through central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.490 | http://cajgh.pitt.edu decreased access to medical care, lack of access condoms, increased incidence of sexually transmitted diseases, etc.5 with the global expansion of the covid19, watching porn sites has increased. according to pornhub, pornography use in several countries increased, with global traffic increasing over 11% from late february to march 17, 2020.6 related concerns include the potential increase of gender-based violence, domestic abuse and effects of stigma and discrimination associated with covid-19.7 there are 27 known viruses associated with viremia in human semen, though there is still little known about sars-cov-2 in semen. one study has reported that sars-cov-2 can be present in the semen of patients with covid-19, and sars-cov-2 may still be detected in the semen of recovering patients.8 data from another study, however, showed that men with covid-19, both the acute phase and the recovery, of sars-cov-2 is absent in samples from both semen and testes.9 in addition, direct contact with saliva can potentially transmit the virus, considering the evidence that covid-19 is a respiratory illness. other possible transmission routes of sars-cov-2 via body fluids include bronchoalveolar-lavage, saliva, blood, urine, feces, sputum, tears.10 therefore, it is important for the general public to know the basics of safe sex to prevent the spread of the covid-19 virus and still enjoy intimate relationships. given the importance of continued sexual health during the covid-19 pandemic, studies of viruses found in semen, especially concerning sars-cov-2 need to be a focus of future research. if future studies were to provide evidence that sars-cov-2 can be sexually transmitted, safe sex will be an important part of preventing transmission, through emphasis of transmission prevention methods such as condoms. community participation, attention to sexual health across all age groups, non-discrimination, access to quality services and information and collaboration will advance the achievement of improved health during the pandemic. further study is needed due to the importance of this area and lack of existing research about sexual health in covid-19. references 1. who directorgeneral’s opening remarks at the media briefing on covid-19. http://www.who.int/dg/speeches/detail/who-directorgen published 2020. accessed march 11, 2020. 2. zhu n zd, wang w. et al. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med 2020. doi: 10.1056/nejmoa2001017 3. sexual health and its linkages to reproductive health: an operational approach world health organization 2017 https://www.who.int/publications/i/item/97892415128 8. accessed 20 september 2017 isbn: 978 92 4 151288 4. mckibbin w & fernando r. the global macroeconomic impacts of covid-19: seven scenarios cama working paper no. 19/2020. doi: 10.2139/ssrn/3547729 5. hamzehgardeshi z, yazdani f, rezaei m, & kiani z. covid-19 as a threat to sexual and reproductive health. iranian journal of public health. 2020;49(supple 1). doi: https://doi.org/10.18502/ijph.v49is1.3688 6. mestre-bach g, blycker gr, potenza mn. pornography use in the setting of the covid-19 pandemic. j behav addict. 2020;9(2):181-183. doi: 10.1556/2006.2020.00015 7. tang k, gaoshan j, ahonsi b, et al. sexual and reproductive health (srh): a key issue in the emergency response to the coronavirus disease (covid19) outbreak. reproductive health. 2020;17(1):59. doi https://doi.org/10.1186/s12978020-0900-9 8. li d, jin m, bao p, et al. clinical characteristics and results of semen tests among men with coronavirus disease 2019. jama netw open. 2020;3(5)e208292. doi: 10.1001/jamanetworkopen.2020.8292 9. song c, wang y, li w, hu b, chen g, xia p, et al. absence of 2019 novel coronavirus in semen and testes of covid-19 patients. biol reprod. 2020 jun;103(1):4–6. doi: 10.1093/biolre/ioaa050 10. mohseni ah, taghinezhad-s s, xu z, fu x. body fluids may contribute to human-to-human transmission of severe acute respiratory syndrome coronavirus 2: evidence and practical experience. chinese medicine. 2020;15(1):58. doi: 10.1186/s13020-020-00337-7 cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. knowledge and attitudes of maintaining bone health among post-menopausal women in malaysia nik noor kaussar nik mohd hatta1, mohd said nurumal1*, muhammad lokman muhammad isa1, azlina daud1, muhammad ibrahim2, mohd ariff sharifudin3, samsul deraman3 1kulliyyah of nursing international islamic university malaysia (iium), kuantan campus, pahang, malaysia; 2kulliyyah of allied health science islamic university malaysia (iium), kuantan campus, pahang, malaysia; 3kulliyyah of medicine, islamic university malaysia (iium), kuantan campus, pahang, malaysia *corresponding author vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.348 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ hatta this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.348|http://cajgh.pitt.edu abstract introduction: public awareness of osteoporosis is low among women in the developing countries. health education was shown to be effective in improving knowledge and awareness on maintaining bone health. this study aims to identify the level of knowledge and attitudes among post-menopausal women in malaysia on achieving bone health throughout the menopausal transition period. methods: a total of 116 post-menopausal female patients of orthopedic menopause clinic were recruited using a purposive sampling approach. data on osteoporosis awareness and knowledge were collected using validated structured questionnaires osteoporosis prevention and awareness tool and osteoporosis attitude knowledge test. the chi-square test was used to determine the association between post-menopausal women’s socio-demographic characteristics and their knowledge and attitude towards maintaining bone health. results: participants’ age ranged between 49 and 82 years (61.84, sd=7.87). the knowledge of osteoporosis varied significantly by age (p=0.014) and education (p=0.001) among the studied population. no significant diffrences were found for participants’ attitude towards bone health. conclusion: this study showed that the age and education levels have significantly different knowledge of bone health. keywords: post-menopausal women; knowledge; attitude; bone health; malasia knowledge and attitudes of maintaining bone health among post-menopausal women in malaysia nik noor kaussar nik mohd hatta1, mohd said nurumal1*, muhammad lokman muhammad isa1, azlina daud1, muhammad ibrahim2, mohd ariff sharifudin3, samsul deraman3 1kulliyyah of nursing international islamic university malaysia (iium), kuantan campus, pahang, malaysia; 2kulliyyah of allied health science islamic university malaysia (iium), kuantan campus, pahang, malaysia; 3kulliyyah of medicine, islamic university malaysia (iium), kuantan campus, pahang, malaysia research introduction the dramatic decline in estrogen levels during the menopause usually leads to a decrease in bone density in women. the prevalence of osteoporosis among postmenopausal women (pmw) is increasing across the globe. one study showed that 28.4% of malaysian women are osteoporotic.1 another study found that 42.1% of postmenopausal and 11.1% of premenopausal women in malaysia were osteoporotic (p < 0.005).2 decline in bone mineral density (bmd) among women accelerates after menopause.3 suppression of estrogen production results in significant increases in bone resorption markers and suppression of bone formation markers.4 post-menopausal women are at high risk of osteoporosis and constitute a majority of fragility fracture hospital admissions. in addition to decreased hormones after menopause, nutritional factors play a significant role in the development of osteoporosis among women5. women tend to have insufficient calcium intake on daily basis, as average calcium intake (426 mg/day) is http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.348|http://cajgh.pitt.edu insufficient for postmenopausal women and is associated with low bone density.6 it has been shown that lifestyle intervention prevents the loss of spinal bone density in premenopausal women.7 osteoporosis, osteoporotic fractures, and other sequela may be avoided by raising knowledge on osteoporosis. therefore, the aim of this study was to assess the knowledge and attitudes to maintaining bone health among post-menopausal malaysian women. methods study population data collection was performed after obtaining the approval from the research ethic committee (irec) of international islamic university and national medical research registry (nmrr). this study was a crosssectional survey of 116 respondents from orthopedic menopause clinic, and specialist clinics of hospital tengku ampuan afzan kuantan, pahang, malaysia. a purposive sample of post-menopausal women aged 50 and older was recruited between april and october of 2016. the inclusion criteria were bmd of osteopenic range (t-score of less than -1 and greater than -2.5 sd) and agreeing to participate in the study. data collection respondents were assessed via selfadministered questionnaires. the information about their knowledge and attitudes towards maintaining bone health was obtained using osteoporosis prevention and awareness tool (opaat) and osteoporosis attitude knowledge test (oakt) questionnaires. oakt questionnaire consist of 20 items with responses forming a 3-point likert scale (true, false, and do not know). questions 1-12 are about knowledge of osteoporosis; questions 13-16 are concerned with the attitude towards osteoporosis, and the remaining four questions test the perception and practice in the prevention of the disease.8 the evaluation was done by assigning each correct answer the score of 1, and for the wrong or didn't know answer the score of 0. the questionnaire was thoroughly reviewed by a panel of health care professionals. the questionnaire was validated to ensure that the questions were not ambiguous, and content was appropriate. opaat questionnaire was adopted from toh et al.9 this questionnaire consists of 30 items and focuses on 3 sub-topics (knowledge on osteoporosis, osteoporosis treatment, and osteoporosis prevention). the responses consisted of a 3-point likert scale answer options (true, false and don’t know). the evaluation of responses was done by assigning each correct answer score of 1, and for the wrong or don't know answer the score of 0. the questionnaire was translated to malay version because a malay version of opaat was not yet available. hence, the opaat questionnaire was piloted after it was translated and retranslated. statistical analysis data entry and analysis were done using the statistical software program spss version 21. the data were presented in the form of percentages and mean ± standard deviation. chi-square value was calculated for the variables where the p value less than 0.05 was considered to be significant. results the average baseline oakt score was 8.8 out of 20. cronbach’s α for each domain was ranged from 0.286 to 0.748. all items were highly correlated (spearman’s rho: 0.761-0.990, p<0.05), with no significant change in the overall test-retest scores, indicating that opaat has achieved stable reliability. the respondents were 116 post-menopausal women, ranging from 49 to 82 years (61.84, sd=7.87). most of the respondents (84.5%) were married, had attended secondary school (56.9%) and belong to middle-income group defined by the range of $246-985 per month http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hatta this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.348|http://cajgh.pitt.edu variables knowledge in assessing attitude in assessing adequate (%) inadequate (%) p-value* positive (%) negative (%) p-value* age 0. 014 50-59 years 9.5 37.1 21.6 25.0 0.721 6069 years 70 and above 11.2 0 24.1 18.1 17.2 6.9 18.1 11.2 ethnicity 0.520 0.552 malay 4.3 26.7 14.7 16.4 chinese indian others 14.7 1.7 46.6 4.3 1.7 27.6 3.4 33.6 2.6 1.7 education level 0.001* 0.187 primary 1.7 25.0 9.5 17.2 secondary certificate degree 11.2 4.3 3.4 45.7 7.8 0.9 30.2 3.4 2.6 26.7 8.6 1.7 marital status 0.060 0.191 single 3.4 2.6 3.4 2.6 married 14.7 69.8 38.8 45.7 widowed divorced 1.7 0.9 6.0 0.9 1.7 1.7 6.0 income 0.076 0.402 < us $246 5.2 31.0 16.4 19.8 us $246-985 >us $1,232 11.2 4.3 43.1 5.2 26.7 2.6 27.6 6.9 *chi-square table 1: association between knowledge attitude and sociodemographic characteristics (based on n=116) (54.3%). the result showed that 20.7% had adequate knowledge range for osteoporosis, while 79.3% had inadequate knowledge range. table 1 presents the distribution of patients’ knowledge and attitude by their sociodemographic characteristics. majority of the participants possessed inadequate knowledge, and knowledge of maintenance of bone health was significantly different between age groups (p=0.014). similar results were found for ethnic groups, though results were not significant (p=0.520). inadequate knowledge was also significantly different between various education levels (p=0.001). participants’ marital status significantly impacted their knowledge in assessing osteoporosis (p=0.060). the knowledge also significantly varied based on the income group (p=0.076). thirty (30) items from opaat questionnaires were selected for assessing the importance of maintaining bone health. among the participants, 80.2% (n=93) incorrectly answered that everybody would get http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.348|http://cajgh.pitt.edu osteoporosis as it is part of aging. 75.9% (n=88) showed that they are confused about the differentiate between osteoporosis and osteoarthritis disease. additionally, nearly half of the respondents 42.2% (n=49) indicated that osteoporosis has no symptoms, while 38.8% (n=45) indicated that pmw are not at risk for getting osteoporosis, and osteoporosis is untreatable disease 42.2% (n=49). whereas, 82.8% (n=96) and 75.9% (n=88) of the participants provided incorrect answers for symptoms of untreated osteoporosis, which were tooth loss and joint pain or swelling of fingers respectively. in osteoporosis prevention, 55.2% of the pmws provided incorrect answers about calcium daily intake requirements. another 66.4% wrongly assumed that it is too late to increase calcium intake after the age of 50. nevertheless, 87.1% (n=101) participants knew that calcium supplements could help prevent osteoporosis, and 90.5% (n=105) recognized that food; such as milk, anchovies, yellow dhal, and spinach are rich in calcium. 74.1% (n=86) of the participants also found that weightbearing exercise can prevent bone loss. in this study, 45.7% of the participants perceived themselves as having a positive attitude regarding maintaining bone health; while 54.3% had a negative attitude. there were 20 items of oakt questionnaires that assessed attitudes for bone health maintenance, with 94% of pmw believing that osteoporosis leads to an increased risk of bone fractures. 87.1% (n=101) incorrectly answered the item ‘osteoporosis usually causes certain symptoms (e.g., pain) before fractures. moreover, 61.2% (n=71) of participants indicated that chinese women are at highest risk of fracture as compared to other races. about 83.6% (n=97) assumed that physical activity is beneficial for osteoporosis. similarly, 87.9% (n=102) indicated that adequate calcium intake could be achieved from two glasses of milk per day. moreover, 65.5% (n=76) and 67.2% (n=78) of the participants mentioned sardines and broccoli are good sources of calcium for those who cannot consume dairy products. discussion this study assessed the knowledge and attitudes for maintaining bone health among post-menopausal malaysian women. results revealed inadequate knowledge and lack of awareness among pmw in maintaining the bone health. this study demonstrated that knowledge on bone health significantly varied based on the age group. the respondents believed that they had adequate knowledge on bone health, while in actuality they did not. these results are corroborated by the previous findings of samia et al.10, which asserted that public awareness of osteoporosis remains low, especially in less developed countries. health education is needed to improve awareness and to motivate healthy behaviors.6 this study identified that there is a low level (p=0.001) of knowledge among pmw in maintaining their bone health. potentially, adequate knowledge would facilitate pmw in maintaining their good health and achieving a higher level of bone health in malayan women. inadequate knowledge was associated with the level of education and the age of the population in this study. these findings are conflicting with previous reports, which found that most of the women in their study had adequate knowledge about osteoporosis (85.2%)11,12. the adequate knowledge is probably due to the overall improvement of education level and better health information about osteoporosis.11 furthermore, the results of the present study are corroborated by the previous findings illustrating that riyadh participants possessed a knowledge score of 57%. which is lower than their attitude scores 72.5% towards osteoporosis disease.13 thirty items from opaat questionnaire have been constructed to identify the level of knowledge in maintaining bone health, where general misconceptions were revealed such as ‘everybody will get osteoporosis as it is part of aging’. the assumption of this statement is incorrect because if the preventive measures are taken, the incidence of osteoporosis will be reduced.14 although http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hatta this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.364|http://cajgh.pitt.edu it is agreed that osteoporosis is considered a disease associated with aging; a growing body of evidence indicates that osteoporosis may have its origins at earlier ages.15 this misunderstanding regarding osteoporosis should be corrected, so that that early disease prevention can be practiced appropriately. the recommended calcium intake for women above the age of 50 is 1000 mg.16 the awareness scores in our study were reflective of need for further education on the relationship between calcium and bone health 11. there was a higher level of agreement about the seriousness of osteoporosis, but less than a quarter of the participants regarded osteoporosis as a disabling disease. these attitudes suggest that there is an opportunity to develop and improve the effectiveness of the future osteoporosis prevention programs. initiatives which increase perceived personal susceptibility could be beneficial. previously published research reported a few barriers to exercise and calcium intake that need to be taken into account for the future research.17 additionally, most of pmw believed that any type of physical activity is beneficial to prevent osteoporosis. this finding was contradicted with other results which found that older women with a positive attitude to physical activity can manage to be physically active on their own if they feel secure about how much stress their bones can endure and which exercises are safe.18 the knowledge and beliefs regarding the appropriate activity level and the benefits of certain exercises can be potentially considered to enhance awareness and belief on the beneficial of strengthening exercise. an interesting finding of this study is the reported belief that calcium supplement alone can prevent bone loss. this misconception on calcium intake was also found in another study, in which although there was a strong agreement with most of the ‘benefits of calcium’ items, only 7% of subjects agreed with the statement ‘i feel good about myself when i take enough calcium’. a significant negative correlation was found between this statement and the item ‘calcium-rich foods have too much cholesterol’ 17. the misconception on calcium intake should been taken consideration in order to educate the pmw regarding this particular knowledge. hence, the findings suggest the need for educational interventions to promote pmw to increase their knowledge about osteoporosis and have positive attitudes and beliefs in osteoporosis prevention towards maintaining bone health. it would be potentially useful to develop nutritional fact sheets for malaysian food and make them accessible especially for the old-aged females, who are at the age when preventive measures act against osteoporosis. the preventive steps can be done by promoting early assessment and prevention programs at an early age to avoid behavioral risk factors. health education was shown to be effective in improving knowledge and awareness among the public in maintaining bone health with the use of the teachinglearning process, especially in therapeutic intervention of chronic diseases.19 proper educational strategies would increase knowledge of osteoporosis and inducing lasting behavioral change during the menopausal transition. the use of purposive sampling for participant recruitment, as well as lack of information on nonrespondents were study limitations. the restriction of the study to a certain region also impacts the applicability of findings to other geographic and socioeconomic areas. therefore, we recommend that future studies need to focus on larger sample sizes and wider reach. acknowledgements this work was supported in part by research grant fundamental research grant scheme (frgs 15200-0441) from the ministry of education (moe), malaysia. references 1. mohammadi f, hamid ta, yazid mn, othman z, mahmud r. lifestyle factors http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.348|http://cajgh.pitt.edu influencing bone mineral density in postmenopausal malaysian women. life science journal. 2011;8(2):132-9. 2. shan lp, bee of, suniza ss, adeeb n. developing a malaysian osteoporosis screening tool (most) for early osteoporosis detection in malaysian women. sexual & reproductive healthcare. 2011 apr 1;2(2):7782. 3. garg n, mol gv, sethi d. (2018). an epidemiological study to assess bone mineral density and its association with contributing factors among premenopausal and postmenopausal women in selected villages of district shimla, himachal pradesh, india. international journal of reproduction, contraception, obstetrics and gynecology, 7(2), 487-494. 4. appelman-dijkstra nm, papapoulos se. modulating bone resorption and bone formation in opposite directions in the treatment of postmenopausal osteoporosis. drugs. 2015 jul 1;75(10):1049-58. 5. aggarwal n, raveendran a, khandelwal n, et al. prevalence and related risk factors of osteoporosis in peri-and postmenopausal indian women. journal of mid-life health. 2011 jul;2(2):81. 6. haron h, shahar s, o’brien ko, et al. absorption of calcium from milk and tempeh consumed by postmenopausal malay women using the dual stable isotope technique. int j food sci nutr. 2010 mar 1;61(2):125-37. 7. hibler e, kauderer j, greene mh, rodriguez gc, alberts ds. bone loss following oophorectomy among high-risk women: an nrg oncology/gynecologic oncology group study. menopause (new york, ny). 2016 nov;23(11):1228. 8. osman a. assessment of osteoporosis kap among women in assir region, saudi arabia. journal of medicine and medical sciences. 2013 feb;4(2):50-5. 9. toh ls, lai ps, wu db, wong kt, low by, anderson c. the development and validation of the osteoporosis prevention and awareness tool (opaat) in malaysia. plos one. 2015 may 4;10(5):e0124553. 10. samia a, hejar ar, suriani i, emilia za. an overview of osteoporosis and heath promotional strategies for community based osteoporosis prevention in malaysia. international journal of public health and clinical sciences. 2017 feb 8;4(1):28-40. 11. puttapitakpong p, chaikittisilpa s, panyakhamlerd k, nimnuan c, jaisamrarn u, taechakraichana n. inter-correlation of knowledge, attitude, and osteoporosis preventive behaviors in women around the age of peak bone mass. bmc women’s health. 2014 dec;14(1):35. 12. kamran m, iftikhar a, awan aa. knowledge and behaviour regarding osteoporosis in women. pakistan armed forces medical journal. 2016 dec 1;66(6). 13. barzanji at, alamri fa, mohamed ag. osteoporosis: a study of knowledge, attitude and practice among adults in riyadh, saudi arabia. j community health. 2013 dec 1;38(6):1098-105. 14. cosman f, de beur sj, leboff ms, lewiecki em, tanner b, randall s, lindsay r. clinician’s guide to prevention and treatment of osteoporosis. osteoporosis international. 2014 oct 1;25(10):2359-81. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hatta this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.364|http://cajgh.pitt.edu 15. nadiah ww, ezane am, foo lh. knowledge, attitude and dietary and lifestyle practices on bone health status among undergraduate university students in health campus, universiti sains malaysia, kelantan. health and the environment journal. 2010;1(1):34-40. 16. malaysian osteoporosis society. clinical guidance on management of osteoporosis, 2012; 12. 17. von hurst pr, wham ca. attitudes and knowledge about osteoporosis risk prevention: a survey of new zealand women. public health nutrition. 2007 jul;10(7):747-53. 18. dohrn im. physical activity and health-related quality of life in older adults with osteoporosis. inst för neurobiologi, vårdvetenskap och samhälle/dept of neurobiology, care sciences and society; 2015 aug 26. 19. coriolano-marinus mw, pavan mi, lima ls, bettencourt ar. validation of educational material for hospital discharge of patients with prolonged domiciliary oxygen prescription. escola anna nery. 2014 jun;18(2):284-9. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abstract keywords: post-menopausal women; knowledge; attitude; bone health; malasia research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. the euclid statistical matrix tool curtis tilves1, saeed yekaninejad2, tetsuro hayashi3, eman eltahlawy4, eugene shubnikov5, shalkar adambekov1 1university of pittsburgh graduate school of public health, usa; 2department of epidemiology and biostatistics, school of public health, tehran university of medical sciences, iran; 3jikei university school of medicine, tokyo, japan; 4environmental health and occupational medicine department, national research center, egypt; 5institute of internal medicine, novosibirsk, russia vol. 6, no. 1 (2017) | issn 2166-7403 (online) doi 10.5195/cajgh.2017.283 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ tilves this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.283|http://cajgh.pitt.edu the euclid statistical matrix tool curtis tilves1, saeed yekaninejad2, tetsuro hayashi3, eman eltahlawy4, eugene shubnikov5, shalkar adambekov1 1university of pittsburgh graduate school of public health, usa; 2department of epidemiology and biostatistics, school of public health, tehran university of medical sciences, iran; 3jikei university school of medicine, tokyo, japan; 4environmental health and occupational medicine department, national research center, egypt; 5institute of internal medicine, novosibirsk, russia editorial global health has definitions of varying levels of complexity, but in essence, it can be summarized as a framework of methods aimed at improving population health. through both observation and intervention, global health researchers can monitor diseases and employ interventions to prevent adverse health outcomes by reducing their incidence. given the large variability in the human population, public health and medical research investigations require rigorous methods and analytics in order to evaluate and to determine the validity of conclusions. moreover, these standardized research methods are critical for comparison of findings across geographic boundaries, ethnic groups, and time periods. however, a lack of skills in the areas of research methods and statistical evaluation is a common limitation among researchers globally, especially in developing countries where research productivity is lower compared to developed countries1-3. this debilitating condition, which is found worldwide and has a far-reaching impact on publications and tenure, is known as “stataphobia”. stataphobia is a phrase which describes the ‘abnormal fear of research design and statistics’4. the fear of statistics, or not having access to a statistician for help, is a major problem for many scientists, as a lack of properly performed methods dooms submissions to rejection for articles, grants, and other scientific communications. it can affect multiple layers of global health, as major policy decisions based on inaccurate, incomplete, or old statistics can waste resources without positively impacting the health issue. the rejection of publications based on poor statistical methods can have a profound impact on the number of scientific publications and the competitiveness of research coming out of many countries, especially those that are non-western countries. publication statistics from the country of kazakhstan highlight the disparities present in global health research productivity. adambekov et al. discusses how health research contributes to only 7% of the overall number of publications coming from kazakhstan, a trend shared by other central asian countries5. even when compared with other countries of a similar population size or gdp, the publication rates are indeed low6. in fact, despite the low number of publications coming from this country, kazakhstan is in the highest output of http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.283|http://cajgh.pitt.edu medical publications in central asia, highlighting the need for regional improvement6-8 (see figure 1). we suggest that stataphobia plays an important role in this phenomenon, as without proper research methods and publication output, not only is scientific progress impeded in these countries, but health research—and public health policy as a whole—suffers. figure 1: general scientific publication trends of central asian countries for 1996-2015 it is believed that the increase in publications from kazakhstan starting in 2012 are likely from the addition of a policy that phd candidates must submit at least one article to a journal with an impact factor greater than 09. the basic understanding of statistics usually comes in the higher education settings. students in health, especially those who are medical and nursing students, require an understanding of statistics to perform clinical research. without an understanding of research publications, it is most difficult to improve clinical performance. even medical students not planning to perform research must be able to understand statistics in order to comprehend clinical research and to understand how it may apply to their patients. in other areas of national and international work, a lack of understanding of statistical concepts can cause even larger issues. for example, a lack of understanding of statistics would make it impossible to accurately interpret and evaluate global health trends and their applications to public health programs. this has had an impact on policies 0 500 1000 1500 2000 2500 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 general scientific publications from central asian countries kazakhstan kyrgyzstan tajikistan turkmenistan uzbekistan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx tilves this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.283|http://cajgh.pitt.edu regarding immigration, where statistics have recently been found to be lacking and inaccurate10. improper statistical training can also result in developing countries becoming exporters of “raw” research data to developed countries because they are unable to properly analyze and publish that data. this has the effect of furthering the establishment of “scientific banana republics” in developing nations, where the economic benefit and the directions of health research are ultimately under the control and influence of already developed countries11. thus, an intervention on a global scale is required to reduce the impact of stataphobia on research, especially in developing countries. this can lead to improved health and can aid in establishing evidencebased programs. one area to intervene on is in the initial teaching of statistical methods and in the access to those teachings. often, students find statistics difficult and boring. stataphobia can take hold in the classroom, where some learners of statistics become frightened by the non-intuitive concepts they most need to learn in order to produce the best research possible. students enter the classroom coming from a variety of backgrounds, from math majors to philosophy majors, thus having marked differences in existing knowledge and interest in statistics. furthermore, students may just learn certain topics best from different approaches than the approach the professor is using, and these ‘best approaches’ may differ from student to student as well as from topic to topic. is it possible to intervene on the classroom, influencing learning through multiple approaches on the same topic? moreover, can this be done in countries facing language barriers to international publications and/or face limitations in teaching resources? cue: the euclid statistical matrix. through the research methods library at the library of alexandria (rmla), egypt, we have constructed a free, malleable, and multilingual tool designed to help learners of basic statistical methods12. the euclid statistical matrix is a compilation of some of the most popular youtube videos which teach statistics. in the euclid matrix, the columns of the matrix serve to house content for a particular youtube channel, and the rows contain various statistical topics or lessons (figure 2). matrix link: http://www.pitt.edu/~super1/researchmethods/statistics matrix.htm using this format, if one wanted to learn about variance, they may move down to the “variance” row, and then choose from a khan academy video, a brandon foltz lecture, a statslectures video, etc., providing multiple presentation approaches to a similar topic. this approach has many strengths. the most important strength is that the statistical matrix is easily accessible. the use of youtube videos as a primary educational source provides a format that is freely accessible by all and allows for multiple visual representations of and approaches to a topic. two, it allows the professor to integrate their own lectures into the matrix, making it an adaptable tool for the classroom. by allowing multiple presentation formats (video, powerpoint, online books, etc.), a student can utilize several matrix resources to understand the difficult topic. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.pitt.edu/%7esuper1/researchmethods/statisticsmatrix.htm http://www.pitt.edu/%7esuper1/researchmethods/statisticsmatrix.htm central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.283|http://cajgh.pitt.edu three, it utilizes much of the high quality statistical open access content that currently exists on the internet. four, the euclid matrix has the ability to be a living matrix. as more quality videos are found or created, the matrix may be updated to better reflect the needs of statistics learners. finally, the concept of the matrix is easy to implement in other languages. statistics is already hard enough to learn, and if your native language is not english, then learning statistics will be even more difficult. by recreating the euclid statistics matrix using educational materials developed in the other languages, we remove this language barrier issue while also utilizing the resources available in non-english languages and empowering the global researcher/lecturer communities. to this point, we have developed the euclid statistical matrix in several languages, including russian, which is the language that many central asian scientists speak. figure 2: schematic of the euclid statistical matrix we disseminated our matrices using a large email network generated as a part of the global health network supercourse project13. as a part of this project we obtained e-mails from top universities in the countries/regions of focus and developed region based teams of interest. individuals from the teams of each region then developed a message on their matrix and distributed it to their local and global colleagues. by http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx tilves this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.283|http://cajgh.pitt.edu having team-developed messages, we are better able to facilitate international collaboration while also promoting these resources from within the regions. using our iranian team as an example, we distributed the information on the farsi statistical matrix to a network of over 10,000 iranian faculty members from top universities in iran. additionally, we have collaborated with an iranian-american student association in the us14, where we shared this information among a few thousand farsi-speaking students. increasing the distribution of information on research methods will require multiple tools. in addition to the euclid statistical matrices, we are also developing matrices with other research methods content, such as matrices with focuses on agricultural statistics, epidemiology, and big data. another future project includes the development of a golden lecture of statistics. the golden lecture concept is to provide very small powerpoint presentations of a particular topic so that it may be adopted for lectures in any subject. a golden lecture for “health” has already been developed so that if, for example, a history professor needs a resource to discuss what health is but does not have the background to do so, they may utilize the health golden lecture slides15. in similar spirit, we also plan to develop a golden lecture for statistics. the euclid statistical matrices are currently housed within the university of pittsburgh supercourse repository, an online collection of health lectures which has previously been used to establish scientific social networks16. this network reaches to many regions, including the central asian region where the network is over 1,300 individuals17. further spread of the statistical matrix concepts can also occur at the meetings of large statistical organizations, where current efforts are ongoing to collect and ship statistical textbooks to the library of alexandria in egypt18. the euclid statistical matrices will be most beneficial for developing countries in central asia, as the language barriers and lack of research methods specialists are crippling health sciences in this region. with a majority of the research intuitions having access to the internet and increasing coverage of the general population, the statistical matrices are the perfect tool to improve knowledge on research methods in central asia. an important next step in the central asian region will be to get support from the universities, public health schools, and healthcare and education ministries of kazakhstan, uzbekistan, tajikistan, turkmenistan, and kyrgyzstan, due to the strong centralized structure of the education system in these countries. we suggest that the matrix model can be a useful tool not only for statistics and research methods, but also for virtually any course or age group. this may be of benefit in the teaching of science, technology, engineering, and mathematics (stem) courses for youth. the matrices also are quite versatile and can be easily adapted. matrices have the potential to be layered into levels, such that a basic course is the foundational level, followed by levels of more advanced courses. various additions could be added onto a matrix, such as the incorporation of questions to test how well a learner http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.283|http://cajgh.pitt.edu mastered the topic, or a help desk where a student may post questions that can be answered by other students or the professor. scientific progress should not be halted because of a fear of statistics. research methods can be learned, and with enough comfort to produce better science. when bright and passionate individuals place their minds and energies together, we can address and mitigate problems like stataphobia. with multilingual tools that utilize already-created internet resources such as the euclid statistical matrix, we can begin to eliminate the issue of stataphobia worldwide, leading to increased and better-quality research as well as global improvements in health. acknowledgments we would like to thank the library of alexandria, egypt, for their wonderful support and services. additional thanks go to the other team members involved in the development of the euclid matrices, including: team farsi matrix — mahdi aminikhah, vahid ghanbari, mehrnoosh hadadi, leila tavakkoli, and ali ardalan; team japanese matrix — makoto kaneko, rieko mutai, yuko nakano, toshifumi yodoshi, and masato matsushima; and team english matrix — ismail serageldin, francois sauer, faina linkov, and ron laporte. references 1. holmgren m, schnitzer sa. science on the rise in developing countries. plos biology. 2004;2(1):e1. 2. adam t, ahmad s, bigdeli m, ghaffar a, rottingen ja. trends in health policy and systems research over the past decade: still too little capacity in low-income countries. plos one. 2011;6(11):e27263. 3. langer a, diaz-olavarrieta c, berdichevsky k, villar j. why is research from developing countries underrepresented in international health literature, and what can be done about it? bulletin of the world health organization. 2004;82(10):802-803. 4. how “stataphobia” is preventing publication and other stories. bmj. 2013;346:f366. 5. adambekov s, dosmukhambetova g, nygymetov g, laporte r, linkov f. why does kazakhstan need new scientific journals? central asian journal of global health. 2014;3(1). 6. adambekov s, askarova s, welburn sc, et al. publication productivity in central asia and countries of the former soviet union. central asian journal of global health. 2016;5(1). 7. yessirkepov m, nurmashev b, anartayeva m. a scopus-based analysis of publication activity in kazakhstan from 2010 to 2015: positive trends, concerns, and possible solutions. journal of korean medical science. 2015;30(12):1915-1919. 8. yamshchikov gv, schmid gp. publication practices and attitudes towards evidence-based medicine in central asia. the lancet global health. 2013;1(2):e73-74. 9. torgayeva b. publikuisia ili pogibnesh. novoe pokoleniye 2012; http://www.np.kz/2012/11/20/publikujjsja_ili_ pogibnesh.html. accessed 4 june 2017. 10. data on movements of refugees and migrants are flawed. nature. 2017;543(7643):5-6. 11. linkov f, adambekov s, goughnour s, et al. scientific banana republics: do they exist? central asian journal of global health. 2016;5(1). 12. research methods library of alexandria. research methods library of alexandria statistical matrix. 2016; http://www.pitt.edu/~super1/researchmethods/ statisticsmatrix.htm. accessed 4 june 2017. 13. supercourse – epidemiology, the internet and global health 2010; http://www.pitt.edu/~super1. accessed 4 june 2017. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.np.kz/2012/11/20/publikujjsja_ili_pogibnesh.html http://www.np.kz/2012/11/20/publikujjsja_ili_pogibnesh.html http://www.pitt.edu/%7esuper1/researchmethods/statisticsmatrix.htm http://www.pitt.edu/%7esuper1/researchmethods/statisticsmatrix.htm http://www.pitt.edu/%7esuper1 tilves this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.283|http://cajgh.pitt.edu 14. iranian student association pittsburgh. http://iraniansptgh.com/. accessed 4 june 2017. 15. linkov f. golden lecture of global health: so near, so far. 2003; http://www.pitt.edu/~super1/lecture/lec40341/i ndex.htm. accessed 4 june 2017. 16. hennon m, laporte re, shubnikov e, linkov f. new directions in building a scientific social network: experiences in the supercourse project and application to central asia. central asian journal of global health. 2012;1(1). 17. freese k, shubnikov e, laporte r, et al. the central asian journal of global health to increase scientific productivity. central asian journal of global health. 2014;2. 18. levine m. sharing the wealth: 2 pitt professors help to set up research methods library in alexandria, egypt. university times 2017; https://www.utimes.pitt.edu/?p=41833. accessed 4 june 2017. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://iraniansptgh.com/ http://www.pitt.edu/%7esuper1/lecture/lec40341/index.htm http://www.pitt.edu/%7esuper1/lecture/lec40341/index.htm https://www.utimes.pitt.edu/?p=41833 the euclid statistical matrix tool editorial microsoft word migriño.docx new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. work preferences in rural health job posting among medical interns in a lower middle-income country— a discrete choice experiment julius r. migriño, jr.1,2,3,* 1san beda university college of medicine, san miguel, manila, philippines; 2ateneo school of medicine and public health, pasig city, philippines; 3university of the philippines—open university, los baños, laguna, philippines *corresponding author email: jrmjrmd1@yahoo.com vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu migriño this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu abstract introduction: timely empirical evidence is important in the success of health systems, and such evidence is necessary for informed policy making to address inequity in the health workforce. literature is ripe with incentives that affect recruitment and retention of physicians in rural and remote areas, but such data in still lacking in the philippine setting. discrete choice experiment is one methodology utilized by the world health organization which provides both qualitative and quantitative information to aid policy makers in health human resource management. methods: the study utilized a discrete choice experiment involving three phases: 1) identification of incentives and levels using key informant interviews and focus group discussions, 2) selection of scenarios utilizing an experimental design, and 3) administration of survey based on who guidelines. conditional logistic regression, point estimates, and correlational analyses were done using stata. results: there is significant association between type of background and considerations for rural practice among the respondents based on pearson’s correlation (p < 0.01). the respondents put more value into non-wage rural job posting incentives than small to modest base salary increases. the high willingness to pay for the presence of supervision, relative location of work areas from families, and status of workplace infrastructure/equipment or supplies suggest the importance of workplace conditions to attract rural health physicians. combinations of wage and non-wage incentives may be necessary to provide for the most cost-efficient increases in rural job post uptake rates based on post-estimate calculations. conclusion: philippine medical interns and young doctors value non-wage incentives in considering rural health job postings. rural health job postings with these incentives are predicted to significantly increase recruitment in rural health job posts, particularly when combinations of wage and high-impact non-wage incentives are considered. keywords: global health; rural job posting; health human resources; health systems; recruitment; preferences work preferences in rural health job posting among medical interns in a lower middle-income country— a discrete choice experiment julius r. migriño, jr.1,2,3,* 1san beda university college of medicine, san miguel, manila, philippines; 2ateneo school of medicine and public health, pasig city, philippines; 3university of the philippines—open university, los baños, laguna, philippines *corresponding author email: jrmjrmd1@yahoo.com research human resource for health (hrh) development is vital in the success of a health system, and its success depends on empirical evidence for informed policy making.1 there is sufficient evidence of an overall scarcity of health workers globally,2–5 and this is compounded by inequitable distribution of health care workers between urban and rural/remote areas of the world. in the philippines, where more than half of the population live in rural and remote areas of the country, the density of doctors situated in primarily urban areas such as in the national capital region (ncr) and southern tagalog are higher compared to some rural and remote provinces in mindanao and western and eastern visayas, and many health sector positions in rural and isolated areas remain vacant.6,7 this inequity of central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu distribution and failure to retain health workers in rural areas reduces the population’s access to much needed health services, resulting in poor health outcomes such as higher infant mortality rates (imr): for instance, eastern visayas, western mindanao, and autonomous region of muslim mindanao have higher imr (31, 32, 33 per 1,000 live births, respectively) compared with the national average (23 per 1,000 live births).8 one way to address this issue is for policymakers to have access to information on health worker preference models. there is limited data on assessments of influencing factors or effective strategies to address this gap in human health resources,9 including within the setting of the philippines.6,10,11 currently, the few preference studies regarding medical practitioners in the philippines rely on descriptive methods such as crosssectional surveys and case studies, and do not take into consideration the hierarchy of preferences as well as possibilities of trade-off between difference choices. the discrete choice experiment (dce) is one method that could be used to quantitatively assess the importance of individual factors which influence health worker preferences to specific job posting incentives. data from dces may aid policy makers in prioritizing rural post incentive packages that would prove to be most costeffective and have higher uptake potential. the study aimed to determine the association of different job incentives and the probability of take-up of rural health job postings among medical interns and recent graduates in the philippines using a discrete choice experiment. the study null hypothesis was that there was no significant association between the presence of different job incentives and the probability of take-up of rural health job postings among medical interns. methods the study employed a mixed methods discrete choice experiment methodology involving three phases: phase 1– identification of incentives and levels phase 2– selection of scenarios phase 3– administration of survey the association of philippine medical colleges foundation, inc. (apmcfi) is a non-stock, non-profit organization that “defines standards and guidelines to promote quality medical education in the philippines” and serves as the umbrella organization of all accredited medical schools in the country.12 a complete enumeration of all the listed medical interns was conducted to enable representation of medical interns from all regions of the philippines. all 7,178 medical students who participated in the medical internship matching system for academic years 2016-2017 and 2017-2018 under apmcfi were included in the sampling frame. the inclusive years used in the sampling coincide with the time frame of the study. sample size was calculated using openepi to be 365 at 95% confidence level, and simple random sampling was done to recruit the dce respondents. phase 1: identification of incentives and levels a literature review was done on incentives to attract and retain health workers in the rural setting, based on the recommendation by who.13 interviews with key informants based on recommendations from the who report “increasing access to health workers in remote and rural areas through improved retention”14 were done. at the end of the key informant interviews (kii), a list of 21 feasible and relevant job incentives and possible levels was identified. two separate focus group discussions (fgd) were conducted with five medical interns and five recently graduated medical doctors. the participants for each fgd were purposively selected based on sex (at least one of each sex was represented per fgd group), current enrollment status as medical interns (for fgd 1), and newly graduated doctors (within 3 years of the study); these respondents closely resemble the final study migriño this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu respondents. defining of incentives and recategorization of similar incentives were also done during the fgd. the respondents were then asked to select a final set of incentives and to identify different levels for each that are realistic and appropriate in the local context. for example, when discussing salary, participants were asked what they thought was a fair and realistic salary level for the job posting. each fgd lasted between 1-1.5 hours and was facilitated and transcribed by the researcher. at the end of the fgd, a final list of seven incentives with corresponding levels was generated. phase 2: selection of scenarios data gathered from phase 1 was used to construct the rural health job postings (“choice sets”). the experimental choice set design was generated using r version 3.4.2 (2017-09-28), using the package algdesign and the function optfederov,15 and analyzed for orthogonality using pspp gnu general public license (version 3, 29 june 2007). this produced an orthogonal array with level balance, minimal overlap, and d-efficiency = 0.926, with minimum collinearity. a systematic level change of the original design16 was then employed in generating the alternative choice set design to ensure a higher efficiency.17,18 at the end of phase 2, a final google form survey questionnaire with 13 choice sets and an embedded informed consent form was constructed. phase 3: administration of survey the link to the google form questionnaire and informed consent was distributed through blind carbon copy emails to each survey respondent. responses were collected within a 4-week period. follow-up emails were made after five and ten working days. manual domain analysis was done to the data gathered in phase 1, using the procedure demonstrated by atkinson and abu el haj19 using the qualitative data analysis software qda miner lite (v2.0.2). the creation of scenarios in phase 2 was based on the data from phase 1 and was performed using orthogonal design from r software version 3.4.2, which generated an orthogonal design for the choice sets that were used in phase 3. coding of phase 3 data was done using a stacked-format initial data matrix. univariate analysis (measures of central tendencies and percentages) were done for the demographic profile using microsoft excel. chi square analysis, conditional logistic regression analysis and computations for willingness to pay, changes in uptake rates, and disaggregation of subgroups were done using stata v.13.0, with the aid of a consultant statistician and using the guidelines set by who (2012). conditional logistic regression analysis was done using the syntax clogit choice wage equipment supervision family qol cpd career const, group(obsid), with wage as a continuous variable and the rest as dummy-coded variables. the value of choice refers to either 0 (job post a) or 1 (job post b) as the respondent’s choice, while the term group(obsid) is the paired observation per choice set. this function assumed a logit model with the probability of choosing job i defined as: vi/j = deterministic utility of posts i/j willingness to pay was calculated as the ratio of the value of the coefficient of interest to the negative of the cost attribute, 𝑊𝑇𝑃! = − "# "!$ "# ""#$%$ = %! %"#$% , with n being the incentive of interest. changes in uptake rates (with corresponding confidence intervals) were calculated using the nlcom command in stata using the following syntax: nlcom(exp(_b[wage]*36000+_b[n])exp(_b[wage]*36000))/(exp(_b[wage]*36000)+exp(_b[ wage]*36000+_b[n])), where n = incentive of interest. central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu calculations for the disaggregation of subgroups were done using the clogit function (as above) but utilizing interaction terms. all calculations were done at 95% confidence level. results there was a total of 345 respondents from the survey, which represents 4.81% of the total population. table 1 presents a summary of the demographic characteristics of the dce respondents. the respondents were distributed across multiple regions of the philippines; however, the majority of the respondents (66.38%) came from schools in luzon, with 48.70% coming from the greater manila area. visayas-based respondents made up 24.35%, while those from mindanao accounted for 9.27% of the total participants. the mean age of the respondents was 26.42 (±2.26) years old, which is the usual age when medical students in the philippines finish their medical school and take up medical internship. most of the respondents were female (68.12%), and a significant majority (93.33%) were single. the general trend in the family income of the respondents belong to middleand upper-class income brackets. seventy-two percent of the respondents have lived mostly in urban environments, while a majority (68.12%) at least considered practicing in a rural area after graduation, whether as doctors to the barrios (dttb), municipal health officers (mho), or in rural private practice. pearson’s chi square results revealed a significant difference (p<0.01) between the type of background in relation to considerations of practicing medicine in rural areas. variable n(%) age (mean(std. dev.)) 26.42 (2.26) sex male 110 (31.88) female 235 (68.12) marital status single 322 (93.33) married 23 (6.67) family’s monthly income (in php) less than 9,000 8 (2.32) 9,000 to less than 17,000 8 (2.32) 17,000 to less than 35,000 47 (13.62) 35,000 to less than 125,000 148 (42.90) 125,000 to less than 185,000 40 (11.59) 185,000 and above 94 (27.25) living environment background rural 96 (27.83) urban 249 (72.17) location of attended medical school luzon 229 (66.38) visayas 84 (24.35) mindanao 32 (9.27) greater metro manila 168 (48.70) considering working in a rural area soon after graduation? yes 235 (68.12) no 110 (31.88) table 1. demographic characteristics of dce respondents (n=345) migriño this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu based on the directly stated preferences for all identified job incentives (“which of the following is the most important factor in your decision to work in a rural area?”, results not shown), career and distance of family from work facility was ranked as the most important, which is consistent with the results of the conditional logit model. main effects conditional logistic regression analysis produced coefficients that were consistent with what was expected: the respondents preferred job postings with higher salaries (“wage”), available equipment (“equipment”), presence of supervision (“supervision”), locations near their families’ residences (“family”), better quality of life amenities (“qol”), and available continuing professional development (cpd; “cpd”) and career opportunities (“career”). all seven incentives included in the model were significant at 1% level. figure 1 shows how much (in philippine currency, php) the respondents are willing to trade off from their monthly salary to get other incentives in the job package. the most significant willingness to pay (wtp) are those for “supervision” (php46,720.38, 95% ci: 26,512.59-66,928.16) and “family” (php43,467.51, 95% ci: 24,919.09-62,015.92), with both incentives having wide confidence intervals. wtpcareer came third (php37,433.40, 95% ci: 27,207.71-47,659.09). as for the status of equipment in a rural job post, wtpequipment ranks fourth (php30,202.40, 95% ci: 25,104.1335,300.67), but respondents have less variation with this incentive. “qol” and “cpd” have consistently low wtp values (php18,281.89, 95% ci: 12,401.89-24,161.89; php16,850.27, 95% ci: 11,688.33-22,012.22, respectively), stating that compared to the other incentives, the respondents are not very much concerned with the availability of daily living amenities and cpd incentives in rural job postings. figure 1. willingness to pay (wtp) for specific incentives, with 95% confidence intervals 10,000.00 20,000.00 30,000.00 40,000.00 50,000.00 60,000.00 70,000.00 80,000.00 equipment supervision family qol cpd career w ill in gn es s t o pa y (in p h p) incentive migriño this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu the relative effectiveness of different policy options was forecasted by calculating for differences in uptake rates compared with the worst-case (“baseline”) job posting scenario: base salary php36,000, poor equipment, absent supervision, family far from work, poor living amenities, cpd unavailable, no avenues for career development. using random utility theory discussed in most health-related dce and econometric studies which states that respondents will select the option with the highest utility relative to the other choices,13,20,21 uptake rates of the baseline job post with a change in level of each of the incentives were calculated (figure 2). among the non-wage incentives, presence of supervision was the most valued incentive (uptake rate=38.84%, se 0.040), estimated to produce an impact a little above what could be expected from a 228% increase in base salary. this is followed by the impact of work facilities being near a physician’s family (36.39%, se 0.040), then by provisions for career development (31.71%, se 0.016). note: all uptake rates are significant at 1% level. baseline job posting incentives include base salary php36,000, poor equipment, absent supervision, family far from work, poor living amenities, cpd unavailable, and no avenues for career development. figure 2. uptake rates for selected job incentives compared to baseline, in % (n=345) 13.08% 24.91% 38.30% 25.89% 38.84%36.39% 15.90% 14.68% 31.71% 0% 5% 10% 15% 20% 25% 30% 35% 40% salary increased to php51,000 salary increased to php65,000 salary increased to php82,000 good equipment/infrastructure/supply supervision/mentoring is presentfamily lives near work facility easy access to daily living amenities cpd activities are available with avenues for career development migriño this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu post-estimation analysis (figure 3) shows the relationship between increases in salary with the estimated uptake probabilities: with a 100% increase in salary alone, uptake rates may increase by 30%. however, a modest (52%) increase in salary plus ensuring provisions of avenues for cpd may provide a similar increase in uptake rates; this is worth noticing since “cpd” has been identified as a low-impact incentive in this study. conversely, providing for a highimpact incentive such as supervision in the workplace may net a perceptible increase (52%) in uptake rates, given the same modest (52%) increase in salary. based on all the permutations presented, it can also be observed that at a certain level, further increases in wage led to decreasing net changes on uptake rates; at a certain level of wage increase, combinations of non-wage incentives might net higher uptake rates. the “sample posting” graph shows the impact of a combination of the three high-impact non-wage incentives (“supervision”, “family”, and “career”) with respect to changes in base salary. note: sample posting= with “supervision”, “family”, “career” figure 3. changes in uptake rates with different job incentives as base salary increases 0.99, 30% 0.52, 52% 0.52, 30% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 ch a n g e in u pt a k e ra te salary increase in multiples of base salary (in php) salary increase only with "equipment" with "supervision" with "family" with "qol" with "cpd" with "career" sample posting central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu discussion the demographic profile of the respondents closely resembled the general characteristics of medical interns in the philippines. the greater distribution of the respondents to the greater manila area reflect the location of most medical schools in the philippines. low response rates are consistent with electronic survey forms;22 however, johnson et al. states that precision of dce studies “flattens out at around 300 observations”,19 while lemiere mentions that dce studies only need a small (~100) effective sample size.23 due to the nature of the survey, it should be noted that the final sample population may not be fully representative of the target population. yun and trumbo have shown that internetbased surveys tend to favor males of above-average socioeconomic backgrounds;22 these finding were not consistent with the result of the study. medical students’ and graduates’ considerations to practice in rural areas rely in part on their rural upbringing: multiple studies have investigated the role of rural vs urban backgrounds in a young physician’s decision to pursue rural practice.24–27 in fact, a local study by leonardia et al. confirms that a larger cohort of dttbs came from rural backgrounds.28 similar analysis for either sex or marital status as showing associations with doctors’ considerations of work opportunities in rural/urban areas were not significant. the result for directly stated preferences for all identified job incentives was consistent with past studies involving both doctors9,20,29 and nurses,30 but most studies on career involve career advancement after serving a specified time in rural practice as opposed to concurrent career advancement identified in this study. additionally, the conditional logistic regression analysis results crossvalidate the results of the qualitative phase of the study and are also consistent with previous dce studies.9,20,21,30–32 presence of supervision has been identified as a major factor in both qualitative and quantitative studies regarding rural job post preferences,20,30,32 and this can be triangulated from comments in phase 1 of this study. it should also be noted that the incentive “family” is not routinely seen in other dce studies; usually, location of the work area is relative to the nearest city.20,32 only one dce study was found to include interaction terms for “family”: the study by smitz et al. in timor-leste noted significantly higher uptake rates of doctors with ruralbased families compared with those with urban-based ones.21 this should be considered in estimating the importance of this incentive in policy exercises. there also appeared to be a discrepancy with the relative importance of supervision: it ranked #5 when respondents were asked the directly stated preference question, but the dce model concluded high βsupervision (0.82) and wtpsupervision (php46,720.38), consistent with previous studies9,20 where some degree of supervision is among the most significant incentives in rural practice. this discrepancy proves the utility of dce to capture preferences not routinely seen in conventional stated preference methodologies.23 kolstad validates the inclusion of “career”, where her study in tanzania confirms the relative importance of professional development early in the careers of young physicians;20 however, this study highlights the greater relative importance of supervision compared with career advancement, which was emphasized in another study by kruk et al. in ghana.9 additionally, this study, a study by rana et al. in pakistan, and a study by hanson and jack in ethiopia confirmed the importance of equipment status as a main consideration in rural job posts,29,32 where respondents mentioned that poor equipment/infrastructure status and availability of supplies gives “a sense of unproductivity” which may lead to frustration.29 the use of dce enables researchers to minimize the major pitfall of other stated preference models, which is manipulation of responses due to direct or indirect incentives for the respondents.20 using fixed effects models such as was done in this study, including that for salary (“wage”), is common practice; however, it migriño this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu may lead to implausible mean wtp estimates33 as was evident in the unrealistically high mean wtp of most incentives. however, in such cases the wtp values should be interpreted relative to each other than as absolute values to provide a more realistic impact of each incentive.31 overall, the post-estimation model predicts better uptake rates for job postings by including any one of the non-wage incentives listed here compared to a moderate increase in base salary. the studies by kruk et al.,9 kolstad20 and serneels et al.,34 as well as by smitz et al.,21 showed similar results, where uptake rates from provision of non-wage incentives such as better equipment status or presence of supervision were comparable to uptake rates from modest to significantly high increases in salary. these studies explained such results by the respondents’ high intrinsic motivation, relatively higher paying jobs, and/or being at the early stages of their professional career.21 the study also tried to predict the impact of increases in wage (base salary) together with specific non-wage improvements in rural job postings. increasing base salary or giving monetary incentives have been identified as “the most obvious way to induce greater labor supply”32 and results from the kiis and fgds in this study back up this argument (“higher base salary may offset the effect of absence of non-wage incentives”); however, estimates of increasing base salary by itself might not be the most efficient way to increase uptake rates, particularly from early-career doctors. due to relatively low levels of financial motivation from recent medical graduates in consideration of rural practice, the department of health (doh) and local government units (lgus) may focus on adding non-wage incentives to current packages to produce a significant effect on uptake rates, taking into consideration the significant impact of a new doctor’s rural upbringing, background, and experience to consideration of the opportunity to practice medicine in rural communities. cost estimates of potentially highimpact non-wage incentives at the lgu level should also be conducted to see if such incentives are financially feasible. policy makers such as officers of the dohhealth human resource development bureau and mhos need to evaluate the cost-effectiveness of combinations of incentives from current rural job posts, as well as in the design of new rural health job posts. this could help increase uptake rates of vacant rural health job posts, improve health indices and even help in the prioritization of the health budget of an lgu. in the selection process for medical students, the study’s disaggregated data (results not shown) signify the need for rural backgrounds and/or rural community experiences to be given higher priority. however, since dce utilizes stated preferences, and few studies have been done to determine the relationship of stated preference and revealed preference models, it is highly recommended that routine monitoring of actual physician choices be done to validate the utility of models from similar studies using longitudinal cohort studies. references 1. diallo k, zurn p, gupta n, dal poz m. monitoring and evaluation of human resources for health: an international perspective. hum resour health. 2003;1(1):3. doi:10.1186/1478-4491-1-3. 2. who. who | the world health report 2006 working together for health. https://www.who.int/whr/2006/en/. accessed july 29, 2020. 3. badr e, mohamed na, afzal mm, bile km. strengthening human resources for health through information, coordination and accountability mechanisms: the case of the sudan. bull world health organ. 2013;91(11):868–73. doi:10.2471/blt.13.118950. 4. packer c, labonte r, spitzer d. who commission on social determinants of health: globalization and health worker crisis. globalization knowledge network. http://www.who.int/social_determinants/resources/gkn_ central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu packer_al.pdf. published 2007. accessed july 29, 2020. 5. who. global strategy on human resources for health: workforce 2030. world health organization. https://www.who.int/hrh/resources/global_strategy_wor kforce2030_14_print.pdf. published 2016. accessed july 29, 2020. 6. romualdez a, dela rosa jf, flavier jd, et al. the philippines health system review. manila, philippines: world health organization, western pacific region. http://www.searo.who.int/entity/asia_pacific_observator y/publications/hits/hit_philippines/en/. published 2011. accessed july 29, 2020. 7. who, doh. health service delivery profile philippines 2012. http://www.wpro.who.int/health_services/service_delive ry_profile_philippines.pdf. published 2012. 8. philippine statistics authority. psai-mdgs-table: infant mortality rate by region and year. http://nap.psa.gov.ph/imdgs/px/dialog/varval.asp?ma =4bvinimr&ti=infant+mortality+rate+by+region+and +year%2e+&path=../database/nscb/goals/goal4/&la ng=1&unit=index. accessed 2019 jan 12. 9. kruk me, johnson jc, gyakobo m, et al. rural practice preferences among medical students in ghana: a discrete choice experiment. bull world health organ. 2010;88(5):333–41. doi:10.2471/blt.09.072892 10. ronquillo k, elegado-lorenzo f, nodora r. human resources for health migration in the philippines: a case study and policy directions. asean learning network for human resources for health. 2005;august 2-5. 11. institute of health policy and development studies. migration of health workers: country case study philippines. http://www.ilo.org/sector/resources/publications/wcm s_161163/lang--en/index.htm . published 2005. accessed july 29, 2020. 12. apmcfi. vision and mission | association of philippine medical colleges foundation inc. (apmcfi). association of philippine medical colleges foundation, inc. http://webv2.apmcfph.net/apmc_wp/about-apmc/vision-and-mission/. published 2016. accessed july 29, 2020. 13. who. how to conduct a discrete choice experiment for health workforce recruitment and retention in remote and rural areas: a user guide with case studies. world health organisation. https://www.who.int/hrh/resources/dce_userguide_w eb.pdf. published 2012. accessed july 29, 2020. 14. dolea c. increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. geneva, switzerland: world health organization; 2010. 72 p. 15. stackexchange. how to create a nearly orthogonal experimental design in r?. cross validated. https://stats.stackexchange.com/questions/110133/howto-create-a-nearly-orthogonal-experimental-design-in-r. accessed july 29, 2020. 16. reed johnson f, lancsar e, marshall d, et al. constructing experimental designs for discrete-choice experiments: report of the ispor conjoint analysis experimental design good research practices task force. value health. 2013;16(1):3–13. doi:10.1016/j.val.2012.08.2223 17. street dj, burgess l, louviere jj. quick and easy choice sets: constructing optimal and nearly optimal stated choice experiments. international journal of research in marketing. 2005;22(4):459–70. doi:10.1016/j/ijresmar.2005.09.003. 18. tang l, luo x, cheng y, yang f, ran b. comparing the state-of-the-art efficient stated choice designs based on empirical analysis. mathematical problems in engineering. 2014. doi:10.1155/2014/740612 19. atkinson s, abu el haj m. domain analysis for qualitative public health data. health policy plan. 1996;11(4):438–42. doi:10.1093/heapol/11.4.438 20. kolstad jr. how to make rural jobs more attractive to health workers. findings from a discrete choice experiment in tanzania. health econ. 2011;20(2):196– 211. doi:10.1002/hec.1581 21. smitz m-f, witter s, lemiere c, et al. understanding health workers’ job preferences to improve rural retention in timor-leste: findings from a discrete choice experiment. plos one. 2016;11(11). doi:10.1371/journal.pone.0165940 migriño this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.344 | http://cajgh.pitt.edu 22. yun gw, trumbo cw. comparative response to a survey executed by post, e-mail, & web form. j comput mediat commun. 2000;6(1). doi:10.1111/j.1083-6101.2000.tb00112.x 23. lemiere c. discrete choice experiment (dce): a methodology for eliciting health workers’ preferences. world health organization; 2009. available from: https://www.hrhresourcecenter.org/node/2424.html. accessed july 29, 2020. 24. chan btb, degani n, crichton t, et al. factors influencing family physicians to enter rural practice: does rural or urban background make a difference?. can fam physician. 2005;51(9):1247. https://pubmed.ncbi.nlm.nih.gov/16926939. accessed july 29, 2020. 25. mcgrail mr, humphreys js, joyce cm. nature of association between rural background and practice location: a comparison of general practitioners and specialists. bmc health serv res. 2011;11(1):63. doi:10.1186/1472-6963-11-63 26. rodriguez k. literature review of recruitment and retention for rural health care providers. maine ahec network. https://www.une.edu/sites/default/files/%281%29%20r ural%20physician%20recruitment%20and%20retentio n%20lit%20review%20final%5b1%5d.pdf. published 2014. accessed july 29, 2020. 27. serneels p, montalvo jg, pettersson g, lievens t, butera jd, kidanu a. who wants to work in a rural health post? the role of intrinsic motivation, rural background and faith-based institutions in ethiopia and rwanda. bull world health organ. 2010;88(5):342–9. doi:10.2471/blt.09.072728. 28. leonardia ja, prytherch h, ronquillo k, nodora rg, ruppel a. assessment of factors influencing retention in the philippine national rural physician deployment program. bmc health serv res. 2012;12(1):411. doi:10.1186/1472-6963-12-411. 29. rana sa, sarfraz m, kamran i, jadoon h. preferences of doctors for working in rural islamabad capital territory, pakistan: a qualitative study. j ayub med coll abbottabad. 2016;28(3):591– 596. https://pubmed.ncbi.nlm.nih.gov/28712243. accessed july 29, 2020. 30. lagarde m, blaauw d. a review of the application and contribution of discrete choice experiments to inform human resources policy interventions. human resour health. 2009;7(1):62. doi:10.1186/1478-4491-762. 31. rockers pc, jaskiewicz w, wurts l, et al. preferences for working in rural clinics among trainee health professionals in uganda: a discrete choice experiment. bmc health serv res. 2012;12:212. doi:10.1186/1472-6963-12-212. 32. hanson k, jack w. health worker preferences for job attributes in ethiopia : results from a discrete choice experiment. washington, d.c: world bank group. http://documents.worldbank.org/curated/en/7161914680 30240068/health-worker-preferences-for-job-attributesin-ethiopia-results-from-a-discrete-choice-experiment. published april 2008. accessed july 29, 2020. 33. hole ar. estimation of willingness to pay in preference space vs. wtp space. university of sheffield. https://www.sheffield.ac.uk/polopoly_fs/1.214046!/file/ dcmd.pdf. published december 8, 2011. accessed july 29, 2020. 34. serneels p, lindelow m, montalvo jg, barr a. for public service or money: understanding geographical imbalances in the health workforce. health policy plan. 2007;22(3):128–38. doi:10.1093/heapol/czm005. cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. honey: a therapeutic agent for disorders of the skin pauline mcloone1, afolabi oluwadun2, mary warnock3, lorna fyfe3 1department of biomedical sciences, school of medicine, nazarbayev university, astana, kazakhstan; 2department of medical microbiology and parasitology olabisi onabanjo university, sagamu, ogun state, nigeria; 3dietetics, nutrition and biological sciences, queen margaret university, musselburgh, east lothian, scotland, united kingdom vol. 5, no. 1 (2016) | issn 2166-7403 (online) doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ mcloone this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu abstract problems with conventional treatments for a range of dermatological disorders have led scientists to search for new compounds of therapeutic value. efforts have included the evaluation of natural products such as honey. manuka honey, for example, has been scientifically recognised for its anti-microbial and wound healing properties and is now used clinically as a topical treatment for wound infections. in this review, scientific evidence for the effectiveness of honey in the treatment of wounds and other skin conditions is evaluated. a plethora of in vitro studies have revealed that honeys from all over the world have potent antimicrobial activity against skin relevant microbes. moreover, a number of in vitro studies suggest that honey is able to modulate the skin immune system. clinical research has shown honey to be efficacious in promoting the healing of partial thickness burn wounds while its effectiveness in the treatment of non-burn acute wounds and chronic wounds is conflicted. published research investigating the efficacy of honey in the treatment of other types of skin disorders is limited. nevertheless, positive effects have been reported, for example, kanuka honey from new zealand was shown to have therapeutic value in the treatment of rosacea. anti-carcinogenic effects of honey have also been observed in vitro and in a murine model of melanoma. it can be concluded that honey is a biologically active and clinically interesting substance but more research is necessary for a comprehensive understanding of its medicinal value in dermatology. keywords: dermatology, honey, skin cancer, wound healing honey: a therapeutic agent for disorders of the skin pauline mcloone1, afolabi oluwadun2, mary warnock3, lorna fyfe3 1department of biomedical sciences, school of medicine, nazarbayev university, astana, kazakhstan; 2department of medical microbiology and parasitology olabisi onabanjo university, sagamu, ogun state, nigeria; 3dietetics, nutrition and biological sciences, queen margaret university, musselburgh, east lothian, scotland, united kingdom commentary historically, honey has been recognised around the world for its healing properties with records of its therapeutic use dating back to 2000 b.c. the ancient greeks and egyptians, for example, used honey to treat skin wounds and burns by applying topically on the skin. 1 honey has been reported to ameliorate a broad array of diseases but the focus of this review is on the therapeutic properties of honey in the treatment of disorders of the skin. traditional medicine in numerous countries around the world has described honey as efficacious in the treatment of a range of skin disorders. in malaysian tradition, honey is used to treat furuncles, carbuncles, diabetic wounds and burns. persian traditional medicine documented honey as effective in the treatment of wounds, eczema, and inflammation. 2,3 in ayurvedic medicine, a traditional medicine native to the indian http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu subcontinent, honey is used to treat cuts and wounds, eczema, dermatitis, burns, skin diseases and fournier’s gangrene. 4-6 similarly, quranic medicine in pakistan recorded honey combined with cinnamon powder as a treatment for pustules, eczema, ringworm and a variety of other skin diseases and in burkina faso, africa, it has been reported that indigenous people use honey as a skin cleansing agent and as a treatment for measles rash. 7,8 the uses of honey in traditional medicine are still significant today, especially, when we consider the fact that most of the population of developing countries presently rely on indigenous medicine as their source of primary health care. 9 honey has also been used extensively as an ingredient in cosmetic skin care products both in the past and present day. 5,10 in clinical practice today, manuka honey produced by honey bees (apis mellifera) feeding on the manuka tree (leptospermum scoparium) in new zealand is used topically in the management of wound infections. 11 it has been approved for clinical use in australia, new zealand, europe, united states of america, canada and hong kong and products include γ irradiated honey in gels, ointments and impregnated dressings. revamil honey is another medical grade honey commonly used in clinical practice for wound care. 12 it is produced by manufacturers in the netherlands in collaboration with the university of wageningen and the academic medical centre, amsterdam. the manufacturers have disclosed that the honey is produced in greenhouses but further details about the origin of the honey have not been revealed. the skin healing ability of honey has been attributed to its antimicrobial properties, its ability to modulate the skin’s immune system and promote tissue repair. 13,14 this review explores clinical and scientific research investigating the efficacy of honey in the treatment of wounds and a variety of other skin disorders. a principle aim was to use the scientific literature to evaluate the potential efficacy of honey in the treatment of a range of dermatological disorders. methods the databases pubmed, medline and sciencedirect were used to carry out a comprehensive search of the scientific literature on the effects of honey in the treatment of skin disorders including wounds. some of the key search terms used in combination were “honey” “antimicrobial activity” “skin immune system” “skin disorders” “wound healing” “seborrheic dermatitis” “atopic dermatitis” “psoriasis” “rosacea” “acne” “pityriasis versicolor” “cutaneous leishmaniasis” “skin cancer” “ kazakhstan” and “central asia”. relevant in vitro and in vivo studies were selected and we also searched the reference list of included papers to ensure that no important papers were omitted. texts in english, published between 1990 and 2016 were included. results the efficacy of honey in the treatment of skin wounds the ability of honey to aid the healing of skin wounds is the most widely researched aspect of honey as a therapeutic agent to date. a plethora of in vitro and in vivo studies have been performed. the efficacy of honey in the treatment of skin wounds: in vitro studies in vitro studies have revealed that honey from diverse floral origins can kill a wide range of wound pathogens, including; methicillin resistant staphylococcus aureus (mrsa), staphylococcus aureus, escherichia coli, pseudomonas aeruginosa and acinetobacter baumannii. 15-18 as an example, the work of cooper et al, (2002) demonstrated that manuka and pasture honey from new zealand were active against 17 strains of p. aeruginosa isolated from infected burns with minimal inhibitory concentrations (mics) below 10%. 19 the authors concluded that these honeys have the potential to be effective treatments for burns http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcloone this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu infected with p. aeruginosa. also, cooper et al (2014) later demonstrated the ability of medihoney to disrupt the structure and inhibit the growth of p. aeruginosa biofilms grown in vitro. 20 as well as killing microbes, studies have shown that sub-lethal concentrations of honey can reduce microbial pathogenicity, for example, kronda et al (2013) demonstrated that sub-lethal concentrations of manuka honey reduced siderophore production, a virulence factor that scavenges iron for bacterial growth, in strains of p. aeruginosa. 21 even more remarkable are the in vitro findings that honey can reverse antimicrobial resistance. jenkins and cooper (2012) reported that manuka honey and oxacillin worked synergistically to inhibit the growth of mrsa and that manuka honey reversed oxacillin resistance in mrsa in vitro. 22 table 1. honey as a therapeutic agent for skin disorders; summary of the key in vitro findings importantly, studies have also shown that honey from a variety of sources can modulate immunological parameters related to the skin immune system. 23 for example, in vitro, honey has been shown to stimulate cytokine production by skin cells such as keratinocytes and other immune cells such as monocytes. 24,25 it has been proposed that increased cytokine production in an early wound could enhance wound healing because cytokines such as tnf-α and il-6 play an important role in the early wound healing process. additionally, some studies have shown that honey or its extracts can down regulate the production of cellular molecules such as matrix metalloproteinases (mmps) and reactive oxygen intermediates (rois) that may contribute to excessive inflammation in the chronic wound. 26,27 it has been suggested that the immunomodulatory properties of honey may contribute to enhanced tissue repair or reduce chronic inflammation in the wound, leading to enhanced healing. as well as its antimicrobial and immunomodulatory properties, honey has been shown to promote re-epithelialisation and angiogenesis in in vitro models of wound healing. ranzato et al (2012) demonstrated that acacia, buckwheat and manuka honey, purchased at an apiculture centre in okayamo, japan, increased re-epithelialisation rates in scratch wounds induced in keratinocyte (hacat) monolayers. 28 furthermore, the mechanism was shown to be due to honey induced activation of pathways that regulate cell locomotion and cell proliferation. barui et al, (2013) demonstrated that a honey alginate fibrous matrix induced faster re-epithelialisation than an alginate only matrix in a keratinocyte (hacat) wound model; ecadherin protein was enhanced in the honey alginate model which may have promoted increased cell to cell adhesion. 29 rossiter et al, (2010) reported that the medicinal honey activon containing 100% manuka honey, the honey based ointment mesitran as well as a supermarket honey (rowse) promoted angiogenic activity in a rat aortic ring assay in vitro. 30 in conclusion, in vitro studies have revealed that honey has some remarkable scientific properties that, plausibly, could promote the healing of wounds. the efficacy of honey in the treatment of skin wounds: in vivo studies ideally, a wound will heal early but sometimes wound healing is delayed and this can be the result of systemic disease, malnutrition and infection of the wound leading to excessive inflammation. indeed, excessive infiltration of neutrophils has been associated with deficient wound healing. 31 micro-organisms can sometimes attach to the wound bed and form a biofilm which is disruptive to the healing process. wound infections exacerbate illness, cause anxiety and increase patient morbidity and mortality. surgical wound infections lengthen hospital stay and chronic wounds http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu require considerably more dressings. hence, effective prevention and management of wound infections will impact positively on both patient health and cost. table 2. honey as a therapeutic agent for skin disorders; summary of the key in vivo findings there are a plethora of in vivo studies investigating the efficacy of honey in the treatment of wounds; 32-55 many of the findings are controversial. however, a recent cochrane based review by jull et al, (2015) 56 concluded that there is quality evidence that honey heals partial thickness burn wounds more quickly than conventional treatments and infected postoperative wounds more effectively than gauze or antiseptics. it was concluded that other studies comparing honey with conventional methods in wound healing were of insufficient quality to form any definitive conclusions. larger, well designed, double blind, clinical studies are required for a fuller understanding of the efficacy of honey in the treatment of different types of wounds. the mechanism of the skin healing properties of honey in relation to burn wounds is not fully understood but may, at least partially, be due to the antioxidant content of honey. there is evidence for free radical activity and reduced antioxidant scavenging capacity in burn wounds leading to oxidative stress. 57 honeys that are rich in antioxidants are likely to increase the antioxidant capacity of burn wounds and mop up free radicals leading to reduced oxidative stress. 58 of course, the antimicrobial and immunomodulatory properties of honey may also positively encourage the wound healing process in burn wounds. mode of administration and combination therapy with other agents such as antibiotics or other natural products could be considered. techniques such as checkerboard and time kill studies are currently being used to determine the synergistic effects of antimicrobial agents (personal communication; oluwadun a. & akinduti p., olabisi onabanjo university). the efficacy of honey in the treatment of other disorders of the skin in vitro studies in vitro studies have revealed that honey can inhibit the growth of a range of dermatologically important microbes. as well as inhibition of microbes responsible for wound infections, honey has been shown to inhibit the growth of dermatophytes a cause of tinea infections, candida albicans a cause of cutaneous candidiasis and propionibacterium acnes a cause of acne. 16,59-61 many studies have demonstrated the antimicrobial effects of honey from a variety of sources against s. aureus. as well as wound infections s. aureus is an important cause of furuncles, styes and impetigo and super-infection with s. aureus is common in atopic dermatitis. 62` research should continue to investigate the in vitro effects of honey against other dermatologically important microbes such as malassezia species, human papilloma virus and bacillus oleronius. some skin disorders such as contact dermatitis, atopic dermatitis and psoriasis have been classified as immune mediated skin disorders. although the aetiology of the majority of immune mediated skin disorders are not fully understood the immune system is believed to play a significant role in the pathogenesis of the disease. such disorders commonly respond to treatment with immunomodulating agents such as corticosteroids or ultraviolet radiation therapy. recently, in vitro studies have revealed that honey is able to modulate the immune system, for example, a study by majtan et al, (2010) demonstrated that acacia honey from slovakia stimulated tnf-α, tgf-β, il-1β and matrix metalloproteinase 9 (mmp-9) mrna http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcloone this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu expression by human primary keratinocytes isolated from human foreskin. 24 subsequently, majtan et al, (2013) reported that an aqueous extract of fir honeydew honey from slovakia inhibited tnf-α induced matrix metalloproteinase-9 (mmp-9) protein and mrna production by human keratinocytes (hacat) cells. 27 since the role of the immune system in skin disorders is complex, it is difficult to infer what effects honey will have in the treatment of immune mediated skin disorders without further investigation. it is likely that both the origin of the honey and the microenvironment of the skin disorder will influence clinical outcome. clearly, more research is necessary for a better understanding of the immunomodulatory properties of honey and their relevance for skin disease. the efficacy of honey in the treatment of other disorders of the skin: in vivo studies the majority of clinical studies performed to date have investigated the efficacy of honey in the treatment of skin wounds. there is a paucity of clinical studies investigating the effects of honey on other types of skin disorders; however, some of the studies that have been carried out have produced positive results. al-waili (2001) reported a remarkable improvement of symptoms in patients with seborrheic dermatitis (n=30) following topical application of a diluted crude honey (90%). 63 the same researcher, later reported that a honey mixture containing natural honey of multi-floral origin from lootah farm, al-theed city, united arab emirates, olive oil and beeswax (1:1:1) markedly improved the symptoms of patients with atopic dermatitis (n=21) and psoriasis (n=18). 64 some of the psoriatic and atopic dermatitis patients received a honey mixture treatment in combination with corticosteroids and this allowed the concentration of corticosteroid to be reduced over time without exacerbation of symptoms. al-waili, (2003) suggested that the antimicrobial, anti-inflammatory and antioxidant properties of honey may explain the observed therapeutic effects. the same honey mixture was found to cure the symptoms of the fungal skin infections pityriasis versicolor in 79% of patients (n=14), tinea cruris in 71% of patients (n=14) and tinea corporis in 62% of patients (n=8). 65 in 2005, al-waili reported that the same honey mixture significantly reduced mean lesion scores in infants with diaper dermatitis (n=12); the presence of c. albicans was found to be reduced in some patients treated with the honey mixture. 66 in a small study (n=16) by al-waili (2004) it was reported that honey was more effective than acyclovir in the treatment of patients with labial and genital herpes simplex lesions, suggesting that honey could potentially be effective in the treatment of oral herpes simplex lesions. 67 table 3. studies investigating the efficacy of honey in the treatment of skin disorders (excluding wounds) acasia honey (yamada bee farm, japan) and the bee product brazilian green propolis (bpe) have also been shown to be efficacious in the treatment of tinea infections in vivo. 68 two hundred and forty two congolese school children with either tinea capitis or pityriasis versicolor were treated with either 2% miconazole (positive control), bpe (100mg/ml or 50mg/ml), acasia honey or vaseline. the results showed that acasia honey, bpe at both concentrations and miconazole significantly improved erythema, desquamation and pruritis in tinea patients in comparison to vaseline. rosacea is an inflammatory skin disorder, characterised by facial redness, papules, pustules and telangiectasia. the bacterium bacillus oleronius isolated from the dermodex folliculorum mite has been implicated in the aetiology of the disease. a recent study by braithwaite et al (2015) has shown that kanuka honey from new zealand was efficacious in the treatment of rosacea. 69 their study included 138 participants with a diagnosis of rosacea and a global assessment of rosacea severity score (iga-rss) of ≥ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu 2.69. sixty nine participants were treated with topical honevo (90% kanuka honey and 10% glycerine) for 8 weeks. the other 69 participants were treated with the control cream cetomacrogol, a moisturising cream, commonly used as a vehicle for delivering topical medications. the results showed that 34.3% in the honevo group and 17.4% in the control group had a ≥ 2 improvement in the iga-rss at week 8. the researchers concluded that honevo is an effective treatment for rosacea and that future research should compare honevo with other conventional treatments, such as topical metronidazole and azelaic cream, both of which have limited efficacy. the mechanisms of the therapeutic properties of kanuka honey in the treatment of rosacea are not fully understood but both the antibacterial and anti-inflammatory properties have been considered. a recent study involving 136 participants with acne (investigators global assessment (iga) score of ≥ 2.68 aged between 16 and 40 years was carried out to investigate the efficacy of topical kanuka honey in the treatment of acne. 70 sixty eight of the participants were randomised to a treatment regime which involved applying protex, a trilocarbon-based antibacterial soap twice daily for 12 weeks whilst the other 68 participants applied the anti-bacterial soap treatment followed by application of honevo directly after washing off the bacterial soap, twice daily for 12 weeks. the results demonstrated that 4 out of 53 patients (7.6%) in the honey treated group and 1 out of 53 (1.9 %) patients in the anti-bacterial soap only treated group had a ≥ 2 improvement in iga score. the authors concluded that there was no evidence that adding honevo to standard anti-bacterial soap treatment for acne is more efficacious than anti-bacterial soap alone. the authors however did raise concerns about treatment compliance due to the young age of many of the participants and the high rate of withdrawal. medical grade kanuka honey has also been tested for its efficacy in the treatment of eczema and psoriasis. 71,72 no evidence of effectiveness in the treatment of eczema above that of an aqueous control cream was reported. the study involved 15 participants with bilateral eczematous lesions on the limbs; medical grade kanuka honey was applied to a representative lesion on one side and aqueous cream bp to the other, every night for 2 weeks. aqueous cream is not a recommended treatment for eczema and therefore represented a negative control. the authors concluded that their study did not demonstrate any evidence that kanuka honey is an effective treatment for eczema, however, the small sample size and incomplete blinding were acknowledged as limitations of the study. the same study design was also used to investigate the efficacy of kanuka honey in the treatment of psoriasis. the results showed that kanuka honey was of similar efficacy to aqueous cream; a recommended treatment for psoriasis but with lower efficacy than corticosteroids. medical grade kanuka honey has also been tested for its efficacy in the treatment of cold sores and compared with acyclovir. 73 the study showed that kaplan-meier estimates of median healing time were similar for honey and acyclovir. however, limitations of the study were that participant size was small with only 15 patients; the authors proposed that a larger clinical study should be conducted. naidoo et al (2011) tested the efficacy of manuka honey as a prophylactic treatment for dermatitis in a phase ii randomised controlled trial involving patients undergoing radiation therapy for breast cancer. 74 81 patients were enrolled in the study; 43 of which were treated with manuka honey and 38 with standard aqueous cream. the results showed that there was a lower incidence of grade >2 dermatitis in the patients treated with honey (37.2%) compared with those treated with aqueous cream (57.8%). when > grade 2 dermatitis did occur the duration was shorter in the honey treated group in comparison to the group treated with aqueous cream. one study also investigated the therapeutic value of honey in the treatment of cutaneous leishmaniasis. 75 in this study, 90 patients with cutaneous http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcloone this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu leishmaniasis were allocated to a treatment regime; 45 patients were treated for 6 weeks with topical honey soaked gauze twice daily and intra-lesional injection of glucantime weekly. the other 45 patients were treated with intra-lesional injection of glucantime only. by the end of the treatment more patients had complete cure in the glucantime only treated group (71%) than in the glucantime and honey treated group (51.1%), suggesting that the honey used in this study is not of therapeutic value in the treatment of cutaneous leishmaniasis. the aforementioned studies investigating the efficacy of honey in the treatment of other types of skin disorders are relatively small scale and several of them have been carried out by the same researcher, nevertheless, they support the possibility that honey may be therapeutic in the treatment of other types of skin disorder such as fungal skin infections and inflammatory skin conditions. systematic reviews are important for evidence based method and this approach has been adopted by jull et al (2015) 56 to evaluate the efficacy of honey in the treatment of wounds. clinical studies investigating the efficacy of honey in the treatment of other types of skin disorders are more limited and we have described all published findings irrespective of the quality of the study design. it is important that all future studies carried out follow international standards for clinical trial reporting. undoubtedly, further research is necessary, incorporating in vitro, animal and clinical studies to determine the medical value of honey in the treatment of a range of dermatological disorders. even if honey is found to be an ineffective treatment for certain skin diseases such studies are important because the knowledge will inform patients and clinicians considering alternative therapies for dermatological disorders. honey and skin cancer recently, fernandez-cabezudo et al, (2013) reported that manuka honey could inhibit the proliferation and induce apoptosis in three cancer cell lines, one of which was the murine melanoma cell line b16.f1. 76 additionally, pichichero et al, (2010) reported that acacia honey inhibited proliferation of murine and human melanoma cells by inducing cell cycle arrest at g0/g1. 77 in vivo, a murine melanoma tumour model treated with intravenous manuka honey displayed a significant reduction in tumour growth. 76 some of the mice received co-administration of manuka honey and the chemotherapeutic drug taxol and this resulted in a significant inhibition of the growth of the tumour and improved overall animal survival suggesting that manuka honey, as well as having anti-tumourogenic properties, may reduce chemotherapy induced toxicity. no changes in haematological and chemical markers were observed in the mice treated with intravenous manuka honey suggesting that it is safe to administer honey in this way. in another study, tualang honey from malaysia was shown to protect murine keratinocytes (pam 212 cells) in vitro from the immunomodulatory and photocarcinogenic effects of uvb radiation. 78 uvb irradiated keratinocytes treated with honey exhibited reduced expression of cox-2 and nf-κb activation in comparison to uvb only treated cells. furthermore, uvb irradiated keratinocytes treated with tualang honey displayed a marked reduction in dna damage in the form of cyclobutane pyrimidine dimers and 8-oxo-7, 8dihydro-2-deoxyguanosine compared with uvb irradiated controls. tualang honey may therefore be able to protect the skin against the immunomodulatory and photocarcinogenic effects of sunlight exposure. the ability of honey to inhibit the proliferation of tumour cells is thought to be due to the various flavonoid and phenolic compounds present in honey. evidence for this comes from the work of pichichero et al, (2010; 2011) showing that chrysin, a flavanoid found in acacia honey inhibited proliferation of melanoma cells via cell cycle arrest and apoptosis. 77,79 honey has also been shown to regulate expression of p53, the tumour suppressor protein and down regulate bcl-2 an anti-apoptotic protein, found at high levels in numerous cancers. 80 the anti-inflammatory effects of honey may http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu also contribute to its anti-carcinogenic properties, particularly as inflammation has been shown to contribute to the progression of cancer. 81 the anti-carcinogenic properties of honey observed to date are promising but more research is necessary, particularly in vivo, for a fuller understanding of the potential efficacy of honey in the treatment or prevention of skin cancer. discussion the ability of honey in vitro to kill skin relevant microbes, alter microbial pathogenicity, reverse antibiotic resistance, modulate immunological parameters, promote tissue repair, inhibit tumour cell growth and protect against uv induced dna damage is really quite remarkable considering it is a scientifically unaltered, purely natural substance produced by bees. in vitro studies have sparked excitement amongst researchers about the therapeutic potential of honey for clinical practice. some of the properties observed in vitro are particularly relevant today when the current global crisis of antimicrobial drug resistance has rendered many infectious diseases, including wound infections, untreatable and malignant melanoma incidence is increasing faster than any other cancer. 82,83 skin cancer is also a significant problem in central asian countries; in kazakhstan for example, incidence figures from the ministry of health (2013) show that skin cancer is one of the most common forms of cancer along with lung and breast cancer. 84 furthermore, a particularly high incidence of basal cell carcinomas was recorded around the semipalatinsk nuclear testing site in kazakhstan. 85 there are countless varieties of honey being produced worldwide and some may have superior healing abilities that are yet to be discovered. central asia possesses a unique biodiversity with open steppe, deserts and high mountains; honey production is abundant in kazakhstan, kyrgyzstan, uzbekistan and tajikistan. beekeeping trailers enable honey producers to reach diverse locations in the region, despite this, the regions honeys have not been fully examined for potential biomedical uses. other local bee products, such as propolis could also be investigated for their medicinal value as research has demonstrated antimicrobial, anti-carcinogenic and wound healing properties. 86-88 the development of locally produced honeys into medical grade honeys suitable for use in clinical practice could be economically advantageous for the country concerned. a recent review has highlighted that there is no statistical monitoring on the prevalence of chronic wounds in kazakhstan and no approved protocols for wound care. 89 the authors described that wound care products made from plant extracts have been developed in kazakhstan although they have not been officially approved for clinical use. the review did not list honey as a treatment used for wound care in kazakhstan despite its approved use in other parts of the world. in conclusion, research has demonstrated that the bioactive properties of honey and the aetiology of skin diseases are complex and that there are considerable gaps in our knowledge and understanding of both. innovative research that can maximally exploit the bioactive properties of this natural substance may in the future lead to the production of a medicinal product that is highly valued in dermatology. references 1. molan pc. the antibacterial activity of honey: 1. the nature of the antibacterial activity. bee world. 1992;73(1):528. 2. barakhbah sasa. honey in the malay tradition. malays j med sci. 2007;14(1):106. 3. sepehr s. the most important medicinal uses of honey and its side effects in the book of the canon by avienna and in the modern medical literature: a comparative study. j apiprod apimed sci. 2010;2(1):43. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcloone this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu 4. deshpande sd kk. indian honey as a medicine. j apiprod apimed sci. 2010;2(1):45. 5. ediriweera er, premarathna ny. medicinal and cosmetic uses of bee's honey a review. ayu. 2012;33(2):178-182. 6. subrahmanyam m. practical application of honey dressing. malays j med sci. 2007;14(1):103. 7. marwat sk, khan ma, rehman f, khan k. medicinal uses of honey (quranic medicine) and its bee flora from dera ismail khan district, kpk, pakistan. pak j pharm sci. 2013;26(2):307314. 8. meda a, lamien ce, millogo j, romito m, nacoulma og. therapeutic uses of honey and honeybee larvae in central burkina faso. j ethnopharmacol. 2004;95(1):103-107. 9. who. who traditional medicine strategy 2014-2023. 2014. accessed 15 dec 2014, 2014. 10. burlando b, cornara l. honey in dermatology and skin care: a review. j cosmet dermatol. 2013;12(4):306-313. 11. irish j, blair s, carter da. the antibacterial activity of honey derived from australian flora. plos one. 2011;6(3):e18229. 12. kwakman ph, te velde aa, de boer l, vandenbrouckegrauls cm, zaat sa. two major medicinal honeys have different mechanisms of bactericidal activity. plos one. 2011;6(3):e17709. 13. majtan j. honey: an immunomodulator in wound healing. wound repair regen. 2014;22(2):187-192. 14. sherlock o, dolan a, athman r, et al. comparison of the antimicrobial activity of ulmo honey from chile and manuka honey against methicillin-resistant staphylococcus aureus, escherichia coli and pseudomonas aeruginosa. bmc complement altern med. 2010;10:47. 15. carnwath r, graham em, reynolds k, pollock pj. the antimicrobial activity of honey against common equine wound bacterial isolates. vet j. 2014;199(1):110-114. 16. mcloone p, warnock m, fyfe l. honey: a realistic antimicrobial for disorders of the skin. j microbiol immunol infect. 2016;49(2):161-167. 17. schneider m, coyle s, warnock m, gow i, fyfe l. antimicrobial activity and composition of manuka and portobello honey. phytother res. 2013;27(8):1162-1168. 18. tan ht, rahman ra, gan sh, et al. the antibacterial properties of malaysian tualang honey against wound and enteric microorganisms in comparison to manuka honey. bmc complement altern med. 2009;9:34. 19. cooper ra, halas e, molan pc. the efficacy of honey in inhibiting strains of pseudomonas aeruginosa from infected burns. j burn care rehabil. 2002;23(6):366-370. 20. cooper r, jenkins l, hooper s. inhibition of biofilms of pseudomonas aeruginosa by medihoney in vitro. j wound care. 2014;23(3):93-96, 98-100, 102 passim. 21. kronda jm, cooper ra, maddocks se. manuka honey inhibits siderophore production in pseudomonas aeruginosa. j appl microbiol. 2013;115(1):86-90. 22. jenkins re, cooper r. synergy between oxacillin and manuka honey sensitizes methicillin-resistant staphylococcus aureus to oxacillin. j antimicrob chemother. 2012;67(6):14051407. 23. mcloone p, warnock m, fyfe l. honey: an immunomodulatory agent for disorders of the skin. food agric immunol. 2016;27(3):338-349. 24. majtan j, kumar p, majtan t, walls af, klaudiny j. effect of honey and its major royal jelly protein 1 on cytokine and mmp-9 mrna transcripts in human keratinocytes. exp dermatol. 2010;19(8):e73-79. 25. tonks aj, cooper ra, jones kp, blair s, parton j, tonks a. honey stimulates inflammatory cytokine production from monocytes. cytokine. 2003;21(5):242-247. 26. ahmad a, khan ra, mesaik ma. anti inflammatory effect of natural honey on bovine thrombin-induced oxidative burst in phagocytes. phytother res. 2009;23(6):801-808. 27. majtan j, bohova j, garcia-villalba r, et al. fir honeydew honey flavonoids inhibit tnf-alpha-induced mmp-9 expression in human keratinocytes: a new action of honey in wound healing. arch dermatol res. 2013;305(7):619-627. 28. ranzato e, martinotti s, burlando b. epithelial mesenchymal transition traits in honey-driven keratinocyte wound healing: comparison among different honeys. wound repair regen. 2012;20(5):778-785. 29. barui a, mandal n, majumder s, et al. assessment of molecular events during in vitro re-epithelialization under honey-alginate matrix ambience. mater sci eng c mater biol appl. 2013;33(6):3418-3425. 30. rossiter k, cooper aj, voegeli d, lwaleed ba. honey promotes angiogeneic activity in the rat aortic ring assay. j wound care. 2010;19(10):440, 442-446. 31. diegelmann rf, evans mc. wound healing: an overview of acute, fibrotic and delayed healing. front biosci. 2004;9:283-289. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu 32. bischofberger as, dart cm, perkins nr, kelly a, jeffcott l, dart aj. the effect of shortand long-term treatment with manuka honey on second intention healing of contaminated and noncontaminated wounds on the distal aspect of the forelimbs in horses. vet surg. 2013;42(2):154-160. 33. boekema bk, pool l, ulrich mm. the effect of a honey based gel and silver sulphadiazine on bacterial infections of in vitro burn wounds. burns. 2013;39(4):754-759. 34. gethin g, cowman s. manuka honey vs. hydrogel--a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. j clin nurs. 2009;18(3):466-474. 35. gupta ss, singh o, bhagel ps, moses s, shukla s, mathur rk. honey dressing versus silver sulfadiazene dressing for wound healing in burn patients: a retrospective study. j cutan aesthet surg. 2011;4(3):183-187. 36. haidari m, nazer mr, ahmadinejad m, almasi v, khorramabadi ms, pournia y. honey in the treatment of fournier's gangrene as an adjuvant: a cross sectional study. j pak med assoc. 2014;64(5):571-573. 37. ingle r, levin j, polinder k. wound healing with honey-a randomised controlled trial. s afr med j. 2006;96(9):831835. 38. jull a, walker n, parag v, molan p, rodgers a. randomized clinical trial of honey-impregnated dressings for venous leg ulcers. br j surg. 2008;95(2):175-182. 39. khoo yt, halim as, singh kk, mohamad na. wound contraction effects and antibacterial properties of tualang honey on full-thickness burn wounds in rats in comparison to hydrofibre. bmc complement altern med. 2010;10:48. 40. maghsoudi h, salehi f, khosrowshahi mk, baghaei m, nasirzadeh m, shams r. comparison between topical honey and mafenide acetate in treatment of burn wounds. ann burns fire disasters. 2011;24(3):132-137. 41. malik ki, malik ma, aslam a. honey compared with silver sulphadiazine in the treatment of superficial partial-thickness burns. int wound j. 2010;7(5):413-417. 42. mat lazim n, abdullah b, salim r. the effect of tualang honey in enhancing post tonsillectomy healing process. an open labelled prospective clinical trial. int j pediatr otorhinolaryngol. 2013;77(4):457-461. 43. mcintosh cd, thomson ce. honey dressing versus paraffin tulle gras following toenail surgery. j wound care. 2006;15(3):133-136. 44. nakajima y, nakano y, fuwano s, et al. effects of three types of japanese honey on full-thickness wound in mice. evid based complement alternat med. 2013;2013:504537. 45. sare jl. leg ulcer management with topical medical honey. br j community nurs. 2008;13(9):s22, s24, s26 passim. 46. shukrimi a, sulaiman ar, halim ay, azril a. a comparative study between honey and povidone iodine as dressing solution for wagner type ii diabetic foot ulcers. med j malaysia. 2008;63(1):44-46. 47. subrahmanyam m. honey impregnated gauze versus polyurethane film (opsite) in the treatment of burns--a prospective randomised study. br j plast surg. 1993;46(4):322-323. 48. subrahmanyam m. honey-impregnated gauze versus amniotic membrane in the treatment of burns. burns. 1994;20(4):331-333. 49. subrahmanyam m. honey dressing versus boiled potato peel in the treatment of burns: a prospective randomized study. burns. 1996;22(6):491-493. 50. subrahmanyam m. a prospective randomised clinical and histological study of superficial burn wound healing with honey and silver sulfadiazine. burns. 1998;24(2):157-161. 51. subrahmanyam m. early tangential excision and skin grafting of moderate burns is superior to honey dressing: a prospective randomised trial. burns. 1999;25(8):729-731. 52. tahmaz l, erdemir f, kibar y, cosar a, yalcyn o. fournier's gangrene: report of thirty-three cases and a review of the literature. int j urol. 2006;13(7):960-967. 53. vijaya kk, nishteswar k. wound healing activity of honey: a pilot study. ayu. 2012;33(3):374-377. 54. gethin g, cowman s. case series of use of manuka honey in leg ulceration. int wound j. 2005;2(1):10-15. 55. zerm r. topical honey for diabetic foot ulcers. dtsch arztebl int. 2013;110(21):373. 56. jull ab, cullum n, dumville jc, westby mj, deshpande s, walker n. honey as a topical treatment for wounds. cochrane database syst rev. 2015;3:cd005083. 57. al-jawad fh, sahib as, al-kaisy aa. role of antioxidants in the treatment of burn lesions. ann burns fire disasters. 2008;21(4):186-191. 58. henriques a, jackson s, cooper r, burton n. free radical production and quenching in honeys with wound healing potential. j antimicrob chemother. 2006;58(4):773-777. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcloone this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu 59. ansari mj, al-ghamdi a, usmani s, et al. effect of jujube honey on candida albicans growth and biofilm formation. arch med res. 2013;44(5):352-360. 60. brady nf, molan pc, harfoot cg. the sensitivity of dermatophytes to the antimicrobial activity of manuka honey and other honey. pharm pharmacol commun. 1996;2(10):471473. 61. wu q. antimicrobial effect of manuka honey and kanuka honey alone and in combination with the bioactives against the growth of propionibacterium acnes atcc 6919. new zealand, massey university; 2011. 62. ong py. recurrent mrsa skin infections in atopic dermatitis. j allergy clin immunol. in practice. 2014;2(4):396399. 63. al-waili ns. therapeutic and prophylactic effects of crude honey on chronic seborrheic dermatitis and dandruff. eur j med res. 2001;6(7):306-308. 64. al-waili ns. topical application of natural honey, beeswax and olive oil mixture for atopic dermatitis or psoriasis: partially controlled, single-blinded study. complement ther med. 2003;11(4):226-234. 65. al-waili ns. an alternative treatment for pityriasis versicolor, tinea cruris, tinea corporis and tinea faciei with topical application of honey, olive oil and beeswax mixture: an open pilot study. complement ther med. 2004;12(1):45-47. 66. al-waili ns. clinical and mycological benefits of topical application of honey, olive oil and beeswax in diaper dermatitis. clin microbiol infect. 2005;11(2):160-163. 67. al-waili ns. topical honey application vs. acyclovir for the treatment of recurrent herpes simplex lesions. med sci monit. 2004;10(8):mt94-98. 68. ngatu nr, saruta t, hirota r, et al. antifungal efficacy of brazilian green propolis extracts and honey on tinea capitis and tinea versicolor. eur j integr med. 2011;3(4):e281-e287. 69. braithwaite i, hunt a, riley j, et al. randomised controlled trial of topical kanuka honey for the treatment of rosacea. bmj open. 2015;5(6):e007651. 70. semprini a, braithwaite i, corin a, et al. randomised controlled trial of topical kanuka honey for the treatment of acne. bmj open. 2016;6(2):e009448. 71. fingleton j, helm c, tofield c, weatherall m, beasley r. a randomised controlled trial of topical kanuka honey for the treatment of eczema. jrsm open. 2014;5(1):2042533313509263. 72. fingleton j, sheahan d, corin a, weatherall m, beasley r. a randomised controlled trial of topical kanuka honey for the treatment of psoriasis. jrsm open. 2014;5(3):2042533313518913. 73. fingleton j, corin a, sheahan d, et al. randomised controlled trial of topical kanuka honey for the treatment of cold sores. adv integr med. 2014;1(3):119-123. 74. naidoo nm, p. littler, r. mok, g. jameson, m. round, g. a phase ii randomized controlled trial of manuka honey as prophylaxis against radiation induced dermatitis in breast cancer patients. eur j cancer. 2011;47(supplement 1):s367. 75. nilforoushzadeh ma, jaffary f, moradi s, derakhshan r, haftbaradaran e. effect of topical honey application along with intralesional injection of glucantime in the treatment of cutaneous leishmaniasis. bmc complement altern med. 2007;7:13. 76. fernandez-cabezudo mj, el-kharrag r, torab f, et al. intravenous administration of manuka honey inhibits tumor growth and improves host survival when used in combination with chemotherapy in a melanoma mouse model. plos one. 2013;8(2):e55993. 77. pichichero e, cicconi r, mattei m, muzi mg, canini a. acacia honey and chrysin reduce proliferation of melanoma cells through alterations in cell cycle progression. int j oncol. 2010;37(4):973-981. 78. ahmad i, jimenez h, yaacob ns, yusuf n. tualang honey protects keratinocytes from ultraviolet radiation-induced inflammation and dna damage. photochem photobiol. 2012;88(5):1198-1204. 79. pichichero e, cicconi r, mattei m, canini a. chrysininduced apoptosis is mediated through p38 and bax activation in b16-f1 and a375 melanoma cells. int j oncol. 2011;38(2):473-483. 80. placzek wj, wei j, kitada s, zhai d, reed jc, pellecchia m. a survey of the anti-apoptotic bcl-2 subfamily expression in cancer types provides a platform to predict the efficacy of bcl-2 antagonists in cancer therapy. cell death dis. 2010;1:e40. 81. jiang x, shapiro dj. the immune system and inflammation in breast cancer. mol cell endocrinol. 2014;382(1):673-682. 82. erdei e, torres sm. a new understanding in the epidemiology of melanoma. expert rev anticancer ther. 2010;10(11):1811-1823. 83. who. antimicrobial resistance: global report on surveillance.: world health organisation;2014. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu 84. baizhumanova a, sakamoto j. cancer in kazakhstan: present situation on cancer. annals of cancer research and therapy. 2010;18(2):65-68. 85. iwata k, takamura n, nakashima m, et al. loss of heterozygosity on chromosome 9q22.3 in microdissected basal cell carcinomas around the semipalatinsk nuclear testing site, kazakhstan. hum pathol.;35(4):460-464. 86. benguedouar l, lahouel m, gangloff sc, et al. ethanolic extract of algerian propolis and galangin decreased murine melanoma tumour progression. anticancer agents med chem. 2016. 87. henshaw fr, bolton t, nube v, et al. topical application of the bee hive protectant propolis is well tolerated and improves human diabetic foot ulcer healing in a prospective feasibility study. j diabetes complications. 2014;28(6):850857. 88. nina n, quispe c, jimenez-aspee f, et al. antibacterial activity, antioxidant effect and chemical composition of propolis from the region del maule, central chile. molecules. 2015;20(10):18144-18167. 89. akhmetova a st, kulsharova g, nurgozhin t, mikhalovsky s. current state of chronic wound care in kazakhstan: focus on topical treatments. russian open medical journal. 2015;4(1). 90. kuncic mk, jaklic d, lapanje a, gunde-cimerman n. antibacterial and antimycotic activities of slovenian honeys. br j biomed sci. 2012;69(4):154-158. 91. shahzad a, cohrs rj. in vitro antiviral activity of honey against varicella zoster virus (vzv): a translational medicine study for potential remedy for shingles. transl biomed. 2012;3(2). 92. canonico b, candiracci m, citterio b, et al. honey flavonoids inhibit candida albicans morphogenesis by affecting dna behavior and mitochondrial function. future microbiol. 2014;9(4):445-456. 93. jenkins r, burton n, cooper r. proteomic and genomic analysis of methicillin-resistant staphylococcus aureus (mrsa) exposed to manuka honey in vitro demonstrated downregulation of virulence markers. j antimicrob chemother. 2014;69(3):603-615. 94. lee jh, park jh, kim ja, et al. low concentrations of honey reduce biofilm formation, quorum sensing, and virulence in escherichia coli o157:h7. biofouling. 2011;27(10):10951104. 95. gannabathula s, skinner ma, rosendale d, et al. arabinogalactan proteins contribute to the immunostimulatory properties of new zealand honeys. immunopharmacol immunotoxicol. 2012;34(4):598-607. 96. raynaud a, ghezali l, gloaguen v, liagre b, quero f, petit jm. honey-induced macrophage stimulation: ap-1 and nfkappab activation and cytokine production are unrelated to lps content of honey. int immunopharmacol. 2013;17(3):874-879. 97. timm m, bartelt s, hansen ew. immunomodulatory effects of honey cannot be distinguished from endotoxin. cytokine. 2008;42(1):113-120. 98. tonks a, cooper ra, price aj, molan pc, jones kp. stimulation of tnf-alpha release in monocytes by honey. cytokine. 2001;14(4):240-242. 99. tonks aj, dudley e, porter ng, et al. a 5.8-kda component of manuka honey stimulates immune cells via tlr4. j leukoc biol. 2007;82(5):1147-1155. 100. tomblin v, ferguson lr, han dy, murray p, schlothauer r. potential pathway of anti-inflammatory effect by new zealand honeys. int j gen med. 2014;7:149-158. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcloone this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu table 1: honey as a therapeutic agent for skin disorders; summary of the key in vitro findings key references key findings (in vitro) 14-17,59-61,90,91 honeys from around the world have potent antimicrobial activity against skin relevant microbes. 22 honey can reverse antimicrobial resistance. 21,92-94 pathogenicity of skin relevant microbes is reduced by honey. 23-25,95-99 honey modulates cytokine production by cells of the skin immune system. 26,27,58,100 anti-inflammatory effects of honey are observed in vitro. 28-30 honey promotes re-epithelialisation and angiogenesis in in vitro wound models. 76-78 honey induces apoptosis of a murine melanoma cell line and protects keratinocytes from the photocarcinogenic effects of uvb radiation. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu table 2: honey as a therapeutic agent for skin disorders; summary of the key in vivo findings key references key findings (in vivo) 56 clinical studies suggest that topical application of honey is more efficacious than conventional treatments in healing partial thickness burn wounds. 34,36-38,43,45,46,53 the efficacy of honey in the treatment of non-burn acute wounds and chronic wounds is controversial. 63-66,68,69 limited human studies suggest that honey is therapeutic in the treatment of some inflammatory skin disorders and fungal skin infections. 76 honey reduces tumour growth in a murine melanoma model. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx mcloone this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu table 3: studies investigating the efficacy of honey in the treatment of skin disorders (excluding wounds) population honey application outcome ref. 37 patients; 14 with pityriasis versicolor, 8 with tinea corporis, 14 with tinea cruris and 1 with tinea faciei honey mixture containing honey, olive oil and beeswax (1:1:1) applied to the lesions 3 times daily for a maximum of 4 weeks. honey was multi-floral from the united arab emirates. complete cure obtained in 79% of patients with pityriasis versicolor; 71% of patients with tinea cruris and 62% of patients with tinea corporis. patient with tinea faciei obtained clinical cure 3 weeks after start of therapy. 65 242 congolese school children with either tinea capitis or pityriasis versicolor treated with either 2% miconazole, brazilian green propolis extract or acasia honey (yamada bee farm, japan) or vaseline. acasia honey (p < 0.05), brazilian green propolis extract (p < 0.05) and 2% miconazole (p < 0.01) significantly improved erythema, desquamation and pruritis in tinea patients in comparison to vaseline. 68 10 patients with atopic dermatitis lesions on the right side of the body treated with vaseline. lesions on the left side of the body treated with a multifloral honey mixture, containing honey beeswax and olive oil in a ratio of 1:1:1 for 2 weeks. each treatment was applied three times daily. honey was from the united arab emirates. significant improvement was seen in lesion scores on the left side of the body in 8 out of the 10 patients. 64 8 patients with psoriasis lesions on the right side of the body were treated with paraffin and lesions on the left were treated with honey mixture (as described above), 3 times daily for 3 weeks. significant improvement was seen in lesion scores on the left side of the body in 5 out of 8 patients. 64 12 infants with diaper dermatitis topical application 4 times daily with a multifloral honey mixture containing honey, beeswax and olive oil in a ratio of 1:1:1 for 7 days. mean total rash score at baseline was 2.91 ± 0.79. decreased to 0.66 ± 0.98 at day 7. at the end of the study 10 of the 12 infants had either mild or no diaper dermatitis. 66 81 patients undergoing radiation therapy for breast cancer prophylatic treatment: 43 treated with a pure sterilized manuka honey umf=18. thirty eight patients treated with standard aqueous cream. topical treatments were applied twice daily starting on day 1 of radiation and continued until 10 days post treatment. lower incidence of > grade 2 dermatitis in the patients treated with honey (37.2%) compared with those treated with aqueous cream (57.8%). when ≥ grade 2 dermatitis did occur duration was shorter in honey treated group. p = 0.08 74 138 patients with rosacea (iga-rss) ≥ 2.69 69 patients treated with topical application of honevo (90% kanuka honey and 10% glycerine) for 8 weeks. 69 patients treated with the control cream cetomacrogol. 34.3 % in the honevo group and 17.4% in the control group had a ≥ 2 improvement in the iga-rss at week 8. p = 0.02 69 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.241 | http://cajgh.pitt.edu 136 patients aged 1640 years with acne iga ≥ 2.68 68 participants applied protex, a trilocarbon based antibacterial soap twice daily for 12 weeks. another 68 participants followed the antibacterial soap treatment regime and applied honevo (90% kanuka honey and 10% glycerine) directly after washing off the anti-bacterial soap, twice daily for 12 weeks. 4/53 (7.6%) of participants in the honey group and 1/53 (1.9%) in the control group had a ≥ 2 improvement in iga score at week 12. trial did not show evidence that adding honevo to the antibacterial soap regime was more effective than soap alone. 70 15 patients with bilateral eczematous lesions on the limbs medical grade kanuka honey was applied to a representative lesion on one side and aqueous cream bp on the other, every night for 2 weeks. kanuka honey was not more efficacious than aqueous cream bp in the treatment of eczema. aqueous cream bp is not a recommended treatment for eczema. 71 15 patients with psoriasis with bilateral lesions on the limbs. medical grade kanuka honey was applied to a representative lesion on one side and aqueous cream bp on the other, every night for 2 weeks. efficacy was similar to that of the aqueous cream which is a recommended treatment for psoriasis. 72 15 participants aged 16 or over with recurrent herpes simplex labialis participants applied either medical grade kanuka honey or acyclovir to the lesion 5 times per day until the lesion resolved. kaplan-meier estimates of median healing time were similar for honey and acyclovir. 73 90 patients with cutaneous leishmaniasis 45 patients treated with topical honey twice daily along with intra-lesional injection of glucantime once weekly for a maximum of 6 weeks. 45 patients treated with glucantime only. more patients had complete cure in the glucantime only treated group (71%) than in the glucantime and honey treated group (51%). p = 0.04 75 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. covid-19: an international public health concern israel oluwasegun ayenigbara1 1department of health education, school and community health unit, university of ibadan, ibadan, nigeria vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.466 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ ayenigbara this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.466|http://cajgh.pitt.edu abstract this review presents a synopsis on the current covid-19 pandemic, with focus on preventive measures. covid-19 is a new viral infection, and is in form of a positive-sense, single-stranded rna coronavirus which belongs to an expanded group of viruses which were identified six decades ago. importantly, the new covid-19 belongs to the group of sars-cov, and it originated in bats but infected humans through smuggled pangolins. at first, the mode of transmission of infection was animal-to-person, but person-to-person and community transmission of the virus has been confirmed in many parts of the world. with an incubation period of between two-fourteen days, signs and symptoms of infection are mild to high respiratory illness; characterized with cough, breathing problems (shortness of breath), high temperature (fever), tiredness (fatigue) and nausea. presently, no vaccines or specific treatment is available for covid-19, in light of the aforementioned; prevention is the only substantial and less expensive option. with the envisaged explosive community transmission of covid-19 in the coming weeks in places with limited daily testing, especially in african countries, it is recommended among many that social distancing which includes avoiding any form of contact with people; either through greetings, hugging or shaking of hands and large gatherings, avoid contact with animal items, dead or alive animals, sick and dead people from areas experiencing covid-19 epidemic, and basic hygienic practices like thorough washing of hands with clean water and antiseptic soap for the duration of at least twenty seconds should be practiced always. however, in the absence of the aforementioned, an alcohol-based hand gel should be used on the hands frequently. furthermore, health care workers should adhere strictly to the standard preventive measures in areas of heightened covid-19 epidemic. keywords: covid-19 infection; reservoir of infection; mode of transmission; signs and symptoms; preventive measures covid-19: an international public health concern israel oluwasegun ayenigbara1 1department of health education, school and community health unit, university of ibadan, ibadan, nigeria research introductions a recently discovered coronavirus named officially as “covid-19” is currently spreading at a fast rate in china, and numerous cases of the new infection has now been confirmed in many countries as well. with the continuous upsurge in the number of laboratory confirmed cases and mortality, scientists, physicians and health care workers around the world are working assiduously to know more about the epidemiology of the new virus, so as to enable appropriate measures to be put in place to forestall and limit its rapid spread [1, 2]. generally, coronaviruses belongs to an expanded family of viruses which were identified exactly six (6) decades ago [2]. the first sets of viruses which belong to the coronaviruses family were indentified in chicken (infectious bronchitis virus) and in humans, namely human coronavirus 229e and human coronavirus oc43; symptoms manifest as common cold [3]. over the years, numerous members of the coronaviruses family were discovered, they are sars-cov (2003), hcov nl63 (2004), hku1 (2005), mers-cov (2012), and the current covid-19 pandemic which was discovered at the end of 2019; majority of these viruses had resulted in the severe infections of the respiratory system, and some http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.466|http://cajgh.pitt.edu causes sickness in people [3, 4]. in addition, many other coronaviruses affect animals like cats, bats and camels [4]. importantly, many individuals are infected with coronaviruses during their lifetime, but signs and symptoms are usually not severe, although, mild pneumonia can result in some cases [2]. the novel covid-19 pandemic is a positivesense, single-stranded rna coronavirus [5, 6, 7]. the world health organization (who) was alerted of the first suspected cases of the infection in late 2019 (31st december 2019), which was just over three weeks after the manifestation of signs and symptoms in the suspected cases [8, 9]. more findings of the new covid-19 infection revealed that the novel virus was genomically identified in a sample from a person with pneumonia in wuhan province, china [10]. although, this current covid-19 pandemic is unprecedented, and scientist, researchers and health workers around the world are still getting to know more about its epidemiology in entirety. with the increase in the number of confirmed cases and deaths been reported every day in the world, the current situation is now a pandemic. hence, this review paper gives a synopsis of the current covid-19 pandemic under its probable reservoir species, mode of transmission, signs and symptoms, current situation around the world, africa and nigeria, and importantly, preventive measures to be adopted to forestall the spread of the pandemic. sources of information this is a review research on covid-19 pandemic, and discussion were outlined under probable reservoir species, mode of transmission, signs and symptoms, current situation around the world, the african continent and nigeria, and importantly and preventive measures were provided. sources of materials for the review were gotten from the various international and national health authorities such as the world health organization and the us centers for disease control and prevention publications. furthermore, major scientific documents included in this review were also gotten from pubmed databases. reservoir species the new covid-19 belongs to the group of sars-cov. in 2015 and 2017, two genome sequences from rhinolophus sinicus with a resemblance of 80% had been published; the third unpublished virus genome from rhinolophus affinis with a resemblance of 96% to the current covid-19 pandemic was mentioned in an article from the wuhan institute of virology [11, 12]. for comparison, this sequence of mutation is the same to the ones seen over a decade ago in the h3n2 human flu epidemic [11, 13]. furthermore, pairwise protein sequence analysis of seven conserved non-structural proteins domains proves that covid-19 belongs to the species of sarsr-cov. in addition, the virus causing the current covid-19 pandemic was isolated from the bronchoalveolar lavage fluid of a critically ill patient; the virus uses the same cell entry receptor-angiotensin converting enzyme ii (ace2) as that of sars-cov [14, 15, 16]. animals sold as human food consumption are the first source of transmission of the current covid-19 outbreak due to the fact that majority of the first sets of human causalities noted and confirmed infected cases were workers at the huanan animal market in wuhan province, before exposure to larger contacts of humans and animals [17]. mode of transmission the first sets of patients from the covid-19 outbreak in wuhan province, china were workers or buyers at the main animal market in the province, indicating transmission through animal-to-human [6, 18]. importantly, there has been an upsurge in the number of sick individuals from the covid-19 who have not had exposure or contact to the wuhan main animal markets http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx ayenigbara this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.466|http://cajgh.pitt.edu whatsoever, this indicates that human-to-human and community transmission of covid-19 is happening [6, 19, 20, 21]. specifically, person-to-person spread of the covid-19 outbreak was affirmed on 20th january 2020 in guangdong, china, by the chinese authority [22]. it is now known how the human-to-human transmission of the current covid-19 pandemic occurred, for instance, when person-to-person transmission occurred with middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars) infections happened, it occurred through respiratory droplets from sick patient’s, and infected coughs or sneezes from sick patients, the same way many respiratory pathogens circulates to humans, and the human-to-human transmission generally occurred between close contacts [6]. importantly, human-to-human transmission of viruses varies, some viruses have high virulence and are highly contagious, while other viruses are less so [6]. the person-to-person spread of the current covid-19 pandemic is primarily spread between people via respiratory droplets from coughs and sneezes [23, 24]. as of 29th february 2020, community transmission of covid-19 pandemic has been confirmed in china, germany, hong kong, iran, italy, spain, france, japan, singapore, south korea and the united states of america [25, 26]. furthermore, there is a possibility that the current covid-19 pandemic might be spread through fecal oral route of transmission as a healthy six-monthold baby with covid-19 had persistently positive nasopharyngeal swabs to day sixteen (16) of admission [27]. firstly, this scenario pinpoints the task in establishing the exact incidence of covid-19 transmission as asymptomatic individuals can excrete the virus which can pose a major threats in areas where there are not good drinking water supply, e.g. in the developing countries. secondly, these set of individuals can be the causative link to some undetected transmission of the virus in the community [27]. signs and symptoms the time for the manifestation of signs and symptoms of covid-19 is between two to fourteen days, as this was the time range the signs and symptoms began to appear after an exposure to mers virus [28]. although, some studies caution that the average incubation period of covid-19 is between six and half days, and ranges from zero to twenty-four days, and the basic reproductive number (r0) of the pandemic is between 2 to 3.5 at the early phase regardless of different prediction models, which presently in comparison, is more than sars and mers [29]. specifically, individuals with confirmed cases of covid-19 have signs and symptoms of low to high respiratory illness; characterized with cough, breathing problems (shortness of breath), high temperature (fever), tiredness (fatigue) and nausea [17, 30, 31, 32]. furthermore, chronic inflammation of the lung (pneumonia), malfunctioning of the kidney (kidney failure) and death have also appeared in patients with severe cases of covid-19 [33, 34, 35, 36]. importantly, in hospitalized individuals, specific vital signs parameters such as body temperature, blood pressure, pulse (heart rate) and breathing rate (respiratory rate) were stable during admission, but infected patients had an abnormally low count of leukocytes (leucopenia) and abnormally reduced number lymphocytes in their blood (lymphopenia) [17, 37]. also, few numbers of individuals with covid-19 experienced serious signs and symptoms, and majority of hospitalized patients have one or two fundamental health conditions such as diabetes, cardiovascular diseases and hypertension [38] (table 1). current situation of covid-19 infection in the world, africa, and nigeria the who was notified of numerous cases of pneumonia on 31st december 2019, specifically in wuhan, hubei province of china [41]. after preliminary investigation, the virus did not match any existing viruses, and this heightened concerns among scientists because the route of transmission was not known since it http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.466|http://cajgh.pitt.edu is a new virus [41]. on 7th january, approximately a week later, the chinese government confirmed they had identified the new virus, and it is a coronavirus which belongs to the group of viruses that include the common cold, and viruses such as sars and mers [41]. with the evolving nature of this current pandemic, and the frequent changes in statistics and figures, as at 29th march 2020, there have been 697,994 confirmed cases of covid-19 from 202 countries and territories and one conveyance ship, and 33,421 deaths recorded, with majority of the world’s population on lockdown to avert the further spread of the infection [42]. explicitly, the western pacific region (nineteen countries and territories affected) has a total number of 104,146 confirmed cases, with 3,660 deaths; the european region (sixty countries and territories affected) has a total number of 397,719 confirmed cases, with 24,246 deaths, the south-east asia region (ten countries affected) has a total number of 4,333 confirmed cases, with 164 deaths, the eastern mediterranean region (twenty-one countries and territories affected) has total number of 46,623 confirmed cases, with 2,828 deaths, the region of the americas (fifty-one countries and territories affected) has a total number of 141,282 confirmed cases, with 2,461 deaths, the african region (forty-one countries and territories affected) has a total number of 3,179 confirmed cases, with 55 deaths, while the conveyance diamond princess ship has a total number of 712 confirmed cases, with 7 deaths [42]. presently, the european region with sixty countries and territories affected with a total number of 397,719 confirmed cases and 24,246 deaths have now overtaken the western pacific region which included china as the current epicenter of the current covid-19 pandemic [42]. the african region with forty-one countries and territories affected has the lowest number of confirmed cases and deaths with 3,179 and 55 respectively. however, massive sensitization and heightened preventive measures which includes rigorous contact tracing and wider testing should be intensified so as to prevent against explosive community transmission and mortalities of covid-19 due to the weak health care system in the african continent [42]. initially, the majority of confirmed cases of covid-19 has been in china where the outbreak started, however, massive covid-19 cases and mortalities have occurred in other countries as well, for instance in the united states of america, italy, iran, france, britain, france and spain [43, 44]. the exact number of individuals who have contracted the virus could be far higher as people with mild symptoms are not been detected due to shortages in test kits, especially in developing countries [44]. the covid-19 pandemic spread to the africa continent on 14th february 2020, with egypt recording the first confirmed case of the virus on the continent, while the first recorded case in the sub-saharan africa was in nigeria; both cases were imported transmission [45, 46, 47]. afterwards, subsequent cases of covid-19 have come from imported cases from europe and the united states rather than from china; the country where the infection broke out [48]. presently, according to the who classification of regions, forty-one africa countries and territories have reported a total number of 3,179 confirmed cases and 55 deaths from covid-19 pandemic, these figures are expected to rise in the coming weeks [42]. also, confirmed cases of infection and deaths from covid-19 pandemic have been reported in some african countries (egypt, morocco, tunisia, sudan, libya and somalia) which are classified in the eastern mediterranean region by the who [42]. as at 28th march 2020, botswana, burundi, comoros, lesotho, malawi, são tomé and príncipe, sierra leone, and south sudan remains the only african countries who have yet to report any cases of covid-19. importantly, numerous preventive measures have been implemented to abate the spread of covid-19 in different countries in africa, these include travel restrictions, school closures, border closures, flights and event cancellations [49, 50]. although, explosive community transmission of the infection is predicted in the african continent due to limited testing and inadequate contact tracing, however, the experience gathered during the ebola and lassa fever http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx ayenigbara this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.466|http://cajgh.pitt.edu epidemics could help in the continents battle to contain the covid-19 pandemic [49]. in nigeria, with the rapid changes in infection statistics, a total of 111 confirmed cases and a single death have been recorded, with three patients discharged after treatment from covid-19 as at 29th of march 2020, and confirmed cases have mild to moderate signs and symptoms that are currently receiving care [51]. in all, lagos state has the highest number of confirmed cases in nigeria with sixty-eight patients, followed by abuja, oyo, ogun, enugu, bauchi, osun, edo, benue, ekiti, kaduna and rivers with combined confirmed cases of forty-three [51]. unfortunately, limited covid-19 tests are been done in nigeria due to shortages of test kits, hence, the number of infection cases due to community transmission is predicted to increase sharply in the coming weeks. although, as precautionary measures to avert the rate of infection, the president ordered the cessation of all none essential movements in lagos and the capital abuja; the two cities with the highest number of confirmed cases for an upward reviewable duration of fourteen days which starts on monday, 30th march 2020 [52]. importantly, several countries in the world have also put up various preventive measures to curtail the spread of covid-19, some of which are travel bans to and from the countries that are massively affected, compulsory quarantine, lockdown of cities, restricted access to some specific places, compulsory checking at borders, airports and railway terminals, and presently, the chinese authorities have stopped and banned wildlife trade nationwide, at least until the current pandemic has ended, as this was believed to be the source of the current covid-19 pandemic and the sars epidemic almost twenty years ago [44]. prevention of covid-19 infection presently, no vaccines or specific treatment is available for covid-19, but there are ongoing studies on preventive vaccines, and some drugs are currently been used for the treatment of this current pandemic [53, 54, 55, 56, 57, 58, 59]. in light of the aforementioned, prevention is the only substantial option against covid19. firstly, if traveling to locations where there are confirmed cases of covid-19 outbreak, it is pertinent to avoid any form of contact either through greetings, hugging, kissing or shaking of hands. also, contact with sick people, items that come from animals such as uncooked meat should be ultimately avoided [2, 60]. furthermore, basic hygienic practices like thorough washing of hands with clean water and antiseptic soap for the duration of twenty seconds should be practiced always. however, in the absence of the aforementioned, an alcohol-based hand gel should be used on the hands frequently [60]. as recommended by the cdc and who; contact with unwashed hands should be avoided on the nose, mouth, eyes and the ears. furthermore, reduce and minimize close contact with people, especially sick individuals, self isolation when sick, fourteen days compulsory quarantine after returning from locations that have recorded cases of the covid-19, cough and sneeze on a tissue paper, afterwards dispose the tissue paper in a waste bin, clean and disinfect frequently touched objects and surfaces; all these are imperative preventive measures to be adopted in the prevention of the current covid-19 [42, 61]. for health workers, infection control training should be to all clinical staff, installation and provision of protective shields, frequent disinfection of equipment, and provision of eye protective equipment should be provided to all medical staff treating covid-19 patients [62]. also, as precautionary, medical workers should measure their own body temperatures before and after work, and promptly report any symptoms of upper respiratory tract infection, vomiting or diarrhea [62]. furthermore, universal masking, hand hygiene, and appropriate use of personal protective equipment (ppe) should be well implemented by medical workers [63]. in addition, medical staff should be extremely careful with blood samples collected for diagnosis, as there is still a risk of transmission of covid-19 virus through the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.466|http://cajgh.pitt.edu transfusion of labile blood products, as more and more asymptomatic infections are being found among the current covid-19 cases [63]. also, to promptly identify patients and prevent further spreading of infection, physicians should be aware of the travel or contact history of patients with compatible covid-19 signs and symptoms [64]. conclusions covid-19 belongs to the group of sars-cov, and it originated from bats, but infected humans through smuggled pangolins. at first, the mode of transmission of the current pandemic was animal-to-person, but personto-person and community transmission of the covid-19 has been confirmed in many parts of the world. with the continuous rise in the number of confirmed cases and mortality rates across all countries and regions in the world, category of people with the highest causalities are older people, especially those with underlying medical conditions; hence, preventive measures should be focused more on this vulnerable group. from this review, it was concluded that the covid-19 is indeed an international public health concern due to the vast majority of countries that have reported confirmed cases of infection and deaths. however, even without the present breakthrough in the urgent search for specific treatment and vaccines, the spread of the current covid19 pandemic can be reduced and ultimately stopped with strict adherence and compliance to basic infection preventive measures that have been provided in this review. furthermore, rigorous contact tracing should be implemented in african countries and in countries where limited testing has been carried as a result of shortages in test materials and equipment to prevent against the envisaged explosive community transmission of covid-19. recommendations based on the findings of this review, the following recommendations are further made; 1. avoid unnecessary travel at this time, especially to areas with confirmed cases of covid-19 outbreak. 2. place self on compulsory fourteen days quarantine and isolation when returning from locations with the confirmed cases of covid19 even if there is manifestation of any signs and symptoms or not. 3. strict testing as border points, airports and terminals should be enforced to prevent against imported cases of the covid-19. 4. rigorous contact tracing should be done to identify people who might have had contact with patients who are infected with covid-19 to further prevent against the community transmission of the virus. 5. with the high numbers of causalities as a result of covid-19 among older people, large gatherings of people, especially the elderly should be banned for now. 6. although, there are few cases of the covid-19 in africa. nevertheless, health education and sensitization programmes on preventive measures should be heightened to enlighten the public due to the vulnerable health care system in the continent. countries experiencing increasing number of cases from the covid-19 should be open with their statistics, as this would help relevant health authorities to putting up appropriate preventive measures, hence helping to reducing further the number of infections. acknowledgements great thanks are given to unknown reviewers for valuable comments. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx ayenigbara this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.466|http://cajgh.pitt.edu references 1. sohrabi c, alsafi z, o'neill n, et al. world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19). int j surg. 2020; pii: s1743-9191(20)30197-7. 2. live science. new coronavirus from china: everything you need to know. 2020. https://www.livescience.com/new-chinacoronavirus-faq.html accessed march 27, 2020. 3. geller c, varbanov m, duval r. human coronaviruses: insights into environmental resistance and its influence on the development of new antiseptic strategies. viruses. 2012; 4 (11): 3044–3068. 4. centers for disease control and prevention. emergency preparedness and response. 2020. https://emergency.cdc.gov/han/han00426.asp accessed march 27, 2020. 5. world health organization. surveillance case definitions for human infection with novel coronavirus (ncov). 2020. https://www.who.int/publicationsdetail/surveillance-case-definitions-for-humaninfection-with-novel-coronavirus-(ncov) accessed march 27, 2020. 6. centers for disease control and prevention. novel coronavirus (2019-ncov): situation summary. 2020. https://www.cdc.gov/coronavirus/2019ncov/index.html?cdc_aa_refval=https%3a%2f %2fwww.cdc.gov%2fcoronavirus%2fnovelcoronavirus-2019.html accessed march 27, 2020. 7. gen bank. wuhan seafood market pneumonia virus isolate wuhan-hu-1, complete genome. 2020. https://www.ncbi.nlm.nih.gov/nuccore/mn908947 accessed march 27, 2020. 8. world health organization. pneumonia of unknown cause – china. 2020. https://www.who.int/csr/don/05-january-2020pneumonia-of-unkown-cause-china/en/ accessed march 27, 2020. 9. center for infectious disease research and policy. report: thailand's coronavirus patient didn't visit outbreak market. 2020. http://www.cidrap.umn.edu/newsperspective/2020/01/report-thailands-coronaviruspatient-didnt-visit-outbreak-market accessed march 27, 2020. 10. xinhua. new-type coronavirus causes pneumonia in wuhan: expert. 2020. http://www.xinhuanet.com/english/202001/09/c_138690570.htm accessed march 27, 2020. 11. domenico b, marta g, alessandra c, silvia s, silvia a, massimo c. the 2019-new coronavirus epidemic: evidence for virus evolution. 2020. https://www.biorxiv.org/content/10.1101/2020.01.2 4.915157v1 accessed march 27, 2020. 12. wuhan institute of virology. discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin. 2020. https://www.biorxiv.org/content/10.1101/2020.01.2 2.914952v2 accessed march 27, 2020. 13. zhou p, yang x, wang x, et al. (2020). a pneumonia outbreak associated with a new coronavirus of probable bat origin. nature. 2020. 14. lu r, zhao x, li j, et al. genomic characterization and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. lancet. 2020; 395(10224):565-574. 15. chan j, kok k, zhu z, et al. genomic characterization of the 2019 novel humanpathogenic coronavirus isolated from a patient with atypical pneumonia after visiting wuhan. emerg microbes infect. 2020; 9(1):221-236. 16. jiang s, shi z. the first disease x is caused by a highly transmissible acute respiratory syndrome coronavirus. virol sin. 2020. 17. lin q, zhao s, gao d, et al. a conceptual model for the outbreak of coronavirus disease 2019 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://emergency.cdc.gov/han/han00426.asp https://www.who.int/publications-detail/surveillance-case-definitions-for-human-infection-with-novel-coronavirus-(ncov) https://www.who.int/publications-detail/surveillance-case-definitions-for-human-infection-with-novel-coronavirus-(ncov) https://www.who.int/publications-detail/surveillance-case-definitions-for-human-infection-with-novel-coronavirus-(ncov) https://www.cdc.gov/coronavirus/2019-ncov/index.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2fnovel-coronavirus-2019.html https://www.cdc.gov/coronavirus/2019-ncov/index.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2fnovel-coronavirus-2019.html https://www.cdc.gov/coronavirus/2019-ncov/index.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2fnovel-coronavirus-2019.html https://www.cdc.gov/coronavirus/2019-ncov/index.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2fnovel-coronavirus-2019.html https://www.ncbi.nlm.nih.gov/nuccore/mn908947 https://www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/ https://www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/ http://www.cidrap.umn.edu/news-perspective/2020/01/report-thailands-coronavirus-patient-didnt-visit-outbreak-market http://www.cidrap.umn.edu/news-perspective/2020/01/report-thailands-coronavirus-patient-didnt-visit-outbreak-market http://www.cidrap.umn.edu/news-perspective/2020/01/report-thailands-coronavirus-patient-didnt-visit-outbreak-market http://www.xinhuanet.com/english/2020-01/09/c_138690570.htm http://www.xinhuanet.com/english/2020-01/09/c_138690570.htm https://www.biorxiv.org/content/10.1101/2020.01.24.915157v1 https://www.biorxiv.org/content/10.1101/2020.01.24.915157v1 https://www.biorxiv.org/content/10.1101/2020.01.22.914952v2 https://www.biorxiv.org/content/10.1101/2020.01.22.914952v2 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.466|http://cajgh.pitt.edu (covid-19) in wuhan, china with individual reaction and governmental action. int j infect dis. 2020. pii: s1201-9712 (20) 30117-x. 18. jalava k. first respiratory transmitted food borne outbreak?. int j hyg environ health. 2020; 226:113490. 19. lai c, shih t, ko w, tang h, hsueh p. severe acute respiratory syndrome coronavirus 2 (sarscov-2) and coronavirus disease-2019 (covid19): the epidemic and the challenges. int j antimicrob agents. 2020: 105924. 20. liu j, liao x, qian s, et al. community transmission of severe acute respiratory syndrome coronavirus 2, shenzhen, china, 2020. emerg infect dis. 2020; 26(6). 21. wu w, li y, wei z, et al. [investigation and analysis on characteristics of a cluster of covid19 associated with exposure in a department store in tianjin]. zhonghua liu xing bing xue za zhi. 2020; 41(4):489-493. 22. canadian broadcasting corporation. china confirms human-to-human transmission of new coronavirus. 2020. https://www.cbc.ca/news/health/coronavirushuman-to-human-1.5433187 accessed march 27, 2020. 23. burke r, midgley c, dratch a, et al. active monitoring of persons exposed to patients with confirmed covid-19 united states, januaryfebruary 2020. mmwr morb mortal wkly rep. 2020; 69(9):245-246. 24. wu y, chen c, chan y. the outbreak of covid19: an overview. j chin med assoc. 2020; 83(3):217-220. 25. european centre for disease prevention and control. presumed ongoing community transmission. 2020. https://web.archive.org/web/20200219092151/https ://www.ecdc.europa.eu/en/areas-presumedongoing-community-transmission-2019-ncov accessed march 27, 2020. 26. ralph r, lew j, zeng t, et al. 2019-ncov (wuhan virus), a novel coronavirus: human-to-human transmission, travel-related cases, and vaccine readiness. j infect dev ctries. 2020; 14(1):3-17. 27. kam k, yung c, cui l, et al. a well infant with coronavirus disease 2019 (covid-19) with high viral load clin infect dis. 2020. pii: ciaa201. 28. centers for disease control and prevention. 2019 novel coronavirus, wuhan, china. symptoms & complications. 2020. https://www.cdc.gov/coronavirus/2019ncov/about/symptoms.html accessed march 27, 2020. 29. wang y, wang y, chen y, qin q. unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (covid-19) implicate special control measures. j med virol. 2020. 30. hui d, azhar e, madani t, et al. the continuing 2019-ncov epidemic threat of novel coronaviruses to global health – the latest 2019 novel coronavirus outbreak in wuhan, china. int j infect dis. 2020; 14 (91): 264–266. 31. tian s, hu n, lou j, et al. characteristics of covid-19 infection in beijing. j infect. 2020. pii: s0163-4453(20)30101-8. 32. corman v, lienau j, witzenrath m. [coronaviruses as the cause of respiratory infections]. internist (berl). 2019; 60(11):1136-1145. 33. wu j, liu j, zhao x, et al. clinical characteristics of imported cases of covid-19 in jiangsu province: a multicenter descriptive study. clin infect dis. 2020. pii: ciaa199. 34. zhao w, zhong z, xie x, yu q, liu j. relation between chest ct findings and clinical conditions of coronavirus disease (covid-19) pneumonia: a multicenter study. ajr am j roentgenol. 2020:1-6. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.cbc.ca/news/health/coronavirus-human-to-human-1.5433187 https://www.cbc.ca/news/health/coronavirus-human-to-human-1.5433187 https://web.archive.org/web/20200219092151/https:/www.ecdc.europa.eu/en/areas-presumed-ongoing-community-transmission-2019-ncov https://web.archive.org/web/20200219092151/https:/www.ecdc.europa.eu/en/areas-presumed-ongoing-community-transmission-2019-ncov https://web.archive.org/web/20200219092151/https:/www.ecdc.europa.eu/en/areas-presumed-ongoing-community-transmission-2019-ncov https://www.cdc.gov/coronavirus/2019-ncov/about/symptoms.html https://www.cdc.gov/coronavirus/2019-ncov/about/symptoms.html ayenigbara this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.466|http://cajgh.pitt.edu 35. ontario. wuhan novel coronavirus (2019-ncov). 2020. https://www.ontario.ca/page/wuhan-novelcoronavirus-2019-ncov#section-4 accessed march 27, 2020. 36. wuhan municipal health commission. experts explain the latest bulletin of unknown cause of viral pneumonia. 2020. http://wjw.wuhan.gov.cn/front/web/showdetail/202 0011109036 accessed march 27, 2020. 37. zhou s, wang y, zhu t, xia l. 2020. ct features of coronavirus disease 2019 (covid-19) pneumonia in 62 patients in wuhan, china. ajr am j roentgenol. 2020: 1-8. 38. world health organization. who directorgeneral's statement on the advice of the ihr emergency committee on novel coronavirus. 2020. https://www.who.int/dg/speeches/detail/whodirector-general-s-statement-on-the-advice-of-theihr-emergency-committee-on-novel-coronavirus accessed march 27, 2020. 39. chen n, zhou m, dong x, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet. 2020; 395 (10223): 507– 13. 40. huang c, wang y, li x, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 395 (10223): 497–506. 41. world health organization. novel coronavirus 2019. 2020. https://www.who.int/emergencies/diseases/novelcoronavirus-2019 accessed march 27, 2020. 42. world health organization. coronavirus disease 2019 (covid-19) situation report – 69. 2020. https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200329sitrep-69-covid-19.pdf?sfvrsn=8d6620fa_2 accessed march 29, 2020. 43. the guardian. coronavirus outbreak: what is the coronavirus and how worried should we be?. 2020. https://www.theguardian.com/science/2020/jan/26/ what-is-the-coronavirus-wuhan-china-virus-sarssymptoms accessed march 27, 2020. 44. reuters. who says new china coronavirus could spread, warns hospitals worldwide. 2020. https://www.reuters.com/article/us-china-healthpneumonia-who-iduskbn1zd16j accessed march 27, 2020. 45. british broadcasting cooperation. coronavirus: beijing orders 14-day quarantine for returnees. 2020. https://www.bbc.com/news/world-asia-china51509248 accessed march 30, 2020. 46. egypt today. egypt announces first coronavirus infection. 2020. https://www.egypttoday.com/article/1/81641/egyp t-announces-first-coronavirus-infection accessed march 30, 2020. 47. british broadcasting cooperation. coronavirus: nigeria confirms first case in sub-saharan africa. 2020. https://www.bbc.com/news/world-africa51671834 accessed march 30, 2020. 48. new york times. africa braces for coronavirus, but slowly. 2020. https://www.nytimes.com/2020/03/17/world/africa/ coronavirus-africa-burkina-faso.html accessed march 30, 2020. 49. cable news network. here are the african countries with confirmed coronavirus cases. 2020. https://www.cnn.com/2020/03/09/africa/nigeriacoronavirus-cases-intl/index.html accessed march 30, 2020. 50. bloomberg. un sees africa sliding into recession without debt help. 2020. https://www.bloomberg.com/news/articles/202003-24/un-sees-africa-sliding-into-recessionwithout-debt-service-help accessed march 30, 2020. 51. nigeria center for disease control covid-19 highlights. 2020. https://covid19.ncdc.gov.ng/ accessed march 30, 2020. 52. punch newspaper. covid-19: buhari exempts health care workers, journalists from 14-day sit-athttp://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.ontario.ca/page/wuhan-novel-coronavirus-2019-ncov#section-4 https://www.ontario.ca/page/wuhan-novel-coronavirus-2019-ncov#section-4 http://wjw.wuhan.gov.cn/front/web/showdetail/2020011109036 http://wjw.wuhan.gov.cn/front/web/showdetail/2020011109036 https://www.who.int/dg/speeches/detail/who-director-general-s-statement-on-the-advice-of-the-ihr-emergency-committee-on-novel-coronavirus https://www.who.int/dg/speeches/detail/who-director-general-s-statement-on-the-advice-of-the-ihr-emergency-committee-on-novel-coronavirus https://www.who.int/dg/speeches/detail/who-director-general-s-statement-on-the-advice-of-the-ihr-emergency-committee-on-novel-coronavirus https://www.who.int/emergencies/diseases/novel-coronavirus-2019 https://www.who.int/emergencies/diseases/novel-coronavirus-2019 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200329-sitrep-69-covid-19.pdf?sfvrsn=8d6620fa_2 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200329-sitrep-69-covid-19.pdf?sfvrsn=8d6620fa_2 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200329-sitrep-69-covid-19.pdf?sfvrsn=8d6620fa_2 https://www.theguardian.com/science/2020/jan/26/what-is-the-coronavirus-wuhan-china-virus-sars-symptoms https://www.theguardian.com/science/2020/jan/26/what-is-the-coronavirus-wuhan-china-virus-sars-symptoms https://www.theguardian.com/science/2020/jan/26/what-is-the-coronavirus-wuhan-china-virus-sars-symptoms https://www.reuters.com/article/us-china-health-pneumonia-who-iduskbn1zd16j https://www.reuters.com/article/us-china-health-pneumonia-who-iduskbn1zd16j https://www.bbc.com/news/world-asia-china-51509248 https://www.bbc.com/news/world-asia-china-51509248 https://www.egypttoday.com/article/1/81641/egypt-announces-first-coronavirus-infection https://www.egypttoday.com/article/1/81641/egypt-announces-first-coronavirus-infection https://www.bbc.com/news/world-africa-51671834 https://www.bbc.com/news/world-africa-51671834 https://www.nytimes.com/2020/03/17/world/africa/coronavirus-africa-burkina-faso.html https://www.nytimes.com/2020/03/17/world/africa/coronavirus-africa-burkina-faso.html https://www.cnn.com/2020/03/09/africa/nigeria-coronavirus-cases-intl/index.html https://www.cnn.com/2020/03/09/africa/nigeria-coronavirus-cases-intl/index.html https://www.bloomberg.com/news/articles/2020-03-24/un-sees-africa-sliding-into-recession-without-debt-service-help https://www.bloomberg.com/news/articles/2020-03-24/un-sees-africa-sliding-into-recession-without-debt-service-help https://www.bloomberg.com/news/articles/2020-03-24/un-sees-africa-sliding-into-recession-without-debt-service-help https://covid19.ncdc.gov.ng/ central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.466|http://cajgh.pitt.edu home order. 2020. https://healthwise.punchng.com/covid-19-buhariexempts-healthcare-workers-journalists-from-14day-sit-at-homeorder/?fbclid=iwar2vqfa5w_ovjtdmigz96crqn pr6ci7qcagy8maqr3vplgry-gkvrptcorm accessed march 30, 2020. 53. lu h. drug treatment options for the 2019-new coronavirus (2019-ncov). biosci trends. 2020. 54. li h, wang y, xu j, cao b. [potential antiviral therapeutics for 2019 novel coronavirus]. zhonghua jie he he hu xi za zhi. 2020; 43(0):e002. 55. morse j, lalonde t, xu s, liu w. learning from the past: possible urgent prevention and treatment options for severe acute respiratory infections caused by 2019-ncov. chembiochem. 2020; 21(5):730-738. 56. jin y, cai l, cheng z, et al. a rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-ncov) infected pneumonia (standard version). mil med res. 2020 feb; 7(1):4. 57. shen k, yang y, wang t, et al. diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts' consensus statement. world j pediatr. 2020. 58. gao j, tian z, yang x. break through: chloroquine phosphate has shown apparent efficacy in treatment of covid-19 associated pneumonia in clinical studies". bioscience trends. 2020. 59. reuters. who says new china coronavirus could spread, warns hospitals worldwide. 2020. https://www.reuters.com/article/us-china-healthpneumonia-who-iduskbn1zd16j accessed march 27, 2020. 60. centers for disease control and prevention. travelers' health: novel coronavirus in china. 2020. https://wwwnc.cdc.gov/travel/notices/watch/novelcoronavirus-china accessed march 27, 2020. 61. centers for disease control and prevention. 2019 novel coronavirus, wuhan, china: prevention. 2020. https://www.cdc.gov/coronavirus/2019ncov/about/prevention-treatment.html accessed march 27, 2020. 62. lai t, tang e, chau s, fung k, li k. stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from hong kong. graefes arch clin exp ophthalmol. 2020. 63. chang l, yan y, wang l. coronavirus disease 2019: coronaviruses and blood safety. transfus med rev. 2020. pii: s0887-7963(20)30014-6. 64. peeri n, shrestha n, rahman m, et al. the sars, mers and novel coronavirus (covid-19) epidemics, the newest and biggest global health threats: what lessons have we learned?. int j epidemiol. 2020. pii: dyaa033. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://healthwise.punchng.com/covid-19-buhari-exempts-healthcare-workers-journalists-from-14-day-sit-at-home-order/?fbclid=iwar2vqfa5w_ovjtdmigz96crqnpr6ci7qcagy8maqr3vplgry-gkvrptcorm https://healthwise.punchng.com/covid-19-buhari-exempts-healthcare-workers-journalists-from-14-day-sit-at-home-order/?fbclid=iwar2vqfa5w_ovjtdmigz96crqnpr6ci7qcagy8maqr3vplgry-gkvrptcorm https://healthwise.punchng.com/covid-19-buhari-exempts-healthcare-workers-journalists-from-14-day-sit-at-home-order/?fbclid=iwar2vqfa5w_ovjtdmigz96crqnpr6ci7qcagy8maqr3vplgry-gkvrptcorm https://healthwise.punchng.com/covid-19-buhari-exempts-healthcare-workers-journalists-from-14-day-sit-at-home-order/?fbclid=iwar2vqfa5w_ovjtdmigz96crqnpr6ci7qcagy8maqr3vplgry-gkvrptcorm https://healthwise.punchng.com/covid-19-buhari-exempts-healthcare-workers-journalists-from-14-day-sit-at-home-order/?fbclid=iwar2vqfa5w_ovjtdmigz96crqnpr6ci7qcagy8maqr3vplgry-gkvrptcorm https://www.reuters.com/article/us-china-health-pneumonia-who-iduskbn1zd16j https://www.reuters.com/article/us-china-health-pneumonia-who-iduskbn1zd16j https://wwwnc.cdc.gov/travel/notices/watch/novel-coronavirus-china https://wwwnc.cdc.gov/travel/notices/watch/novel-coronavirus-china https://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html https://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. dietary and lifestyle factors associated with dyspepsia among pre-clinical medical students in ajman, united arab emirates noorallah jaber1, marwa oudah1, amer kowatli1, jabir jibril1, inbisat baig1, elsheba mathew2, aji gopakumar3, jayakumary muttappallymyalil2 1gulf medical university, ajman, united arab emirates; 2department of community medicine, gulf medical university, ajman, united arab emirates; 3statistical support facility, gulf medical university, ajman, united arab emirates vol. 5, no. 1 (2016) | issn 2166-7403 (online) doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/4.0/ jaber this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu abstract introduction: dyspepsia is a common gastrointestinal diseases worldwide with a prevalence ranging from 7 to 40%. dyspepsia, more commonly known as heartburn or indigestion, is defined as one or more of the following symptoms: postprandial fullness, early satiation (the inability to finish a normal size meal), or epigastric pain or burning for at least 3 months in the past year. dyspepsia has been studied extensively, but little is known of factors associated with dyspepsia among medical students. objectives: the purpose of this study was to analyze the prevalence of dyspepsia and to evaluate the association between lifestyle and dietary factors associated with dyspepsia among pre-clinical medical students in ajman, united arab emirates. methods: a cross-sectional survey study was conducted among pre-clinical medical students at gulf medical university, ajman and collected basic demographic data, dyspepsia prevalence, dietary factors, and lifestyle factors. data was analyzed using microsoft excel and spss software. descriptive statistics were used to summarize the participant characteristics. chi-square tests were used to test the association between dietary and lifestyle factors and dyspepsia. logistic regression was used to measure the association of predictors (dietary and lifestyle factors) on the odds of having dyspepsia, independently. multinomial logistic regression was used to examine the full association of predictors on the odds of having dyspepsia. results: the resulting sample was 176 pre-clinical medical students, with a mean age of 20.67 ± 2.57 years. a total of 77 (43.8%) respondents reported having dyspepsia while 99 (56.2%) did not. there was a significant association between smoking and dyspepsia (p<0.05), as well as a marginally significant association between inadequate sleep and dyspepsia (p<0.10). there was no significant association with alcohol or analgesic use on dyspesia. dietary habits showed no association with dyspepsia. conclusion: dyspepsia was reported by 43.8% of the repondents. these findings emphasize the importance of improving lifestyle and dietary factors associated with dyspepsia and raising awareness of reducing risk factors associated with dyspepsia. further studies are needed on dyspepsia in a larger cohort of students in order to fully understand the complexity of this problem and be able to generalize the findings to other cohorts. keywords: dyspepsia, lifestyle factors, dietary factors, smoking, analgesic, alcohol, medical students dietary and lifestyle factors associated with dyspepsia among pre-clinical medical students in ajman, united arab emirates noorallah jaber1, marwa oudah1, amer kowatli1, jabir jibril1, inbisat baig1, elsheba mathew2, aji gopakumar3, jayakumary muttappallymyalil2 1gulf medical university, ajman, united arab emirates; 2department of community medicine, gulf medical university, ajman, united arab emirates; 3statistical support facility, gulf medical university, ajman, united arab emirates research dyspepsia is a term that is often used to characterize abdominal pain centered in the epigastrium and is often combined with other gastrointestinal disorders. historically, ‘dyspepsia’ originates from the greek ‘δυς-’ (dys-) and ‘πέψη’ (pepse), which means indigestion.1 in the mid-18th century, it was thought to http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu be one of the ‘nervous disorders,’ along with hypochondria and hysteria.2 the rome criteria was developed to classify the functional gastrointestinal disorders (fgids), disorders of the digestive system in which symptoms cannot be explained by the presence of structural or tissue abnormality, based on clinical symptoms. rome ii, defined dyspepsia as a pain or discomfort centered in the upper abdomen,3 specifically one or more of the following symptoms: postprandial fullness, early satiation (meaning inability to finish a normal size meal) epigastric pain or burning with at least a 3 month history in the last year.4 some disorders may cause dyspepsia, such as gastroesophageal reflux disease (gerd), peptic ulcer, lactose intolerance, cholecystitis, anxiety or depression, stomach cancer, and often as a side effect of alcohol or medication.5 one of the risk factors for dyspepsia is lifestyle habits (e.g. smoking, increased caffeine intake) and non-steroidal anti-inflammatory drug use (e.g. aspirin), which is more relevant to ulcer dyspepsia.6 a study conducted in columbia (n=937 students) on the prevalence of dyspepsia, concluded that around 40% of students had frequent dyspepsia.7 the annual incidence of dyspepsia was 9-10% and chronic dyspepsia was 15% with frequency of occurrence greater than 3 months in a year.8,9 certain studies defined dyspepsia as “upper abdominal pain” in which prevalence of uninvestigated dyspepsia ranges from 7% to 34.2%.10-15 a study examining gastrointestinal symptoms in a multiracial asian population reported that the prevalence of uninvestigated dyspepsia (a type of functional dyspepsia in which symptoms do not clearly fit standard definitions) is lowest in singapore at 7.9% and highest in new zealand with 34.2% of the population affected by the disease.14 dyspepsia prevalence was reported as 7-8% in south east asia,14 30.4% in india,15 14.5% in scandinavian countries,16 and 23.0-25.8% in the u.s.16 the studies that defined dyspepsia as “upper gastrointestinal symptoms” reported prevalence of dyspepsia 23-25% with lower prevalence reported in spain (23.9%).17 the prevalence rate of uninvestigated dyspepsia in us has been reported to be 32%, 38-41% reported in uk, and prevalence in nigeria estimated at 45%.18-23 dyspepsia has also been defined as pain centered in the upper abdomen and associated discomforts such as distention, belching, nausea or anorexia.24-26 a community-based study on the epidemiology of dyspepsia reported that 34.1% of respondents had dyspepsia within the past year.27 a study done in kuwaiti dyspeptic patients reported that the overall prevalence of helicobacter pylori (hp) infection related to dyspepsia was 88.5%.28 various notable research studies have shown that dyspepsia is common, but the relationship between individualized symptoms, diet, and pathophysiology of dyspepsia remains unclear.27 potential lifestyle factors associated with dyspepsia include tobacco, alcohol, and analgesic consumption. furthermore, dietary habits that include consumption of smoked food, fast food, salty food, coffee/tea, and spicy food were associated with aggravating the symptoms of dyspepsia; while fruits, vegetables, and water were noted to improve the symptoms.29-32 studies showed that smoking negatively affects dyspepsia symptoms by decreasing mucosal production, limiting the neutralizing base production, and decreasing blood flow to the inner layers of the stomach, interfering with normal physiological protective mechanisms of the stomach.33-35 the analgesic effects are explained as delayed gastric emptying, increased pyloric zonal contraction, and the release of acid.36 alcohol has a similar role in damaging the stomach as analgesics, where it increases the production of acid.37 though dyspepsia is a common problem among students, probably due to the interaction of various factors, there is no published research on the associations of dietary and lifestyle factors on dyspepsia among medical students. previous studies have found risk factors such as diet, health, and lifestyle affect and exacerbate symptoms of dyspepsia. therefore, we http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jaber this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu conducted a study among the pre-clinical medical students of one medical university in united arab emirates (uae) to identify the magnitude of dyspepsia among them and the associated risk factors. this is one of the first of its kind in the uae that has been designed to provide a better understanding of the problem, as well as to guide future lifestyle intervention programs. methods this cross-sectional survey study was conducted among pre-clinical medical students in gulf medical university, ajman, uae from september 2013 to march 2014. the total number of students in the three pre-clinical years of mbbs (mbbs year 1-3) was 176. all of the pre-clinical medical students who agreed to participate were included in the study. as adequate toefl/ielts score is a basic requirement for the university acceptance, all questionnaires were administered in english. a pilot feasibility study was conducted by administering the draft of the questionnaire to 5 students. after obtaining approval from the ethics and research committees of gmu, the investigators recruited the participants using email and paper invitations. the survey was administered after obtaining the written consent of the participants. data were collected in the classrooms during free time to ensure maximum participation. the investigators were present at the time of survey completion and were available to answer participant questions about the survey. self-report questionnaires were used to gather data on basic participant characteristics, dyspepsia prevalence, dietary factors, and lifestyle factors. the short-form leeds dyspepsia questionnaire assessed the prevalence of dyspepsia.18 a separate questionnaire was used to examine lifestyle factors regarding smoking, consumption of alcohol, and use of analgesics. here, analgesic use refers to over the counter analgesics such as paracetamol (acetaminophen), brufen (ibuprofen), aspirin, etc. a final questionnaire examined dietary factors such as the frequency of consumption of various food types. short-form leeds dyspepsia questionnaire was scored as per the instructions in the manual. the summed up total score of the frequency and severity responses for each symptom was calculated. categorized scores were calculated by rating the single most frequent or severe symptom from 0 (not at all) to 4 (once a day or more).the range was 0-32 and the cut off value for dyspepsia was 7 or more. a lifestyle questionnaire was made based on 2 sets of questions. the first set asked about the tobacco, alcohol, and analgesic intake. the next set assessed general lifestyle risk factors of dyspepsia and they were scored according to the number of risk factors marked as “often”; 1-3 risk factors as mild, 4-6 as moderate and 7-9 as severe. the sensitivity test of shortform leeds dyspepsia questionnaire is 77.3% and the specificity is 73.2%.38 data was analyzed using microsoft excel and statistical package for the social sciences (spss) software version 20 in four major steps. first, descriptive statistics were used to summarize the participant characteristics. secondly, chi-square tests were used to test the association between dietary and lifestyle factors and dyspepsia. thirdly, simple logistic regression was used to measure the association of predictors (dietary and lifestyle factors) on the odds of having dyspepsia, independently. finally, multinomial logistic regression was used to examine the full association of predictors on the odds of having dyspepsia. a p<0.05 was considered as significant. results the mean age of the participants was 20.67±2.57 years, with 45.5% male participants. table 1 shows the distribution of participant characteristics. males did not differ significantly from females in terms of age distribution (20.90±2.83 years and 20.48±2.32 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu years, respectively). participants aged 20 years and older made up 51.7% of the study population. table 1: participant descriptive characteristics table 2 summarizes lifestyle factors and dietary factors of the study participants. tobacco users were defined as ever smokers and never smokers (who had not ever smoked in their life time). ever smokers included both current and former smokers, as they smoked at least once in their life time, and the type of tobacco products considered were cigar, bidi, shisha, and midwakh (dokha). participants’ alcoholic habits were also categorized as ever alcohol consumer (including current and former users) and non-consumers. the majority of the participants were non-smokers (79%) and a higher proportion reported no alcohol consumption (86.4%). however, 97 (65.5%) reported having used analgesics often. in terms of dietary consumption, majority of students were not consuming of smoked food, fast food, salty food, coffee/tea, and spicy food. most of the participants (65.3%) reported that they were not performing any physical activities, and almost half (45.5%) of the participants self-reported inadequate sleep in the last two months. table 2: distribution of participants based on lifestyle and dietary factors out of 176 participants, 77 (43.8%) participants reported experiencing dyspepsia and 99 (56.3%) reported no dyspepsia. table 3 shows the association between the sociodemographic characteristics and dyspepsia. no statistically significant association was observed for age group, gender, nationality, and marital status with dyspepsia. with regard to batch of study, there was found statistical significant association with dyspepsia (p<0.05). among the total participants with dyspepsia, 34 (44.2%) were belonged to the year 2 mbbs batch. table 3: association between sociodemographic characteristics and dyspepsia table 4 shows the distribution of participants’ lifestyle factors, including smoking, alcohol, and analgesic usage in relation to dyspepsia. among the respondents with dyspepsia, 22 (28.6%) were ever smokers whereas 55 (71.4%) were never smokers. the association observed was statistically significant (p<0.05). no statistically significant association was observed for alcohol consumption and analgesic use with dyspepsia. table 4: association between substance use and dyspepsia table 5 describes the distribution of participants according to dietary factors and their association with dyspepsia. consumption of smoked food, fast food, and salty food has been associated with higher occurrence of dyspepsia. among the participants with dyspepsia, 41 (53.2%) had history of inadequate sleep, which trended towards being significantly associated with dyspapesia (p<0.10). no statistical significant association was observed between for any other dietary factors and dyspepsia. table 5: association between dietary factors and dyspepsia chi-square test showed batch of study, participant’s tobacco use and inadequate sleep trended towards a significant association (p<0.10) with the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jaber this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu occurrence of dyspepsia. in a secondary analysis, simple logistic regression was performed on these variables. all variables except inadequate sleep were statistically significant with p<0.05; however, inadequate sleep did show trends towards significance (p<0.10). in the final multinomial logistic regression model, tobacco use was found statistically significant (p<0.05). after adjusting for batch of study, it was concluded that tobacco use as the most predictable factor of dyspepsia (or: 2.19, p<0.05, 95%ci: 1.02, 4.71). moreover, both the factors are found to be independent without any confounding effect (since crude and adjusted odds ratios are almost same in both the variables). from table 6, it was concluded that there is 2.2 greater odds (95%ci: 1.02, 4.71) of dyspepsia in tobacco users compared to nonusers and 2.4 greater odds (95%ci: 1.16, 5.14) occurrence in batch ii mbbs students compared to other batches. table 6. logistic regression of predictors of dyspepsia discussion the study was conducted among 176 students of the junior three batches of the mbbs program offered at gulf medical university, ajman, uae to assess the prevalence of self-reported dyspepsia among pre-clinical students and its association with lifestyle and dietary factors. in a study conducted by novis et al., the population selected was healthy male and female students.39 the results found that out of 142 students 68 had developed dyspepsia during a period of 10 years.39 in a study conducted among randomly selected people in peru, prevalence of dyspepsia was 37.6%. the prevalence of dyspepsia decreased as age increased. ethnicity and dyspepsia were highly associated.40 a study was conducted by rashed et al., to determine the incidence and significance of detection of h. pylori in an arab population, observed that among 116 patients with dyspepsia 89% had h. pylori.41 it was suggested that h. pylori might be hyper-endemic among arab patients with dyspepsia.41 a study survey of functional dyspepsia among the ethnic malays in a primary care setting found results in which of the married subjects, females were more likely to have functional dyspepsia and psychosocial symptoms than men (6.3% vs. 1.9%).42 however, our study found that males were more likely to have dyspepsia in both married and single groups. our study found that smoking tobacco was associated with a significantly increased odds of having dyspepsia, similar to a study in australia that identified smoking as an independent risk factor for dyspepsia (or: 2.1, 95%ci: 1.3, 3.6).43 in our research 139 (78.9%) individuals who do not smoke have dyspepsia. a study conducted at university of manchester in saudi arabia to determine the prevalence of smoking among medical and non-medical students showed that only 0.86% of students in college of medicine smoked tobacco products.44 a total of 74 (8.5%) reported smokers and 785 (91.5%) were nonsmokers. the same research highlighted the impact of alcohol on dyspepsia. it indicated that individuals who consume alcohol of 7 or more times per week have higher risk of reporting dyspepsia (or: 2.3; 95% ci: 1.1, 5.0).44 in our study, 45.8% of participants who drank alcohol had dyspepsia compared to the participants who never drank alcohol (43.4%), while not significant these results warrant additional investigation. dyspepsia is more common in middle aged females.45 published evidence suggested that independent risk factors for dyspepsia included the use of aspirin (or: 2.2; 95%ci: 1.3, 3.7) and smoking (or: 2.1; 95%ci: 1.3, 3.6), but not age, sex, marital status, educational level, income, or the use of alcohol, coffee, or nonsteroidal anti-inflammatory drugs.44 while there was a trend for increased dyspepsia among analgesics users, this relationship was not statistically siginifcant. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu results of a study in china indicated that prevalence of smoking was higher among college undergraduate students.46 a study conducted in brazil shows that alcohol and tobacco were the substances more frequently used by the students, 85.2% and 16.3% respectively among medical students.47 it was also reported that 30 percent alcohol users in society were susceptible to developing dyspepsia.48 another study reports alcohol consumption has been identified as one of the causes of dyspepsia.49 the management of uninvestigated dyspepsia traditionally included the reduction and cessation of coffee intake, although there was no strong research evidence that these changes in lifestyle could relieve the upper gastrointestinal symptoms.50 in our research, the percent of medical students that consumed coffee and tea on regular basis was 81 (46.0%). there was no significant association was found between coffee and tea intake and dyspepsia. nearly two-third of the medical students included in this study did not engage in physical activity. a similar research study conducted among medical students in the united arab emirates concluded that 77% of the students do not engage in any physical activity.51 in this study, engagement in physical activity was not associated with dyspepsia. in summary, the following factors showed a trend in the relation with dyspepsia: tobacco use, alcohol use, and the use of analgesics. these factors were highly linked with the increasing prevalence of dyspepsia amongst pre-clinical students in gulf medical university, ajman, uae. limitation findings of this study cannot be generalized to the general population of uae or populations outside uae; however, they may have important implications for student populations. recall bias was present because some parts of the questionnaire required the students to recall previous events in the past few months. as most students in this study are expatriates, knowledge about family history may have been incomplete due to lack of knowledge about family members living elsewhere. another limitation related to the concept of dyspepsia is that it was self-reported dyspepsia identified on the symptoms of indigestion, regurgitation, feeling of heartburn and nausea; the current study did not involve clinical confirmation of dyspepsia prevalence. conclusion results of this study indicated that 43.8% of pre-clinical medical students had dyspepsia. history of smoking was significantly associated with dyspepsia while alcohol intake, analgesic use and other sociodemographic characteristics were not. batch of study was also found association with dyspepsia as students’ stress and academic factors were related to their level of study. the dietary factors such as consumption of smoked food, fast food, salty food, fruits and vegetables, coffee, spicy food, water, and level of physical activity had no association with dyspepsia; however, inadequate sleep trended towards having a significant influence on dyspepsia. although smoking habit and batch of study were found to be independent factors without any confounding effect, the present study concluded that tobacco use as the most predictive factor for dyspepsia among preclinical medical students in ajman, uae. references 1. baron jh, watson f, sonnenberg a. three centuries of stomach symptoms in scotland. aliment pharmacol ther. 2006;24(5):821-829. 2. hare e. the history of 'nervous disorders' from 1600 to 1840, and a comparison with modern views. br j psychiatry. 1991;159:37-45. 3. chey wd. accurate diagnosis of helicobacter pylori. 14curea breath test. gastroenterol clin north am. 2000;29(4):895902. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jaber this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu 4. tack j, talley nj, camilleri m, et al. functional gastroduodenal disorders. gastroenterology. 2006;130(5):1466-1479. 5. harmon rc, peura da. evaluation and management of dyspepsia. therap. adv. gastroenterol. 2010;3(2):87-98. 6. mahadeva s, goh kl. epidemiology of functional dyspepsia: a global perspective. world j gastroenterol. 2006;12(17):2661-2666. 7. caro jm, ortiz sp, melo cl. dyspepsia and reflux disease in adolescents. rev col gastroenterol. 2008;23(1):46-56. 8. talley nj, weaver al, zinsmeister ar, melton lj. onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders. am j epidemiol. 1992;136(2):165177. 9. paré p. systematic approach toward the clinical diagnosis of functional dyspepsia. can j gastroenterol. 1999;13(8):647654. 10. talley nj, zinsmeister ar, schleck cd, melton lj. dyspepsia and dyspepsia subgroups: a population-based study. gastroenterology. 1992;102(4 pt 1):1259-1268. 11. talley nj, fett sl, zinsmeister ar, melton lj. gastrointestinal tract symptoms and self-reported abuse: a population-based study. gastroenterology. 1994;107(4):10401049. 12. agréus l, talley nj, svärdsudd k, tibblin g, jones mp. identifying dyspepsia and irritable bowel syndrome: the value of pain or discomfort, and bowel habit descriptors. scand j gastroenterol. 2000;35(2):142-151. 13. bernersen b, johnsen r, straume b. non-ulcer dyspepsia and peptic ulcer: the distribution in a population and their relation to risk factors. gut. 1996;38(6):822-825. 14. ho ky, kang jy, seow a. prevalence of gastrointestinal symptoms in a multiracial asian population, with particular reference to reflux-type symptoms. am j gastroenterol. 1998;93(10):1816-1822. 15. shah ss, bhatia sj, mistry fp. epidemiology of dyspepsia in the general population in mumbai. indian j gastroenterol. 2001;20(3):103-106. 16. kay l, jørgensen t. epidemiology of upper dyspepsia in a random population. prevalence, incidence, natural history, and risk factors. scand j gastroenterol. 1994;29(1):2-6. 17. caballero-plasencia am, sofos-kontoyannis s, valenzuela-barranco m, martín-ruiz jl, casado-caballero fj, lópez-mañas jg. irritable bowel syndrome in patients with dyspepsia: a community-based study in southern europe. eur j gastroenterol hepatol. 1999;11(5):517-522. 18. shaib y, el-seraq hb. the prevalence and risk factors of functional dyspepsia in a multiethnic population in the united states. am j gastroenterol. 2004;99(1):2210-2216. 19. jones rh, lydeard se, hobbs fd, et al. dyspepsia in england and scotland. gut. 1990;31(4):401-405. 20. jones r, lydeard s. prevalence of symptoms of dyspepsia in the community. bmj. 1989;298(6665):30-32. 21. penston jg, pounder re. a survey of dyspepsia in great britain. aliment pharmacol ther. 1996;10(1):83-89. 22. moayyedi p, forman d, braunholtz d, et al. the proportion of upper gastrointestinal symptoms in the community associated with helicobacter pylori, lifestyle factors, and nonsteroidal antiinflammatory drugs. leeds help study group. am j gastroenterol. 2000;95(6):1448-1455. 23. ihezue ch, oluwole fs, onuminya je, okoronkwo mo. dyspepsias among the highlanders of nigeria: an epidemiological survey. afr j med med sci. 1996;25(1):23-29. 24. talley nj, colin-jones d, koch kl, koch m, nyren o, stanghellini v. functional dyspepsia: a classification with guidelines for diagnosis and management. gastroenterology. 1991;88(5 pt 1):1223-1231. 25. holtmann g, talley nj. functional dyspepsia. current treatment recommendations. drugs. 1993;45(6):918-930. 26. armstrong d. helicobacter pylori infection and dyspepsia. scand j gastroenterol suppl. 1996;215:38-47. 27. castillo ej, camilleri m, locke gr, et al. a communitybased, controlled study of the epidemiology and pathophysiology of dyspepsia. clin gastroenterol hepatol. 2004;2(11):985-996. 28. abahussain ea, hasan fa, nicholls pj. dyspepsia and helicobacter pylori infection: analysis of 200 kuwaiti patients referred for endoscopy. ann saudi med. 1998;18(6):502-505. 29. marsden k. what doctors don't tell you: ulcers & indigestion developing good gut sense. 1988; http://www.healthy.net/health/article/ulcers_indigestion/ 3357/4. accessed december 10, 2013. 30. ganasegeran k, al-dubai sa, qureshi am, al-abed aa, am r, aljunid sm. social and psychological factors affecting eating habits among university students in a malaysian medical school: a cross-sectional study. nutr j. 2012;11:48. 31. courteney h. indigestion help sheet. http://hazelcourteney.com/indigestion-help-sheet/. accessed december 9, 2013. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu 32. akhondi-meybodi m, aghaei ma, hashemian z. the role of diet in the management of non-ulcer dyspepsia. middle east journal of digestive diseases. 2015;7(1):19-24. 33. abdulghani hm, alkanhal aa, mahmoud es, ponnamperuma gg, alfaris ea. stress and its effects on medical students: a cross-sectional study at a college of medicine in saudi arabia. j health popul nutr. 2011;29(5):516-522. 34. ramakrishnan k, salinas rc. peptic ulcer disease. am fam physician. 2007;76(7):1005-1012. 35. gralnek im, barkun an, bardou m. management of acute bleeding from a peptic ulcer. n engl j med. 2008;359(9):928937. 36. talley nj, zinsmeister ar, schleck cd, melton lj. smoking, alcohol, and analgesics in dyspepsia and among dyspepsia subgroups: lack of an association in a community. gut. 1994;35(5):619-624. 37. nhs choices. heartburn and gastro-oesophageal reflux disease. 2014; http://www.nhs.uk/conditions/gastroesophageal-refluxdisease/pages/introduction.aspx. accessed march 13, 2014. 38. fraser a, delaney bc, ford ac, qume m, moayyedi p. the short-form leeds dyspepsia questionnaire validation study. aliment pharmacol ther. 2007;25(4):477-486. 39. novis bh, marks in, bank s, sloan aw. the relation between gastric acid secretion and body habitus, blood groups, smoking, and the subsequent development of dyspepsia and duodenal ulcer. gut. 1973;14(2):107-112. 40. curioso wh, donaires mendoza n, bacilio zerpa c, ganoza gallardo c, león barúa r. prevalence and relation of dyspepsia to irritable bowel syndrome in a native community of the peruvian jungle. rev gastroenterol peru. 2002;22(2):129-140. 41. rashed rs, ayoola ea, mofleh ia, chowdhury mn, mahmood k, faleh fz. helicobacter pylori and dyspepsia in an arab population. trop geogr med. 1992;44(4):304-307. 42. lee yy, wahab n, mustaffa n, et al. a rome iii survey of functional dyspepsia among the ethnic malays in a primary care setting. bmc gastroenterol. 2013;13:84. 43. nandurkar s, talley nj, xia h, mitchell h, hazel s, jones m. dyspepsia in the community is linked to smoking and aspirin use but not to helicobacter pylori infection. arch intern med. 1998;158(13):1427-1433. 44. abdulghani hm, alrowais na, alhaqwi ai, et al. cigarette smoking among female students in five medical and nonmedical colleges. int j gen med. 2013;6:719-727. 45. carbone f, holvoet l, tack j. rome iii functional dyspepsia subdivision in pds and eps: recognizing postprandial symptoms reduces overlap. neurogastroenterol. motil. 2015;27(8):1069-1074. 46. zhu t, feng b, wong s, choi w, zhu sh. a comparison of smoking behaviors among medical and other college students in china. health promot int. 2004;19(2):189-196. 47. petroianu a, reis dc, cunha bd, souza dm. prevalence of alcohol, tobacco and psychotropic drug use among medical students at the universidade federal de minas gerais. rev assoc med bras. 2010;56(5):568-571. 48. hyams js, burke g, davis pm, rzepski b, andrulonis pa. abdominal pain and irritable bowel syndrome in adolescents: a community-based study. j pediatr. 1996;129(2):220-226. 49. colledge nr, walker br, ralston sh. davidson's principles and practice of medicine. 21st ed: churchill lingstone elsevier; 2010. 50. khot a, polmear a. practical general practice: guidelines for effective clinical management. 6th ed: churchill livingstone elsevier; 2011. 51. carter ao, elzubeir m, abdulrazzaq ym, revel ad, townsend a. health and lifestyle needs assessment of medical students in the united arab emirates. med teach. 2003;25(5):492-496. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jaber this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu table 1: participant descriptive characteristics variables groups gender male female n (%) n (%) age group ≤20 36 (42.4) 49 (57.6) >20 44 (48.4) 47 (51.6) batch 2011 26 (49.1) 27 (50.9) 2012 31 (51.7) 29 (48.3) 2013 23 (36.5) 40 (63.5) nationality arabs 48 (55.8) 38 (44.2) nonarabs 32 (35.6) 58 (64.4) marital status married 3 (27.3) 8 (72.7) single 77 (46.7) 88 (53.3) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu table 2: distribution of participants based on lifestyle and dietary factors lifestyle factors n (%) tobacco use ever smoked 37 (21.0) never smoked 139 (79.0) alcohol consumption ever drank alcohol 24 (13.6) never drank alcohol 152 (86.4) analgesics use yes 97 (65.5) no 51 (34.5) dietary factors n (%) smoked food consumption yes 14 (8.0) no 162 (92.0) fast food consumption yes 59 (33.5) no 117 (66.5) salty food consumption yes 61 (34.7) no 115 (65.3) fruit/vegetable consumption yes 74 (42.0) no 102 (58.0) coffee/tea consumption yes 81 (46.0) no 95 (54.0) spicy food consumption yes 74 (42.0) no 102 (58.0) beverage consumption during meals http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jaber this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu yes 115 (65.3) no 61 (34.7) physical activity yes 61 (34.7) no 115 (65.3) inadequate sleep yes 80 (45.5) no 96 (54.5) note. all dietary factors refer to dietary consumption. details given for dietary consumption, physical activity and sleep are of the past two months. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu table 3: association between sociodemographic characteristics and dyspepsia sociodemographics groups dyspepsia p value yes no n (%) n (%) age group in years ≤20 38 (44.7) 47 (55.3) 0.875 >20 39 (42.9) 52 (57.1) gender male 36 (45.0) 44 (55.0) 0.76 female 41 (42.7) 55 (57.3) batch i mbbs 20 (37.7) 33 (62.3) 0.045 ii mbbs 34 (56.7) 26 (43.3) iii mbbs 23 (36.5) 40 (63.5) nationality arabs 34 (39.5) 52 (60.5) 0.271 non-arabs 43 (47.8) 47 (52.2) marital status married 6 (54.5) 5 (45.5) 0.537 single 71 (43.0) 94 (57.0) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jaber this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu table 4: association between substance use and dyspepsia lifestyle factors groups dyspepsia p value yes no n (%) n (%) tobacco use ever smoked 22 (59.5) 15 (40.5) 0.030 never smoked 55 (39.6) 84 (60.4) alcohol use ever drank 11 (45.8) 13 (54.2) 0.825 never drank 66 (43.4) 86 (56.6) analgesic use users 47 (48.5) 50 (51.5) 0.283 non-users 30 (38.0) 49 (62.0) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu table 5: association between dietary factors and dyspepsia dietary factors dyspepsia groups yes no n (%) n (%) p value smoked food consumption yes 7 (50.0) 7 (50.0) 0.623 no 70 (43.2) 92 (56.8) fast food consumption yes 29 (49.2) 30 (50.8) 0.305 no 48 (41.0) 69 (59.0) salty food consumption yes 29 (47.5) 32 (52.5) 0.460 no 48 (41.7) 67 (58.3) fruit/vegetable consumption yes 30 (40.5) 44 (59.5) 0.465 no 47 (46.1) 55 (53.9) coffee/tea consumption yes 35 (43.2) 46 (56.8) 0.894 no 42 (44.2) 53 (55.8) spicy food consumption yes 33 (44.6) 41 (55.4) 0.847 no 44 (43.1) 58 (56.9) beverage consumption during meals yes 53 (46.1) 62 (53.9) 0.391 no 24 (39.3) 37 (60.7) physical activity yes 28 (45.9) 33 (54.1) 0.675 no 49 (42.6) 66 (57.4) inadequate sleep yes 41 (51.2) 39 (48.8) 0.060 no 36 (37.5) 60 (62.5) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jaber this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 5, no. 1 (2016) | issn 2166-7403 (online) | doi 10.5195/cajgh.2016.192 | http://cajgh.pitt.edu table 6: logistic regression of predictors of dyspepsia crude adjusted variables or (95% ci) or (95% ci) study batch i mbbs 1.05 (0.50 – 2.25) 1.27 (0.58 – 2.78) ii mbbs 2.27 (1.10 – 4.69)* 2.44 (1.16 – 5.14)* ref: iii mbbs 1 (--) 1 (--) tobacco use ever smoked 2.24 (1.07 – 4.69) 2.19 (1.02 – 4.71)* ref: never smoked 1 (--) 1 (--) note. *denotes p<0.05 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. non-communicable chronic diseases among residents of a remote settlement in the transbaikal region of the russian federation oleg gaisenok1,2 1research center for medical forecasting and analysis, moscow, russia; 2united hospital with outpatient department, moscow, russia vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.338 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ gaisenok this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.338|http://cajgh.pitt.edu abstract introduction: over a quarter of the population of the russian federation resides in rural communities. however, the data on chronic disease rates in these communities are limited, which makes screening for chronic diseases extremely important. the aim of this study was to measure the prevalence of chronic noncommunicable diseases among residents of a remote settlement in the transbaikal region, russian federation. methods: a sample of residents from the transbaikal region settlement was screened in august 2017. the screening included a survey to determine the frequency of self-reported chronic diseases as well as sociodemographic and behavioral risk factors. additionally, vascular stiffness was measured by volumetric sphygmography using the vasera-1500 device. descriptive statistics have been used for data analysis. results: 126 residents were screened for this study. the prevalence of chronic non-communicable diseases and their risk factors were: hypertension (56.3%), gastrointestinal diseases (33.3%), chronic obstructive pulmonary disease (13.5%), smoking (35.7%), obesity (19.1%), and diabetes mellitus (6.3%). pathological vascular changes typical of atherosclerosis were found by volumetric sphygmography in 17.5% of cases, with 5.5% of those cases corresponding to significant forms of severe peripheral atherosclerosis (abi<0.9). an analysis of mortality causes for this settlement for 2016-2017 found that cardiovascular diseases accounted for over 50% of the total number of deaths. conclusion: this study showed a high prevalence of detectable chronic non-communicable diseases and their associated risk factors. cardiovascular diseases were the main cause of mortality. active prevention programs and screenings are required to reduce the burden of chronic diseases in this region. keywords: chronic noncommunicable diseases; screening programs; vascular stiffness; circulatory system diseases; mortality non-communicable chronic diseases for residents of a remote settlement in the transbaikal region of the russian federation oleg gaisenok1,2 1research center for medical forecasting and analysis, moscow, russia; 2united hospital with outpatient department, moscow, russia research introduction cardiovascular diseases (cvd) are the most common cause of death in the world. in 2013, 32% (17.3 million) of all deaths worldwide, were associated with cvd.1 many of these deaths were due to the lack of access to cardioprotective medications such as aspirin, statins, and antihypertensive drugs. the burden of cvd is exacerbated in russia by logistic issues of reaching remote geographic areas and the complexity required to coordinate the delivery of skilled medical assistance to individuals located hundreds of kilometers away from medical facilities. as of january 1st, 2018, the rural and urban population of russia were 37.5 million and 109.3 million respectively.2 the majority of observational and epidemiological http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx gaisenok this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.338|http://cajgh.pitt.edu figure 1. ksenyevka's location on the map of the russian federation studies in russia are based on urban populations because of easier access to the participants. this bias of focusing on urban populations, may underestimate the burden of cvd and their risk factors in rural russia, where only a few studies have been conducted. therefore, studies focusing on the morbidity and mortality of rural population in russia are needed to fill this important research gap. the study "epidemiology of cardiovascular diseases in different regions of the russian federation" reported rates of mortality from circulatory system diseases (csd) for 12 regions of russia.3 in five regions, csd mortality in men aged 25-64 years exceeded the national russian federation average of 573 per 100,000 men; three of the five regions had csd mortality rates more than 600 per 100,000 men. among women aged 2564 years, three regions had csd mortality rates, exceeding the average for the russian federation.3 the epidemiology of cardiovascular risk factors and diseases in regions of the russian federation study (esse-rf) reported on the prevalence of major diseases in almost 22 thousand individuals across 13 regions of the russian federation between 2012 and 2013. the overall prevalence of cardiovascular diseases was as following: arterial hypertension 43.0% (men 47.9%, women 39.6%); coronary artery disease 7.9% (men 8.0%, women 7.8%); liver diseases 36.1% (men 27.5%, women 41.3%); and diabetes 3.9% (men 3.7%, women 4.0%).4 based on 2013 standardized total mortality rates for men in the russian federation the highest mortality rate was in far eastern federal district.5 the trans-baikal region (figure 1), which is apart of the far eastern federal district, is one the least populated regions in russia. the trans-baikal region was not included in the russian epidemiological study of esse-rf, and there have been no recent specialized epidemiological studies analyzing the morbidity and mortality in this region. in addition, current comprehensive statistical data on csd mortality are not http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx gaisenok this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.338|http://cajgh.pitt.edu characteristics % (n) age, yrs1 45.3 ± 14.2 male 51.6% (65) current smokers 35.7% (45) mean blood pressure (bp), mm hg (in the group) 146.0/92.5 ± 23.4/12.3 bp at the time of the examination: more than 130/80 mm hg more than 140/90 mm hg 74.6 % (97) 52.4% (66) bmi, kg /m2 27.4 ± 5.9 underweight (bmi <18.5 kg /m2) 2.4% (3) lean (bmi: 18.5 to <25 kg /m2) 37.3% (47) overweight (bmi = 25 to <30 kg /m2) 41.2% (52) obese (bmi> 30 kg /m2) 19.1% (24) obese iii (bmi> 40 kg /m2)2 6.3% (8) currently employed 92.0% (116) 1continious variables are listed as mean ± standard deviation 2is this a subset of the obese group. table 1. general characteristics of study participants available for trans-baikal’s rural and remote regions. the primary objective of this study was to assess the prevalence of chronic noncommunicable diseases and their respective risk factors among residents of the remote settlement of transbaikal region. our second objective was to determine the prevalence of atherosclerosis and vascular diseases using volumetric sphygmography. to our knowledge, this is the first study in the past decades to assess chronic diseases in remote settlements of the trans-baikal region. methods study population for this cross-sectional study, we surveyed ksenyevka residents who applied for screening in august of 2017. ksenyevka settlement is located in the mogochinsky district of the transbaikal region. it is 800 km away from the capital of the trans-baikal region, chita (figure 1), and 100 kilometers away from the nearest hospital. residents were recruited through local advertisements. inclusion criteria for our study were settlement residency and consenting to participate in the screening. no exclusion criteria were used. all participants gave written informed consent before participating in this study. survey data data on sociodemographic, family history, and other risk factors for cardiovascular disease were collected. data were also collected on gender, age, marital status, education, employment, disability, dietary habits, physical activity, smoking, and alcohol use. presence of diseases, history of angina pectoris and myocardial infarction was assessed using rose's questionnaire.6 physical examination blood pressure was measured using a welhallyn tonometer (germany) in accordance with the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx gaisenok this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.338|http://cajgh.pitt.edu disease frequency (%) n arterial hypertension 56.3 71 gastrointestinal diseases 33.3 42 copd or bronchial asthma 13.5 17 heart rhythm disturbances (including atrial fibrillation) 8.7 11 diabetes mellitus 6.3 8 previous history of myocardial infarction 6.3 8 coronary artery disease 5.5 7 neoplasms 5.5 7 heart valve diseases 4.0 5 previous history of cerebral stroke 4.0 5 psoriasis 2.4 3 nephritis 2.4 3 severe sleep apnea 2.4 3 moshkovsky-shaffar hereditary hemolytic anemia 1.6 2 rheumatic diseases 1.6 2 thrombophlebitis 0.8 1 tuberculosis 0.8 1 epilepsy 0.8 1 table 2. prevalence of self-reported non-communicable conditions national recommendations.7 body weight measurements were performed using maxwell electronic floor scales (china). participants were measured once, without shoes and wearing light clothing. height was measured using a stadiometer. participants’ bmi were classified using the us center for disease control criteria: underweight (bmi <18.5 kg /m2), normal weight (bmi 18.5 to <25kg/m2), overweight (bmi 25 to <30kg/m2), obese (≥30kg/m2), and obese class iii (bmi ≥40kg/m2).8 cardiovascular assessments individuals were screened for the following cardiovascular diseases: arterial hypertension, angina pectoris, previous history of myocardial infarction and cerebral stroke, cerebrovascular diseases, valvular heart diseases, cardiac arrhythmias, and heart failure. we measured vascular stiffness using the vasera vs-1500 volumetric sphygmograph (fukuda denshi, japan). the estimated vascular age of the patient (evap) was determined automatically by the device on the basis of a graphical transformation of the cardioankle vascular index (cavi) and the age of the patient. date of birth was confirmed using the passport of each participant. the following health indicators were evaluated: cardiovascular vascular index on the right extremities (r-cavi), estimated vascular age based on r-cavi (r-cavi age evap), cardiovascular vascular index on the left extremities (l-cavi), estimated vascular age based on l-cavi (l-cavi age evap), ankle-brachial index (abi) on the right extremities (rabi), and ankle-brachial index on the left extremities (labi). the following generally accepted intervals were adopted as criteria for atherosclerotic vascular lesion: abi 1.0—1.29 norm, 0.91—0.99 borderline condition, 0.41—0.9 peripheral arterial disease of mild / moderate degree, <0.40 severe peripheral arterial disease.9 normative indicators of the cavi index for the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx gaisenok this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.338|http://cajgh.pitt.edu clinical parameter mean ± sd normal range % of patients outside of normal range abi (right) 1.07 ± 0.09 >1.00 5.5 abi (left) 1.07 ± 0.02 >1.00 4.1 cavi (right) 7.39 ± 1.45 <8.0 15.1 cavi (left) 7.40 ± 1.51 <8.0 17.5 evap (right)1 43.4 ± 17.9 <71 yrs 11.0 evap (left)1 43.4 ± 18.5 <71 yrs 12.6 pet/et 0.32 ± 0.05 <0.36 12.6 1reference value was determined from the oldest true age of the study participants table 3. volumetric sphygmography vascular characteristics assessment of pathology were as follows: cavi <8.0 norm; 8.0—9.0 borderline condition; > 9.0 atherosclerotic lesion.10 the basic indicator for the assessment of the reduced left ventricle (lv) systolic function was an indicator pep / et> 0.36, which rises above this value with a decrease in lv systolic function.11 based on the results of the screening, patients were provided health recommendations and referral to cardiologist. mortality data mortality rates in ksenyevka for 2016 and 2017 were obtained using death certificates from the local death registry and funeral home in ksenyevka. statistical analysis continuous variables were represented using means and standard deviations and categorical variables were listed as frequencies by absolute numbers and percentages. results 126 residents were included in this study. this accounted for 4.6% of the total settlement population in 2017 (n=2717)12. the general demographic and anthropometric characteristics of patients are presented in table 1. the screening revealed that only 37.3% (n=47) of the research participants had a normal body weight in accordance with who criteria.8 almost three quarters of those surveyed had elevated blood pressure values (130/80 mmhg) at the time of the examination (74.6%; n=97). more than 25% (n=32) found out about the elevated blood pressure at the time of screening and were not aware of it prior to the study. interviews and medical record reviews revealed that 20% of participants were not regularly taking their prescribed blood pressure medication at the time of screening. 35.2% patients with arterial hypertension (n=25) were aware of their disease diagnosis but were not aware which medications they were supposed to take. 76.2% (n=96) had reported having chronic disease diagnosis at the time of screening. the frequency of major chronic diseases among ksenyevka residents included in this study are presented in table 2. the most common diseases among the residents of ksenyevka were arterial hypertension (56.3%), gastrointestinal diseases (33.3%), and copd (13.5%). volumetric sphygmography data was collected from 124 residents (98.4%). results for ankle-brachial index (abi), cardiovascular vascular index (cavi), estimated vascular age of the patient (evap), weissler coefficient (pep / et) are presented in table 3. 12.6% (n=16) of study participants had an evap greater than the maximum recorded true age and had disturbances in the systolic function based on pet/et (weissler’s coefficient). based on the cavi criterion for pathological changes in the vascular system, pathologies http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx gaisenok this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.338|http://cajgh.pitt.edu cause of death 2016 % (n) 2017 % (n) cardiovascular diseases 50.0 (22) 65.0 (23) cancer 20.5 (9) 8.6 (3) cirrhosis 0.0 (0) 2.8 (1) diabetes mellitus 2.3 (1) 8.6 (3) infection 0.0 (0) 2.8 (1) suicide 13.6 (6) 5.7 (2) tuberculosis 0.0 (0) 5.7 (2) total 100 (44) 100 (35) table 4. january 2016 to september 2017 mortality rates by clinical indication for the ksenyevka population typical for atherosclerosis were detected in 17.5% (n=22) of cases, while in 5.5% (n=7) of patients hadsignificant forms of severe peripheral atherosclerosis. mortality trends in ksenyevka for 2016 and 2017 are presented in table 4. cvds were the main cause of mortality in this settlement. we noted that the contribution of cardiovascular diseases in the structure of mortality of the settlement slightly increased from 2016 (50%) to 2017 (65%). in 2016 cancer (20.5%) and suicide (13.6%) were the second and the third leading causes of mortality, whereas in 2017 second and third leading causes weere cancer and diabetes (8.6% each). the mortality rate from suicide was 13.6% in 2016 and 5.7% in 2017. discussion in this study we explored the prevalence of chronic non-communicable diseases and cardiovascular health status of residents of ksenyevka, a remote settlement of the trans-baikal region, russian federation. few studies report on the rural settlements of trans-baikal region, which has the second highest standardized total mortality rate among men in siberian federal district.5 in this study, we identified that the most prevalent diseases were arterial hypertension (56.3%), gastrointestinal diseases (33.3%), and copd (13.5%). one quarter of patients with arterial hypertension did not receive the therapy prescribed by the doctor. almost three quarters of those surveyed had elevated blood pressure values. 19.1% of study participants were obese and 41.2% were overweight. we found that 6.3% of screened participants suffered from diabetes mellitus, 5.5% from coronary artery disease, and 6.3% and 4.0% had previous history of myocardial infarction and cerebral stroke respectively. we used volumetric sphygmography to evaluate vascular stiffness and identify preclinical and clinical atherosclerosis. volumetric sphygmography is a simple and convenient method for screening programs that has been widely used in observational studies.13-16 in our study, pathological vascular changes typical for atherosclerosis were detected in 17.5% of cases, with 5.5% of them having signs of severe stenotic atherosclerosis. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx gaisenok this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.338|http://cajgh.pitt.edu reducing the incidence of cvd and its complications in russia will require the introduction of preventive programs both at the population and state institutions level.17 non-pharmacological preventive programs, aimed at modifying known risk factors, is a critical part of reducing the burden of cvd. the north karelia project in finland aimed at promoting healthy lifestyles, resulted in a significant reduction in blood pressure and total cholesterol in the population, as well as a reduction in the percentage of smokers from 52% to 32%. this led to a reduction in mortality rates from coronary heart disease in finland by 65%18. anticoagulants and statins are effective drugs cardiovascular disease, in which low adherence is a problem.19,20 we have found that many patients have low adherence to prescribed treatment and do not follow the doctor's recommendations. one of the reasons for the low adherence to taking statins is the perceived lack of clinical effect by the patients.21 preventive population screening programs are an effective tool that allows timely detection cvd in patients, as well as informs necessary treatments and motivates healthy lifestyle.13,14 data on the prevalence of diseases among those surveyed in ksenyevka showed higher prevalence of hypertension and diabetes compared to esse-rf study, whereas the prevalence of cad and gastrointestinal diseases was lower.4 interestingly, vascular age of patient was higher than the patient's chronologic age in 23.2% of screened moscow residents compared to 12.3% of screened participants in ksenyevka14. sumin a.n. et al reported the 16.6% prevalence of type 2 diabetes mellitus in western siberia22. the authors also reported that cavi increase in a population sample of western siberia associated with type 2 diabetes.22 interestingly, the suicide rate has decreased most than two times in 2017 compared to 2016. suicide prevention should be an important priority of the future intervention programs. there were a few limitations for our study. first, study used self-report for the identification of several chronic diseases. second, we surveyed only a small percentage of the settlement population (4.6%). the low recruitment may reflect the lack of motivation of the community to improve health in our study population or short recruitment period. assessment period was 3 days which was another potential reason for the small turn-out. third, there was a risk of volunteer and healthy worker bias, as 92% of the participants were of working age, which may not be reflective of the entire settlement. this study did not collect data on participant nationality; however, the overwhelming majority self-identify as russians.23 this study did provide a general depiction of the major clinical conditions of ksenyevka, which has never been previously reported in scientific medical journals. given the high prevalence of cardiovascular disease in our study and previous data on cardiovascular disease prevalence in the russian federation, we suggest that health care efforts emphasis preventative strategies especially in the remote regions. regular simple screening programs for cardiovascular risk factors would also assist in efforts to increase patient adherence to treatment regimens, to monitor health status, and to maintain a healthy lifestyle.24,25 the study reported a large percentage of detectable chronic non-communicable diseases and risk factors in a remote settlement population in the transbaikal region of the russian federation. cardiovascular diseases were the main cause of mortality. our findings support the need for preventive screening programs to effectively identify chronic non-communicable diseases and reduce know risk factors for these diseases. references 1. heart disease and stroke statistics-2017 update: a report from the american heart association. circulation. 2017 mar 7;135(10): e146-e603. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.338|http://cajgh.pitt.edu 2. estimate of the number of resident population on january 1, 2018 and an average for 2017. www.gks.ru/free_doc/new_site/population/dem o/prpopul2018.xlsx. accessed on 13 may 2019. 3. shalnova s.a., konradi a.o., karpov yu.a., kontsevaya a.v., deev a.d., kapustina a.v., khudyakov m.b., shlyakhto e.v., boytsov s.a. cardiovascular mortality in 12 russian federation regions – participants of the “cardiovascular disease epidemiology in russian regions” study. russ j cardiol 2012, 5 (97): 6-11. [in russ.] 4. shalnova s.a., oganov r.g., deev a.d., imaeva a.e., lukyanov м.м., artamonova g.v., gatagonova т.м., et al, on behalf of the esse-rf study work team. comorbidities of ischemic heart disease with other noncommunicable diseases in adult population: age and risk factors association. cardiovascular therapy and prevention, 2015; 14(4): 44–51 [in russ.] 5. kolesnikov si, savilov ed, savchenkov mf, leshchenko yaa, malov iv, anganova ev, astaf'ev va, shugaeva sn. sanitaryepidemiological status of siberian population (medico-demographical and epidemiological characteristics). annals of the russian academy of medical sciences. 2016;71(6):472481 6. rose g.a., blackburn h., gillum r.f., prineas r.j. cardiovascular survey methods. in who monograph series no. 56 2nd edition. geneva: world health organization 1982; 149-172. 7. chazova i.e., ratova l.g., boitsov s.a., nebieridze d.v. recommendations for the management of arterial hypertension russian medical society of arterial hypertension and society of cardiology of the russian federation. system hypertension 2010;3:5-26 / http://www.gipertonik.ru/files/journals/sg3(20 10).pdf. accessed on 13 may 2019. 8. defining adult overweight and obesity. https://www.cdc.gov/obesity/adult/defining.ht ml. accessed on 13 may 2019. 9. esc guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the task force on the diagnosis and treatment of peripheral artery diseases of the european society of cardiology (esc). eur heart j. 2011 nov;32(22):2851-906. 10. namekata t., suzuki k., ishizuka n., shirai k. establishing baseline criteria of cardio-ankle vascular index as a new indicator of arteriosclerosis: a cross-sectional study. bmc cardiovasc disord 2011;10:11:51. 11. the method of volumetric sphygmography on the device vasera vs-1500n: guidelines. v.a. milyagin, i.v. milyagina, m.a. purygina, t.a. osipenkova. smolensk: ssma 2014. [in russ.] 12. the population of the russian federation for municipalities on january 1, 2017 published on july 31, 2017. federal service of state statistics. http://www.gks.ru/wps/wcm/connect/rosstat_m ain/rosstat/ru/statistics/publications/catalog/afc 8ea004d56a39ab251f2bafc3a6fce. accessed on 13 may 2019. 13. gaisenok o.v., dorokhov s.i., kalashnikov s.v., leonov a.s., vlasova l.a. the value of population-based programs within “healthy heart day” moves to identify hypertension and major risk factors for cardiovascular diseases. profilakticheskaya meditsina 2017;20(3):17-21. [in russ.] http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.gks.ru/free_doc/new_site/population/demo/prpopul2018.xlsx http://www.gks.ru/free_doc/new_site/population/demo/prpopul2018.xlsx http://www.gipertonik.ru/files/journals/sg3(2010).pdf http://www.gipertonik.ru/files/journals/sg3(2010).pdf https://www.cdc.gov/obesity/adult/defining.html https://www.cdc.gov/obesity/adult/defining.html http://www.gks.ru/wps/wcm/connect/rosstat_main/rosstat/ru/statistics/publications/catalog/afc8ea004d56a39ab251f2bafc3a6fce http://www.gks.ru/wps/wcm/connect/rosstat_main/rosstat/ru/statistics/publications/catalog/afc8ea004d56a39ab251f2bafc3a6fce http://www.gks.ru/wps/wcm/connect/rosstat_main/rosstat/ru/statistics/publications/catalog/afc8ea004d56a39ab251f2bafc3a6fce gaisenok this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.338|http://cajgh.pitt.edu 14. gaisenok ov, medvedev pa, trifonova ss, shatalova iv, martsevich sy, sidorenko ba. application of cavi index in clinical practice: calculated vascular age as a tool for decision on additional examination of patients with cardiovascular diseases. kardiologiia 2015;55(7):51-6. [in russ.] 15. rogoza a.n., kaveshnikov v.s., trubacheva i.a., serebriakova v.n., zairova a.r., zhernakova y.v., oshepkova e.v., karpov r.s., chazova i.e. vascular wall in adult population of tomsk in the framework of the project essay rf. systemic hypertension 2014;11(4):42-48. [in russ.] 16. sumin a.n., shcheglova a.v., fedorova n.v., artamonova g.v. values of cardial-ankle vascular index in healthy people of different age by the data of esse-rf study in kemerovskaya region. cardiovascular therapy and prevention. 2015;14(5):67-72. [in russ.] 17. diagnostics and correction of lipid metabolism disorders in order to prevent and treat atherosclerosis. russian recommendations vi revision. the russian society of cardiology. the russian national atherosclerosis society. russian society of cardiosomatic rehabilitation and secondary prevention. journal of atherosclerosis and dyslipidaemias (jad) 2017; 3: 5-22. [in russ.] https://elibrary.ru/download/elibrary_29667695 _24847695.pdf. accessed on 13 may 2019. 18. jousilahti p, laatikainen t, salomaa v, pietilä a, vartiainen e, puska p. 40-year chd mortality trends and the role of risk factors in mortality decline: the north karelia project experience. glob heart. 2016 jun;11(2):20712. doi: 10.1016/j.gheart.2016.04.004. 19. gaisenok o, martsevich s, tripkosh s, lukina y. analysis of lipid-lowering therapy and factors affecting regularity of statin intake in patients with cardiovascular disease enrolled in the profile registry. rev port cardiol. 2015 feb;34(2):111-6. 20. oleg v. gaisenok, anton s. leonov. therapy in the prevention of thromboembolic complications in patients with atrial fibrillation: prospects for higher appointment of new oral anticoagulants in сlinical рractice. cardiology and cardiovascular research 2017; 1(2): 29-31 21. wei my, ito mk, cohen jd, brinton ea, jacobson ta. predictors of statin adherence, switching, and discontinuation in the usage survey: understanding the use of statins in america and gaps in patient education. j clin lipidol. 2013 sep-oct;7(5):472-83. 22. sumin a.n., bezdenezhnykh n.a., fedorova n.v., bezdenezhnykh a.v., indukaeva e.v., artamonova g.v. the relationship of visceral obesity and cardio-ankle vascular index with impaired glucose metabolism according to the esse-rf study in west siberian region. klin med (mosk) 2018;96(2):137-146. [in russ.] 23. national composition of russia 27.07.2017 http://www.statdata.ru/nacionalnyj-sostavrossii. accessed on 13 may 2019. 24. schwalm jd, mckee m, huffman md, yusuf s. resource effective strategies to prevent and treat cardiovascular disease. circulation. 2016 feb 23;133(8):742-55. 25. yusuf s. why do people not take life-saving medications? the case of statins. lancet. 2016 sep 3;388(10048):943-5. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://elibrary.ru/download/elibrary_29667695_24847695.pdf https://elibrary.ru/download/elibrary_29667695_24847695.pdf http://www.statdata.ru/nacionalnyj-sostav-rossii http://www.statdata.ru/nacionalnyj-sostav-rossii non-communicable chronic diseases among residents of a remote settlement in the transbaikal region of the russian federation abstract keywords: chronic noncommunicable diseases; screening programs; vascular stiffness; circulatory system diseases; mortality non-communicable chronic diseases for residents of a remote settlement in the transbaikal region of the russian federation research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. trends and determinants of attitudes towards people living with hiv/aids among women of reproductive age in tajikistan hakim zainiddinov1 1rutgers university, united states vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.349 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.349|http://cajgh.pitt.edu abstract introduction: despite having one of lowest rates of newly diagnosed hiv infections among former soviet countries, tajikistan has a substantial level of discriminatory attitudes towards people living with hiv/aids (plwha). while initial attempts were made to explore discriminatory attitudes of a wide range of professionals, women’s general attitudes towards plwha received less scholarly attention. employing a nationally representative sample from the 2000 and 2005 multiple indicator cluster surveys (mics), sociodemographic determinants of hiv-related discriminatory attitudes of women aged 15-49 in tajikistan were identified and examined over time. methods: a representative sample included 5,453 women of reproductive age from the capital city and four regions of tajikistan. two dichotomized scenarios representing the agreement to let an hiv-infected teacher continue teaching in school and the willingness to buy food from an hiv-infected cashier were constructed. univariate and multivariable analyses of hiv-related discriminatory attitudes were obtained using stata 14. results: insignificant but positive changes were observed in the women’s attitudes between 2000 and 2005. logistic regression models showed that negative attitudes were associated with the lack of knowledge of hiv/aids prevention methods, endorsement of hiv/aids transmission misconceptions, and never having been tested for hiv (p≤0.001). women living in the rural areas, married, with lower education, and from low income households were less tolerant towards plwha. conclusions: the data from tajikistan underscore the persistence of hiv-related discriminatory attitudes among low socioeconomic status women. the study findings can be potentially used to target the disadvantaged groups and guide the design and implementation of programs that promote voluntary hiv-testing, raise awareness about hiv/aids prevention methods, and help dispel transmission misconceptions. keywords: tajikistan; hiv/aids; discriminatory attitudes; women; plwha trends and determinants of attitudes towards people living with hiv/aids among women of reproductive age in tajikistan hakim zainiddinov1 1rutgers university, united states; research introduction despite the recent advances in hiv prevention and treatment technologies that transformed hiv into a manageable disease, hiv-related stigma and discrimination still represent a problem. tajikistan, reporting one of lowest rates of newly diagnosed hiv infections among the former soviet countries,1 is not exception from this general trend. according to the first national study on discrimination and stigmatization of hiv-infected people conducted by the strategic research center under the president of tajikistan, nearly every third person (28.9%) held negative attitudes towards people living with hiv/aids (plwha).2 discriminatory attitudes towards plwha have been reported in the form of labor and education restrictions, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.349|http://cajgh.pitt.edu in the context of medical care, and within families and communities.2 although initial attempts were made to explore discriminatory attitudes of a wide range of professionals, including medical personnel, lawenforcement men, service sector workers, teachers, local officials, mass media employees, lawyers, judges, and religious leaders,2 studies that examine women’s attitudes towards plwha in tajikistan are nearly absent. most of the previously published studies on hiv/aids in tajikistan focused on high risk of hiv infection among injection drug users and labor migrants3 or assessed comprehensive hiv/aids knowledge among women.3,4 consequently, a limited number of qualitative research looked at the discrimination against hiv-positive injection drug users by health care providers5, as well as labor migrants’ wives’ knowledge, attitudes, and behaviors about hiv/aids risk and protection.6 the aim of this study was to identify sociodemographic determinants of hiv-related discriminatory attitudes of a nationally representative sample of women aged 15-49 in tajikistan and examine these changes over time. methods data source the data were obtained from the 2000 and 2005 multiple indicator cluster surveys (mics), conducted by the state committee on statistics of the republic of tajikistan with the financial and technical support of the united nations children’s fund.7,8 the mics employed a representative sample of women from the capital city and all four regions of tajikistan. the final sample included 5,453 women aged 15-49 years. both mics surveys had high response rates of 98.8% and 96% for 2000 and 2005 respectively.7,8 measures to measure discriminatory attitudes towards people living with hiv/aids, the 2000 survey included two questions: (1) “should teacher with hiv/aids be allowed to teach in school?”; and (2) “would you buy food from cashier with hiv/aids?”. the 2005 survey assessed discrimination using four questions: (1) “if a female teacher has the aids virus but is not sick, should she be allowed to continue teaching in school?”; (2) “would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the aids virus?”; (3) “if a member of your family became infected with the aids virus, would you want it to remain a secret?”; and (4) “if a member of your family became sick with the aids virus, would you be willing to care for him or her in your household?”. to be consistent across two years of the study, the first two questions from each survey were used. key independent variables were women’s knowledge about hiv/aids prevention methods, transmission misconceptions, and their hiv/aids testing status. research has already reported the association between these predictors and discriminatory attitudes towards plwha.9,10,11,12,13,14 following prior research,3 the first two independent variables were operationalized as followed. a score measure of knowledge about hiv/aids prevention methods was created by combining answers from three questions asking whether women knew that they can avoid the aids virus by (1) having one uninfected and faithful partner; (2) using condoms; and (3) not having sex at all. the second independent variable, which is also a score measure, was based on three questions: can people get infected with the aids virus through (1) witchcraft or other supernatural means, (2) from mosquito bites, and (3) whether or not it is possible for a healthy-looking person to have the aids virus. all three answers were combined and coded into a dichotomous variable signifying respondent who did not endorse myths and misconceptions about hiv/aids transmission. the study also employed a number of demographic and socioeconomic status characteristics known to affect discriminatory attitudes towards hiv-infected people.12,14,15,16 demographic characteristics were http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.349|http://cajgh.pitt.edu figure 1. trends in positive attitudes towards people living with hiv/aids captured through variables such as age (ranging from 15 to 49 years old), marital status (currently married versus all else), region of residence (a series of five dummy variables: dushanbe, khatlon, sogd, direct rule districts (drds) and gorno-badakhshan autonomous region (gbao)), and area of residence (rural versus urban). socioeconomic status measures were education (higher versus all else), and household income (recoded as tertiles: low, medium and high). the study used a dichotomous variable ‘year 2005’ that contrasted respondents who participated in the 2005 survey with those who did not. statistical analysis first, a univariate analysis was used to show changes across the analyzed years. second, chi-square and t-tests were conducted to assess whether independent and control variables differ significantly on two attitudes. finally, three sets of binary logistic regression models were run to identify main sociodemographic determinants of hiv-related discriminatory attitudes among women aged 15-49 years in tajikistan. model 1 displayed the logistic regression predicting tolerant attitudes towards plwha by three key independent measures: knowledge of hiv/aids prevention, myths about hiv/aids transmission, and having ever had an hiv/aids test. model 2 added demographic characteristics. model 3 built upon the previous model while controlling for socioeconomic characteristics. stata 14 was used for all analyses. results figure 1 presents the change in attitudes towards plwha from 2000 to 2005. the percentages of women who did not express discriminatory attitudes have increased insignificantly for both questions/scenarios beteween 2000 and 2005. the change was slightly higher for respondents who believed that an hiv-positive teacher should continue teaching (1.31%) than for respondents who would not buy food from an hivpositive cashier (1.02%). 16.31 8.09 17.62 9.11 0 2 4 6 8 10 12 14 16 18 20 should teacher with hiv/aids be allowed to teach in school would buy food from shopseller with hiv/aids t ol er an t a tt itu de s t ow ar ds p l w h a notes: source: mics 2000, 2005. proportions (%) are given for answer "yes." 2000 2005 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.349|http://cajgh.pitt.edu characteristics should teacher with hiv/aids be allowed to teach in school would buy food from shopseller with hiv/aids knowledge of hiv/aids prevention yes no myths about hiv/aids transmission do not endorse myths endorse myths ever had hiv/aids test yes no age in years (range: 15-49) marital status currently married not married region of residence dushanbe khatlon sogd drd gbao residence type urban rural education else higher household income low medium high n percent *** 19.79% 11.58% *** 19.66% 4.64% *** 25.14% 17.08% 30.21 9.69 *** 14.96% 23.66% *** 27.84% 13.60% 11.84% 8.09% 23.07% *** 24.65% 12.32% *** 13.80% 33.78% *** 9.32% 13.35% 24.97% 5,453 17.88% ** 9.58% 7.17% *** 10.07% 1.24% *** 14.23% 8.45% 29.64 9.73** *** 6.73% 13.55% *** 11.88% 9.07% 4.98% 3.18% 14.58% *** 11.76% 6.78% *** 7.37% 15.45% *** 5.75% 6.65% 12.14% 5,453 9.02% notes: means and standard deviations are presented for continuous variables; proportions (%) are presented for categorical variables. proportions are given for answer “yes.” t-tests are used to assess significant differences between means for continuous variables; χ2 are used for categorical variables *p ≤ .05, **p ≤ .01, ***p ≤ .001. table 1. proportion of respondents showing positive attitudes, mics 2000, 2005 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.349|http://cajgh.pitt.edu table 1 presents descriptive statistics for all variables used in the study. overall, less than one in five (17.88%) respondents believed that an hiv-positive teacher should be allowed to teach. only one in ten (9.02%) said that they would buy food from an hivpositive cashier. significant differences in tolerance towards plwha were observed on all measures, except for the age variable on allowing an hiv-positive teacher to teach in school. significantly higher proportions of respondents who knew about hiv/aids prevention and transmission methods and had ever been tested for hiv/aids said that an hiv-positive teacher should continue teaching and that they would buy food from an hiv-positive cashier. compared to respondents from other regions of the country, significantly higher proportions of respondents from the capital city of dushanbe and gbao had positive attitudes to hivinfected teachers and cashiers. significantly higher proportions of unmarried women and those who live in urban areas expressed less discriminatory attitudes compared to their married and rural dweller comparisons. for example, the percentage of urban respondents who believed that an hiv-positive teacher should continue teaching was twice as high (24.65%) in comparison to those from rural areas (12.32%). additionally, the proportion of women who showed less hiv discriminatory attitudes had higher socioeconomic status characteristics. table 2 reports results from the three sets of binary logistic regression models. as the baseline models (columns 1 on both panels) indicated, all three key independent measures were strong predictors of stigmatizing attitudes, except for the insignificant association between knowledge of hiv/aids prevention and buying food from an hiv positive cashier. women who had knowledge on hiv/aids prevention methods, correctly identified myths about hiv/aids transmission, and had ever been tested for hiv/aids, were respectively 1.63, 4.45, and 1.46 (p≤0.001) times more likely than their counterparts to believe that an hiv-positive teacher should continue teaching. similarly, women who did not endorse myths and had an hiv/aids test before, were over eight (or=8.36, p≤0.001) and near two times (or=1.74, p≤0.001) more likely to buy food from an hiv-positive cashier. no substantial changes occurred once demographic and socioeconomic status characteristics were introduced in models 2 and 3. overall, the effects of three key predictors of stigmatization attitudes persisted in these models (columns 2 and 3 on both panels). a noticeable difference was observed with respondents who had an hiv/aids test. the magnitudes of effects for these respondents who believe that an hivpositive teacher should continue teaching attenuated by 10% and further 5% with the introduction of demographic and socioeconomic measures respectively, turning the previously highly significant estimate (or=1.46, p≤0.001) into significant (or=1.31, p≤0.05) and marginally significant (or=1.24, p≤0.10) when comparing the coefficients in model 1 to model 2 and model 2 to model 3. the introduction of the demographic characteristics increased the magnitudes of effects nearly by 5%, turning the highly significant estimate into significant (or=1.74, p≤0.001 vs or=1.82, p≤0.05), whereas the inclusion of socioeconomic controls decreased the magnitudes and returned the estimate to highly significant (or=1.82, p≤0.05 vs or=1.76, p≤0.001). there was no association between age and discriminatory attitudes. marital status and rural location were negatively associated, whereas education and household income were positively associated with discriminatory attitudes. on the first outcome (an hivpositive teacher should continue teaching in school), women living in the capital city of dushanbe were less likely to report discriminatory attitudes than respondents from all regions of the country, except for gbao. similar associations were observed on the second outcome (buying food from an hiv-positive shopseller), http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.349|http://cajgh.pitt.edu should teacher with hiv/aids be allowed to teach in school would buy food from shopseller with hiv/aids model 1 model 2 model 3 model 1 model 2 model 3 knowledge of hiv/aids prevention myths about hiv/aids transmission hiv/aids test (yes) age (range: 15-49) currently married (ref. not married) khatlon (ref. dushanbe) sogd (ref. dushanbe) drd (ref. dushanbe) gbao (ref. dushanbe) rural (ref. urban) higher education (ref. other) medium income (ref. low income) high income household (ref. low income) year 2005 1.63*** (1.34-1.97) 4.45*** (3.05-6.47) 1.46*** (1.16-1.83) 1.08 (0.88-1.31) 0.03*** 1.61*** (1.32-1.98) 3.45*** (2.36-5.05) 1.31* (1.04-1.67) 1.01 (0.95-1.07) 0.60*** (0.50-0.72) 0.64*** (0.49-0.84) 0.60*** (0.48-0.76) 0.44*** (0.32-0.61) 1.43** (1.13-1.82) 0.54*** (0.44-0.65) 0.85 (0.69-1.05) 0.09*** 1.51*** (1.23-1.85) 3.04*** (2.07-4.45) 1.24+ (.98-1.58) .98 (0.92-1.04) 0.66*** (0.54-0.79) 0.79+ (0.59-1.04) 0.69** (0.54-0.87) 0.50*** (0.36-0.70) 1.47** (1.15-1.88) 0.74** (0.59-0.92) 2.05*** (1.73-2.43) 1.14 (0.89-1.46) 1.55*** (1.19-2.02) 0.99 (0.80-1.23) 0.08*** 1.15 (0.911.47) 8.36*** (4.13-16.94) 1.74*** (1.31-2.32) 1.20 (0.92-1.57) 0.01*** 1.23 (0.95-1.58) 5.87*** (2.89-11.95) 1.82* (1.35-2.46) 1.01 (0.94-1.09) 0.49*** (0.39-0.63) 1.20*** (0.86-1.69) 0.69* (0.50-0.94) 0.49** (0.30-0.80) 2.25*** (1.66-3.06) 0.55*** (0.43-0.71) 0.87 (0.66-1.16) 0.02*** 1.17 (0.91-1.52) 5.39*** (2.65-10.98) 1.76*** (1.30-2.38) 0.99 (0.91-1.07) 0.53*** (0.41-0.67) 1.40+ (0.99-1.98) 0.75* (0.54-1.04) 0.54* (0.33-0.89) 2.35*** (1.73-3.19) 0.71* (0.54-0.95) 1.52*** (1.22-1.91) 0.87 (0.63-1.19) 1.30 (0.93-1.82) 0.96 (0.72-1.28) 0.02*** notes: effect estimates are presented as odds ratios. confidence intervals are given in parentheses. +p < 0.10, *p ≤ 0.05, **p ≤ 0.01, ***p ≤ 0.001. table 2. binary logistic regression predicting positive attitudes towards people living with hiv/aids, mics 2000, 2005 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.349|http://cajgh.pitt.edu where women from khatlon joined women from gbao in reporting less discriminatory attitudes than women from dushanbe. discussion using a nationally representative sample, the study aimed to identify sociodemographic determinants of hiv-related discriminatory attitudes of women aged 15-49 in tajikistan, as well as to examine changes over time. over five years, changes in women’s attitudes occurred insignificantly or at very low rates. the shortage of hiv/aids awereness program and incentives for voluntary hiv testging, due to the slow recovery of the country following a five-year civil war from 1992-1997, might account for such low and insignificant changes. the key finding of the study, demonstrating that women’s knowledge of hiv prevention and transmission methods and hiv testing are significant predictors of tolerant attitudes towards plwha, supports this assertion. the the association remained significant even after controlling for demographic and socioeconomic status characteristics. prior research indicates that during the period of 20002005 there was a two-fold increase in general knowledge about hiv/aids, accompanied by a substantial decrease in the ability to correctly identify prevention methods and transmission misconceptions among women of reproductive age in tajikistan.3 with the availability of next waves of the survey, the study should be replicated to continue monitoring changing trends of discriminatory attitudes towards plwha. some positive changes were shown by recent studies. according to the 2007 national study, the percentages of people who believed that an hiv-infected teacher should be allowed to teach and that they would buy food from an hiv-positive vendor were 39.4% and 23.3% respectively.2 the findings on the first two main predictors are consistent with numerous previous studies.12,13,14 concerning the third predictor, the finding corroborates with some studies that found negative association between the probability of being tested and hiv stigmatizing attitudes10,11,12 and contradicts others that demonstrated that hiv testing was not a significant factor in achieving positive attitudes towards plwha.13 our findings suggests the importance of hiv testing in reducing discriminatory attitudes. efforts should be made towards programs that promote and encourage voluntary hiv testing. debilitating fear of encountering discrimination affects negatively women’s intentions, whereas health education on hiv counselling and testing increases their willingness to test for hiv.17 consistent with previous research, it was found that women’s tolerant attitudes were positively associated with education, high income, and urban residency.12,16 women in poverty, less educated, and from rural areas were found to be more likely to express discriminatory attitudes towards plwha. with the exception of women from gbao, respondents from other regions reported higher rates of discriminatory attitudes than those from the capital. this could be linked to high rates of education among the gbao women. these women participate more actively in household decisions, have higher rates of modern contraceptives use, highest median age at first marriage, and more advanced median age at first birth,18 which are comparable to women with higher education. the finding on significance of marital status is consistent with previous research.15 married women were more likely to report discriminatory attitudes. an explanation can be sought in fear related to aids.15 tajikistan has an estimated one million male labor migrants who are “likely to have unprotected contacts with sex workers and return home without hiv testing.”6 fear concerning contracting the disease might shape negative attitudes of married women whose husbands construct the backbone of labor migrant force of the country. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.349|http://cajgh.pitt.edu the study has several limitations. first, the mics survey focuses on women’s attitudes towards plwha, as this study has not collected data from people experiencing discriminatory acts. prior research demonstrates a weak relationship between attitudes and discrimination.19,20 future surveys should include questions that measure plwha’s own perceptions of hiv-related discrimination. a significantly negative impact of perceived hiv stigma on quality of plwha’s both physical and psychosocial dimensions of life has been demonstrated by previous research.21 second, since the data focus primarily on female respondents, it is not possible to identify gender differences in attitudes towards people living with hiv/aids. prior studies show that men express discriminatory attitudes towards hiv-infected people at higher rates than women.12 third, the data do not reveal socioeconomic status of plwha. studies demonstrate that discriminatory attitudes are more austere towards marginalized groups, such as homosexual men, sex workers, and injection drug users who engaged in behaviors that potentially led to the disease.9 finally, since the current mics surveys on tajikistan were conducted 14 and 19 year ago, applicability of such data to current situation can raise questions. with the emergence of new data, the study should be replicated to demonstrate evolution of attitudes over the current period. although worldwide advances in medicine, technology, and treatment have transformed hiv into a managed and chronic disease, pervasiveness and harmful consequences of hiv-related discrimination remain acute. combatting negative attitudes towards plwha to ensure that plwha enjoy their human rights, maintain a good quality of life, and continue to be productive local and global citizens is an essential component of the global hiv response toward the creation of an aids-free generation. while local communities, national governments, and international organizations around the globe employ policies and implement programs to reduce hiv-related discrimination, empirical studies identifying effective interventions to guide such policies are crucial. the data from tajikistan underscore the persistence of hiv-related discriminatory attitudes among women of reproductive age. consistent with previous research, lack of adequate knowledge on hiv/aids prevention and transmission methods and restraining practices on hiv testing are shown to be powerful factors that shape negatively women’s attitudes towards plwha. the study suggests the need for programs that promote voluntary hiv-testing, raise awareness about hiv/aids prevention methods, and help dispelling transmission misconceptions aimed at reduction of hiv-related discrimination. these findings also call for designing and implementing comprehensive interventions for women who are in poverty, married, live in rural areas, and less educated to change their attitudes towards plwha. given the importance of reducing hiv-related discrimination worldwide, the findings from tajikistan could inform policy interventions in the former soviet central asian countries with similar sociopolitical background and economic transformation, as well as in other countries across the world with low hiv prevalence. references 1. unaids. world aids day report 2012. geneva: unaids; 2012. 2. src (strategic research center under president of tajikistan). national study on the stigmatization and forms of discrimination against people living with hiv, 2007. dushanbe, tajikistan: strategic research center under president of tajikistan; 2007. 3. zainiddinov h, habibov n. trends and predictors of knowledge about hiv/aids and its prevention and transmission methods among women in tajikistan. european journal of public health 2016; 26(6):1075-9. 4. zainiddinov h, habibov n. a comparison of comprehensive hiv/aids knowledge among women across seven post-soviet countries. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx zainiddinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.349|http://cajgh.pitt.edu central asian journal of global health 2018; 7(1) doi: 10.5195/cajgh.2018.295|http://cajgh.pitt.edu. 5. latypov a. two decades of hiv/aids in tajikistan: reversing the tide or the coming of age paradigm? china and eurasia forum quarterly 2008; 6(3):101-28. 6. golobof a, weine s, bahromov m, luo j. the roles of labor migrants’ wives in hiv/aids risk and prevention in tajikistan. aids care 2011; 23:91–7. 7. ssa (state statistical agency of the republic of tajikistan). tajikistan multiple indicator cluster survey 2000. dushanbe, tajikistan: state statistical agency of the republic of tajikistan; 2000. 8. scs (state committee on statistics of the republic of tajikistan). tajikistan multiple indicator cluster survey 2005. dushanbe, tajikistan: state committee on statistics of the republic of tajikistan; 2007. 9. herek gm, capitanio jp, widaman kf. hivrelated stigma and knowledge in the united states: prevalence and trends, 1991–1999. american journal of public health 2002;92(3):371–7. 10. genberg bl et al. a comparison of hiv/aidsrelated stigma in four countries: negative attitudes and perceived acts of discrimination towards people living with hiv/aids. social science & medicine 2009; 68(12):2279–87. 11. young sd et al. hiv-related stigma, social norms, and hiv testing in soweto and vulindlela, south africa: national institutes of mental health project accept (hptn 043). journal of acquired immune deficiency syndrome 2010; 55(5):620-4. 12. corno l, de walque d. socioeconomic determinants of stigmatization and hiv testing in lesotho. aids care 2013; 25(1):108-13. 13. mutombo n, maina b. factors influencing attitudes towards people living with hiv/aids in zambia: does hiv testing matter? j infect dis ther 2014; 3:197. 14. terzic-supic z et al. cross sectional study on attitudes of serbian mothers with preschool children: should a hiv-positive female teacher be allowed to continue teaching in school? bmc international health and human rights 2015; 15:31. 15. lau jft, tsui hy. discriminatory attitudes towards people living with hiv/aids and associated factors: a population based study in chinese general population. sex transm infect 2005; 81:113–9. 16. gurmu e, etana d. hiv/aids knowledge and stigma among women of reproductive age in ethiopia. african journal of aids research 2015; 14(3):191-9. 17. adeneye ak et al. willingness to seek hiv testing and counseling among pregnant women attending antenatal clinics in ogun state, nigeria. international quarterly of community health education 2006; 26(4):337–53. 18. statistical agency, republic of tajikistan, and icf international. 2012 tajikistan demographic and health survey: key findings. dushanbe, tajikistan and calverton, maryland, usa: statistical agency (tajikistan), and icf international; 2013. 19. lapiere rt. attitudes vs. actions. social forces 1934; 13:230–7. 20. eagly a, chaiken s. the impact of attitudes on behavior. in: eagly a, chaiken s, youngblood d, editors. the psychology of attitudes, new york: harcourt; 1993, p. 155-281. 21. holzemer wl et al. exploring hiv stigma and quality of life for persons living with hiv infection. j assoc nurses aids care 2009; 20(3):161–8. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.cabdirect.org/cabdirect/search/?q=au%3a%22coates%2c+t.%22 trends and determinants of attitudes towards people living with hiv/aids among women of reproductive age in tajikistan abstract keywords: tajikistan; hiv/aids; discriminatory attitudes; women; plwha trends and determinants of attitudes towards people living with hiv/aids among women of reproductive age in tajikistan research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. cannabis and amphetamine use among adolescents in five asian countries karl peltzer1,2, supa pengpid2,3 1hiv/aids/stis/and tb (hast), human sciences research council, pretoria, south africa; 2department of research and innovation, university of limpopo, turfloop, south africa; 3asean institute for health development, mahidol university, salaya, phutthamonthon, nakhonpathom, thailand vol. 6, no. 1 (2017) | issn 2166-7403 (online) doi 10.5195/cajgh.2017.288 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ peltzer this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.288|http://cajgh.pitt.edu abstract introduction: there has been a global increase in illicit drug use among young people. the aim of this study was to estimate the prevalence of lifetime cannabis and amphetamine use, as well as to explore factors associated with substance use among adolescents in five asian countries: iraq, kuwait, malaysia, mongolia, and vietnam. methods: 38,941 school children (mean age 15.4 years, sd=1.5) completed the cross-sectional global school-based student health survey (gshs). topics covered in the questionnaire included cannabis and amphetamine use. personal, parental, and environmental attributes were explored as predictors of cannabis and amphetamine use. logistic regression was used to assess the contribution of potential predictors on lifetime cannabis and lifetime amphetamine use. results: overall, the prevalence of lifetime cannabis use was 0.9% and lifetime amphetamine use was 1.0% among research participants. cannabis use was influenced by male gender (kuwait, mongolia), parental smoking habits (kuwait, iraq), and current cigarette smoking in all countries. amphetamine use was associated with suicidal ideation (kuwait, malaysia, vietnam), school truancy (malaysia, mongolia, vietnam), being a victim of physical assault (kuwait, mongolia), bullying victimization (iraq, malaysia, vietnam), as well as anxiety and current cigarette use in all countries. conclusions: our preliminary results show the importance of personal attributes such as mental distress and environmental stressors on lifetime cannabis and lifetime amphetamine use. future prospective studies are needed to identify causal relationships among personal attributes, parental attributes, environmental stressors, and illicit substance use. keywords: cannabis use; amphetamine use; adolescents; asia cannabis and amphetamine use among adolescents in five asian countries karl peltzer1,2, supa pengpid2,3 1hiv/aids/stis/and tb (hast), human sciences research council, pretoria, south africa; 2department of research and innovation, university of limpopo, turfloop, south africa; 3asean institute for health development, mahidol university, salaya, phutthamonthon, nakhonpathom, thailand research previous research suggested that substance use among youth under the age of 24 may have negative effects on cognitive and emotional development in the transition from adolescence to early adulthood.1 the initiation of substance use usually takes place during adolescence, mostly in the form of tobacco and alcohol use prior to the use of illicit drugs.1 a recent review reported that the global burden of disease attributable to substance use among adolescents and young adults has substantially increased.1 there are significant gaps in the literature regarding epidemiological data on the extent of illicit drug use among adolescents in asia, which we are addressing in this paper. the world health organization (who), in collaboration with the centers of disease control and prevention (cdc) and national governments, have been conducting global school-based health survey (gshs) in various asian countries to generate epidemiological http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.288|http://cajgh.pitt.edu data on health behaviors, including illicit drug use.2 since 2010, a new module on cannabis and amphetamine use was added to gshs, which was implemented in iraq and kuwait in the middle east, in mongolia in central asia, and in malaysia and vietnam in southeast asia.2 based on the who atlas on substance use disorders,3 the estimated 12-month prevalence of drug use disorders in 2004 was 0.24% among women (15 years and over) and 0.66% among men (15 years and over) in iraq. for mongolia, the prevalence was 0.15% among women and 0.61% among men, and for vietnam it was 0.10% among women and 0.47% among men.3 alhemiary et al.4 reported that there was an increase in illicit drug use, including cannabis (in the form of hashish) and methamphetamines in iraq in the decade prior to 2012. in a study among male university students in kuwait, the prevalence of lifetime illicit drug use was 14.4%.5 in previous national school surveys, lifetime cannabis use was 1.5% among males and 0.4% among females (aged 12-19 years) in malaysia,6 and the prevalence of lifetime illicit drug use among adolescents (12-19 years) was 1.7% in malaysia.7 in a local survey in malaysia conducted in 1979, spencer and navaratnam8 found that 11% of secondary students (12-19 years) had prior experience of drug use (mostly cannabis). in vietnam, amphetamine use continues to increase, especially among adolescents in major cities.9 in a previously published systematic review of cannabis use in high school and college students (≤18 years) in iran, the prevalence of lifetime cannabis use was 5.0% (95% ci = 3.0%,7.0%).10 in a study focusing on high school students (mean age 15.0 years, sd=3.7) in eastern india, the lifetime illicit drug use was 6.1% among rural and 0.6% among urban students.11 lifetime illicit drug use was reported to be 7.9% among adolescents (15-18 years) attending primary health care centers in saudi arabia.12 in 38 european and north american countries, 19.9% of adolescents (22.9% of males and 17.0% of females) reported lifetime cannabis use.13 among 15-16 year olds in europe, lifetime amphetamine use ranged from 1% in finland, norway and romania to 6% in bulgaria and latvia.14 only a few studies were conducted in asian countries, and information on the types of illicit drugs included in these studies was limited.15 risk factors for cannabis and/or amphetamine use among adolescents can be grouped following an ecological framework16 into 1) sociodemographic factors, 2) personal attributes, 3) parental attributes, 4) environmental stressors, and 5) peer factors. sociodemographic factors influencing drug use include male gender17,18 and age.19 personal attributes may include mental distress,20-22 smoking,7,18 school truancy,7,21 and lack of peer support.7 parental attributes may include parental substance use,23 lack of parental support, including lack of parental monitoring,7,21,24 and lack of parental connectedness.21 environmental stressors may include hunger, lower economic status,18,21,25 bullying, fighting,17,19 and aggression.26 the aim of this study was to estimate the prevalence of cannabis and amphetamine use and explore factors associated with drug use among adolescents in five asian countries. it was hypothesized that the prevalence of lifetime cannabis and amphetamine use was lower in asian countries than in europe and north america. methods participants this study was a secondary analysis of preexisting data from the gshs from five asian countries (limited to countries that utilized the cannabis and amphetamine use module). the purpose of the gshs is to provide nationally representative data on health behaviors and protective factors among students aged 1317 years.2 the gshs used a two-stage (schools and classrooms) cluster sampling design to produce nationally representative samples of students.2 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx peltzer this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.288|http://cajgh.pitt.edu variables question response options cannabis use “during your life, how many times have you used marijuana (also called hashish)?” or other country specific names 1=0 times, 2=1 or 2 times, 3=3-9 times, 4=10-19 times and 5==20 or more times (coded 1=0 and 2-5=1) “during the past 30 days, how many times have you used marijuana (also called hashish)?” or other country specific names 1=0 times, 2=1 or 2 times, 3=3-9 times, 4=10-19 times and 5==20 or more times (coded 1=0 and 2-5=1) amphetamine use “during your lifetime, how many times have you used amphetamines or methamphetamines (also called parkizol or artane)?” or other country specific names 1=0 times, 2=1 or 2 times, 3=3-9 times, 4=10-19 times and 5==20 or more times (coded 1=0 and 2-5=1) personal attributes anxiety “during the past 12 months, how often have you been so worried about something that you could not sleep at night?” 1=never to 5=always (coded 1–3=0 and 4–5=1) loneliness “during the past 12 months, how often have you felt lonely?” 1=never to 5=always (coded 1–3=0 and 4–5=1) suicidal ideation “during the past 12 months, did you ever seriously consider attempting suicide?” 1 = yes, 2 = no current smoking cigarettes “during the past 30 days, on how many days did you smoke cigarettes?” 1=0 days to 7=all 30 days (coded 1=0 and 2-7=1) school truancy “during the past 30 days, on how many days did you miss classes or school without permission?” 1=0 days to 5= 10 or more days (coded 1=0 and 2–5=1) peer support “during the past 30 days, how often were most of the students in your school kind and helpful?” 1=never to 5=always (coded 1–3=0 and 4–5=1) parental attributes either or both parents use tobacco which of your parents or guardians use any form of tobacco? 1=neither, 2=my father or male guardian, 3=my mother or female guardian parental monitoring “during the past 30 days, how often did your parents or guardians check to see if your homework was done?” 1=never to 5=always (coded 1–3=0 and 4–5=1) “during the past 30 days, how often did your parents or guardians go through your things without your approval?” 1=never to 5=always (coded 1–3=0 and 4–5=1) parental connectedness “during the past 30 days, how often did your parents or guardians understand your problems and worries?” 1=never to 5=always (coded 1–3=0 and 4–5=1) parental bonding “during the past 30 days, how often did your parents or guardians really know what you were doing with your free time? 1=never to 5=always (coded 1–3=0 and 4–5=1) environmental stressors hunger “during the past 30 days, how often did you go hungry because there was not enough food in your home?" 1 = never to 5 = always (coded 1–3=0 and 4–5=1) bullied “during the past 30 days, on how many days were you bullied?” 1=0 days to 7=all 30 days (coded 1=0 and 2–7=1) in a physical fight “during the past 12 months, how many times were you in a physical fight?” 1=0 times to 8=12 or more times (coded 1=0 and 2–8=1) physically attacked “during the past 12 months, how many times were you physically attacked?” =0 times to 8=12 or more times (coded 1=0 and 2–8=1) table 1. description of variables http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx peltzer this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.288|http://cajgh.pitt.edu students were requested to complete a self-administered questionnaire under the supervision of trained survey administrators.2 national ethics committees (e.g., in kuwait: the ministry of health; in malaysia: the medical research and ethics committee, ministry of health malaysia; in mongolia: the committee on ethics, ministry of health) approved the study protocol, and written informed consent was obtained from the students, parents, and/or school officials.2 questionnaire the gshs questionnaire (translated into the national languages of the study countries) utilized in this study consisted of modules on tobacco cannabis and amphetamine use, violence, and a range of other health related behaviors, such as hygiene and physical activity, as well as demographics such as age and gender.2 the study variables are described in table 1. statistical analysis descriptive statistics were used to describe the characteristics of participants and patterns of illicit drug use. logistic regression was used for assessing the contribution of potential predictors (sociodemographic factors such as age and gender, personal attributes such as anxiety and current smoking, parental attributes such as parental tobacco use and parental monitoring, and environmental stressors such as experiencing hunger and being bullied) on lifetime cannabis and lifetime amphetamine use. all analyses were adjusted for the multi-stage stratified cluster sampling strategy, and performed using stata software version 12.0 (stata corporation, college station, tx, usa). results the sample included 38,941 school-aged adolescents (mean age 15.4 years, sd=1.5), age range 11-18 years, from iraq (response rate=88%), kuwait (85%), malaysia (89%), mongolia (88%), and vietnam (response rate=96%). the range of students participating per country ranged from 2,038 in kuwait to 25,507 in malaysia. across all respondents from all countries, lifetime cannabis use was 0.9%, ranging from 0.6% in vietnam to 3.2% in kuwait, and lifetime amphetamine use was 1.0%, ranging from 0.2% in vietnam to 3.1% in kuwait. the prevalence of past month cannabis use was 2.1% in iraq, 3.1% in kuwait, 0.9% in malaysia, and 1.1% in mongolia (table 2). in multivariable unconditional regression analysis, male gender in kuwait (or=11.17, 95% ci=2.97, 42.02) and mongolia (or=2.01, ci=1.03, 3.95) was associated with lifetime cannabis use. in terms of personal attributes, anxiety (or=2.48, 95% ci=1.19, 5.20) and suicidal ideation (or=3.91, 95% ci=1.63, 9.35) in kuwait, current smoking in all five countries (or ranging from 5.25 in mongolia to 38.12 in vietnam), and school truancy (or=6.70, 95% ci=2.65, 16.96) in vietnam were positively associated with lifetime cannabis use. school truancy was negatively associated with lifetime cannabis use (or=0.35, 95% ci=0.17, 0.71) in iraq. lack of peer support (or=0.39, 95% ci=0.22, 0.68) in malaysia and having positive peer support (or=2.73, 95% ci=1.45, 5.15) in mongolia were associated with lifetime cannabis use. in relation to parental attributes, parental or guardian tobacco use in iraq (or=2.59, 95% ci=1.04, 6.47) and kuwait (or=2.13, 95% ci=1.30, 3.49) were associated with lifetime cannabis use. while lack of parental or guardian bonding (or=0.40, 95% ci=0.24, 0.68) in malaysia was associated with lifetime cannabis use, parental or guardian bonding (or=5.18, 95% ci=1.87, 14.37) in vietnam and parental or guardian monitoring (or=2.15, 95% ci=1.18, 3.90) in malaysia were positively associated with lifetime cannabis use. with environmental stressors, food insecurity (or=9.77, 95% ci=3.03, 31.56) in iraq, being bullied (or=11.26, 95% ci=1.83, 69.38) in vietnam, and having been physically attacked (or=2.14, 95% ci=1.02, 4.46) in mongolia were associated with lifetime cannabis use (table 3). http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx peltzer this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.288|http://cajgh.pitt.edu variable sample size lifetime cannabis use lifetime amphetamines use past month cannabis use country (study year) all males females all males females all n (%) n (%) n (%) n (%) n (%) n (%) n (%) iraq (2012) 2038 (2.4) 30 (3.0) 13 (1.6) (2.6) 27 (2.7) 20 (2.4) 42 (2.2) kuwait (2011) 2672 (3.2) 77 (5.7) 6 (0.4) (3.1) 61 (5.0) 8 (0.7) 80 (3.1) malaysia (2012) 25507 (0.9) 173 (1.5) 37 (0.4) (1.0) 179 (1.6) 37 (0.4) 208 (0.9) mongolia (2013) 5393 (1.3) 43 (1.8) 22 (0.8) (1.7) 43 (1.9) 36 (1.3) 53 (1.1) vietnam (2013) 3331 (0.6) 14 (6.7) 4 (1.1) (0.2) 12 (0.9) 4 (0.3) na all 38941 (0.9) 337 (1.5) 82 (0.4) (1.0) 332 (1.4) 105 (0.6) 383 (1.5) na = not assessed table 2. prevalence of drug use in five asian countries in multivariable unconditional regression analysis, male gender (or=4.76, 95% ci=1.10, 20.55) in kuwait, younger age (or=0.78, 95% ci=0.63, 0.98) in malaysia, and older age (or=1.84, 95% ci=1.07, 3.15) in vietnam were associated with lifetime amphetamine use. in terms of personal attributes, anxiety (or= ranging from 2.29 in kuwait to 3.82 in iraq), current smoking (or=ranging from 2.68 in mongolia to 17.23 in vietnam) in all countries, suicidal ideation in kuwait (or=3.19, 95% ci=1.35, 7.55), malaysia (or=2.28, 95% ci=1.26, 4.12) and vietnam (or=6.86, 95% ci=1.07, 43.91), and school truancy in malaysia (or=2.31, 95% ci=1.40, 3.81), mongolia (or=1.90, 95% ci=1.11, 3.28) and vietnam (or=9.12, 95% ci=3.06, 27.19) were associated with lifetime amphetamine use. lack of peer support (or=0.35, 95% ci=0.20, 0.62) was associated with lifetime amphetamine use in malaysia. in relation to parental attributes, no associations were found with lifetime amphetamine use. with environmental stressors, experiencing food insecurity (or=4.98, 95% ci=1.35, 18.33) in iraq, being bullied in iraq (or=5.16, 95% ci=1.55, 17.18), malaysia (or=2.51, 95% ci=1.55, 4.08) and vietnam (or=9.16, 95% ci=1.05, 79.60), and having been physically attacked in kuwait (or=2.27, 95% ci=1.14, 4.52) and mongolia (or=3.07, 95% ci=1.55, 6.07) were associated with lifetime amphetamine use (table 4). discussion in this study of school-going adolescents in five asian countries from middle east, central asia, and southeast asia the prevalence of lifetime cannabis and amphetamine use was found to be generally lower than previously reported in north america and europe,13,14 india,11 iran10 and saudi arabia,12 but was similar to previously reported results in malaysia.6,7 compared to the studied countries, the higher prevalence of cannabis and possibly amphetamine use in north america and europe may be related to a greater cannabis liberalization.13 this study demonstrated a large geographic variation in the prevalence of lifetime and past month cannabis use and lifetime amphetamine use, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx peltzer this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.288|http://cajgh.pitt.edu variable aor (95% ci) aor (95% ci) aor (95% ci) aor (95% ci) aor (95% ci) iraq kuwait malaysia mongolia vietnam sociodemographic age (years) 0.63 (0.35, 1.11) 0.99 (0.75, 1.31) 1.00 (0.80, 1.26) 0.93 (0.74, 1.17) 1.16 (0.66, 2.02) gender females (48.2%) males (51.8%) reference 0.75 (0.14, 3.91) reference 11.17 (2.97, 42.02)*** reference 1.51 (0.77, 2.99) reference 2.01 (1.03, 3.95)* reference 0.93 (0.05, 16.98) personal attributes anxiety (14.4%) 0.77 (0.29, 2.04) 2.48 (1.19, 5.20)* 1.73 (0.89, 3.36) 2.01 (0.79, 5.14) not assessed loneliness (15.3%) 2.02 (0.74, 5.50) 1.35 (0.60, 3.04) 1.91, 0.98, 3.71) 1.09 (0.45, 2.67) 1.82 (0.36, 9.23) suicidal ideation (19.1%) 2.52 (0.95, 7.05) 3.91 (1.63, 9.35)** 1.74 (0.87, 3.50) 1.46 (0.56, 3.83) 1.69 (0.29, 9.93) current smoking (8.9%) 9.20 (3.62, 23.41)*** 7.30 (2.34, 22.73)** 11.06 (5.41, 22.60)*** 5.26 (2.35, 11.81)*** 38.12 (8.02, 181.19)*** school truancy (36.6%) 0.35 (0.17, 0.71)** 1.34 (0.84, 2.13) 2.07 (0.90, 4.76) 1.86 (0.88, 3.97) 6.70 (2.65, 16.96)*** peer support (29.2%) 0.60 (0.13, 2.72) 0.65 (0.26, 1.62) 0.39 (0.22, 0.68)*** 2.73 (1.45, 5.15)** 1.41 (0.51, 3.89) parental attributes either or both parents use tobacco (21.4%) 2.59 (1.04, 6.47)* 2.13 (1.30, 3.49)** 1.03 (0.71, 1.49) 1.34 (0.65, 2.77) not assessed parental or guardian monitoring (25.6%) 0.40 (0.12, 1.32) 0.99 (0.49, 2.02) 2.15 (1.18, 3.90)* 0.69 (0.39, 1.24) 0.26 (0.04, 1.54) parental or guardian connectedness (31.9%) 1.13 (0.47, 2.75) 1.82 (0.50, 6.67) 1.02 (0.67, 1.57) 0.77 (0.29, 2.00) 0.40 (0.05, 3.42) parental or guardian bonding (36.4%) 0.22 (0.05, 1.06) 1.34 (0.66, 2.72) 0.40 (0.24, 0.68)*** 0.54 (0.28, 1.04) 5.18 (1.87, 14.37)** environmental stressors hunger (11.2%) 9.77 (3.03, 31.56)*** 1.24 (0.48, 3.21) 1.35 (0.70, 2.61) 2.87 (0.65, 12.69) not assessed bullied (45.1%) 1.25 (0.47, 3.32) 1.70 (0.60, 4.80) 1.59 (0.96, 2.61) 0.78 (0.36, 1.66) 11.26 (1.83, 69.38)** in physical fight (44.8%) 1.12 (0.33, 3.80) 1.01 (0.51, 2.00) 1.84 (0.84, 4.03) 1.33 (0.61, 2.86) 0.95 (0.37, 2.49) physically attacked (34.0%) 1.10 (0.41, 2.96) 1.43 (0.66, 3.12) 1.10 (0.64, 1.88) 2.14 (1.02, 4.46)* 0.49 (0.19, 1.26) aor = adjusted odds ratio; ci = confidence interval; ***p<0.001; **p<0.01; *p<0.05 table 3. factors associated with lifetime cannabis use http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx peltzer this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.288|http://cajgh.pitt.edu with a higher prevalence in iraq and kuwait, and lower prevalence in malaysia, mongolia, and vietnam. the higher prevalence of cannabis and amphetamine use in iraq may be explained by a high degree of exposure to environmental stressors, such as ongoing violence and unrest, as well as the experience of hunger or food insecurity. the relatively low lifetime amphetamine use in southeast asia (malaysia and vietnam) in this study may reflect a further stabilizing of the past “peak of the methamphetamine epidemic” in southeast asia.27 the low prevalence of illicit drug use in malaysia may also be attributed to school prevention programs.7 overall, the study found that a higher number of males when compared to females were lifetime cannabis users in kuwait and mongolia. lifetime amphetamine use among males in kuwait was higher in males. there was no significant gender difference in the other countries, which is an interesting finding. the role of gender in substance abuse requires further investigation28, as unodc29 noted that the “gender gap (i.e. the difference between the prevalence of substance use among males and females) has in fact been closing.” the gender difference in kuwait and mongolia may reflect stronger gender role differences that predispose men to engage in substance use behavior when compared with iraq, malaysia, and vietnam.20 the study found that adolescents who were current smokers were more likely to be lifetime amphetamine users. this seems to indicate that certain problem behaviors may become a trend during adolescence, and the use of one drug may lower the barriers of taking another drug.30 poly-drug use (tobacco use and cannabis and/or other drugs) has also been reported by previous studies18,31,32 and suggests the need for poly-drug use interventions. when it comes to personal attributes, mental distress (anxiety and suicidal ideation) and school truancy were found to be associated with cannabis and amphetamine use in several countries that we investigated, corroborating previous studies in malaysia and africa.7,19-21 having mental distress may increase adolescents’ vulnerability to drug use.16 adolescents who are mentally distressed may use cannabis and/or amphetamine to alter their well-being,33 or they may want to cope with mental distress by using illicit drugs.20 illicit drug use or school truancy may be seen as a marker of other deviant behaviors, which may lead to a greater likelihood of experimenting with cannabis and/or amphetamine use outside of school settings.34 in agreement with a previous study,5 this study found an association between lack of peer support and cannabis and amphetamine use in malaysia, but not in the other countries. strong peer relations or support may help to protect from illicit drug use. regarding parental attributes, this study corroborated a study from ghana,23 suggesting that parental tobacco use was associated with lifetime cannabis use. parents play an important role in the formation of norms and practices among adolescents.35 adolescents are more likely to engage in similar behavior as their parents when it comes to substance abuse behaviors.35 although parental or guardian monitoring and/or bonding was protective from cannabis use in malaysia, none of the parental support measures were protective in relation to lifetime amphetamine use, unlike in findings from previous investigations.7,21,24 parental monitoring and bonding behavior may demonstrate concern and support, which may prevent children from the development of illicit drug use habits.23 in agreement with previous studies,17-19,21 this study found that environmental stressors, including experiencing hunger (or low socioeconomic status), being bullied and having been physically attacked, were associated with lifetime cannabis and/or amphetamine use in several countries. it is possible that adolescents who experience various forms of environmental stressors are more likely to associate themselves with deviant http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx peltzer this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.288|http://cajgh.pitt.edu variable aor (95% ci) aor (95% ci) aor (95% ci) aor (95% ci) aor (95% ci) iraq kuwait malaysia mongolia vietnam sociodemographic age (years) 0.75 (0.51, 1.10) 0.86 (0.59, 1.26) 0.78 (0.63, 0.98)* 1.02 (0.82, 1.26) 1.84 (1.07, 3.15)* gender females (48.2%) males (51.8%) reference 0.88 (0.20, 4.08) reference 4.76 (1.10, 20.55)* reference 1.47 (0.75, 2.90) reference 0.92 (0.52, 1.64) reference 2.78 (0.10, 79.01) personal attributes anxiety (14.4%) 3.82 (1.08, 13.50)* 2.29 (1.68, 3.14)*** 2.52 (1.36, 4.66)** 2.82 (1.36, 5.86)** not assessed loneliness (15.3%) 0.76 (0.13, 4.55) 1.06 (0.58, 1.94) 1.71 (0.90, 3.25) 0.91 (0.40, 2.06) 0.91 (0.16, 5.18) suicidal ideation (19.1%) 1.28 (0.30, 5.50) 3.19 (1.35, 7.55)* 2.28 (1.26, 4.12)** 1.32 (0.67, 2.62) 6.86 (1.07, 43.91)* current smoking (8.9%) 6.66 (2.03, 15.74)** 5.97 (2.92, 12.20)*** 5.73 (3.47, 0.48)*** 2.68 (1.28, 5.62)** 17.23 (3.07, 96.77)** school truancy (36.6%) 0.63 (0.27, 1.49) 1.36 (0.89, 2.08) 2.31 (1.40, 3.81)*** 1.90 (1.11, 3.28)* 9.12 (3.06, 27.19)*** peer support (29.2%) 0.48 (0.16, 1.45) 0.87 (0.35, 2.13) 0.35 (0.20, 0.62)*** 1.32 (0.50, 3.48) 2.27 (0.64, 7.98) parental attributes either or both parents use tobacco (21.4%) 1.87 (0.76, 4.59) 1.74 (0.87, 3.49) 0.95 (0.62, 1.44) 1.35 (0.73, 2.49) not assessed parental or guardian monitoring (25.6%) 0.74 (0.25, 2.22) 0.99 (0.56, 1.78) 1.70 (0.95, 3.05) 0.62 (0.30, 1.30) 0.59 (0.05, 6.77) parental or guardian connectedness (31.9%) 0.40 (0.06, 2.59) 1.40 (0.51, 3.88) 0.77 (0.42, 1.40) 0.35 (0.10, 1.28) 0.13 (0.01, 3.09) parental or guardian bonding (36.4%) 0.45 (0.07, 2.98) 1.07 (0.52, 2.24) 0.65 (0.38, 1.14) 0.80 (0.36, 1.78) 3.62 (0.80, 16.37) environmental stressors hunger (11.2%) 4.98 (1.35, 18.33)* 1.15 (0.39, 3.43) 1.35 (0.51, 3.56) 0.88 (0.10, 7.56) not assessed http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx peltzer this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.288|http://cajgh.pitt.edu bullied (45.1%) 5.16 (1.55, 17.18)** 2.20 (0.63, 7.77) 2.51 (1.55, 4.08)*** 1.13 (0.55, 2.34) 9.16 (1.05, 79.60)* in physical fight (44.8%) 1.16 (0.38, 3.51) 0.97 (0.38, 2.51) 1.72 (0.99, 2.99) 2.05 (0.93, 4.53) 0.94 (0.15, 5.72) physically attacked (34.0) 0.62 (0.27, 1.43) 2.27 (1.14, 4.52)* 1.26 (0.77, 2.07) 3.07 (1.55, 6.07)** 0.55 (0.08, 3.56) aor = adjusted odds ratio; ci = confidence interval; ***p<0.001; **p<0.01; *p<0.05 table 4. factors associated with lifetime amphetamine use peers in trying to cope with a stressful environment, and thus more likely engage in illicit drug use.16 due to the cross-sectional study design, causal inferences cannot be made. further, the self-report of illicit cannabis and amphetamine use may be interpreted with caution because of poor memory recall and possibly underreporting of illicit drug use. moreover, several indicators, such as anxiety and loneliness were only measured with single question items, which has its limitations. some of the variables (anxiety, parental tobacco use, and food insecurity) assessed in the gshs were not available for all the countries our study was focusing on, which need to be further investigated. this study found that relatively low proportion of adolescents in five asian countries engage in cannabis and amphetamine use, and identified various risk factors associated with its use. our findings contribute to the body of knowledge on illicit drug use among adolescents in asian countries, which can facilitate effective global policy responses. school health policy and interventions should target the prevention of cannabis and amphetamine use, while taking into account environmental stressors and personal attributes such as anxiety and school truancy. translational research may help in identifying the risk factors most amenable to address or change in the future public health interventions focusing on reduction in illicit drug use. future prospective studies are needed to identify causal relationships among personal attributes, parental attributes, environmental stressors, and illicit substance use. acknowledgements we thank the world health organization for making the data available for analysis, and the ministries of education and health. we also would like to thank the study participants for making the gshs possible. references 1. degenhardt l, stockings e, patton g, hall wd, lynskey m. the increasing global health priority of substance use in young people. lancet psychiatry. 2016;3(3): 251-64. 2. centers for disease control and prevention (cdc). global schoolbased student health survey (gshs), 2017. available at: https://www.cdc.gov/gshs/ (accessed december 4, 2017). 3. world health organization (who). atlas on substance use: resources for the prevention and treatment of substance use disorders, 2010. available at: http://www.who.int/substance_abuse/activities/atlas/en/ (accessed december 4, 2017) 4. al-hemiary nj, al-diwan jk, hasson al, rawson ra. drug and alcohol use in iraq: findings of the inaugural iraqi community epidemiological workgroup. subst use misuse. 2014;49(13):175963. 5. bajwa hz, al-turki as, dawas am, behbehani mq, al-mutairi am, al-mahmoud s, shukkur m, thalib l. prevalence and factors associated with the use of illicit substances among male university students in kuwait. med princ pract. 2013;22(5):458-63. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.288|http://cajgh.pitt.edu 6. howard j, ali h. cannabis use among young people in pacific island countries and territories. aust n z j public health. 2014;38(1):89-90. 7. yusoff f, sahril n, rasidi nm, zaki na, muhamad n, ahmad n. illicit drug use among school-going adolescents in malaysia. asia pac j pub health. 2014, 26(5 suppl), 100s-7s. 8. spencer c, navaratnam v. patterns of drug use amongst malaysian secondary schoolchildren. drug alcohol depend. 1980;5(5):379-91. 9. united nations office on drugs and crime (unodc). patterns and trends of amphetamine-type stimulants and other drugs: challenges for asia and the pacific. vienna: unodc, 2013. available at: https://www.unodc.org/documents/scientific/2013_regional_ats_re port_web.pdf (accessed december 4, 2017) 10. nazarzadeh m, bidel z, mosavi jarahi a, et al. prevalence of cannabis lifetime use in iranian high school and college students: a systematic review, meta-analyses, and meta-regression. am j mens health. 2015;9(5):397-409. 11. tsering d, pal r, dasgupta a. licit and illicit substance use by adolescent students in eastern india: prevalence and associated risk factors. j neurosci rural pract. 2010;1(2):76-81. 12. aleissa ei. the frequency of health-related behaviors among saudi adolescents visiting primary health care centers in riyadh city. j family community med. 2001;8(1):19-26. 13. shi y, lenzi m, an r. cannabis liberalization and adolescent cannabis use: a cross-national study in 38 countries. plos one. 2015;10(11):e0143562. 14. united nations office on drugs and crime (unodc). world drug report 2010. vienna: unodc, 2010. available at: https://www.unodc.org/documents/wdr/wdr_2010/world_drug_rep ort_2010_lo-res.pdf (accessed december 4, 2017) 15. yi s, peltzer k, pengpid s, susilowati ih. prevalence and associated factors of illicit drug use among university students in the association of southeast asian nations (asean). subst abuse treat prev policy. 2017;12(1):9. 16. brook js, morojele nk, pahl k, brook dw. predictors of drug use among south african adolescents. j adolesc health. 2006;38(1):26-34. 17. sznitman sr, kolobov t, bogt tt, kuntsche e, walsh sd, boniel-nissim, harel-fisch, y. exploring substance use normalization among adolescents: a multilevel study in 35 countries. soc sci med, 2013;97:143-51. 18. tu aw, ratner pa, johnson jl. gender differences in the correlates of adolescents’cannabis use. subst use misuse. 2008;43(10):1438-63. 19. siziya s, muula as, besa c, babaniyi o, songolo p, kankiza n, rudatsikira e. cannabis use and its socio-demographic correlates among in-school adolescents in zambia. ital j pediatr. 2013; 39:13. 20. alwan h, viswanathan b, rousson v, paccaud f, bovet p. association between substance use and psychosocial characteristics among adolescents of the seychelles. bmc pediatrics. 2011; 11:85. 21. peltzer k. prevalence and correlates of substance use among school children in six african countries. int j psychol. 2009;44(5): 378-86. 22. plüddemann a, flisher aj, mcketin r, parry cd, lombard cj. a prospective study of methamphetamine use as a predictor of high school non-attendance in cape town, south africa. subst abuse treat prev policy. 2010; 5: 25. 23. asiseh f, owusu a, quaicoe o. an analysis of family dynamics on high school adolescent risk behaviors in ghana. j child adolesc subst abuse. 2017; 5: 425-431. 24. rudatsikira e, maposa d, mukandavire z, muula as, siziya s. prevalence and predictors of illicit drug use among school-going adolescents in harare, zimbabwe. ann afr med. 2009;8(4): 215-20. 25. peltzer k, pengpid s. cannabis use and its social correlates among in-school adolescents in algeria, morocco, palestine, peru, and tonga. mediterranean j soc sci. 2014;5(9): 558-563. 26. plüddemann a, flisher aj, mcketin r, parry c, lombard, c. methamphetamine use, aggressive behavior and other mental health issues among high-school students in cape town, south africa. drug alcohol depend. 2010; 109(1-3):14-9. 27. mcketin r, kozel n, douglas j, ali r, vicknasingam b, lund j, li jh. the rise of methamphetamine in southeast and east asia. drug alcohol rev. 2008;27(3):220-8. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx peltzer this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.288|http://cajgh.pitt.edu 28. saban a, flisher aj, distiller g. association between psychopathology and substance use among school-going adolescents in cape town, south africa. j psychoactive drugs. 2010;42(4): 46776. 29. united nations office on drugs and crime (unodc). guidelines on drug prevention and treatment for girls and women. vienna: unodc, 2016. available at: https://www.unodc.org/documents/drug-prevention-andtreatment/unodc_2016_drug_prevention_and_treatment_for_girls_and _women_e.pdf (accessed december 4, 2017) 30. suerken ck, reboussin ba, sutfin el, wagoner kg, spangler j, wolfson m. prevalence of marijuana use at college entry and risk factors for initiation during freshman year. addict behav. 2014;39(1):302–7. 31. degenhardt l, coffey c, moran p, carlin jb, patton gc. the predictors and consequences of adolescent amphetamine use: findings from the victoria adolescent health cohort study. addiction. 2007;102(7):1076-84. 32. agrawal a, budney aj, lynskey mt. the co-occurring use and misuse of cannabis and tobacco: a review. addiction. 2012;107(7): 1221-33. 33. baumann m, spitz e, predine r, choquet m, chau n. do male and female adolescents differ in the effect of individual and family characteristics on their use of psychotropic drugs? eur j pediatr. 2007;166(1):29-35. 34. siziya s, muula as, rudatsikira e 2007. prevalence and correlates of truancy among adolescents in swaziland: findings from the global school-based health survey. child adoles psychiatry ment health, 1(1): 15. 35. kuntsche en, kuendig h. what is worse? a hierarchy of familyrelated risk factors predicting alcohol use in adolescence. subst use misuse. 2006;41(1):71-86. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cannabis and amphetamine use among adolescents in five asian countries abstract keywords: cannabis use; amphetamine use; adolescents; asia cannabis and amphetamine use among adolescents in five asian countries research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. healthcare access experiences among indigenous women in northern rural thailand: a focused ethnographic study onouma thummapol1, sylvia barton2, tanya park1 1university of alberta, canada; 2university of northern british columbia, canada vol. 7, no. 1 (2018) | issn 2166-7403 (online) doi 10.5195/cajgh.2018.328 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ thummapol this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu abstract introduction: persistent inequities in health and access to healthcare services for indigenous women living in thailand remain a significant challenge. this study provides narrative accounts of indigenous women’s experiences accessing healthcare in northern and rural thailand and explores the complexity of culture and its interaction with multiple intersecting influences on health behaviours. methods: a focused ethnographic study was conducted to understand and describe the culture of health behaviors and other cultural phenomena. we recruited 21 female participants aged 20-41 years between march and april of 2017. in-depth semi-structured interviews conducted in thai were used to explore the experiences of the participants living in a northern rural village. data analysis was informed and guided by roper and shapira’s framework for ethnographic analysis. results: seven themes presented across three phases of experience (pre-access, making choices, and encountering difficulties) revealed an in-depth understanding of the indigenous women’s lives, the broader sociocultural context in which they lived, and the challenges they faced when accessing healthcare. analysis of data showed that the participants did not have equal access to healthcare and often disproportionately experienced discriminatory practices and negative attitudes of mainstream healthcare providers. conclusions: this is the only study to date that discusses healthcare access challenges experienced by indigenous women living in a northern rural thai village. there is an urgent need to focus on citizenship, employment, and general health conditions; gender, familial, and labor roles; specific health conditions, wellness, and cultural practices; the seeking of healthcare services; healthcare provider relationships; the ability to access needed care; and optimization of self-care. future efforts to improve healthcare access and reduce disease burden might benefit from these findings and allow for the development of more effective strategies, programs, and policies. keywords: indigenous women, northern rural thailand, ethnic minorities, healthcare services, access to healthcare, gender equality, human rights healthcare access experiences among indigenous women in northern rural thailand: a focused ethnographic study onouma thummapol1, sylvia barton2, tanya park1 1university of alberta, canada; 2university of northern british columbia, canada research introduction access to healthcare is complex and multidimensional. culturally diverse populations experience layers of complexity when accessing healthcare. although access to quality healthcare is internationally recognized as a fundamental human right,1,2 inequities in health and healthcare access persist for many ethnic groups.1 asian indigenous women are more likely than non-indigenous women to bear a greater burden of disease and have higher rates of suboptimal http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu health.2 they are less likely to receive appropriate healthcare services and face a myriad of obstacles in their quest for achieving optimal health.2,3 in asia, previously published studies provide evidence of the significant inequities for indigenous and non-indigenous populations. however, few studies have been published to understand healthcare access among indigenous groups; thus asian indigenous health research remains largely overlooked.2,4-5 the existing literature shows that there are significant differences in asian indigenous women’s access and use of health services in comparison to the rest of the population.3,6-8 for example, indigenous women are excluded from sexual and reproductive health services and are less likely to seek care when they are ill.2,6 the health status of asian indigenous women is a low priority and is often overlooked by the governments.2 approximately 70% of the world’s indigenous people reside in asia.2 thailand is a country in southeast asia, with 3,429 indigenous villages and an indigenous population of approximately 923,257 people.2,4 indigenous peoples of asia, including thailand, as defined by the united nations, are those who have a long connection with the lands and an experience of marginalization or discrimination, largely because they have a distinct and different cultural tradition and history compared to other groups within the state.2 while ‘indigenous’ is a commonly-used international term, its use in asia, particularly thailand, is limited.4,9 in recognition of the right to self-identification declared in the united nations declaration on the rights of indigenous peoples2, this paper primarily uses the term ‘indigenous women’ to describe indigenous women in thailand. in thailand, many different indigenous groups reside in northern rural highland areas. the government legally recognizes ten indigenous groups, leaving almost half a million of indigenous peoples in thailand stateless.4 these stateless people can become subjects of discrimination and denial of basic human rights.4 many of these stateless people are ethnic minorities living in northern rural areas near the thai-myanmar border.10-11 health inequities exist for indigenous groups in thailand.12 indigenous peoples often live in northern rural areas, where access to healthcare is limited or not available and these people are less likely to access public health services.4,13 this healthcare access inequity between indigenous and non-indigenous groups in thailand can lead to negative health consequences. many of the women who are affected by preventable diseases, such as cervical cancer14 and hiv/aids15, are indigenous. they also experience multiple forms of discrimination and often have difficulty obtaining healthcare.10,15 this is attributed to the ‘double burden’ of indigenous identity and gender inequalities.12 globally, literature on indigenous peoples’ healthcare access is available; however, few studies are gender specific.2 the current literature on healthcare access for indigenous women is from countries such as bangladesh16, canada17-19, guatemala20, india7-8, and vietnam.6 these studies report on inequitable healthcare access and high disease burden; however, there is no thai-specific literature. furthermore, healthcare access experiences among indigenous women in thailand have not yet been explored. the purpose of this study is to understand the healthcare access experiences among indigenous women in northern rural thailand and to explore within these experiences the complexity of culture. methods institutional review board human ethics approval of the study protocol was received in both canada and thailand. informed written consent was obtained prior to conducting all of the interviews, which included a request to audio-record, as well as an opportunity to check back with participants to confirm the credibility of their responses. when obtaining http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thummapol this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu figure 1. the study setting informed consent, the researcher ensured that participants fully understood the purpose of the research, and potential risks/benefits associated with research participation. participants were informed that they could make a voluntary decision to participate in the study, withdraw at any time, and choose not to answer any given question. the research was a focused ethnographic study conducted using purposive sampling and snowball strategies guided by knoblauch’s applied research methodology.21 research questions included: 1) what are the experiences of indigenous women accessing healthcare services in northern thailand?; 2) how do cultural beliefs and practices influence access to healthcare for these women?; 3) what do indigenous women believe are the facilitators and impediments to accessing quality healthcare?; and 4) how do these women experience engagement with healthcare providers in the healthcare system? the study site was a village located in the rural highland areas of mae hong son province, one of the northern and mountainous provinces of thailand that borders myanmar (figure 1). this province is approximately 924 kilometers (574 miles) away from the national capital, bangkok. according to the department of provincial affairs of thailand (2014), ethnic groups represent approximately 63 % of the mae hong son’s population. participants were from the tai-yai group (also known as shan); they have inhabited the rural highlands of mae hong son for generations and make up the majority of the province’s populations.22 the village has a population of 457 indigenous people and is located 55 kilometers (34.17 miles) from the closest hospital. it has poor road conditions and no access to public transportation. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu data collection twenty-one women aged 20-41 years participated in interviews between march and april of 2017. we approached twenty-three women; however, due to language barriers and a lack of translation resources, two women who were not able to fully understand and communicate in thai were excluded. demographic data were collected from each participant at the beginning of the interview. the researcher identified and recruited participants using purposive and snowball sampling, the researcher’s personal networks, an indigenous mentor (identified during a study feasibility trip), face-to-face approach, and study posters23-27. data saturation dictated the sample size28-30 and occurred after 21 interviews. field notes (e.g., observations and information recorded during the interviews) and a reflexive journal (e.g., the researcher’s thoughts, reactions to people and the setting, or personal feelings and emotions) were maintained during the course of fieldwork and used for analysis.30 the first author conducted face to face, in-depth interviews in thai language with 21 women. these interviews focused on participants’ past and current experiences with the healthcare system. the interviews were semi-structured, with questions and probes that included: where do you usually go for healthcare? can you tell me about your last (or last two) healthcare visits? what influenced your decision to seek healthcare? how was it for you to get needed healthcare services? the interviews lasted approximately 45 minutes and were transcribed verbatim. data analysis data collection and analysis proceeded concurrently after the first interview, with the first author transcribing and translating the first three interviews into english for review and analysis by the research team. the other transcripts were kept in the original language (thai), with analysis completed by the first author. roper and shapira’s framework for ethnographic analysis guided the work using five strategies: a) coding for descriptive labels, (b) sorting for patterns, (c) identifying outliers or negative cases, (d) generalizing themes, and (e) noting reflective remarks (e.g., ideas or insights from the research team when collecting data and reviewing interview or relevant documents).25 nvivo qualitative data analysis software and a manual approach were used to organize and code narrative data. written materials compiled from field notes, a reflexive journal, and transcribed interviews were read and re-read prior to coding. initial coding was discussed and refined by the research team and then grouped into meaningful, descriptive categories. these categories were then compared, contrasted, and sorted for patterns that reflected the similarities and differences between interviews, as well as for patterns related to cultural beliefs and practices. following this pattern identification and notation, the data was re-read to abstract themes that captured the nature of the women’s experiences. finally, this iterative process of data analysis resulted in organizing the seven themes across three phases of the women’s experiences, which was further discussed and refined by the research team, taking both emic and etic perspectives into the account.25 translation and back-translation the interviews were conducted in thai; however, english was the language used with the research team and reporting of the findings. therefore, translation of the interviews was required. all audiotapes were transcribed verbatim in thai. the first author read the transcribed transcripts in conjunction with the audiotapes to verify the accuracy of the transcription and to correct any transcription errors. the process of translation and back-translation began after themes and categories had been identified.31-33 three people were involved in the translation and back-translation process: 1) the first author who conducted all of the interviews in thai, 2) a thai nurse researcher who conducted research in english and thai, and 3) another thai nurse researcher who conducted research in english and thai. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thummapol this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu the translated documents were compared and any discrepancies were resolved through discussion between the first two translators.31-33 the final english version was reached by agreement with the first two translators.32 to ensure the accuracy of translation, the process of back-translation was conducted by the third translator.31-33 to achieve equivalence between original and targeted languages, and to avoid misrepresentation of participants’ feedback, the first researcher compared the back-translated transcript with the original version.31-33 the translation and back-translation processes were repeated multiple times and discussed throughout, in order to minimize any discrepancies in meaning.34 it has been well recognized that achieving equivalence between two languages is a challenge.35 therefore, working with a bilingual translator who possessed an understanding and knowledge of the participants’ culture and language, and was familiar with medical terminology and research, was an optimal way to produce accurate and meaningful data.32-33, 35 results three phases: pre-access, making choices, and encountering difficulties which integrate seven overlapping themes exemplify participants’ experiences accessing healthcare. table 1 presents the demographic characteristics of the participants and table 2 lists the themes and their definitions. pre-access the pre-access phase of healthcare access focused on the participants’ experiences of employment and income, gender roles and responsibilities, and views on health and treatment. the majority of participants were self-employed (farmers, shop owners, and cooks), while others were government-employed schoolteachers. the selfemployed participants reported that they faced additional difficulties, such as fear of income loss when taking time away from work for medical visits. one participant stated, “i was crying in pain at work because i could not afford to take my day off to go to see the doctor…the employer will only pay me 100-200 baht [$ 3-6 usd] a day and if i take a day off work we will not have money to buy food…” (participant 11). in addition to unpaid work in the household, participants also engaged in paid work to supplement family income and explained that they had little time to think about their own health needs, let alone access healthcare. one participant shared, “besides cooking, doing household chores and looking after children and the family, i’m also working on the farm…i have to do everything and have no time for myself” (participant 4). participants reported that they usually met gender expectations related to their domestic and reproductive roles. one participant stated, “…cooking, washing clothes, and caring for children are our responsibility…we work within and outside the home. so caring for children and going to the hospital…it’s hard for me” (participant 3). participants also mentioned having to assume unpaid caregiving duties for the ill, elderly, and young children had significant impact on their decisions to seek healthcare. one participant explained, “i have two siblings but they are not here. i live with my mom and have to look after her and take care of everything…like going to town to fill her prescriptions…i will not go to see the doctor unless i’m really sick because i don’t want to leave my mom alone” (participant 2). during many of the interviews, traditional beliefs and practices during the postpartum period were described, such as herbal steam baths, keeping the body covered from head to toe, and food beliefs. one participant stated, “herbal steam baths made by boiling a mixture of herbs such as roots and leaves will promote a mother’s perspiration which eliminate residual impurities, improve the skin and stimulate breastmilk” (participant 6). another participant shared, “keeping the body of both, mother and baby covered from head to toe http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thummapol this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu table 1. demographic characteristics of the study sample of 21 participants for at least a month after delivery is important to prevent further cooling. we believe it will give strength and protect mother and baby from getting sick” (participant 5). making choices the making choices phase of healthcare access focused on the participants’ experiences of traditional and western medicines, support networks and resources, the referral system, and previous experiences. all participants used a combination of traditional and western practices, which were largely influenced by the perceived nature and severity of health conditions. as one participant explained, “if you were not feeling well and did not get better after visiting the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thummapol this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu doctor, you have ‘lom nok’ [physical symptoms for which the doctor can find no cause, which was believed to be caused by supernatural forces]. i would go to see a traditional healer for religious rituals and drink ‘nam mon’ [holy water] and then i would get better” (participant 7). several participants mentioned health conditions that they believed to be caused by demons or supernatural forces. one participant revealed, “when my son was three months old, he cried inconsolably for several nights for no apparent reason. i took him to the village traditional healer at night for healing, who got him to drink ‘nam mon’ [holy water] and put ‘sai sin’ [a white holy cord] around his neck. my son got better” (participant 17). positive social support and resources from family, neighbors, and community were mentioned as important factors contributing to participants’ decisions about health and access to healthcare services. several narrative accounts emerged regarding support systems. for example, during a crisis, neighbors offered rides to the doctor. one participant stated, “i did not make it to the hospital to deliver my first child. the village vehicle at the community clinic was not available, but luckily one of our neighbors drove me to the district hospital. the health worker at the community clinic tagged along and i gave birth to my child in the car on our way to hospital.” (participant 12). all participants discussed healthcare services that they accessed inside or outside the village as a referral system for sub-district (traditional healer, traditional herbs or medicines, and community health center), district (private clinics, drug stores, and district hospital), and hospitals within and outside the provincial areas. the majority of the participants primarily accessed the community health centers when experiencing symptoms of illness, while some participants bypassed the community health centers and directly accessed the hospitals, often paying extra for this. the latter group was more educated, had a higher income, had experience with medical conditions, and/or knew someone working in healthcare setting. one participant shared, “i will go to the [provincial] hospital when i’m sick because i like the quality of services there better, even though i have to pay extra for it. i paid 800 baht [equivalent to $23 usd] for blood tests because it was not covered by universal healthcare when you bypassed the community health center and district hospital” (participant 19). throughout the interviews, it became apparent that participants’ opinions of the quality of the healthcare they have received was highly dependent on the interactions with their healthcare providers. participants reported feeling that they were respected, accepted, and cared for, particularly when a strong positive relationship/interaction was formed. the presence of indigenous health providers, in particular, was perceived as crucial because of the shared cultural and linguistic heritage, which created an environment of belonging and acceptance. as one participant stated, “i really appreciated that i got to see an indigenous nurse when i visited the district hospital. she was very friendly and understanding...made me feel at ease” (participant 3). encountering difficulties the encountering difficulties phase of healthcare access focused on the participants’ personal characteristics and circumstances, transportation and distance, as well as racism and discrimination. the majority of participants reported having thai citizenship. participants who had citizenship status generally reported that they were able to access basic education, healthcare and social services, and had freedom of movement and employment opportunities. participants who did not have thai citizenship reported difficulties in achieving the rights and benefits given to ‘citizens’. the following excerpt illustrates challenges undocumented participants faced when attempting to obtain essential care, “i took my child to the community clinic early in the morning on a weekend because of fever and got yelled at by the health worker… she was not friendly and refused to provide care, saying, “come back http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thummapol this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu understanding the lives of the women women’s roles in thai society wellness and cultural practices seeking out healthcare services engaging with health care providers navigating access to quality healthcare facilitating healthcare access non-citizen women have restricted access to care health-seeking behaviour is influenced by employment more disadvantaged and vulnerable to poor health outcomes the expected gender roles create ‘double burden’ caregiving as a female responsibility unequal distribution of responsibilities reproduction, chronic conditions, and accidents are most common issues traditional herbs/medicines, farm work, and religious rituals used to stay healthy some cultural specific practices and religious beliefs influence health and decisions about care the provision of services not equally distributed traditional and western medicines are complementary structural barriers and socioeconomic characteristics identified as reasons for avoidance or delayed access having familial connections is described as beneficial a sense of belonging and acceptance created by meaningful interactions a discriminatory and insensitive behaviours a desire to engage enhanced when feeling treated with respect unequal treatment and discrimination based on different characteristics long waiting time viewed as the most challenging the complexity of gender and its intersection between social categories strong family and community relationships promoted care seeking and outcomes need for reducing wait times; better healthcare environment; outreach services; and transport system table 2: list of themes and their definitions during the operating hours.” i did not want to go there again and would rather treat my son’s symptoms myself” (participant 17). another undocumented participant stated, “i do not have citizenship… i am stuck here, i cannot go anywhere i want to” (participant 16). multiple intersecting influences affecting participants’ access to healthcare were identified throughout the interviews. these included specific transportation and distance challenges due to the rural and mountainous geography, contending with time away from work, long wait times, financial constraints, family responsibilities, severity of symptoms, and cultural discrimination. one participant shared, “i could spend a day waiting to see a doctor. it’s a waste of time. i would rather not go and suffer, wait for the symptoms to go away on their own. it’s difficult, we are living far from town and if we are not extremely sick, we won’t go. many of us are poor and do not have a vehicle, asking others who have private vehicles to drive us, which cost thousands of baht, not to mention cost of food. transportation alone will cost 1000 baht [$29 usd]” (participant 5). several suggestions were made regarding how to improve access to healthcare services, and included reducing wait times, making the waiting room more inviting and welcoming, providing outreach services in the village, and establishing a transport system, especially in case of emergency. one participant shared, “i would like them [health care providers] to http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thummapol this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu come to the village…every once in a while if possible, for services like pap smears or physical check-ups for those who are ill. we are poor and many do not have money to go to the hospital, so they would miss the appointment. if they [healthcare providers] brought the services to us, it would save us a lot” (participant 7). many participants reported a lack of trust in non-indigenous healthcare providers resulting from firsthand experience of discriminatory and insensitive behaviors; such as unfriendliness, lack of attention, and negative reactions to indigenous accent, appearance and a lack of education. one participant shared, “the last time i was there [district hospital] was when i had an ankle sprain from a motorcycle accident. i was not okay with the way i was treated. i felt like the doctor did not respect me as a patient when he talked to me. i wished he knew how to treat patients fairly and not based on how we look or how much money we have” (participant 5). discussion the findings of this study highlight the significance of personal, socioeconomic, cultural/geographical contexts, and previous healthcare experiences that affect participants’ access/use of healthcare services. these experiences provide a window into understanding the complexity of culture affecting healthcare access inequitties. one striking aspect of the findings is related to gender inequality. the participants’ accounts of life based in traditional and patriarchal norms perpetuate their status as subordinate, creating a ‘double burden’ for women.36 the unequal distribution of responsibilities (within and outside of the home) leads to unequal opportunities to seek care, invest in educational and vocational skills, and participate in paid work.36-40 these unequal opportunities offer an important snapshot into how cultural values and gender roles affect health inequities. the united nations sustainable development goal 5 (sdgs) provides strong support for the action to reduce health inequities for indigenous women.41 action priorities include the recognition of women’s roles, implementation of strategies to change cultural and social norms that can form barrier to equal opportunity, and better integration of gender perspectives into the healthcare system.41-42 this will, in turn, ensure effective use of healthcare services and reduce health inequities. understanding women’s unique health needs and experiences, the differences in how they view and take care of their health, their cultural and religious beliefs and practices related to health and decisionsmaking, are all critical in identifying appropriate strategies and interventions to enhance healthcare access. for example, the findings revealed that participants are more likely to self-treat or use alternatives (e.g., traditional medicines), depending on the perceived cause and severity of conditions. domestic duties prevent women from going to the hospital during operating hours, resulting in adverse consequences on their health. in addition, the findings showed that participants were not aware of the benefits and importance of preventive health services. this suggests the necessity of providing linguistically and culturally appropriate education, in order to increase women’s participation in screening and early detection.14,18,20 the results also demonstrated that women adhered to beliefs and taboos on food during the postpartum period. these findings parallel the extensive literature suggesting the importance of integrating holistic approaches to health into mainstream healthcare practices and policies, such as the development of culturally appropriate nutritional programs.43 programs that could improve pregnancy outcomes and long-term quality of life for this underserved population are needed to be implemented.43 participants are subject to complex and different socioeconomic and cultural influences that impact their options for healthcare practices. our findings indicated that healthcare services were not available to the participants on an equitable basis due to geographic factors. this introduces financial costs associated with http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu access to childcare, transportation, accommodation, and etc., which leads to further health inequity for women. the literature that has explored this issue among indigenous women supports this view.7,18,44 although the use of traditional and western medicines is commonplace, the findings raise concerns about equitable healthcare access and highlight factors associated with avoidance or delayed access. understanding why women fail to seek or come late for care can inform efforts and interventions to reduce treatment delay; which will result in early detection of disease, timely care, increased survival, and ultimately, desired health outcomes.7,45-46 this study revealed that structural factors, including long wait times and the discriminatory behavior of healthcare providers, negatively affect participants’ experiences, satisfaction, and decision to engage with healthcare. participants described how experiences of unequal treatment, discrimination, and long waits discouraged them from seeking healthcare and developing trusting relationships with care providers. these findings corroborate several studies suggesting that strong, respectful and trusting relationships, as well as meaningful and familiar connections, are integral for encouraging care seeking.47-48 it also highlights the need for education and professional development to increase the sensitivity, compassion, and reflective practices of healthcare providers.3,49-50 the three access phases and seven integrated themes revealed the intersectionality of influences on the participants’ health and access to healthcare. many participants faced additional challenges that interfered with the enjoyment of their human rights, particularly in relation to the right to healthcare on the basis of factors such as ethnicity, gender roles, cultural beliefs and practices, socioeconomic status, and geography.51-52 participants were further affected by discrimination as indigenous people, and therefore access to healthcare was further limited. this study offers insight and understanding into indigenous women’s lives, the broader sociocultural context in which they live, and the challenges they face when accessing healthcare. intersectionality is particularly useful in informing such analyses because it draws attention to multiple intersecting social influences and how they shape the ways in which healthcare is experienced, received, and provided.51-53 understanding the intersections and taking into account women’s perspectives will enable policy makers and health care providers to better design contextspecific strategies that will improve equitable access to healthcare. there are several limitations to this project. the first author interviewed a small and select sample of thai speaking participants who had similar backgrounds and social levels (educational, geographical, or occupational). in particular, the research setting was relatively homogeneous with respect to gender and ethnicity. as is essential in qualitative research, the participants were selected based on their ability to provide information in thai, not on the basis of how they represented the general population. it is acknowledged that the qualitative research results are not generalizable, and that the participants may not be representative of the general population. given the lack of translation facilities, participants who did not speak thai were excluded; this may have resulted in the study not capturing the healthcare challenges of non-thai-speaking indigenous participants who may have different experiences. future research is needed on healthcare access inequalities for indigenous women in thailand. it can replicate the findings of this study within similar contexts, such as northern and rural communities across thailand, supporting the urgent need to improve healthcare access for indigenous women. another area for future research would be on exploring the experiences of healthcare providers working with indigenous communities, which may enhance the understanding of gaps and inform strategies to remove or minimize barriers to access. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx thummapol this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu in this study, we identified the impacts of gender and family roles on the cultural understandings and experiences in seeking healthcare among indigenous women. it would be interesting to examine in-depth the impact of indigenous women’s illnesses or diseases on family function and relationships. thus, ethnographic studies with this focus are recommended. last, given the lack of disaggregated data on indigenous peoples in thailand and of culturally relevant indicators, research is warranted pertaining to indigenous data collection on gender, race/ethnicity, culture, indigenous identity, health status, socioeconomic status, or geography. collecting and using such data is important to advance human rights, achieve equal opportunities, redress discriminatory disadvantages, and improve indigenous health outcomes. this study might potentially have important implications for current gender policy discussions. gender equality and women’s rights are increasingly recognized by international institutions, such as the united nations sustainable development goal and the convention on the elimination of discrimination against women (cedaw). because of disadvantaged position in society, women who belong to minority groups suffer disproportionately from multiple forms of discrimination and are less likely to enjoy the full enjoyment of human rights, including equitable access to quality healthcare. thus, the results of this study can assist advocates, policy makers, and allied healthcare professionals to understand the differences among women with respect to multiple influences and contexts (e.g., socioeconomic, cultural, ethnic, citizenship, and geographical). this is the only study to date that discusses healthcare access challenges experienced by indigenous women living in a northern rural thai village; emphasizing an urgent need to enhance nondiscriminatory access to, and quality delivery of, healthcare services to indigenous women in northern rural thailand. future research should focus on equitable healthcare access and disease burden reduction, in order to develop effective strategies, culturally sensitive programs, and evidenced-based policies. references 1. world health organization. health and human right [internet]. geneva: who media centre; 2015. available from: http://www.who.int/mediacentre/factsheets/fs3 23/en/. accessed october 8, 2018. 2. united nations. state of the world’s indigenous peoples (2nd volume): indigenous peoples access to health services [internet]. new york: department of economic and social affairs; 2015. available from: https://www.un.org/development/desa/indigeno uspeoples/publications/2015/09/state-of-theworlds-indigenous-peoples-2nd-volumehealth/. accessed october 8, 2018. 3. thummapol o, park t, barton s. exploring health services accessibility by indigenous women in asia and identifying actions to improve it: a scoping review. ethnicity and health. 2018;1-20. 4. dhir rk. indigenous peoples in the world of work in asia and the pacific: a status report [internet]. geneva: international labour organization; 2015. available from: https://www.ilo.org/global/topics/indigenoustribal/publications/wcms_438853/lang-en/index.htm. accessed october 8, 2018. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/mediacentre/factsheets/fs323/en/ http://www.who.int/mediacentre/factsheets/fs323/en/ https://www.un.org/development/desa/indigenouspeoples/publications/2015/09/state-of-the-worlds-indigenous-peoples-2nd-volume-health/ https://www.un.org/development/desa/indigenouspeoples/publications/2015/09/state-of-the-worlds-indigenous-peoples-2nd-volume-health/ https://www.un.org/development/desa/indigenouspeoples/publications/2015/09/state-of-the-worlds-indigenous-peoples-2nd-volume-health/ https://www.un.org/development/desa/indigenouspeoples/publications/2015/09/state-of-the-worlds-indigenous-peoples-2nd-volume-health/ https://www.ilo.org/global/topics/indigenous-tribal/publications/wcms_438853/lang--en/index.htm https://www.ilo.org/global/topics/indigenous-tribal/publications/wcms_438853/lang--en/index.htm https://www.ilo.org/global/topics/indigenous-tribal/publications/wcms_438853/lang--en/index.htm central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu 5. united nations. state of the world’s indigenous peoples (volume 1) [internet]. new york: department of economic and social affairs; 2010. available from: http://www.un.org/esa/socdev/unpfii/document s/sowip/press%20package/sowip-presspackage-en.pdf. accessed october 8, 2018. 6. dang h-a. vietnam: a widening poverty gap for ethnic minorities [internet]. in gillette h, harry, p. (eds.). indigenous peoples, poverty and development. cambridge university press, forthcoming; 2012. available from: https://papers.ssrn.com/sol3/papers.cfm?abstra ct_id=2346307. accessed october 8, 2018. 7. jose ja, sarkar s, kumar s, kar ss. utilization of maternal health-care services by tribal women in kerala. journal of natural science, biology & medicine. 2014;5(1):144147. 8. shah r, bélange d. socioeconomic correlates of utilization of maternal health services by tribal women in india. canadian studies in population. 2011;38(1/2):83. 9. asia indigenous peoples pact. overview of the state of indigenous peoples in asia [internet]. chiang mai: publications; 2014. available from: http://www.gapeinternational.org/wpcontent/uploads/2011/08/asia-ip-overviewfinal.pdf. accessed october 8, 2018. 10. cadchumsang j. people at the rim: a study of thai ethnicity and nationalism in a thai border village [dissertation]. ontario: university of toronto, department of anthropology; 2011. 11. spindler w. thousands of stateless people given nationality in thailand [internet]. geneva: united nations high commissioner for refugees; 2015. available from: http://www.unhcr.org/news/latest/2015/12/565 db8939/thousands-stateless-people-givennationality-thailand.html. accessed october 8, 2018. 12. lutvey t. gender mainstreaming manual: good practices and lessons learnt of an indigenous peoples organization [internet]. chiang mai: asia indigenous peoples pact; 2014. available from: https://aippnet.org/gender-manual-goodpractices-and-lessons-learnt-by-an-indigenouspeoples-organization/. accessed october 8, 2018. 13. united nations high commissioner for refugees. good practices addressing statelessness in south east asia [internet]. geneva: resources and publications; 2010. available from: http://www.unhcr.org/protection/statelessness/ 4d7de47f9/good-practices-addressingstatelessness-south-east-asia-reportregional.html?query=stateless peoples. accessed october 8, 2018. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.un.org/esa/socdev/unpfii/documents/sowip/press%20package/sowip-press-package-en.pdf http://www.un.org/esa/socdev/unpfii/documents/sowip/press%20package/sowip-press-package-en.pdf http://www.un.org/esa/socdev/unpfii/documents/sowip/press%20package/sowip-press-package-en.pdf https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2346307 https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2346307 http://www.gapeinternational.org/wp-content/uploads/2011/08/asia-ip-overview-final.pdf http://www.gapeinternational.org/wp-content/uploads/2011/08/asia-ip-overview-final.pdf http://www.gapeinternational.org/wp-content/uploads/2011/08/asia-ip-overview-final.pdf http://www.unhcr.org/news/latest/2015/12/565db8939/thousands-stateless-people-given-nationality-thailand.html http://www.unhcr.org/news/latest/2015/12/565db8939/thousands-stateless-people-given-nationality-thailand.html http://www.unhcr.org/news/latest/2015/12/565db8939/thousands-stateless-people-given-nationality-thailand.html https://aippnet.org/gender-manual-good-practices-and-lessons-learnt-by-an-indigenous-peoples-organization/ https://aippnet.org/gender-manual-good-practices-and-lessons-learnt-by-an-indigenous-peoples-organization/ https://aippnet.org/gender-manual-good-practices-and-lessons-learnt-by-an-indigenous-peoples-organization/ http://www.unhcr.org/protection/statelessness/4d7de47f9/good-practices-addressing-statelessness-south-east-asia-report-regional.html?query=stateless%20peoples http://www.unhcr.org/protection/statelessness/4d7de47f9/good-practices-addressing-statelessness-south-east-asia-report-regional.html?query=stateless%20peoples http://www.unhcr.org/protection/statelessness/4d7de47f9/good-practices-addressing-statelessness-south-east-asia-report-regional.html?query=stateless%20peoples http://www.unhcr.org/protection/statelessness/4d7de47f9/good-practices-addressing-statelessness-south-east-asia-report-regional.html?query=stateless%20peoples thummapol this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu 14. kritpetcharat o, sirijaichingkul s, kritpetcharat p, wutichouy w. comparison of pap smear screening results between akha hill tribe and urban women in chiang rai province, thailand. asian pacific journal of cancer prevention. 2012;13(11): 5501-5504. 15. apidechkul t. a 20-year retrospective cohort study of tb infection among the hill-tribe hiv/aids populations, thailand. bmc infectious diseases. 2016;16(72):1-14. doi:10.1186/s12879-016-1407-4 16. chowdhury he. framework for tribal peoples plan-health sector support program [internet]. bangladesh: ministry of health and family welfare; 2017. available from: http://documents.worldbank.org/curated/en/397 301492068554569/pdf/sfg3262-ippp160846-box402901b-public-disclosed-411-2017.pdf. accessed october 8, 2018. 17. denison j, varcoe c, browne a. aboriginal women's experiences of accessing health care when state apprehension of children is being threatened. journal of advanced nursing. 2014;70(5): 1105-1116. 18. morgan l, wabie j. aboriginal women’s access and acceptance of reproductive health care. a journal of aboriginal & indigenous community health. 2012;10(3):313-325. 19. van herk k, smith d, andrew c. identity matters: aboriginal mothers' experiences of accessing health care. contemporary nurse. 2011;37(1):57-68. 20. schooley j, mundt c, wagner p, fullerton j, o’donnell m. factors influencing health careseeking behaviours among mayan women in guatemala. midwifery. 2009;25411-421. 21. knoblauch h. focused ethnography. forum qualitative social research. 2005;6(3): 1-11p. 22. ord m. shan: thailand for beginners. the travelfish [intternet]; 2015. available from: https://www.travelfish.org/beginners_detail/tha iland/77. accessed october 8, 2018. 23. bonevski b1, randell m, paul c, chapman k, twyman l, bryant j, brozek i, hughes c. reaching the hard-to-reach: a systematic review of strategies for improving health and medical research with socially disadvantaged groups. bmc med res methodol. 2014;14:42. 24. liamputtong p. researching the vulnerable. london: sage; 2007. 25. roper j, shapira j. ethnography in nursing research. [electronic resource]. thousand oaks, calif: sage; 2000. 26. sixsmith j, boneham m, goldring j. accessing the community: gaining insider perspectives from the outside. qualitative health research. 2003;13(4): 578-589. 27. higginbottom g, pillay j, boadu n. guidance on performing focused ethnographies with an http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://documents.worldbank.org/curated/en/397301492068554569/pdf/sfg3262-ipp-p160846-box402901b-public-disclosed-4-11-2017.pdf http://documents.worldbank.org/curated/en/397301492068554569/pdf/sfg3262-ipp-p160846-box402901b-public-disclosed-4-11-2017.pdf http://documents.worldbank.org/curated/en/397301492068554569/pdf/sfg3262-ipp-p160846-box402901b-public-disclosed-4-11-2017.pdf http://documents.worldbank.org/curated/en/397301492068554569/pdf/sfg3262-ipp-p160846-box402901b-public-disclosed-4-11-2017.pdf https://www.travelfish.org/beginners_detail/thailand/77 https://www.travelfish.org/beginners_detail/thailand/77 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu emphasis on healthcare research. qualitative report. 2013;18(17):1-16. 28. cruz ev, higginbottom g. the use of focused ethnography in nursing research. nurse researcher. 2013;20(4):36-43. 29. guest g, bunce a, johnson l. how many interviews are enough? an experiment with data saturation and variability. field methods. 2006;18(1): 59-82. 30. ortlipp m. keeping and using reflective journals in the qualitative research process. qualitative report. 2008;13(4):695-705. 31. al-amer r, ramjan l, glew p, darwish m, salamonson y. translation of interviews from a source language to a target language: examining issues in cross-cultural health care research. journal of clinical nursing. 2015;24(9/10): 1151-1162. 32. chen h, boore j. translation and backtranslation in qualitative nursing research: methodological review. journal of clinical nursing. 2010;19(1-2): 234-239. 33. nurjannah i, mills j, park t, usher k. conducting a grounded theory study in a language other than english. sage open. 2014;4(1):1-10. 34. maneesriwongul w, dixon j. instrument translation process: a methods review. journal of advanced nursing. 2004;48(2):175-186. 35. squires a. language barriers and qualitative nursing research: methodological considerations. international nursing review. 2008;55(3):265-273. 36. ferrant g, pesando gl, nowacka k. unpaid care work: the missing link in the analysis of gender gaps in labour outcomes. paris: oecd development centre; 2014. available from: https://www.oecd.org/dev/developmentgender/unpaid_care_work.pdf. accessed october 8, 2018. 37. binder-finnema p, lien p, hoa d, målqvist m. determinants of marginalization and inequitable maternal health care in northcentral vietnam: a framework analysis. global health action. 2015;8(1). 38. munro j, mcintyre l. (not) getting political: indigenous women and preventing mother-tochild transmission of hiv in west papua. culture, health & sexuality. 2016;18(2):157172. 39. norsa'adah b, wnorlida w. preventive health practices among women at rural villages in malaysia. international medical journal. 2014;21(2):143-145. 40. wongwatcharanukul l, promthet s, bradshaw p, jirapornkul c, tungsrithong n. factors affecting cervical cancer screening uptake by hmong hilltribe women in thailand. asian http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.oecd.org/dev/development-gender/unpaid_care_work.pdf https://www.oecd.org/dev/development-gender/unpaid_care_work.pdf thummapol this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu pacific journal of cancer prevention. 2014;15(8):3753-3756. 41. united nations sustainable development goals. sustainable development goal 5: achieve gender equality and empower all women and girls [internet]. un: department of public information; 2015. available from: http://www.un.org/sustainabledevelopment/gen der-equality/. accessed october 8, 2018. 42. sen g, ostlin p. unequal, unfair, ineffective and inefficient gender inequity in health: why it exists and how we can change it [internet]. who: women and gender equity; 2007. available from: http://www.who.int/social_determinants/resour ces/csdh_media/wgekn_final_report_07.pdf?ua =1. accessed october 8, 2018. 43. riang'a r, nangulu a, broerse j. food beliefs and practices among the kalenjin pregnant women in rural uasin gishu county, kenya. journal of ethnobiology and ethnomedicine. 2017;13(29):1-16 44. browne a. issues affecting access to health services in northern, rural and remote regions of canada. british columbia: university of northern british columbia; 2010. available from: https://www.unbc.ca/assets/northern_studies/n orthern/issues_affecting_access_to_health_serv ices_in_northern.pdf. accessed october 8, 2018. 45. lama s, krishna a. barriers in utilization of maternal health care services: perceptions of rural women in eastern nepal. kathmandu university medical journal. 2014;12(48):253258. 46. cameron b, carmargo plazas m, salas a, bourque bearskin r, hungler k. understanding inequalities in access to health care services for aboriginal people: a call for nursing action. advances in nursing science. 2014;37(3): 1-16. 47. askew d, brady j, brown a, cass a, davy c, devries j, fewquandie b, hackett m, howard m, ingram s, liu h, mentha r, peiris d, simon p, rickards b, togni s. to your door: factors that influence aboriginal and torres strait islanders peoples seeking care. kanyini qualitative study monograph series. 2008;1:125. 48. davy c, cass a, brady j, devries j, fewquandie b, ingram s., & ... brown a. facilitating engagement through strong relationships between primary healthcare and aboriginal and torres strait islander peoples. australian & new zealand journal of public health. 2016;40(6):535-541. 49. castro a, savage v, kaufman h. assessing equitable care for indigenous and afrodescendant women in latin america. revista panamericana de salud publica-pan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.un.org/sustainabledevelopment/gender-equality/ http://www.un.org/sustainabledevelopment/gender-equality/ http://www.who.int/social_determinants/resources/csdh_media/wgekn_final_report_07.pdf?ua=1 http://www.who.int/social_determinants/resources/csdh_media/wgekn_final_report_07.pdf?ua=1 http://www.who.int/social_determinants/resources/csdh_media/wgekn_final_report_07.pdf?ua=1 https://www.unbc.ca/assets/northern_studies/northern/issues_affecting_access_to_health_services_in_northern.pdf https://www.unbc.ca/assets/northern_studies/northern/issues_affecting_access_to_health_services_in_northern.pdf https://www.unbc.ca/assets/northern_studies/northern/issues_affecting_access_to_health_services_in_northern.pdf central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.328|http://cajgh.pitt.edu american journal of public health. 2015;38(2):96-109. 50. sharma b, ramani k, christensson k, giri g, johansson e. the transition of childbirth practices among tribal women in gujarat, india a grounded theory approach. bmc international health and human rights. 2013;13(1). 51. hankivsky o, reid c, cormier r, varcoe c, clark n, brotman s, et al. exploring the promises of intersectionality for advancing women's health research. international journal for equity in health. 2010;91:15. 52. iyer a, sen g, östlin p. the intersections of gender and class in health status and health care. global public health. 2008;313-24. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx healthcare access experiences among indigenous women in northern rural thailand: a focused ethnographic study abstract keywords: indigenous women, northern rural thailand, ethnic minorities, healthcare services, access to healthcare, gender equality, human rights healthcare access experiences among indigenous women in northern rural thailand: a focused ethnographic study research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. fructose consumption among students at the university of guanajuato rosa dejanira medina terán1, joel ramírez emiliano2, hilda lissette lópez lemus1* 1department of nursing and obstetrics, celaya-salvatierra campus, university of guanajuato, mexico; 2department of medical sciences, león campus, university of guanajuato, mexico *e-mail: h.lopez@ugto.mx vol. 8, suppl. (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.375 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ terán this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, suppl. (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.375|http://cajgh.pitt.edu abstract introduction: fructose is a monosaccharide commonly found in fruits. however, it can also be found in carbonated beverages, cereals, fruit juices, and in other processed fruit. the consumption of fructose in moderate to high amounts increases levels of triglycerides in plasma and alters hepatic glucose homeostasis. little information is avialble on fructose consumption in mexico. the aim of this study was to determine the amount of fructose consumption among college students enrolled at the unviersity of guanajuato in mexico (celaya-salvatierra campus). methods: this was an explorative, cross-sectional descriptive study. a total of 57 full time students attending physical therapy and rehabilitation program were included in the analysis. demographic data, food frequency questionnaire, and body mass index (bmi) were collected from all students. data were analyzed by descriptive statistics; discrete variables were reported as frequencies or percentages and continuous variables were reported as means and standard deviations. results: the average age of participants was 19.5 ± 2.8 years. 72% of participants were female and 28% were male. the average bmi was 24.0 ± 4.1 kg / m2, indicating normal bmi range. fructose consumption was roughly 55g per day. conclusion: previous research demonstrated that levels below 50 mg per day are safe. madero et al. reported that that consumption of 50-70 g of fructose per day is considered to be moderate. we found that students consumed 55g of fructose, so their fructose intake is at a moderate level and should not be an obesity-inducing factor, also consistent with bmi ranges of our research participants. considering obesity epidemic in mexico, further studies examining the source of calories in mexican poipualation are warranted, especially among young people. keywords: fructose; obesity; students; university of guanajuato http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abstract keywords: fructose; obesity; students; university of guanajuato cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. hydatid disease in the central region of iran: a 5-year epidemiological and clinical overview aliasghar farazi1*, nader zarinfar1, farhad kayhani2, firoozeh khazaie3 1infectious disease research center, school of medicine, arak university of medical sciences, arak, iran; 2medical student, faculty of medicine, arak university of medical sciences, arak, iran; 3department of disease control and prevention, arak university of medical sciences, arak, iran *corresponding author vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.364 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ farazi this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.364|http://cajgh.pitt.edu abstract introduction: hydatid cyst is caused by an infection by the larval stage of echinococcus granulosus. patients with cystic echinococcosis often remain asymptomatic until the hydatid cysts grow large enough to cause symptoms and signs. the cysts grow in the course of several years before reaching maturity and the rate of growth depends on the location of the cyst. methods: this study was conducted in the central region of iran and involved all patients diagnosed with hydatid disease from 2012 to 2016 with the records identifed from 10 centers for disease control. descriptive statistics including range and percentage were used in analyzing the patient characteristics. results: hydatid disease was confirmed in 84 cases. the mean age of patients was (23.1±5.1) years (range: 15-53 years) and 55.9% of cases were female. single organ involvement was found in 86.9% of cases. 98.8% cases were successfully treated. the most common sites of infection were lung (42.9%), followed by liver (38.1%), and joint liver/lung (10.7%). the diagnosis was established by abdominal ultrasound, abdominal ct, and serology in all patients. the diagnosis was confirmed by histology in 80 (95.2%) of cases. all of cases were treated with albendazole, and 80 (95.2%) of cases had surgical intervention. the prevalence of human hydatidosis in our study was 1.16 per 100,000 population. conclusions: hydatid disease is common in iran and should be a focus of public health interventions. the organ sites affected in this study include lung and liver. keywords: echinococcus granulosus; epidemiology; hydatid disease hydatid disease in the central region of iran: a 5-year epidemiological and clinical overview aliasghar farazi1*, nader zarinfar1, farhad kayhani2, firoozeh khazaie3 1infectious disease research center, school of medicine, arak university of medical sciences, arak, iran; 2medical student, faculty of medicine, arak university of medical sciences, arak, iran; 3department of disease control and prevention, arak university of medical sciences, arak, iran research introduction echinococcosis is an infestation with a tapeworm of the genus echinococcus1. echinococcosis has been recognized since 1950 as a public health problem. echinococcosis is included in the list of 17 neglected tropical diseases and in the list of priority neglected zoonotic diseases for which who advocates concerted control efforts. the vision of controlling, eliminating, and eradicating neglected tropical diseases has gathered momentum in recent years. interventions in selected countries of central asia, north africa, and latin america for the control and elimination of the echinococcosis as a public health problem will be scaled up by 20202. echinococcosis is an important socioeconomic and public health problem in many areas of the world. iran is known as one of the endemic regions of e. granulosus with high rates of infection, especially in rural communities. three known species of echinohttp://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx farazi this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.364|http://cajgh.pitt.edu variable subgroup males (n=37) females (n=47) p-value * location urban 14(37.8%) 19(40.4%) 0.809 rural 23(62.2%) 28(59.6%) age group 0–20 10(27%) 11(23.4%) 0.772 21–40 20(54.1%) 29(61.7%) >40 7(18.9%) 7(14.9%) occupation farmer 12(32.4%) 14(29.8%) 0.003 housekeeper 3(8.2%) 18(38.3%) herdsman 14(37.8%) 5(10.6%) other 8(21.6%) 10(21.3%) organ involvement liver 14(37.8%) 18(38.3%) 0.452 lung 15(40.5%) 21(44.7%) liver + lung 3(8.2%) 6(12.7%) other organs 5(13.5%) 2(4.3%) *statistical analysis was performed using chi-square. table 1. comparison of demographic characteristics of cases with hydatid cyst by sex in the central region of iran coccus are of medical importance in humans. these are e. granulosus, causing cystic echinococcosis (ce), e. multilocularis causing alveolar echinococcosis (ae), and e. vogeli. echinococcus granulosus is the most prevalent form of these; e. multilocularis is rare but virulent, while e. vogeli is the rarest. the humans are an accidental intermediate host in echinococcosis by eggs ingestion. the eggs then release oncospheres in the small intestine where oncospheres migrate through the circulatory system and produce hydatid cysts in the liver, lungs, muscles, and other organs3. the endemic areas are south america, new zealand, southern parts of africa, middle east, iceland, australia, and central asia4-6. the overall incidence of cystic echinococcosis in endemic areas ranges from 1-220 cases per 100,000 population, while the incidence of alveolar echinococcosis ranges from 0.03-1.2 cases per 100,000 population. the hydatid disease has the capability of infecting individuals of different races equally and its incidence does not vary between females and males7. all common complications of hydatid disease are related to the enlargement of cyst and complications of surgical procedure8. patients with hydatid disease are asymptomatic until hydatid cysts are sufficiently large to cause discomfort. the cysts grow in the course of several years before reaching maturity and the rate of growth depends on the location of the cyst. the hydatid cysts are commonly found in the liver and lungs but can also appear in any organ, including heart, bone, spleen, kidneys, and central nervous system. rupture of the cyst is frequently caused by trauma and may cause mild to severe anaphylactic reactions and sometimes death9-11. there is a lack of information on the prevalence, epidemiology and clinical patterns of human hydatidosis in most provinces of iran. therefore, this retrospective study was conducted to determine the prevalence and to describe the clinical findings and outcomes of human hydatidosis in the central region of iran. methods this study was conducted in the central province of iran and involved all patients diagnosed with hydatid disease from 2012 to 2016. all cases were identified by retrospective review of hospital records. data on cases were obtained from registries in ten centers for diseases control of the central province of iran, which has about 1,500,000 people, with about 23% of those http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx farazi this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.364|http://cajgh.pitt.edu figure 1. absolute frequency of organ involvement in cases with hydatid cyst residing in rural areas. demographic data, clinical presentation, treatment received, and outcomes were extracted. the data were analyzed using spss 18 software (spss, inc., chicago, il, us) using simple descriptive statistics. chi-square test was also used, and all statistical analyses were performed at 0.05 significance levels. this study was given ethical approval by the medical research committee at arak university of medical sciences (ir.arakmu.rec.1394.273). results hydatid disease was confirmed in 84 cases. the mean age of cases was (23.1±5.1) years (range: 15-53 years) and 55.9% of cases were female, with the majority residing in rural areas. single organ involvement was found in 86.9% of cases. the most common sites of infection were lung 42.9%, followed by liver 38.1%, and joint liver/lung 10.7% (figure 1). the diagnosis was established by abdominal ultrasound, abdominal computerized tomography, and serology in all patients. the majority of cases were found in the age group of 2130 years. there were no significant differences between males and females in regards to location, age group, and organ involvement, except for occupation where 37.8% of infected males were herdsmen and 38.3% of infected women were housekeepers (p=0.003) (table 1). the diagnosis was confirmed by histology in 95.2% of cases. the prevalence of human hydatidosis in the central region was 1.16 per 100,000 population. the prevalence of human hydatidosis in rural area was 2.96 per 100,000 population; while it was 0.57 per 100,000 (p < 0.001) in the urban area. all patients were treated with albendazole, and 95.2% patients received surgical intervention. duration of albendazole therapy was 104.5±36.1 days (range: 28-180 days) and 98.8% cases were successfully treated. lung cyst in one patient (1.2%) was ruptured and the patient died due to the anaphylactic reaction. for the diagnosis of the cyst, ct scan and ultrasonography were performed and revealed that 38.1% of cysts were ≥10 cm. the chief complaint in 46.4% was abdominal pain. other complains were abdominal mass in 7.1%, dyspnea in 21.4%, icterus in 4.8%, chest pain in 6%, dyspepsia in 3.6%, cough in 13.1%, heart pain in 1.2%, and headache in 1.2% of cases. nine patients (10.7%), had complicated hydatid cyst including rupture, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.364|http://cajgh.pitt.edu infection, and obstruction. the most frequent site of complication was liver. discussion in the present study, a total of 84 human hydatidosis cases were studied. females were found to have a higher infection rate of hydatid cyst (55.9%) than males (44.1%). the prevalence of human hydatidosis in the central region was 1.16 per 100,000 population. the prevalence of human hydatidosis in rural area was 2.96 per 100,000 population and in urban area was 0.57 (p < 0.0001). although progress has been made in some regions, substantial effort is still required to move cystic echinococcosis and alveolar echinococcosis forward, to mitigate the burden of these diseases. interventions should be tailored to each target area or region and take advantage of new tools for diagnosis and control of the disease. the actual incidence of human hydatidosis in iran is not precisely known. hydatidosis must be considered as a public health problem in iran because of its endemicity in our country12, 13. according to the results of our study, females were found to have a higher infection rate of hydatid cyst than males but the differences is not significant (55.9% versus 44.1% p = 0.127). this finding is similar to other reports on hydatid cyst in iran14-16 and consistent with other reports from other endemic countries in the middle east17, 18. the rate of infection with hydatid cyst in any given group is determined by local customs involving contact with vegetables and soil that is contaminated with dogs’ feces and its rate is relatively higher in women19. hydatid disease is generally considered to be a female's rural disease, seemingly because iranian women, especially in rural areas, have more contacts with domestic animals and infected products. they also have more frequent contact with unwashed raw vegetables, which may have higher contamination level with echinococcus eggs. although different organs were affected by hydatid cyst, only 13.1% of cases had multi organs infections with most of them being hepatopulmonary infection. these results are consistent with other published reports20. the age of cases ranged from 15 to 53 years and the highest rate of infection and complications were in patients of 2030 years of age. in some studies, the peak incidence of hydatid cyst in iran was between 20 40 years old, since this age group has the most contact with livestock. on the other hand, original infection might have occurred in childhood, as hydatid cysts grow very slowly21. clinical examination revealed that abdominal pain was the most common complaint and was present in 46.4% of the cases. other most common complaints were dyspnea, cough, abdominal mass, chest pain, icterus, dyspepsia, heart pain, and headache, which was similar to previously studies from iran22. the prevalence rate of human hydatidosis in iran was reported to be 0.61-2 per 100,000 population13 and in our study, the prevalence of human hydatidosis in central province was 1.16 per 100,000 population. surveillance data is fundamental in order to show the burden of disease and to evaluate progress and success of control programs. however, as with other neglected diseases which are affecting underserved population and remote areas data are scarce and more resources are required for the disease control programs. this study might potentially serve as baseline data for monitoring future changing trends of this infection, and thus may help us to design strategies and programs for hydatid disease control. acknowledgements this paper is extracted from the final doctoral thesis of medical student and hereby we thank the deputy of research of arak university of medical sciences and infectious diseases research center for their support. we thank the physicians for referring cases and patients for their cooperation. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx farazi this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.364|http://cajgh.pitt.edu references 1. ravis e, theron a, lecomte b, gariboldi v. pulmonary cyst embolism: a rare complication of hydatidosis. eur j cardiothorac surg. 2018 jan 1. 53 (1):286-7. 2. meeting of the who informal working group on echinococcosis (who-iwge), geneva, switzerland, 15–16 december 2016. geneva, switzerland: world health organization; 2017 (who/htm/ ntd/nzd/2017.01). license: cc by-nc-sa 3.0 igo. 3. siracusano a, delunardo f, teggi a, ortona e. host-parasite relationship in cystic echinococcosis: an evolving story. clin dev immunol. 2012. 2012:639362. 4. wang k, zhang x, jin z, ma h, teng z, wang l. modelling and analysis of the transmission of echinococcosis with application to xinjiang uygur autonomous region of china. j theor biol. 2013 may 10. 5. torgerson pr. the emergence of echinococcosis in central asia. parasitology. 2013 may 10. 1-7. 6. ito a, budke cm. the echinococcoses in asia: the present situation. acta trop. 2017 dec. 176:11-21. 7. moldovan r, neghina am, calma cl, marincu i, neghina r. human cystic echinococcosis in two south-western and central-western romanian counties: a 7-year epidemiological and clinical overview. acta trop. 2012 jan. 121(1):26-9. 8. manterola c, otzen t, munoz g, alanis m, kruuse e, figueroa g. surgery for hepatic hidatidosis. risk factors and variables associated with postoperative morbidity. overview of the existing evidence. cir esp. 2017 dec. 95 (10):566-76. 9. ahmadi na, badi f. human hydatidosis in tehran, iran: a retrospective epidemiological study of surgical cases between 1999 and 2009 at two university medical centers. trop biomed 2011; 28: 450-456. 10. yang yr, rosenzvit mc, zhang lh, zhang jz, mcmanus dp. molecular study of echinococcus in west-central china. parasitology 2005; 131: 547-555. 11. sako y, nakao m, nakaya k, yamasaki h, ito a. recombinant antigens for sero diagnosis of cysticercosis and echinococcosis. parasitol int 2006; 55(suppl): s69-s73. 12. sadjjadi sm. present situation of echinococcosis in the middle east and arabic north africa. parasitol int. 2006; 55 suppl: s197-202. 13. rokni mb. the present status of human helminthic diseases in iran. ann trop med parasitol. 2008; 102(4):283-295. 14. montazeri, v, sokouti m, rashidi h. comparison of pulmonary hydatid disease between children and adult. tanaffos. 2007; 6(1):1318. 15. priego p, nuño j, lópez hervás p, lópez buenadicha a, peromingo r, díe j, et al. hepatic hydatidosis. radical vs. conservative surgery: 22 years of experience. revista espanola de enfermedades digestivas. 2008; 100(2):82-5. 16. rokni m. echinococcosis/hydatidosis in iran. iranian j parasitol, 2009; 4(2):1-16. 17. shambesh ma, craig ps, macpherson cn, rogan mt, gusbi am, echtuish ef. an extensive ultrasound and serologic study to investigate the prevalence of human cystic echinococcosis in northern libya. the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.364|http://cajgh.pitt.edu american journal of tropical medicine and hygiene. 1999; 60(3):462-8. 18. al-shibani l. cases of hydatidosis in patients referred to governmental hospitals for cyst removal in sana’a city, republic of yemen. trop biomed, 2012; 29(1):18r23. 19. alghoury a, el-hamshary e, azazy a, hussein e, rayan hz. hydatid disease in yemeni patients attending public and private hospitals in sana’a city, yemen. oman medical journal. 2010; 25(2):88. 20. sarkari b, sadjjadi s, beheshtian m, aghaee m, sedaghat f. human cystic echinococcosis in yasuj district in southwest of iran: an epidemiological study of seroprevalence and surgical cases over a ten‐year period. zoonoses and public health. 2010; 57(2):146-50. 21. harandi mf, budke cm, rostami s. the monetary burden of cystic echinococcosis in iran. plos neglected tropical diseases. 2012;6(11):1915 22. mousavi s, samsami m, fallah m, zirakzadeh h. a retrospective survey of human hydatidosis based on hospital records during the period of 10 years. journal of parasitic diseases. 2012;36(1):7-9. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx hydatid disease in the central region of iran: a 5-year epidemiological and clinical overview abstract keywords: echinococcus granulosus; epidemiology; hydatid disease research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. prevalence of chronic kidney disease in adults with type 2 diabetes mellitus from oxcutzcab, yucatán andrea muñoz lara1*, jorge garcía vega1, juan pablo moncada patiño1, alma rosa tovar1, patricia isolina del socorro gómez aguilar2 1university of guanajuato, mexico; 2autonomous university of yucatán, mexico *e-mail: anmula18@gmail.com vol. 8, suppl. (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.379 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ lara this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, suppl. (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.379|http://cajgh.pitt.edu abstract introduction: the complications of type 2 diabetes mellitus (t2dm), such as chronic kidney disease (ckd), are the second leading cause of death in oxcutzcab municipality of yacatan, mexico. the objective of the study was to estimate the burden of chronic kidney disease in a sample of patients with t2dm from oxcutzcab municipality of yacatan, mexico, region characterized by high amound of poverty and vulnerabidity. methods: this is a descriptive study involving 108 adult patients between 26 and 79 years old with t2dm who attended the prospera, social protection program under the direction of ministry of social development of mexico (88% female and 12% male). weight, height, bmi, and years of post t2dm diagnosis were measured. estimated glomerular filtration rate (egfr) was calculated using the cockcroft-gault formula. results: we found that 39.81% of participants had stage one kidney damage, 34.26% stage two, 24.07% stage three, one case of stage four, and one of stage five. bmi measurements indicated that 40.74% of participants were obese (≥30kg/m2), 35.19% were overweight, and 1.85% were underweight. in terms of years since diagnosis, 37.04% of the participants were diagnosed five years ago and less, 29.63% of participants were diagnosed 6-10 years ago, 22.22% between 11-15 years ago, 8.33% between 16-20 years ago, and 2.78% of participants over 20 years ago. conclusions: most participants were in stages one to three of kidney damage, where the main objective of the medical team was medical treatment of t2dm and comorbidities, as well as nutritional support to prevent further complications. there was only one case in stage four and five each, where dialysis and kidney transplantation became necessary. both cases presented had a history of t2dm for over 20 years. it is important to identify early kidney damage to improve quality of life, reduce the treatment costs, and lower mortality. keywords: glomerular filtration rate; chronic kidney disease; type 2 diabetes mellitus; glomerular filtration rate http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abstract keywords: glomerular filtration rate; chronic kidney disease; type 2 diabetes mellitus; glomerular filtration rate cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. evaluation of micronuclei in oral mucosa of individuals exposed to ionizing radiation: a pilot study from celaya, méxico nicolas padilla-raygoza1*, maría del rocio adame gutiérrez2, itza zelene moreno martínez3, vicente beltran-campos4, silvia del carmen delgado-sandoval1, maria de lourdes garcia-campos4, modesto antonio sosa-aquino5, teodoro cordova-fraga5, rafael guzman-cabrera6 1department of nursing and obstetrics, division of health sciences and engineering, universidad of guanajuato mutualismo, méxico; 2academic unity of nursing n°1, university autonomous of guerrero, méxico; 3division of health sciences and engineering, university of guanajuato, méxico; 4department of clinical nursing, division of health sciences and engineering, university of guanajuato, méxico 5department oh physical engineering, division of sciences and engineering, university of guanajuato, méxico 6departmentof electrical engineering, division of engineerings, university of guanajuato, méxico *corresponding author. vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.331 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ padilla-raygoza this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.331|http://cajgh.pitt.edu abstract introduction: occupational exposure to ionizing radiation can potentially lead to adverse health effects, including cancer and genetic defects. genetic damage caused by radiation can be detected if micronuclei are observed. the objective of this pilot study was to detect the presence of micronuclei in cells of the oral mucosa in inidividuals occupationally exposed to ionizing radiation. methods: we implemented a pilot case-control study in which we compared oral mucosa micronuclei in 30 medical and nursing personnel in radiology centers in celaya, mexico, with 30 volunteers not exposed to ionizing radiation recruited from a public university. the oral mucosa was brushed and the amount of micronuclei was quantified. chi-square test or t-test for two proportions were used to compared ionizing radiation and genetic damage between exposed and non-exposed groups. results: the exposed group had an average of 5.37 ± 3.49 micronuclei and the non-exposed had 0.37 ± 0.61 (p<0.01). in the exposed group, 90% of participants exhibited genetic damage compared to 6.67% in the unexposed group (p<0.05). conclusion: in this pilot study, medical and nursing staff from radiology centers presented with higher genetic damage compared to control group. further studies are needed to identify the prevalence of genetic damage due to occupational radiation exposure in mexico. keywords: ionizing radiation; micronuclei; genetic damage evaluation of micronuclei in oral mucosa of individuals exposed to ionizing radiation: a pilot study from celaya, méxico nicolas padilla-raygoza1*, maría del rocio adame gutiérrez2, itza zelene moreno martínez3, vicente beltrancampos4, silvia del carmen delgadosandoval1, maria de lourdes garciacampos4, modesto antonio sosa aquino7, teodoro cordovafraga7, rafael guzman-cabrera9 1department of nursing and obstetrics, division of health sciences and engineering, universidad of guanajuato mutualismo, méxico; 2academic unity of nursing n°1, university autonomous of guerrero, méxico; 3division of health sciences and engineering, university of guanajuato, méxico; 4department of clinical nursing, division of health sciences and engineering, university of guanajuato, méxico 7department oh physical engineering, division of sciences and engineering, university of guanajuato, méxico 9departmentof electrical engineering, division of engineerings, university of guanajuato, méxico research introduction chronic exposure to ionizing radiation can potentially lead to significant negative health effects, including increased incidence of cancer as well as genetic and immunological defects1. moreover, exposure to low doses of radiation (less than 50 msv/year) early in life increases susceptibility to damage from high-dose radiation exposure later in life2. studies on ionizing radiation have been predominantly focused on the highdose radiation exposure, such as nuclear bombs and nuclear plant spills1. the effects of chronic occupational low-dose radiation exposure received little attention. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.331|http://cajgh.pitt.edu many countries have adopted the international commission on radiological protection (icrp) recommendations of a 20-msv-per-year occupational effective dose limit with allowances to go as high as 50 msv per year, as long as the average annual dose over five years does not exceed 20 msv3. however, workers may be exposed to much higher doses during routine operations due to the nature of their occupation. micronuclei (mn) are one way of detecting genetic damage caused by radiation. damage from the radiation leads to the incorrect incorporation of genetic material into the nuclei of the daughter cells, resulting in chromosomal losses and unequal distribution of the genetic material. these genetic aberrations cause the emergence of mn4,5, small extranuclear bodies that contain centric or acentric chromatid, chromosomal fragments, or complete chromosomes that are not included in the daughter nuclei during mitosis. thus, mn are cellular markers of chromosomal damage4,6-8. since buccal epithelial cells reported to be sensitive to radiation, observing mn presence in these cells can be used to accurately monitor potential exposure9,10. the mn testing has been used to identify early genotoxic effects, as well as to evaluate occupational exposure to mutagenic substances11. since the mn test is noninvasive, individuals are more willing to be screened through this method. the mexican official norm nom-229-ssa12002 environmental health, establishes the dose limit for individuals working in the radiology centers at 50 msv per year12. for individuals who do not work in the radiology centers, the annual limit is 5 msv. little research has been done on occupation radiation exposure in mexico, a research gap this study is aiming to fill. the objective of this pilot study was to measure the presence of mn in personnel exposed to ionizing radiation compared to non-exposed personnel in celaya, mexico. the hypothesis was that personnel exposed to radiation will have higher mn compared to non-exposed individuals. methods participants this was a case-control pilot study in which subjects exposed to ionizing radiation were compared to a group of unexposed individuals. research participants were assessed at the life style laboratory of the division of health sciences and engineering, celaya salvatierra campus of the university of guanajuato in celaya, mexico. the inclusion criteria for exposed group were full-time employment at public or private x-ray center who reported direct involvement with x-ray equipment. research participantes included physicians, nurses, and secretaries). the unexposed group consisted of nursing students, nurses, and medical doctors recruited from the university of guanjuato who did not have regular exposure to x-ray and lived in the same city as the exposed group. the exclusion criteria for both the exposed and unexposed groups were any history of cancer diagnosis and/or presence of acute infectious disease (such as influenza) at the time of oral scraping. the project was approved by the bioethics committee (registration cbdcsi-87141126) through the division of health sciences and engineering of the celaya salvatierra campus, university of guanajuato, mexico. data collection information on demographic factors, including age, gender, residence, marital status, and education, was collected using interviewer administered survey. detailed information about occupational history, including previous experience in x-ray rooms and duration of previous employment, was also collected. smoking was assessed as a dichotomous categorical variable and was defined as smoking two or more cigarettes a day. radiation was measured as 1-month http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx padilla-raygoza this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.331|http://cajgh.pitt.edu table 1. sociodemographic characteristics by group variable exposed group n % non-exposed group n % p-value gender male female 14 46.67 16 53.33 8 26.67 22 73.33 >0.05 residence urban suburban rural 26 86.67 1 3.33 3 10.00 21 70.00 6 20.00 3 10.00 >0.05 marital status single married separated widowed divorced free union 9 30.00 15 50.00 1 3.33 2 6.67 1 3.33 2 6.67 25 93.33 5 16.67 0 0.00 0 0.00 0 0.00 0 0.00 <0.01* education elementary secondary high school technical career bachelor degree postgraduate 2 6.67 1 3.33 3 10.00 15 50.00 2 6.67 7 23.33 0 0.00 1 3.33 1 3.33 0 0.00 26 86.67 2 6.67 <0.01* occupation receptionist assistant technician nurse medical doctor support team 2 6.67 2 6.67 15 50.00 5 16.67 4 13.33 2 6.67 1 3.33 0 0.00 2 6.67 15 50.00 7 23.33 5 16.67 <0.02* smoking yes no 4 13.33 26 86.67 8 26.67 22 73.33 0.20 age(years) mean ± s 37.80 ±11.59 25.30 ± 7.09 <.01¥ time at the work (years) mean±s 10.83±7.86 2.08±2.49 <.01¥ *fisher’s exact-test ¥student’s t test http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx padilla-raygoza this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.331|http://cajgh.pitt.edu uptake of ionizing radiation using a dosimeter. the dosimeters used in this study consisted of one pair of thermoluminescent crystals chips (tld-100, thermofisher scientific, waltham, ma, usa) were placed in appropriated badges as previously described13. before use, tlds were annealed to 400oc for one hour and to 100oc for two hours in a muffle in order to erase any environmental or spurious signals. the badges were worn by the participants on the upper left side of the chest during work hours as the highest radiation exposure is expected in this part of the body14. the dosimeter readings were performed using the harshaw tld 3500 equipment with appropriated readings parameters. all participants were given a dosimeter to carry during work hours for a month to measure exposure to ionizing radiation. after a month, the dosimeters were collected and sent for analysis to the medical physics academic body and biomedical instrumentation (león, mexico). radiation was defined as high exposure ( ≥4.1 msv) or low exposure ( ≤4.0 msv) based on the official mexican norm standards12. genetic damage was determined as the number of micronuclei present in the oral samples. oral samples were taken during the study enrollment by brushing the cheek of the mouth and storing the samples in a neutral ph buffer at 10ºc until processing, fixation, staining with giemsa, and second fixation according to the technique previously described by thomas et al15. mn were then quantified by clear field microscopy at 100x magnification and were defined as the number of cells with micronuclei per 1000 cells. genetic damage was defined as ≥2 mn per 1000 cells and no genetic damage was defined as <2 mn per 1000 cells. statistical analysis the distribution of categorical variables, including gender, residence, marital status, education, occupation, and smoking, was compared between exposed and non-exposed groups using chi-square test or t-test for two proportions. the continuous age variable was compared between exposed and non-exposed groups using student’s t-test. the frequency of highand lowradiation exposure (≥4.1/month or <4.1 msv/month) and presence of genetic damage (≥2 or <2 mn per 1000 cells) were represented using percentages and compared between exposed and non-exposed radiation groups using fisher’s exact test. a two-tailed p value of 0.05 or less was considered to be significant. all statistical analyses were performed using stata 13.0® (stata corp., college station, tx, usa). results we recruited 30 participants who worked in the x-ray centers (exposed group) and 30 participants who did not work in the x-ray center (non-exposed group). the distribution of the sociodemographic variables for the exposed and non-exposed groups is shown in table 1. both groups were predominantly female (53.33% vs 73.30%, p >0.05), urban residents (86.67% vs 70.00%, p >0.05), smokers (86.67% vs 73,33%, p=0.2), and married (50% vs 16.67%, p=0.02). the mean age and time at work were higher in the exposed than nonexposed group (p <0.01). in the exposed group, there was a mean of mn 5.37±3.49 and in the non-exposed group there was a mean 0.37±0.61 (t-test=-7.73, df 58, p<0.01). high radiation exposure (≥4.1msv) was significantly more common among the exposed group compared to the non-exposed group (13.33% vs 0.00%, p<0.05) (table 2). genetic damage (≥2 mn per 1000 cells) was more common among the exposed group compared to the non-exposed group (90.00% vs 6.67%, p<0.05) in this sample. discussion we found a significant difference in mn count between radiation exposed and non-exposed groups in celaya, mexico. the exposed group had higher number of participants with http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx padilla-raygoza this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.331|http://cajgh.pitt.edu exposed group (n=30) f % non-exposed group (n=30) f % p-value exposure to radiation (msv/month)* high (≥4.1) 4 13.33 0 0.00 0.04* low (<4.1) 26 86.67 30 100.00 number of micronuclei (per 1000 cells) genetic damage non-genetic damage 27 90.00 3 10.00 2 6.67 28 93.33 <.01 *fisher exact test table 2. distribution of exposure to ionizing radiation and genetic damage by the exposure group unsafe level of exposure (13% vs 0%) based on the official mexican standard -ssa1-2002, environmental health12. our results are consistent with previously published literature. qian et al.,16 found that personnel working with x-rays have a higher mn count than the control group of healthy adults without history of expose to radiation, which similar to the results found in this study, where the exposed group had a higher mn number per 1000 cells compared to the non-exposed group (table 2). we have also found that individuals working in x-ray centers have been exposed to more radiation than permitted by national guidelines. kanaragaj et al.,17 quantified the presence of mn in binucleated cells (lymphocytes from peripherical blood) in subjects before and after undergoing computed tomography and found a significant increase in mn after the procedure. their findings demonstrate that acute exposure to ionizing radiation causes genetic damage. in our study, we measured chronic occupational radiation exposure and found the number of mn in oral cells was significantly higher (p<0.05) in those exposed occupationally to ionizing radiation compared with the non-exposed group. the key limitation of this study is its small sample size. however, this was a pilot study designed to inform future larger investigations. another limitation is that there was an age difference between exposed and non-exposed group, which may have influenced findings. also, the measurement of radiation exposure was performed over the course of one month, which may not be sufficient. another limitation is that there are other methods to identify genetic damage that could provide more insight, such as screening for micronuclei in lymphocytes. the strength of our study is that the measurement of exposure to ionizing radiation was performed in a consistent way, using standard dosimetry techniques. the results of this study warrant careful interpretation. while our results show significant differences for markers of genetic damage, the exposed and non-exposed groups are somewhat different in terms of age and several other characteristics to make definitive conclusions. future studies should concentrate on establishing more robust methodology, recruiting more comparable study populations, as well as improving the sample size. exposure to ionizing radiation may have a significant effect on genetic damage in individuals, therefore it is important to implement protective measures. in mexico and other countries, it is very important to provide concise guidelines on planning, performing, and interpreting studies to monitor groups or individuals exposed to genotoxic agents. acknowledgments http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.331|http://cajgh.pitt.edu the authors thank all the participants, without their support the study would not have been carried out. financial support the research and postgraduate support department of the university of guanajuato financed the study; they did not participate in design of the study, neither analysis references 1. world health organization. ionizing radiation, health effects and and protective measures. fact sheets n° 371. world health organization 2018. http://www.who.int/news-room/factsheets/detail/ionizing-radiation-health-effectsand-protective-measures accessed 3 may, 2019. 2. caicedo r, argüelles g, alzate ajcm. exposición a dosis bajas de radiación ionizante en el hospital universitario del valle, cali, 1980-1992. 1996;27(3, 4):134-137. 3. international commission on radiological protection. dose limits. icroaedia. http://www.icrp.org/icrpaedia/limits.asp accessed 3 may, 2019. 4. albertini rj, anderson d, douglas gr, et al. ipcs guidelines for the monitoring of genotoxic effects of carcinogens in humans. international programme on chemical safety. mutation research. 2000;463(2):111-172. 5. zalacain m, sierrasesumaga l, patino a. [the cytogenetic assay as a measure of genetic instability induced by genotoxic agents]. anales del sistema sanitario de navarra. 2005;28(2):227-236. 6. norppa h, falck gc-mjm. what do human micronuclei contain? 2003;18(3):221-233. 7. fenech mjmrf, mutagenesis mmo. the in vitro micronucleus technique. 2000;455(12):81-95. 8. lindberg hk, wang x, järventaus h, et al. origin of nuclear buds and micronuclei in normal and folate-deprived human lymphocytes. 2007;617(1-2):33-45. 9. popova l, kishkilova d, hadjidekova v, et al. micronucleus test in buccal epithelium cells from patients subjected to panoramic radiography. 2007;36(3):168-171. 10. da silva ae, rados pv, da silva lauxen i, et al. nuclear changes in tongue epithelial cells following panoramic radiography. 2007;632(12):121-125. 11. holland n, bolognesi c, kirsch-volders m, et al. the micronucleus assay in human buccal cells as a tool for biomonitoring dna damage: the humn project perspective on current status and knowledge gaps. 2008;659(1-2):93-108. 12. norma oficial mexicana -ssa1-2002, salud ambiental. requisitos técnicos para las instalaciones, responsabilidades sanitarias, especificaciones técnicas para los equipos y protección radiológica en establecimientos de diagnóstico médico con rayos x (12)), diario oficial, 2006. http://www.cenetec.salud.gob.mx/descargas/eq uipomedico/normas/nom_229_ssa1_2002.p df. accessed may 3, 2019. 13. stranden e, widmark a, sekse tjar. assessing doses to interventional radiologists using a personal dosimeter worn over a protective apron. 2008;49(4):415-418. 14. nassef m, kinsara ajjotufs. occupational radiation dose for medical workers at a university hospital. 2017;11(6):1259-1266. 15. thomas p, holland n, bolognesi c, et al. buccal micronucleus cytome assay. 2009;4(6):825. 16. qian q-z, cao x-k, shen f-h, wang qjrpd. effects of ionising radiation on micronucleus formation and chromosomal aberrations in chinese radiation workers. 2015;168(2):197203. 17. kanagaraj k, basheerudeen sas, jose m, et al. assessment of dose and dna damages in individuals exposed to low dose and low dose rate ionizing radiations during computed tomography imaging. 2015;789:1-6. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/news-room/fact-sheets/detail/ionizing-radiation-health-effects-and-protective-measures http://www.who.int/news-room/fact-sheets/detail/ionizing-radiation-health-effects-and-protective-measures http://www.who.int/news-room/fact-sheets/detail/ionizing-radiation-health-effects-and-protective-measures http://www.icrp.org/icrpaedia/limits.asp http://www.cenetec.salud.gob.mx/descargas/equipomedico/normas/nom_229_ssa1_2002.pdf http://www.cenetec.salud.gob.mx/descargas/equipomedico/normas/nom_229_ssa1_2002.pdf http://www.cenetec.salud.gob.mx/descargas/equipomedico/normas/nom_229_ssa1_2002.pdf abstract keywords: ionizing radiation; micronuclei; genetic damage research microsoft word henry.docx new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. family planning in the republic of tajikistan: a narrative review from soviet times to 2017 ellison henry1*, zarrina h. juraqulova2 1maternal and child health department, gillings school of public health, university of north carolina at chapel hill, chapel hill, north carolina, usa; 2economics department, denison university, granville, ohio, usa *corresponding author email: ebhenry2@live.unc.edu vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.404 | http://cajgh.pitt.edu henry this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.404 | http://cajgh.pitt.edu abstract introduction: tajikistan’s dramatic shift from a high to a low fertility society has taken place over a little more than two decades. while some fertility beliefs remained the same throughout the rapid economic and political transitions of tajikistan, other beliefs may have changed to respond to the financial realities of the newly independent and central asian republic, such as having fewer children. the objective of this review was to describe and analyze the state of family planning in the republic of tajikistan from soviet period (1929-1991) until 2017. methods: the review is based on materials obtained from various sources including google scholar and pubmed, relevant to family planning in tajikistan, including government policies, open-access nationally representative data, journal articles, and program reports, identified through a selective search of google scholar and pubmed databases, and the grey literature. conclusion: this narrative review presents the history of family planning in tajikistan, outlines an understanding of the health system context as it relates to family planning, and analyzes the latest national family planning policy (2017). the authors suggest further research is required to (a) understand the beliefs and practices related to family planning; and (b) define strategies to address the issue of unmet need of family planning services. keywords: tajikistan; family planning; fertility; family size; soviet; women family planning in the republic of tajikistan: a narrative review from soviet times to 2017 ellison henry1*, zarrina h. juraqulova2 1maternal and child health department, gillings school of public health, university of north carolina at chapel hill, chapel hill, north carolina, usa; 2economics department, denison university, granville, ohio, usa *corresponding author email: ebhenry2@live.unc.edu research during the tajik soviet socialist republic’s (tajik ssr) membership within the soviet union (ussr) from 1929-1991, pro-natalist policies were in place. ussr aimed to expand the population of member republics to meet economic targets defined in five-year plans. in that period, it was possible to support high fertility rates with financial and other resources provided by the centralized government in moscow. cheap housing, free education and health care, free plots of land for members of communal and state farms, and the low costs of essential food stuffs all made it possible for most families to afford the economic costs of many children without too much hardship.1 the tajik ssr, along with today’s central asian republics, had the highest fertility rates within the ussr. according to census data, the tajik ssr experienced the highest average annual rates of population growth between 1959-1970, 1970-79, and 1979-1989.2 the soviet health system was designed to provide uniform quality of services across member republics; however, there were large variations in the central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.404 | http://cajgh.pitt.edu number of health workers and the range and quality of services provided. for example, in 1987, georgia (5.7) had more than two times the number of physicians per 1,000 population in comparison to tajikistan (2.7). per international agreements, the government supported family planning service provision and utilization, though in practice, it was not promoted.3-6 after legalization in 1955, abortion was the primary method of fertility control throughout the ussr.3,5,7 the ministry of public health published abortion statistics in 1988, the first such publication in nearly 60 years. this report confirmed the use of abortion as the primary method of contraception and reported wide use of traditional methods of contraception (i.e. withdraw, rhythm) among those who used any method. in 1988 there were nearly 5.8 million abortions in the ussr.3 shortages of modern contraceptives coupled with an easily accessible network of abortion clinics and lack of access to family planning education were primary contributors to low utilization of modern methods.3-5 in 1989, as a response to people’s growing concerns about abortion safety, the soviet family health association was created. this ngo focused its efforts on family planning initiatives. further, in 1990 the government created the committee on problems of women, family and maternal and child health care.5 researchers have been cautious in interpreting data from the ussr due to possible lack of completeness and questions of validity and reliability.3,7 available data on contraceptive method mix is largely based on behaviors of women in moscow. surveys conducted between the 1960s-1980s report a consistent trend of preference for traditional methods– withdraw and rhythm– followed by condoms.3 researchers used 1990 survey data to estimate fertility rates and contraceptive prevalence rates across member republics. according to these estimates, the tajik ssr’s high fertility rate was paired with the lowest contraceptive prevalence rate; only three percent of married couples reported using any method of contraception.7 the purpose of this narrative review of the literature is to describe and analyze the state of family planning in the republic of tajikistan from soviet time until 2017. this review is the first to synthesize family planning literature from academic and non-academic sources within the context of tajikistan using the most updated nationally representative survey, the 2017 demographic and health surveys (dhs). methods a narrative review of english articles was conducted using two databases (google scholar and pubmed), grey literature and reference lists of key articles. all search results were reviewed and included if they addressed the key outcome of family planning within the context of tajikistan. secondary searches were conducted to include articles addressing fertility and/or family planning in the ussr and central asia. articles were included if data presented were disaggregated to republic-level statistics. “grey literature” refers to publications outside of academia and peer-reviewed journals that are disseminated by governments and organizations. the authors searched grey literature to identify relevant government policies and reports from nonprofits and donor agencies. these documents were included if directly pertaining to family planning in tajikistan. the authors conducted a search for open-access nationally representative data. after identifying several such surveys (i.e. mics, tlss, dhs), the authors chose to include the 2012 and 2017 dhs as primary data sources for this review. the dhs were chosen because they provided the most thorough and updated data on family planning. the literature as it relates to family planning in tajikistan is centered on other primary outcome measures, using family planning as a dependent variable.8-10 the authors offer this review as a contribution to the family planning literature, as a starting point to understanding the current status of family henry this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.404 | http://cajgh.pitt.edu planning in tajikistan and how the country’s related public health efforts have developed since independence. by focusing on english-language publications with a focus on tajikistan, it is possible that the authors missed seminal publications that otherwise met the inclusion criteria but were published in russian language or focused on other central asian republics. the authors chose to limit their scope within these broader language and geographical parameters. discussion women, marriage and fertility tajikistan is officially a secular state; however, since independence there has been a resurgence of some traditional islamic (tajik) values that define a woman’s main role in the private sphere (i.e. in the home). the government has publicly promoted the traditional interpretation of the role of women in tajik society.11,12 as roche notes, “...post-soviet domestic gender politics have focused primarily on women in their role as glorified mothers. along with a revival of islam since independence, motherhood has been reinforced as a sacred status by both the government and the islamic opposition, albeit in different ways.”13 the effect this may have on women’s roles in tajik society has not been thoroughly studied.14,15 there are rather significant generational differences among women in tajik society. for example, today’s young women navigate a space that is somewhere between progressive (i.e. soviet) and traditional (i.e. tajik). soviet policy and propaganda promoted gender equality and the participation of women in the public sphere. the authors note certain aspects of soviet life may have reinforced traditional gender roles, particularly regarding women’s reproductive lives (i.e. mother awards and birth incentives). the traditional patriarchal influences of tajik culture promote the role of women as mothers and homemakers, i.e. as a central figure in the private sphere.14,15 the empowerment of women has broad implications for improving health outcomes and vice versa. the ability to control fertility is associated with a woman’s status in the home and her sense of self-worth. both the 2012 and 2017 dhs examined the degree of women’s empowerment among married tajik women and its relationship with family planning decisions. both dhs reported that contraceptive use was “…positively associated with women’s participation in household decision-making.” the surveys asked women about three types of decisions: those related to their own health care, major household purchases, and visits to their family or relatives.16,17 using the 2012 dhs, juraqulova and henry (2020) examined the impact of decision-making abilities on women’s contraceptive behavior. the authors found that the probability of using birth control was higher for a woman who reported having voice in household decisions and the financial means to get medical help, compared with women who do not have both or either of these choices.18 the shock of political and economic transition from being a member of the ussr to an independent republic prompted families, especially women of reproductive age, to adopt family planning to achieve desired family size. in the “new” economy, one dependent on household-generated resources to establish and maintain a level of well-being, couples who once had ten or more children during the soviet period now have four or fewer.16,17 tajikistan navigated three socioeconomic challenges that contributed to a national reduction in family size: civil war (1992-1997); food crisis (1995); and drought (2000-2001), which caused food shortages. a fourth factor contributing to the fertility decline was a temporary labor migration of working-aged males.19 labor migration continues to impact marriage and childbearing.20,21 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.404 | http://cajgh.pitt.edu marriage is a central event in tajik culture, especially in rural areas. it is often the woman’s first exposure to sexual activity and the possibility of pregnancy.1 as of 2017, about 75% of tajik women aged 15-49 reported being currently married.17 societal expectations necessitate newlyweds have a child within one year of union. approximately seven percent of teenage girls aged 15-19 in tajikistan have begun childbearing.17 figure 1 shows that women in every oblast report having more children than desired. the difference between wanted and actual fertility rates suggest an unmet need for family planning services throughout the four oblasts and the capital, dushanbe.16,17 an unmet need for family planning occurs when women are unable to space and/or limit childbearing as they desire.22 data presented from tajikistan 2017 demographic and health survey, available at https://dhsprogram.com/pubs/pdf/fr341/fr341.pdf figure 1. wanted and total fertility rates, tajikistan, 2017 family planning the ministry of health and social protection of the population (mohspp) prioritizes family planning under the umbrella of reproductive health and oversees providing family planning guidance to local-level implementers (i.e. oblast-level facilities). the ministry’s main objectives, specific to family planning, include: 1) “ensuring low-risk pregnancy and safe motherhood; and 2) reducing complications caused by closelyspaced pregnancies and pathological conditions among women of reproductive age.”23 the ministry is responsible for training providers, providing “extensive” family planning education to all tajiks, and supplying contraceptives throughout the nation. family planning services are provided at regional, district and city reproductive health centers at the primary health center level and monitored by the national center on reproductive health.23 these departments work in conjunction with local city authorities to define and deliver health services throughout facilities in each oblast.6 in the strategic plan for reproductive health (2005-2014) the mohspp formulated an initiative to improve the reproductive health of tajiks, specifically women, by: 0 1 2 3 4 5 khatlon rrs gbao sughd dushanbe number of children wanted fertility rate total fertility rate henry this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.404 | http://cajgh.pitt.edu 1) increasing access to family planning services and contraceptives; 2) increasing access to antenatal and safe delivery services; and 3) decreasing mortality and morbidity during pregnancy and improving perinatal outcomes.6 while the objective of the plan was to integrate reproductive health services into primary care services, the program has yet to be successfully defined and implemented. consequently, measures to increase public awareness of the importance of reproductive health and to train adequate human resources to meet reproductive health needs have not been fully implemented.6 the most recent reproductive health and family planning implementation policy, passed in 2017, recommends key interventions to: (a) create an enabling environment favorable to reproductive health and family planning; (b) adapt the health system to address reproductive health challenges; and (c) provide programs that meet the needs of adolescents and youth.24 the distribution of functioning health facilities, funding for health services and provision of care is uneven across tajikistan. the overall ratio of health worker to population has declined over the last twentyfive years. today, there are fewer health professionals per capita in tajikistan than any other country in central asia. outmigration of educated and skilled medical providers has been a significant contributing factor. health worker shortages are most severe in rural areas. this is the result of low salaries, outdated medical equipment, poor human resource training, re-training and management, and the deteriorating health infrastructure.6 while the mohspp advocates for a ratio of one family medicine physician per 1,500 population and one family nurse per 750 population across the country, most physicians and nurses are concentrated in the capital, dushanbe. currently, the combined ratio of physicians and nurses to population is one of the lowest in the who european region.6 mid-level medical professionals typically practice in rural areas, carry out preventive and diagnostic tasks and perform some administrative duties. nurses train for four years but hold low status within the medical community and extremely modest salaries when compared with physicians.6 assumptions could be made about which level of medical provider is responsible for providing family planning services and reproductive health counseling, but specific responsibilities remain unclear and are not specified in the national implementation plan for family planning services (2017-2020). the majority of tajikistan’s health expenditures come from out-of-pocket payments for services, primarily payments for curative care. in 2014 a total of us$1.7 billion was spent on curative health care services, over half of which came from out-of-pocket payments.25 it is estimated that by the year 2040, around 40% of all funds spent on health will come from out-of-pocket payments.26 while the government promotes family medicine and preventative programs, government (oblast-level, i.e. hukumat) financing gives primary attention to hospital services and continues to be dominated by input-based budgeting that is based on the number of hospital beds and/or personnel rather than on health objectives, quality of care and outcomes.6,27 the united nations population fund (unfpa) has been the largest donor of reproductive health and family planning services in tajikistan. in total, 40% of all integrated sexual and reproductive health programs in 2016 were financed by unfpa; other ngos were responsible for 54% of the financing. the tajik government financed less than 5% of integrated reproductive health programs (figure 2, right side).28 figure 2 (left side) shows 2016 data, which reported about us$130,000 (11%) of the total integrated sexual and reproductive health service funding was set aside to finance family planning initiatives. unfpa funded 67% of the family planning-specific programs in 2016. central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.404 | http://cajgh.pitt.edu data presented from unfpa, available at https://www.unfpa.org/data/transparency-portal/unfpa-tajikistan figure 2. family planning program funding, tajikistan, 2016 the 2017-2020 national policy on family planning includes the mohspp’s estimate of the total funding needed for family planning and proposal for how those funds will be allocated. however, the plan does not designate the source(s) of funds nor indicate how the projected program costs were calculated. figure 3 shows the distribution of funds by action area; in total these efforts are estimated to cost about us$1.9 million.24 around us$1.6 million will be spent on interventions, the remaining funds are allocated to purchase contraceptives required to meet the target contraceptive prevalence rate increase of 1.5% per year for each of the plan’s years (2017-2020). the source for these contraceptive methods and a plan for distribution and use were not identified. within the us$1.6 million for programs, about us$110,000 is slated for provider education. us$964,000 is allotted to “increase access to family planning services and methods”. this increase will be achieved through additional provider training and a bit of service monitoring in selected facilities.24 there is no mention of efforts to train additional providers, retain those graduating from medical education programs or to extend family planning services more equitably across the country. according to the 2012 and 2017 dhs’, most tajik women received family planning information via a home visit by a health worker or a facility-based provider. women in khatlon (16.1%) were less likely to be visited in the home than women in other regions in 2012. however, in 2017 home visits by health workers increased for women in khatlon by 11.2%, perhaps a consequence of usaid’s feed the future program activities that promote home health visits. women in dushanbe experienced the greatest percentage increase of home visits, from 18.6% in 2012 to 32.1% in 2017.16,17 it is unclear how women in both khatlon oblast and regions of republican subordination receive reproductive health information if they lack access to a home health visitor or a facility-based provider. fifty three percent of women had not received any messaging from radio, tv or print media (i.e. newspaper, magazine).17 many women may be subject to myths about family planning and reproductive health and are unaware of useful family planning information. the 2017 dhs reported about 71% of currently married women were not using any method of contraception (modern or traditional) as compared with 72% reported in the 2012 dhs. the top three reasons henry this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.404 | http://cajgh.pitt.edu data from the ministry of health and social protection of the population, available in print figure 3. distribution of funds by priority action area, costed implementation plan for family planning, 2017-2020 women reported discontinuation of use were wanting to become pregnant (32.6%), side effects/health concerns (26.3%) and infrequent sex/husband away (17.7%). eighteen percent of women using any method of contraception reported using the intrauterine device (iud), and a marginal percentage used pills, male condoms, injectables or traditional methods. in total, 20% of women want to stop having children while 11% want another child in two or more years.17 this suggests that 33% of married women in tajikistan need access to long acting contraceptive methods (i.e. implant or sterilization) to achieve fertility goals. the dhs identified an association between decision-making power and unmet need for family planning. the use of any method of contraception and any modern method both steadily increased with the number of household decisions women participated in (i.e. those related to their own health care, major household purchases, and visits to their family or relatives). tajik women who reported not participating in household decisions had the highest unmet need (25%), while those who participated in all three measured decisions had lower unmet need (21%) according to 2012 dhs. however, these numbers changed in 2017 – unmet need was higher among women who participated in all three decisions (34.6%) compared to women not taking part in any decisions (23.7%).17 in the costed implementation plan for family planning (2017-2020), the mohspp identified unmet need of family planning as a specific area of public health concern. the government proposed a target of 1.5% annual increase in the contraceptive prevalence rate (cpr) as a pathway to reducing unmet need.24 however, the plan does not provide the details of how cpr will be increased; it does indicate that “to reach this goal a number of key interventions were developed making use of the…expertise of national experts and technical assistance partners”.24 conclusion in 2014, with support from usaid, engenderhealth’s respond project used dhs data to 26.30% 57.10% 4.10% 0.30% 15.80% delay early childbearing and promote health birth spacing increase acceess to quality family planning services integrate family planning services into phcs enhance community support for delaying marriage purchase additional contraceptives central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.404 | http://cajgh.pitt.edu work with the mohspp and other national stakeholders to project fertility and contraceptive prevalence trends in tajikistan until 2020. respond published a report specifying the inputs (i.e. finances, contraceptive methods) necessary to achieve two outcomes of interest: (1) maintain current cpr among married women of reproductive age through 2020; and (2) reduce the current unmet need by 2020 by providing a more balanced method mix. an estimate of us$1.3 million was given to meet the first outcome, and an additional us$450,000 to achieve the second outcome. the source of funds and other recommended inputs were not identified.29 the respond activity and most recent national implementation strategy are encouraging steps towards providing the reproductive healthcare services that tajik women seek to achieve fertility goals. the 2017-2020 costed implementation plan for family planning suggests reproductive health is a core component of the political agenda of the tajik government. this narrative review has collected relevant information about family planning in tajikistan, from soviet time until 2017. data has been provided to show that women experience an unmet need for family planning and access to these services is insufficient for women to achieve desired fertility. research is needed to provide an understanding of the family planning beliefs and practices of key populations. for example the beliefs and practices of women in khatlon oblast, an important location because both dhs surveys reported khatlon’s unmet need and fertility rates as the highest in tajikistan, coupled with early marriages and low contraceptive method uptake.16,17 further research is crucial to develop an in-depth understanding of women and provider experiences utilizing and providing family planning services. this information is necessary to inform strategies to address unmet need and inequitable access to quality services across the country. reproductive health and family planning relate to all aspects of population health and must be maintained as pillars of tajikistan’s future health policies and reforms. references 1. harris c. muslim views on population: the case of tajikistan. in: islam in the era of globalization: muslim attitudes towards modernity and identity. routledgecurzon, london, pp.211-222; 2002. 2. anderson ba, silver bd. demographic sources of the changing ethnic composition of the soviet union. population and development review. 1989 dec.;15(4):609-656. doi: 10.2307/1972593 3. popov aa. family planning and induced abortion in the ussr: basic health and demographic characteristics. studies in family planning. 1991 dec.;22(6):368-377. doi:10.2307/1966450 4. popov aa. family planning in the ussr. sky-high abortion rates reflect dire lack of choice. entre nous cph den. 1990;(16):5-7. http://www.ncbi.nlm.nih.gov/pubmed/12222340. accessed july 18, 2020. 5. taniguchi h. the agenda for family planning in the ussr. integration. 1991;(29):2-3. http://www.ncbi.nlm.nih.gov/pubmed/12284285. accessed july 18, 2020. 6. khodjamurodov g, rechel b. tajikistan: health system review. world health organization. regional office for europe. 2010;(12). https://apps.who.int/iris/handle/10665/330334. accessed july 18, 2020 7. turner r. tajiks have the highest fertility rates in newly independent central asia family planning perspectives. 1993 may jun.;25(3):141-142. doi: 10.2307/2136166 8. habibov n, zainiddinov h. do family planning messages improve antenatal care utilization? evidence from tajikistan. sexual & reproductive healthcare. 2017 oct.;(13):29-34. doi:10.1016/j.srhc.2017.05.005 9. falkingham j. inequality and changes in women’s use of maternal health-care services in tajikistan. studies in family planning. 2003;34(1):32-43. doi:10.1111/j.1728-4465.2003.00032.x henry this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.404 | http://cajgh.pitt.edu 10. merali s. the relationship between contraceptive use and maternal and infant health outcomes in tajikistan. contraception. 2016 march;93(3):216-221. doi:10.1016/j.contraception.2015.11.009 11. haarr rn. wife abuse in tajikistan. feminist criminology. 2007 july;2(3):245-270. doi:10.1177/1557085107302869 12. sokolova r. special: constructing female identity in modern tajikistan. https://pulsofcentralasia.wordpress.com/2015/05/04/spe cial-constructing-an-identity-of-a-woman-incontemporary-tajikistan-by-regina-sokolova/. accessed july 18, 2020. 13. roche s. a sound family for a healthy nation: motherhood in tajik national politics and society. nationalities papers. 2016 march;44(2):207-224. doi:10.1080/00905992.2015.1087486 14. falkingham j. women and gender relations in tajikistan: country briefing paper. 2000. http://www.gender.cawaterinfo.net/publications/pdf/women_in_tajikistan.pdf. accessed july 18, 2020. 15. dodkhudoeva l. everday life of tajik women. some considerations.; codrul cosminului”, xix, 2013;2:399-406. http://atlas.usv.ro/www/codru_net/cc19/2/women.pdf. accessed july 18, 2020. 16. tajikistan demographic and health survey 2012. dushanbe, tajikistan: sa/tajikistan, moh/tajikistan, and icf international. https://dhsprogram.com/publications/publicationfr279-dhs-final-reports.cfm. accessed july 18, 2020. 17. tajikistan demographic and health survey 2017. dushanbe, republic of tajikistan, and rockville, maryland, usa: statistical agency under the president of the republic of tajikistan/sa, ministry of health and social protection of population of the republic of tajikistan/mohsp, and icf. https://dhsprogram.com/what-we-do/survey/surveydisplay-521.cfm. accessed july 18, 2020 18. juraqulova zh, henry e. women’s bargaining power and contraception use in post-soviet tajikistan. central asian survey. 2020. forthcoming. 19. clifford d, falkingham j, hinde a.through civil war, food crisis and drought: trends in fertility and nuptiality in post-soviet tajikistan. eur j popul. 2010 feb.;26:325-350. doi:10.1007/s10680-010-9206-x 20. clifford dm. marriage and fertility change in postsoviet tajikistan. doctoral dissertation. 2009. https://eprints.soton.ac.uk/72368/1/clifford_phd_thesis. pdf. accessed july 18, 2020 21. tajikistan | un women – europe and central asia. https://eca.unwomen.org/en/where-we-are/tajikistan. accessed july 18, 2020. 22. who | unmet need for family planning. who. 2016. https://www.who.int/reproductivehealth/topics/family_p lanning/unmet_need_fp/en. accessed july 18, 2020. 23. national health strategy of the republic of tajikistan 2010-2020. dushanbe; 2010. https://extranet.who.int/countryplanningcycles/sites/defa ult/files/planning_cycle_repository/tajikistan/tajikistan_ nhs_2020_eng.pdf. accessed july 18, 2020 24. costed implementation plan for family planning for the period 2017-2020. dushanbe; 2017. ministry of health and social protection of population of the republic of tajikistan/in-print 25. tajikistan. institute for health metrics and evaluation. http://www.healthdata.org/tajikistan. accessed july 18, 2020. 26. rechel b, richardson e, mckee m. trends in health systems in the former soviet countries. european journal of public health. 2014 oct.;24(2). doi:10.1093/eurpub/cku162.088 27. falkingham j. poverty, out-of-pocket payments and access to health care: evidence from tajikistan. social science and medicine. 2004 jan.;58(2):247-258. doi:10.1016/s0277-9536(03)00008-x 28. tajikistan 2018 the united nations population fund. https://www.unfpa.org/data/transparencyportal/unfpa-tajikistan. accessed july 18, 2020. 29. dushanbe t. tajikistan’s national family planning stakeholders meeting: summary report, key highlights, and recommendations. 2014. http://www.respondproject.org. accessed july 18, 2020. cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. uptake of hiv testing among women of reproductive age in tajikistan: an assessment of individual determinants salima kasymova1 1independent researcher and consultant vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.370 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ kasymova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.370|http://cajgh.pitt.edu abstract introduction: over the past decade, the incidence of human immunodeficiency virus (hiv) infections in tajikistan increased significantly, with women particularly vulnerable to acquiring hiv. this research assessed individual determinants associated with hiv testing among women of reproductive age. methods: secondary data analysis was done using data from 5,867 females aged 15–49 years. chi-square test, t-test, and multivariate analysis were applied to find associations between women's socio-demographic characteristics, reproductive health variables, and hiv testing uptake. results: overall, only 26% (1,501) of women in the present research reported hiv testing in the past. multiple regression indicated that hiv testing was significantly associated with participants' age (25–34 age group: or 0.7, p ≤ 0.001; 35–49 age group: or 0.2, p ≤ 0.001), education (or 2.2, p ≤ 0.001), area of residence (or 0.6, p ≤ 0.001), marital status (or 2.4, p ≤ 0.001), hiv knowledge (or 1.1, p ≤ 0.001), and pregnancy history (or 6.7, p ≤ 0.001). conclusion: results of this research suggest that there is a need for culturally acceptable interventions, including outreach to increase the overall hiv testing rate among women in tajikistan. keywords: hiv; hiv testing; individual determinants; tajikistan; women uptake of hiv testing among women of reproductive age in tajikistan: an assessment of individual determinants salima kasymova1 1independent researcher and consultant research introduction tajikistan is one of the few countries in the world where the incidence of hiv infections is on the rise at a concerning rate. between 2008 and 2017, the new hiv diagnosis rate increased in tajikistan from 5.0 to 13.5 per 100,000 population. particularly concerning is the growing number of new hiv cases attributable to heterosexual contact. the total number of people who acquired hiv via heterosexual contact increased between 2008 and 2017 by 640 cases (460%).1 currently, about half of the country's population of nine million people is women. evidence suggests that multiple structural and socio-cultural factors contribute to hiv risk for women in tajikistan. gender inequality, limited abilities to discuss fidelity and negotiate condom use, early marriage practices, and domestic violence may lead to increased hiv exposure. women's vulnerability is also exacerbated by poverty, migration, and limited access to education and economic opportunities.2-4 the reported hiv prevalence rate in females increased in the country between 2008 and 2017 from 2.2 to 10.6 per 100,000 population, and aids diagnosis rate in females increased from 0.2 to 1.8 per 100,000 population. it is estimated that the cumulative total number of hiv cases among women in tajikistan is 3,334.1 hiv testing is one of the most effective ways to halt the transmission of hiv. preand posttest http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.370|http://cajgh.pitt.edu counseling sessions that occur during hiv testing services provide an opportunity for primary prevention.5 hiv testing also allows the provision of psychosocial support and links hiv positive individuals to antiretroviral therapy sites. currently, hiv testing is mandatory for pregnant women in tajikistan. evidence suggests that hiv testing services are underutilized in the country and limited research explored this problem.6,7 considering that tajikistan has been experiencing one of the fastest growing hiv epidemics in the world, there is an urgent need to study the factors that govern individual choice to seek hiv testing services. therefore, the goal of this study was to address this need by examining individual determinants associated with hiv testing among women in tajikistan. results of this research will potentially inform the development of future hiv prevention policies in tajikistan aimed at reducing individual risk and vulnerability to hiv infection. methods data source the current research used cross-sectional data from the demographic and health survey (dhs)8, a nationally representative sample survey. the survey was conducted in tajikistan in 2012 with an aim to collect data on maternal and child health, fertility and contraceptive use, domestic violence, tuberculosis, hiv, and other sexually transmitted infections (stis) from women of reproductive age. the survey randomly selected 9,794 women aged 15–49 years from 6,674 households, of whom 9,656 were interviewed; the response rate for dhs was 99%.9 measures for the hiv testing variable, participants' responses to the question "have you ever been tested to see if you have the aids virus" were used; it was scored dichotomously (yes vs. no). independent variables included several demographic and socioeconomic characteristics, as well as reproductive health variables, which were selected based on results of previous research.10-13 demographic measures included respondents' age (15–24, 25–34, and 35–49), area of residence (urban vs. rural) and marital status (married/living with partner vs. unmarried/widowed/ divorced/separated). socioeconomic variables included education (no education/primary, secondary, and higher) and household income (low, middle, and high). hiv knowledge was assessed through an eight-item scale (α = 0.76) with response options of “yes”, “no”, and “i do not know”. hiv knowledge was defined as knowing two primary methods of hiv prevention (consistent condom use and staying faithful to one uninfected partner), rejecting four misconceptions about hiv transmission (hiv cannot be transmitted by mosquito bites, by sharing food, or by kissing, and a healthy-looking person can be infected with hiv) and knowing two facts about motherto-child (i.e., vertical) hiv transmission (hiv can be transmitted during pregnancy and delivery). women received one point for each correct answer, and all points summed to create an hiv knowledge score (range 0–8). higher scores indicated higher levels of knowledge about hiv. reproductive health variables included pregnancy history (had ever been pregnant vs. had never been pregnant) and had stis in last 12 months (yes vs. no/do not know). statistical analysis as the first step of statistical analysis, descriptive approaches such as frequencies for binary and categorical variables, as well as means and standard deviations for continuous variables, were generated to describe the samples and understand the data distribution. then, separate simple logistic regression equations with corresponding 95% confidence intervals (cis) were conducted to identify the odds of having hiv testing for each of the independent variables: age, area of residence, marital status, education, income, hiv knowledge, pregnancy history, and had stis in the last 12 months. finally, a multivariate logistic regression model that http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kasymova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.370|http://cajgh.pitt.edu included the hiv testing variable and all independent variables was estimated. a significance level of 0.05 was used during statistical analysis. the statistical analysis was conducted using stata 13. variable not tested n (%) mean (sd) had been tested n (%) mean (sd) total n (%) mean (sd) p-value age 15–24 1,583 (36) 395 (26) 1,978 (34) ≤ 0.001¹ 25-34 1,107 (25) 645 (43) 1,752 (30) 35-49 1,676 (38) 461 (31) 2,137 (36) area of residence urban 1,577 (36) 743 (50) 2,320 (40) ≤ 0.001¹ rural 2,789 (64) 758 (50) 3,547 (60) marital status married/living with partner 2,795 (64) 1,345 (90) 4,140 (71) ≤ 0.001¹ unmarried/widowed/divorced/separated 1,571 (36) 156 (10) 1,727 (29) education no education/primary 116 (3) 36 (2) 152 (3) ≤ 0.001¹ secondary 3,278 (75) 913 (61) 4,191 (71) higher 972 (22) 552 (37) 1,524 (26) wealth index low 1,374 (31) 337 (22) 1,711 (29) ≤ 0.001¹ middle 761 (17) 226 (15) 987 (17) high 2,231 (51) 938 (62) 3,169 (54) hiv knowledge 4.7 (2.4) 5.4 (2.1) 4.9 (2.3) ≤ 0.001² pregnancy history had ever been pregnant 2,744 (63) 1,359 (91) 4,103 (70) ≤ 0.001¹ had never been pregnant 1,622 (37) 142 (9) 1,764 (30) had sti in last 12 months yes 14 (0.3) 7 (0.5) 21 (0.4) 0.415¹ no/do not know 4,352 (99.7) 1,494 (99.5) 5,846 (99.6) ¹chi-square test; ²t-test. table 1. demographic and socioeconomic characteristics of participants by hiv testing history (n = 5,867) results of the 9,656 women surveyed, 3,587 reported not having heard of hiv and they were excluded from analysis. in addition, 202 cases with missing data were also excluded. thus, the final sample for this research was 5,867 women. sample characteristics are presented in table 1. age of the respondents ranged from 15 to 49 years, with a mean (sd) of 31 (9.8) years. most women reported their marital status as married/living with partner (71%). the majority of respondents resided in rural areas (60%), had at least secondary education http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.370|http://cajgh.pitt.edu (97%), and were in the high wealth quintile (54%). approximately 70% of the sample had been pregnant, and only 21 women (0.4%) indicated that they had an sti in the last 12 months. lastly, hiv knowledge score ranged from 0 to 8, with participants’ mean total hiv variable unadjusted adjusted or 95% ci or 95% ci age 15–24 (ref.) 1.0 1.0 25-34 2.3*** 2.0-2.9 0.7*** 0.6-0.9 35-49 1.1 0.9-1.3 0.2*** 0.2-0.3 area of residence urban (ref.) 1.0 1.0 rural 0.6*** 0.5-0.6 0.6*** 0.5-0.7 marital status unmarried/widowed/ divorced/separated (ref.) 1.0 1.0 married/living with partner 4.8*** 4.1-5.8 2.4*** 1.9-3.0 education no education/primary (ref.) 1.0 1.0 secondary 0.9 0.6-1.3 1.0 0.7-1.6 higher 1.8** 1.2-2.7 2.2*** 1.4-3.4 household wealth low (ref.) 1.0 1.0 middle 1.2* 1.0-1.5 1.0 0.8-1.2 high 1.7*** 1.5-2.0 1.0 0.9-1.3 hiv knowledge 1.2*** 1.1-1.2 1.1*** 1.1-1.2 pregnancy history had never been pregnant (ref.) 1.0 1.0 had ever been pregnant 5.7*** 4.7-6.8 6.7*** 5.1-8.8 had sti in last 12 months no/do not know (ref.) 1.0 1.0 yes 1.5 0.6-3.6 0.7 0.3-1.9 *p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001 table 2. unadjusted and adjusted estimates from logistic regression models predicting hiv testing among women (n = 5,867) knowledge score at 4.9 (sd = 2.3), indicating moderate levels of overall hiv knowledge. overall, 1,501 (26%) of respondents reported hiv testing in the past. table 2 presents unadjusted and adjusted estimates from logistic regression models predicting the odds of having hiv testing for each of the independent variables with corresponding 95% cis. the odds of being hiv tested were significantly lower among rural women, unmarried/widowed/divorced/separated women, and those with lower education and income. in addition, women with hiv testing history had http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kasymova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.370|http://cajgh.pitt.edu significantly higher hiv knowledge scores as compared with their counterparts who had not been tested. lastly, the likelihood of hiv testing was correlated with respondents' age and pregnancy history. in the adjusted logistic regression model, six significant predictors of hiv testing: age, area of residence, marital status, education, hiv knowledge, and pregnancy history. the strongest predictor of hiv testing was pregnancy history; women who had ever been pregnant were almost seven times (or 6.7, 95% ci 5.1– 8.8, p ≤ 0.001) more likely to report that they had been tested for hiv in the past. in addition, married women and women who lived with a partner were more than twice (or 2.4, 95% ci 1.9–3.0, p ≤ 0.001) as likely to report hiv testing uptake as compared to unmarried women and women who were divorced, separated, and widowed. the odds of ever testing for hiv were also significantly higher among urban women (or 0.6, 95% ci 0.5–0.7, p ≤ 0.001), women with higher education (or 2.2, 95% ci 1.4–3.4, p ≤ 0.001), and women with higher levels of hiv knowledge (or 1.1, 95% ci 1.1– 1.2, p ≤ 0.001). lastly, the odds of ever being tested for hiv decreased with women's age (for 25–34 age group: or 0.7, 95% ci 0.6–0.9, p ≤ 0.001 and for 35–49 age group: or 0.2, 95% ci 0.2–0.3, p ≤ 0.001). discussion this research was motivated by the need to learn more about uptake of hiv testing among women of reproductive age in tajikistan. results of this research suggested that within the sample, approximately three out of four women aged 15–49 years had never been tested for hiv. respondents' age, area of residence, marital status, education, hiv knowledge, and pregnancy history were significant predictors of undergoing hiv testing. taking into consideration that according to the national legislations, pregnant women are subject to mandatory hiv testing, it is not surprising that pregnancy history was the strongest hiv testing predictor. this result corroborates the idea that antenatal care is an important gateway to hiv testing among women in tajikistan. on the other hand, it raised the concern of access to hiv testing for women who had never been pregnant and older women who are less likely to seek antenatal care services. findings also indicate that urban women were more likely to have been tested for hiv than rural women. lower hiv testing uptake among rural women may be related to lower accessibility to hiv testing services in rural areas of tajikistan.3 this finding could also be related to the geography of the hiv epidemic, since the prevalence of hiv in tajikistan is higher in urban areas.4 consistent with the results of previous research10, marital status was one of the significant determinants of hiv testing. this finding may reflect the fact that the hiv testing promotion strategies fail to reach women who are unmarried, widowed, divorced, and separated. in addition, as previously documented11-13, higher level knowledge about hiv was associated with higher odds of hiv testing. this finding could be an indication that women with more accurate hiv knowledge acknowledge their risk for contracting hiv and seek opportunities to know their hiv serostatus. lastly, the unadjusted logistic regression models indicate hiv testing uptake increased with women’s wealth status. however, in the adjusted regression model, the relationship between these variables was positive but not significant. this finding contradicts results of studies conducted in other developing countries.10,11,14,15 this result may suggest that epidemiological and contextual factors play a more significant role for seeking hiv testing services than individual determinants. nevertheless, further studies are needed to understand how individual, epidemiological, and contextual factors influence hiv testing uptake in tajikistan. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.370|http://cajgh.pitt.edu the following limitations should be considered in interpretation of these research findings. due to the cross-sectional design of this research, it was not possible to determine causal inferences about relationships among hiv testing and independent variables. another limitation is that the research sample consisted of women aged 15–49 years and more than half of them were from households with high income, which makes it difficult to generalize the findings to females of other age and income groups. in addition, dhs data were self-reported, which may have introduced social desirability and recall bias. this research focused on how individual characteristics affect uptake of hiv testing; however, available literature suggests that community-level determinants may play a significant role in hiv testing uptake. for example, previous research14 has shown that women from more educated and higher income communities had higher odds of hiv testing. moreover, kuehne and colleagues12 found that respondents who lived in the communities that discussed hiv were twice as likely to have been tested for hiv. hence, future research should consider the incorporation of broader arrays of variables, including community-level determinants, which can affect women's behaviors to seek hiv testing services. finally, for this research, data collected in 2012 was used, and its applicability today may be a matter of concern. therefore, when 2017 dhs data becomes available, future research should replicate the analysis to determine any changes in factors that play a significant role in hiv testing behaviors among women of tajikistan. in view of results of this research, to increase hiv testing uptake among women in tajikistan, several policies and interventions can be considered. there is a need for innovative and culturally acceptable interventions that include outreach efforts targeting adolescent females; older women; women from rural areas; unmarried, widowed, divorced, and separated women; as well as women who had never been pregnant. special attention should also be given to the promotion of hiv testing among pregnant women. every year, approximately 200,000 women in tajikistan become pregnant3 with a high proportion never receiving antenatal care. according to the 2012 tajikistan dhs report9, 21% of women did not receive any antenatal care for their most recent pregnancy. moreover, between 2010 and 2013, the number of new hiv infections diagnosed among pregnant women increased from 53 to 112 cases.4 available literature suggests that home-based hiv testing and mobile-clinic hiv testing can contribute to improving coverage and accessibility to hiv testing.16,17 in addition, provider-initiated testing can help to increase the overall hiv testing rate13, and it should be promoted in the future. finally, previous research reported that many women do not seek hiv testing services because their brothers or mothers-in-law forbid them to do so.3 moreover, available data suggests that spouses rarely discuss hiv testing between each other.18 asking a husband/partner to test for hiv is particularly difficult for a woman due to power dynamics within the relationship. therefore, hiv prevention interventions should focus on increasing general knowledge about hiv, addressing community norms about hiv testing, and eliminating hiv-related stigma. in addition, communication with a spouse/partner should be included in hiv prevention efforts. to conclude, the findings of this research add to the scant literature on determinants of hiv testing uptake among women aged 15–49 years in tajikistan. results of this research suggest that there is a need for culturally acceptable interventions, including outreach to increase the overall hiv testing rate among women in tajikistan. acknowledgements i would like to thank the dhs program for granting access to the tajikistan dhs data. references http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx kasymova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.370|http://cajgh.pitt.edu 1. european centre for disease prevention and control, world health organization regional office for europe. hiv/aids surveillance in europe 2018 – 2017 data. copenhagen, denmark: who regional office for europe; 2018. 2. ancker s, rechel b. policy responses to hiv/aids in central asia. glob public health. 2015;10(7):817-33. doi: 10.1080/17441692.2015.1043313. 3. who regional office for europe. hiv/aids in tajikistan. mid-term review of the national aids programme 2011-15 (october 2013). who regional office for europe. http://www.euro.who.int/__data/assets/pdf_file/0010/ 257275/hivaids-in-tajikistan.pdf?ua=1. published 2014. accessed november 22, 2018. 4. who regional office for europe, centre for health and infectious disease research, who collaborating centre on hiv and viral hepatitis. hiv programme review in tajikistan. evaluation report (september 2014). who regional office for europe. http://www.euro.who.int/__data/assets/pdf_file/0008/ 270539/hiv-programme-review-intajikistan.pdf?ua=1. published 2015. accessed november 27, 2018. 5. cremin i, nyamukapa c, sherr l, et al. patterns of self-reported behaviour change associated with receiving voluntary counselling and testing in a longitudinal study from manicaland, zimbabwe. aids behav. 2010;14(3):708-15. doi: 10.1007/s10461-0099592-4. 6. saadat vm. hiv risks, testing, and treatment in the former soviet union: challenges and future directions in research and methodology. cent asian j glob health. 2015;4(2):225. doi: 10.5195/cajgh.2015.225. 7. smolak a, el-bassel n. multilevel stigma as a barrier to hiv testing in central asia: a context quantified. aids behav. 2013;17(8):2742-55. doi: 10.1007/s10461-013-0571-4. 8. statistical agency under the president of the republic of tajikistan (sa), ministry of health of tajikistan (moh), icf international. tajikistan demographic and health survey 2012. tjir61fl.dta [database online]. rockville, maryland: sa, moh, icf international [producers]. icf international [distributor]; 2013. accessed november 1, 2018. 9. statistical agency under the president of the republic of tajikistan (sa), ministry of health of tajikistan (moh), icf international. tajikistan demographic and health survey 2012. dushanbe, tajikistan & calverton, maryland, usa: sa, moh, and icf international; 2013. 10. cherutich p, kaiser r, galbraith j, et al. lack of knowledge of hiv status a major barrier to hiv prevention, care and treatment efforts in kenya: results from a nationally representative study. plos one. 2012;7(5):e36797. doi: 10.1371/journal.pone.0036797. 11. jean k, anglaret x, moh r, lert f, dray-spira r. barriers to hiv testing in cote d'ivoire: the role of individual characteristics and testing modalities. plos one. 2012;7(7):e41353. doi: 10.1371/journal.pone.0041353. 12. kuehne a, koschollek c, santos-hovener c, et al. impact of hiv knowledge and stigma on the uptake of hiv testing results from a community-based participatory research survey among migrants from sub-saharan africa in germany. plos one. 2018;13(4):e0194244. doi: 10.1371/journal.pone.0194244. 13. ziraba ak, madise nj, kimani jk, et al. determinants for hiv testing and counselling in nairobi urban informal settlements. bmc public health. 2011;11:663. doi: 10.1186/1471-2458-11-663. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.370|http://cajgh.pitt.edu 14. kirakoya-samadoulougou f, jean k, maheu-giroux m. uptake of hiv testing in burkina faso: an assessment of individual and community-level determinants. bmc public health. 2017;17(1):486. doi: 10.1186/s12889-017-4417-2. 15. takarinda kc, madyira lk, mhangara m, et al. factors associated with ever being hiv-tested in zimbabwe: an extended analysis of the zimbabwe demographic and health survey (2010-2011). plos one. 2016;11(1):e0147828. doi: 10.1371/journal.pone.0147828. 16. labhardt nd, motlomelo m, cerutti b, et al. homebased versus mobile clinic hiv testing and counseling in rural lesotho: a cluster-randomized trial. plos med. 2014;11(12):e1001768. doi: 10.1371/journal.pmed.1001768. 17. sharma m, ying r, tarr g, barnabas r. systematic review and meta-analysis of community and facilitybased hiv testing to address linkage to care gaps in sub-saharan africa. nature. 2015;528(7580):s77-85. doi: 10.1038/nature16044. 18. king ej, maksymenko km, almodovar-diaz y, johnson s. 'if she is a good woman ...' and 'to be a real man ...': gender, risk and access to hiv services among key populations in tajikistan. cult health sex. 2016;18(4):422-34. doi: 10.1080/13691058.2015.1089603. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. spatial distribution and trends of waterborne diseases in tashkent province veluswami saravanan subramanian1, min jung cho1, siwei zoe tan1, dilorom fayzieva2, christian sebaly1 1department of political and cultural change, center for development research, university of bonn, germany; 2research institute of irrigation and water problems, tashkent, uzbekistan vol. 6, no. 1 (2017) | issn 2166-7403 (online) doi 10.5195/cajgh.2017.277 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ saravanan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu abstract introduction: the cumulative effect of limited investment in public water systems, inadequate public health infrastructure, and gaps in infectious disease prevention increased the incidence of waterborne diseases in uzbekistan. the objectives of this study were: (1) to spatially analyze the distribution of the diseases in tashkent province, (2) to identify the intensity of spatial trends in the province, (3) to identify urban-rural characteristics of the disease distribution, and (4) to identify the differences in disease incidence between pediatric and adult populations of the province. methods: data on four major waterborne diseases and socio-demographics factors were collected in tashkent province from 2011 to 2014. descriptive epidemiological methods and spatial-temporal methods were used to investigate the distribution and trends, and to identify waterborne diseases hotspots and vulnerable population groups in the province. results: hepatitis a and enterobiasis had a high incidence in most of tashkent province, with higher incidences in the eastern and western districts. residents of rural areas, including children, were found to be more vulnerable to the waterborne diseases compared to other populations living in the province. conclusions: this pilot study calls for more scientific investigations of waterborne diseases and their effect on public health in the region, which could facilitate targeted public health interventions in vulnerable regions of uzbekistan. keywords: spatiotemporal analysis; environmental health; tashkent province; uzbekistan; central asia spatial distribution and trends of waterborne diseases in tashkent province veluswami subramanian saravanan1, minjung cho1, siwei zoe tan1, dilorom fayzieva2, christian sebaly1 1center for development research, university of bonn, bonn, germany; 2research institute of irrigation and water problems, tashkent, uzbekistan research developing countries with inefficient public health infrastructure, such as those in central asia, struggle to address public health challenges1. one of the major challenges in the region is access to clean drinking water and sanitation with the urban population having better access to drinking water and sanitation compared to their rural counterparts2. due to a lack of funds dedicated to public health programs, insufficient institutional infrastructure, and inadequate technical expertise, the water utility companies are primarily carrying out emergency repairs rather than renovations, placing the health of central asian people at risk. waterborne diseases caused by microbiological contaminants and pathogens – such as intestinal infections, typhoid3, intestinal parasites4, 5, and viral hepatitis6 – are commonly reported health problems in central asian countries7. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu while waterborne diseases are an established health threat in the region, there is a lack of studies that examine the spatial-temporal variation of these conditions8. several published reports suggested the importance of access to safe water supply, environment, and sanitation for children’s health in central asian countries4, 9, 10. the who reports that diarrhea is the leading cause of death among children under 5 in this region9, 11, 12, and this figure ranges from 4-5% in kazakhstan and kyrgyzstan to 9-10% in tajikistan, turkmenistan, and uzbekistan13-17. rotavirus infections, which cause severe gastroenteritis in children, lead to the death of 886 children annually in kazakhstan, kyrgyzstan, and uzbekistan, suggesting that 1 in 1153 children in these central asian states is vulnerable to rotavirus-related death before the age of 510. intestinal parasitic infections (including helminths and intestinal protozoa) are also a public health problem that appears to disproportionately affect school-age children4. these studies have highlighted issues at the national level8, 18, 19, but there have been few investigations at the sub-national level, and in particular at the provincial level. water quality is a concern in uzbekistan20 as over half of the population does not have access to a piped water supply21 and relies on various sources of water, including outside taps, water pumps in the yard, and public standpipes19. the quality of water is further degraded by pollution from domestic waste, organic matter, mineral fertilizers, pesticides, and industrial waste, which has a considerable effect on human health19 , 22. furthermore, the industrial sector in uzbekistan withdraws about 1.2 km3 of water annually, and almost http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saravanan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu half of this volume is returned as industrial wastewater that poses a serious threat to the quality of drinking water sources23. tashkent province is in the north-eastern part of the country, between the syr darya river and the tian shan mountains. it has an area of 15,300 km², and as of 2014, has a population of 2,644,400 people, which is about 10 % of the total population of uzbekistan. the province includes five towns (figure 1) and, excluding tashkent city, which is governed as an independent administrative unit, is divided into fifteen administrative units called districts. despite proximity to the capital, only about 82% of the population in the province had access to a piped water supply as of 200524, which is a marginal increase from 79% in 2000. only about 70% of the population had access to sewage systems, septic tanks, or other hygienic sanitation and sewage disposal systems. this exploratory study utilizes the available social and demographic information to identify hotspots in the distribution of waterborne diseases in tashkent province, uzbekistan. this province was selected for the study due to its proximity to the capital city and due to the accessibility of information. we examined four of the most prevalent waterborne diseases (enterobiasis, acute intestinal infections, hepatitis a, and dysentery) and explored their spatial distributions and trends, focusing on identifying patterns in rural vs. urban populations as well as in pediatric vs. adult cases. methods this paper uses statistical information for tashkent province for 2011-2014 to carry out spatial distributions of four waterborne diseases (thematic maps) and to analyze their spatial-temporal trends. the sociodemographic information for the country was based on a sampling of 10% of the population, rather than the traditional census data due to absence of recent census data. the last census was undertaken in 1989 under the soviet period and results were published in 199025. a census was planned for 2000 but has been postponed due to financial constraints. the health-related statistical data was obtained from the republican centre for sanitaryepidemiological surveillance (cses) in tashkent province. the cses is a surveillance system that has been in operation since the soviet period26, and collects cases of infectious diseases with the help of physicians and healthcare workers in a standardized format that includes basic information about the patients, such as name, age, birthdate, sex, address, primary diagnosis, date of diagnosis, and date of hospitalization27. within 12 hours of diagnosis, all suspected or confirmed cases are reported via telephone (followed up by a written report) to the district (smallest administrative unit, called tuman) cses, which is then forwarded to the provincial (called viloyat) cses27. the district-level socio-demographic information was available for the following categories: total population, children under 14 years of age, and urban and rural classification. these were used to calculate the incidence rates in the province and its urban-rural divisions. the total population of children under 14 years of age was available only for 2014; therefore, the year 2014 was used as a basis to calculate the incidence rates among children. the district-level cses obtains additional cases of infectious diseases from clinical, laboratory, and epidemiological information within 24 hours in order to properly respond to a potential outbreak27. a separate case report form was prepared by tuman cses to summarize the epidemiological work as well as the information collected27, 28. the district pools monthly data from both the provincial and national levels27. the incidence rates for the urban, rural, and total population were calculated for the districts in tashkent province for the years 2011, 2012, 2013, and 2014, and spatially mapped. pediatric population data were not available for urban and rural populations as separate categories27. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu the base map for tashkent province was created using the open-street map29 and esri/delorme30. using this base map, thematic maps were prepared for each disease to identify spatial-temporal characteristics in their distribution. the districts’ yearly incidence rates for 2011 to 2014 were displayed as grouped bar charts, while the average incidence rates of the individual infections are symbolized by the red-color gradation. those values were generated using the equal interval classification scheme of arcmap, which divides the given range of attribute values into equal-sized subranges. in order to emphasize the amount of an attribute value relative to other values, four equal-sized classes were created to derive the data from. these four classes were categorized as very high, high, moderate, and low incidences of diseases, with decreasing red intensity indicating lower incidence. the range for these classes varies depending on the attribute values for each specific disease. trend surface analysis models the geographic distribution of the average incidence rates throughout space and identifies general tendencies of the sample data31. the average incidence rates (z-axis) were projected as sticks on the coordinate system (x = west to east, y = south to north) reflecting the location and value (height) of each incidence rate. two coordinate systems with specific geographic alignments (west-east and south-north, southwest-northeast and southeastnorthwest) were created to identify trends. the polynomial lines drawn through the projected points display the trends in specific directions. results spatio-temporal trends in waterborne diseases of the four waterborne diseases, the incidence rates for enterobiasis were found to be the highest, with a four-year average of about 1084 cases per 100,000 population; and the lowest for dysentery with an average of 28 cases per 100,000 population (table 1). the spatialtemporal trend revealed a marginal increase in enterobiasis and hepatitis a from 2011 to 2014. although hepatitis a and enterobiasis incidence rates dropped in 2012, they sharply increased thereafter. acute intestinal infections decreased since 2011 but increased in 2014. dysentery was the exception, and its incidence rates have been steadily decreasing since 2011. 2011 2012 2013 2014 dysentery 38.23 27.56 23.38 22.30 hepatitis a 124.34 103.98 147.33 189.68 acute intestinal infections 201.57 174.31 167.62 173.77 enterobiasis 1110.22 1018.55 1055.54 1152.01 source: republican center for epidemiology and sanitary system (cess) table 1: average incidence rates (cases per 100,000) of the four major waterborne diseases in tashkent province (2011–2014) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saravanan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saravanan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu spatial distribution of the diseases the overall spatial distribution of the diseases revealed high incidence rates of enterobiasis and hepatitis a in the central and eastern districts, and of acute intestinal infections and dysentery in the central and western districts of the province (figure 2). enterobiasis appeared to be spatially focused in the eastern and southern parts of the province (figure 2a). bekabad city had the highest average incidence rates, about six times higher than the district and twice that of the total average for tashkent province. a high incidence of hepatitis a (more than 185 cases) was reported in yangiyul district and olmalik city (figure 2b). a moderate incidence (62 to 124 incidence rates) of hepatitis a was reported in the central districts of the province. acute intestinal infections were reported to be high in angren city and olmalik city (figure 2c). dysentery showed a decreasing trend across the province and has the lowest incidence rates of the four diseases in this study (figure 2d). the highest average incidence rates for the 2011–2014 period were found in olmalik city and angren city, while the lowest rates were found in urtachirchik, bustanlik, and bekabad city. spatio-temporal trends in the incidence spatio-temporal trends in the incidence of diseases revealed increasing trends of enterobiasis in the east (figure 2). hepatitis a revealed an increasing trend among eastern and western districts. acute intestinal infections remained stable, while dysentery showed a decreasing trend across the province. an increasing trend in the incidence of enterobiasis was found in ohangaron district, and in buka, chirchik city, and olmalik city (figure 2a). hepatitis a incidence rates were increasing across the province (figure 2b), but spatially focused in the southern and eastern parts of tashkent province. olmalik city and yangiyul district could be considered as hotspots, as the trend of increasing incidence was strongest there, along with bekabad district. only districts parkent and kuyichirchik and two cities, bekabad and chirchik showed a decreasing trend. for acute intestinal infections, a decreasing trend was observed in the majority of the districts (figure 2c). however, an increasing trend was observed in angren city, olmalik city, and bekabad district, and in the two northwestern districts of yangiyul and zangiota. the spatial trends for dysentery were closely related to those for acute intestinal infections, although its incidence rates were much lower (figure 2d). there was an overall decreasing trend; however, several districts in the western part of the province registered a slight increase in total incidence rates. the trend surface analysis for 2011–2014 demonstrated two sets of diseases presenting two different geographical trends (appendix 2). the disease that showed strongest spatial variation was enterobiasis, which was concentrated towards the east, southeast, and southwest. hepatitis a incidence also showed a spatial concentration towards the center and east, and tends towards southeast and southwest. overall, the trend surface analyses revealed the east, southeast, and southwest as hotspots vulnerable to enterobiasis and hepatitis a. in contrast, the center and southeast regions were vulnerable to dysentery and acute intestinal infections. urban and rural distribution all four major waterborne diseases had higher incidence rates in the rural areas of the province compared to the urban areas during 2011–2014. the urban-rural gap was more than 50% for enterobiasis and hepatitis a, followed by acute intestinal infections. dysentery was reported to have the lowest urban-rural gap in its incidence rates. enterobiasis had higher average incidence (rates of more than 1500 per 100,000) in rural regions and in bekabad city during the four-year period (figure 3a). a higher incidence rate (more than 150 per 100,000) of hepatitis a was reported across ten districts and in two cities (olmalik and angren) in the province (figure 3b). http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saravanan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saravanan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu while acute intestinal infections were more dominant in the rural areas, the urban areas were comparable in terms of incidence rates (figure 3c). dysentery was more common (more than 40 cases) in the districts where higher rates of acute intestinal infections were reported (figure 3d). distribution of disease among children children were found to be more vulnerable to these diseases compared to the adult population. the average incidence rates among children under 14 years of age were more than double the incidence rates among the adult population in the province in 2014, with enterobiasis more than three times more common than in the adult population. in a few selected districts the spatial distribution revealed a wider gap between children under 14 years of age and the adult population in the incidence of enterobiasis (figure 4a). for hepatitis a, a persistent and large gap between incidence in the adult population and among children was found across the province (figure 4b). a higher incidence in acute intestinal infections among children under 14 years of age was reported in angren and olmalik cities, and in kibray and zangiota districts (figure 4c). in the case of dysentery, a reduced difference was observable across the province, except in angren and olmalik cities, and parkent district (figure 4d). the temporal trends among children under 14 years of age for 2011–2014 were higher in angren and olmalik cities, and ohangaron, bekabad, and zangiota districts. the incidence rates of enterobiasis among children significantly increased in ohangaron and buka districts, while bekabad city reported a stable high incidence rate across the four years. hepatitis a showed an increasing trend in olmalik and angren cities, and yangiyul, bekabad, and ohangaron districts. interestingly, a decrease was seen in bustanlik district. there was an increasing trend of acute intestinal infections in zangiota, bekabad, and kuyichirchik districts, while angren and olmalik cities and kibray and zangiota districts reported high but stable incidence across the four years. dysentery showed a decreasing trend across the province, except in akkurgan district. discussion the findings of this analysis revealed that hepatitis a and enterobiasis had high incidence rate in most of tashkent province, with both diseases sharing similar characteristics: they were transmitted through the fecal-oral route and were more prevalent in the younger populations. people living in rural areas, including children, were found to be more vulnerable to the waterborne diseases compared to the more urban population. a persistent rural bias was reported for all four of the waterborne diseases. among the districts, akkurgan and zangiota were vulnerable to all four diseases in rural areas. the districts of bekabad, ohangaron, kuyichirchik, and urtachirchik had vulnerability to enterobiasis and hepatitis a, and the kibray and parkent districts were vulnerable to acute intestinal infections and dysentery. the average rural incidence rates of enterobiasis and hepatitis a were twice as high as in urban areas. among the cities, olmalik and angren could be considered as hotspots for increased incidence rates of the waterborne diseases. bustanlik and bekabad showed considerable difference in the distribution of enterobiasis incidence rates between urban and rural sectors, but it is unclear if the low urban incidence rates reflected the level of urban population density or whether the urban areas in these two districts had better access to healthcare. another example were the districts that reported higher rural incidence rates, such as yangiyul. interestingly, piskent and buka both showed higher urban incidence rates for enterobiasis and hepatitis a compared rural incidence rates. there are several plausible explanations of why the disease incidence is higher in rural areas worthy of further investigation. one explanation could be a growing gap in healthcare access between the urban and rural areas, with a growing population residing in rural areas. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saravanan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saravanan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu this study demonstrated that children are more vulnerable in the province. this is consistent with other studies32, which reported over 70% of observed cases involving children under 14 years of age, and also with the reports from fayzieva33 and alimova and fayzieva24 which also identified the districts of yangiyul, akkurgan, kuyichirchik, and urtachirchik in tashkent province as being at high risk for waterborne diseases. these hotspots require further investigation to understand the causes and epidemiological characteristics of the diseases. bekabad district is an area with a significant industrial presence, where mining, pulp mills, and tanneries discharge toxic waste24. yangiyul district is at the receiving end of the wastewater discharged from tashkent city. in many cases, wastewater from these industries not only drains directly into rivers but also seeps into the ground, contaminating aquifers and wells34. improper treatment of industrial and municipal wastewater may explain adverse health events among residents of olmalik and angren cities, as well as bekabad and yangiyul districts. while these studies suggest poor quality of water in the water systems, it is difficult to establish a link without appropriate information on water quality and adequate information on the socio-demographic and health parameters. this study may suggest that existing water quality monitoring system and its analysis of microbial indices are potentially insufficient to prevent infectious disease outbreaks. these are complex issues requiring a resolution35. in most low-income countries, the problem arises from the lack of separation of water sources used in agriculture irrigation and industrial wastewater management 35. this also applies to uzbekistan, as its insufficient regulations of industrial pollution control and wastewater agricultural usage increased the risk of microbiological contamination of surface water and groundwater, and the transfer of chemical and biological contaminants to crops, ultimately affecting public health 35. the cses plays a major role in environmental health, food safety, and control of communicable diseases in the central asian region. in the case of uzbekistan, cses plays a crucial role in health protection with its extensive infrastructure and network within the nation. yet, the effectiveness of this system is not well known due to lack of external evaluation36, 34. there is a potential for low reliability of the data collected through this system due to several factors such as lack of qualified medical personnel and lack of inadequate laboratory resources as pointed out by other studies done in the central asian region27, 28, 37. gradual steps need to be taken to improve ways of administration and management of cses, which would open possibilities to focus on learning international methods and practices. another option to help evaluating its adequacy and relevance for policy making is to make public information such as socio-demographic statistics accessible to general population. the findings of this study can help to underline the potential of cses’s existing capacities and recommend ways for advancing practice. while national and international studies have highlighted the importance of investigating environmental health issues at the national level18, 19, 33, 34, little has been done on the local level. this study helps to fill this gap. across the province, these diseases were more prevalent in rural areas compared to urban regions. the most vulnerable districts were ohangaron, urtachirchik, bekabad, kibray, and zangiota, while among the cities, olmalik and angren reported high incidence rates. children under 14 years of age were found to be twice as vulnerable to waterborne diseases as compared to the adult population. these findings are only exploratory, but highlight the importance of improving our scientific understanding of public health challenges in the region. given the scarcity of literature and the lack of accurate etiological data on the four diseases in tashkent province, this paper can serve as a foundation for developing more in-depth epidemiological studies and providing targeted http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx saravanan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu interventions for vulnerable regions and populations 27, 38. corroborating previous studies37, 39, our findings suggest the need for a long term commitment, collaborative efforts with international partners, as well as political will from the local authorities, in order to advance the development of a modern infectious disease surveillance system in uzbekistan. references 1. unfcc. climate change: impacts, vulnerabilities and adaptation in developing countries. bonn: united nations framework for climate convention (1), 2007. https://unfccc.int/resource/docs/publications/im pacts.pdf. accessed 4 july 2017. 2. gwp. central asia and caucasusregional review, water supply and sanitation in the countries of central asia and southern caucasus. global water partnership, 2009. http://www.gwp.org/en/learn/knowledge_ resources/case_studies/asia/central_asi a_and_caucasus_regional_review_of_water _supply_and_sanitation_in_the_countries_of_ central_asia_and_caucasus/. accessed 4 july 2017. 3. mermin j, villar r, carpenter j, roberts l, samaridden a, gasanova l, et al. a massive epidemic of multidrug-resistant typhoid fever in tajikistan associated with consumption of municipal water. the journal of infectious diseases. 1999;179(6):1416-22. 4. matthys b, bobieva m, karimova g, mengliboeva z, jean-richard v, hoimnazarova m, et al. prevalence and risk factors of helminths and intestinal protozoa infections among children from primary schools in western tajikistan. parasites vectors. 2011;4(195):13. 5. steinmann p, usubalieva j, imanalieva c, minbaeva g, stefiuk k, jeandron a, et al. rapid appraisal of human intestinal helminth infections among schoolchildren in osh oblast, kyrgyzstan. acta tropica. 2010;116(3):178-84. 6. small i, falzon d, lbw vdm, ford n. safe water for the aral sea area. could it get any worse? european journal of public health. 2003;13(1): 87-89. 7. fao. irrigation in central asia in figures. geneva: fao land and water division, 2013. www.fao.org/3/a-i3289e.pdf. accessed 4 july 2017. 8. bekturganov z, tussupova k, berndstsson r, sharapatova n, aryngazin k, zhanasova m. water-related health problems in central asia – a review. water. 2016;8(6-219):13. 9. crighton e, barwin l, small i, upshur r. what have we learned? a review of the literature on children's health and the environment in the aral sea area. international journal of public health. 2011;56:126-38. 10. latipov r, utegenova e, kuatbayeva a, kasymbekova k, anbdykarimov s, juraev r, et al. epidemiology and burden of rotavirus disease in central asia. international journal of infectious diseases. 2011;15:e464-e9. 11. herbst s, fayzieva d, kistemann t. risk factor analysis of diarrhoeal diseases in the aral sea area (khorzem, uzbekistan). international journal of environmental health research. 2008;18(5). 12. semenza j, roberts l, henderson a, bogan j, rubin c. water distribution system and diarrheal disease transmission: a case study in uzbekistan. the american journal of tropical medicine and hygiene. 1998;59(6):941-6. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://unfccc.int/resource/docs/publications/impacts.pdf https://unfccc.int/resource/docs/publications/impacts.pdf http://www.gwp.org/en/learn/knowledge_resources/case_studies/asia/central_asia_and_caucasus_regional_review_of_water_supply_and_sanitation_in_the_countries_of_central_asia_and_caucasus/ http://www.gwp.org/en/learn/knowledge_resources/case_studies/asia/central_asia_and_caucasus_regional_review_of_water_supply_and_sanitation_in_the_countries_of_central_asia_and_caucasus/ http://www.gwp.org/en/learn/knowledge_resources/case_studies/asia/central_asia_and_caucasus_regional_review_of_water_supply_and_sanitation_in_the_countries_of_central_asia_and_caucasus/ http://www.gwp.org/en/learn/knowledge_resources/case_studies/asia/central_asia_and_caucasus_regional_review_of_water_supply_and_sanitation_in_the_countries_of_central_asia_and_caucasus/ http://www.gwp.org/en/learn/knowledge_resources/case_studies/asia/central_asia_and_caucasus_regional_review_of_water_supply_and_sanitation_in_the_countries_of_central_asia_and_caucasus/ http://www.fao.org/3/a-i3289e.pdf central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu 13. global health observatory, kazakhstan. 2015 http://www.who.int/gho/countries/kaz/country_ profiles/en/ . accessed 4 july 2017. 14. global health observatory kyrgyzstan. 2015. http://www.who.int/gho/countries/kgz.pdf?ua= 1. accessed 4 july 2017. 15. global health observatory tajikistan 2015. http://www.who.int/gho/countries/tjk.pdf?ua=1 accessed 4 july 2017. 16. global health observatory turkmenistan 2015. http://www.who.int/gho/countries/tkm.pdf?ua= 1. accessed 4 july 2017. 17. global health observatory uzbekistan 2015. http://www.who.int/gho/countries/uzb.pdf?ua= 1. accessed 4 july 2017. 18. unece. environmental performance reviews: uzbekistan second review. 2010 environmental performance reviews series no. 29. http://www.unece.org/fileadmin/dam/env/epr/ epr_studies/uzbekistan%20ii%20e.pdf accessed 4 july 2017. 19. mirshina o. water and hygiene in uzbekistan: an overview. global environmental change and water-related diseases: improving risk assessment strategies for public health care in uzbekistan; 2-6 may 2011; tashkent, uzbekistan 2011. 20. who. public health risk assessment and interventions: kyrgystan and uzbekistan. bonn: world health organization (who) regional office for europe, 2010. 21. who/unicef. joint monitoring program for water supply and sanitation estimates on the use of water sources and sanitation facilities. world health organization, unicef, 2015. https://www.wssinfo.org/documents/?tx_displa ycontroller[type]=country_files. accessed 4 july 2017. 22. world bank. social impact analysis of water supply and sanitation services in central asia: the case of uzbekistan. world bank, 2015. http://documents.worldbank.org/curated/en/860 101467994584583/social-impact-analysis-ofwater-supply-and-sanitation-services-incentral-asia-the-case-of-uzbekistan. accessed 4 july 2017. 23. undp. water: crtical resource for uzbekistan's future. tashkent, uzbekistan: united nations development program, 2007. http://wash.earthforever.org/lib/uz/water_critic al%20resource_uzbekistan_en_ru_uz/english/ water_en.pdf. accessed 4 july 2017. 24. alimova f, fayzieva d. spatial pattens of water-borne diseases in relation with climatic conditions in tashkent province, uzbekistan. conference paper presented at the ‘water and health’ conference; university of north carolina: water institute; 2013. 25. republic of uzbekistan. uzbekistan health examination survey 2002. tashkent: analytical and information center, ministry of health, republic of uzbekistan, orc macro calverton, maryland usa, 2002. http://dhsprogram.com/pubs/pdf/fr143/fr143.pd f . accessed 4 july 2017. 26. ahmedov m, azimov r, mutalov z, huseynov s, tsoyi e, rechel b. uzbekistan: health system review. 2014. health syst transit. 2014;16(5):1-137, xiii. 27. sharapov m, favorov m, yashina t, brown m, onischenko g, margolis h, et al. acute viral hepatitis morbidity and mortality associated with hepatitis e virus infection: uzbekistan http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.who.int/gho/countries/kaz/country_profiles/en/ http://www.who.int/gho/countries/kaz/country_profiles/en/ http://www.who.int/gho/countries/kgz.pdf?ua=1.%20 http://www.who.int/gho/countries/kgz.pdf?ua=1.%20 http://www.who.int/gho/countries/tjk.pdf?ua=1 http://www.who.int/gho/countries/tkm.pdf?ua=1 http://www.who.int/gho/countries/tkm.pdf?ua=1 http://www.who.int/gho/countries/uzb.pdf?ua=1 http://www.who.int/gho/countries/uzb.pdf?ua=1 http://www.unece.org/fileadmin/dam/env/epr/epr_studies/uzbekistan%20ii%20e.pdf http://www.unece.org/fileadmin/dam/env/epr/epr_studies/uzbekistan%20ii%20e.pdf https://www.wssinfo.org/documents/?tx_displaycontroller%5btype%5d=country_files https://www.wssinfo.org/documents/?tx_displaycontroller%5btype%5d=country_files http://documents.worldbank.org/curated/en/860101467994584583/social-impact-analysis-of-water-supply-and-sanitation-services-in-central-asia-the-case-of-uzbekistan http://documents.worldbank.org/curated/en/860101467994584583/social-impact-analysis-of-water-supply-and-sanitation-services-in-central-asia-the-case-of-uzbekistan http://documents.worldbank.org/curated/en/860101467994584583/social-impact-analysis-of-water-supply-and-sanitation-services-in-central-asia-the-case-of-uzbekistan http://documents.worldbank.org/curated/en/860101467994584583/social-impact-analysis-of-water-supply-and-sanitation-services-in-central-asia-the-case-of-uzbekistan http://wash.earthforever.org/lib/uz/water_critical%20resource_uzbekistan_en_ru_uz/english/water_en.pdf http://wash.earthforever.org/lib/uz/water_critical%20resource_uzbekistan_en_ru_uz/english/water_en.pdf http://wash.earthforever.org/lib/uz/water_critical%20resource_uzbekistan_en_ru_uz/english/water_en.pdf http://dhsprogram.com/pubs/pdf/fr143/fr143.pdf http://dhsprogram.com/pubs/pdf/fr143/fr143.pdf saravanan this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 6, no. 1 (2017) | issn 2166-7403 (online) | doi 10.5195/cajgh.2017.277|http://cajgh.pitt.edu surveillance data. bmc infectious diseases. 2009;9:35. 28. niyazmatov b, shefer a, grabowsky m, vitek c. diphtheria epidemic in the republic of uzbekistan-1993-196. journal of infectious diseases. 2000;181(supplement 1):s104-9. 29. open street map. available from: https://osm.wno-edv-service.de/boundaries/. accessed 4 july 2017. 30. delorme world basemap. http://www.arcgis.com/home/item.html?id=b1 65c3df453e4be6b5ac4fdb241effbe. accessed 4 july 2017. 31. hota t. trend surface analysis of spatial data. gondwana geological magazine. 2014;29:3944. 32. ibadov g, akhmedova m, kasymbekova k, khodjaev n, shirinova n, baltabaeva m. environment and infectious diseases. in: fayzieva d, editor. environmental health in central asia: the present and the future. southhampton, boston: wit press; 2004. p. 129-55. 33. fayzieva d. environmental health in central asia: the past and future. southampton, boston: wit press; 2004. 257 p. 34. corcoran e, nellemann c, baker e, bos r, osborn d, savelli h, editors. sick water? the central role of wastewater management in sustainable development. a rapid response asessment: united nations environment pro gramme, un-habitat, grid-arendal. 2010. http://gridarendalwebsite.s3.amazonaws.com/production/docum ents/:s_document/208/original/sickwater_scre en.pdf?1486721310 accessed 4 july 2017. 35. raschid-sally l, jayakodi p. drivers and characteristics of wastewater agriculture in developing countries: results from a global assessment. colombo, sri lanka: international water management institute, 2008. research report 127. http://www.iwmi.cgiar.org/publications/iwmi _research_reports/pdf/pub127/rr127.pdf accessed 4 july 2017. 36. maier c, martin-moreno j. quo vadis sanepid? a cross country analysis of public health reforms in 10 post-soviet states. health policy. 2011;102(1):18-25. 37. usmanov i, favorov mo, chorba t. universal immunization: the diphtheria control strategy of choice in the republic of tajikistan-19931997. journal of infectious diseases. 2000;181 (supplement -1):s86-s93. 38. gungoren b, latipov r, regallet g, musabaev e. effect of hygiene promotion on the risk of reinfection rate of intestinal parasites in children in rural uzbekistan. transactions of the royal society of tropical medicine and hygiene. 2007;101(6):564-9. 39. hay j, yeh k, dasgupta d, shapieva z, omasheva g, deryabin p, et al. biosurveillance in central asia: successes and challenges of tick-borne disease research in kazakhstan and kyrgyzstan. frontiers in public health. 2016; 4(4). http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://osm.wno-edv-service.de/boundaries/ http://www.arcgis.com/home/item.html?id=b165c3df453e4be6b5ac4fdb241effbe http://www.arcgis.com/home/item.html?id=b165c3df453e4be6b5ac4fdb241effbe http://gridarendal-website.s3.amazonaws.com/production/documents/:s_document/208/original/sickwater_screen.pdf?1486721310 http://gridarendal-website.s3.amazonaws.com/production/documents/:s_document/208/original/sickwater_screen.pdf?1486721310 http://gridarendal-website.s3.amazonaws.com/production/documents/:s_document/208/original/sickwater_screen.pdf?1486721310 http://gridarendal-website.s3.amazonaws.com/production/documents/:s_document/208/original/sickwater_screen.pdf?1486721310 http://www.iwmi.cgiar.org/publications/iwmi_research_reports/pdf/pub127/rr127.pdf http://www.iwmi.cgiar.org/publications/iwmi_research_reports/pdf/pub127/rr127.pdf spatial distribution and trends of waterborne diseases in tashkent province abstract keywords: spatiotemporal analysis; environmental health; tashkent province; uzbekistan; central asia spatial distribution and trends of waterborne diseases in tashkent province research microsoft word mihret.docx new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. sociodemographic factors associated with bottle feeding practices in infants under two years of age: a hospital-based study in woldia, ethiopia yalew mihret1, fentanesh endalew1, hunegnaw almaw2, melese linger3* 1department of midwifery, college of health science, woldia university, woldia, ethiopia; 2department of public health nutrition, college of medicine and health science, bahir dar university, bahir dar, ethiopia; 3department of public health, college of health science, woldia university, woldia, ethiopia *corresponding author email: melselinger@gmail.com vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu mihret this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu abstract introduction: bottle feeding should be avoided when possible in infants under the age of two to improve health outcomes. the magnitude of bottle feeding practice is currently increasing in ethiopia, however factors associated with bottle feeding usage are rarely addressed in research. we aimed to fill this gap and assess the magnitude of bottle feeding and its association with sociodemographic factors among infants in woldia, ethiopia in 2019. methods: a hospital-based cross-sectional study was conducted in woldia general hospital at the immunization clinic. a total of 255 mothers who had infants were selected by systematic random sampling method. data was collected through face-to-face interview using a structured standardized questionnaire. the data was entered to epidata version 3.1 and analyzed using spss version 20. binary logistic regression analysis models were used to assess the association between dependent and independent variables. variables with p-value < 0.2 in bivariable logistic regression analysis were entered to multivariable logistic regression analysis. finally, variables with p-value < 0.05 with 95% ci in multivariable logistic regression were taken as independent predictors. cor and aor were used to show the strength of association between the dependent and independent variables. results: the rate of bottle feeding practice in this study was 42.7% (95%ci: 35.8,48.2). being an infant age 0-5 months old [aor=0.16; 95%ci: 0.06,0.4], being a mother age 35-50 years old [aor=0.43; 95%ci: 0.22, 0.85], having 2-5 children [aor=6.37; 95%ci: 1.33, 30.44], and being a farmer as reported mother’s occupation [aor=2.72; 95%ci: 1.30, 5.67] showed significant association with bottle feeding practice. conclusion: the magnitude of bottle feeding practice was significantly higher in the current study as compared to national prevalence. several sociodemographic factors showed significant association with bottle feeding practice which need to be explored further in the future research. keywords: bottle feeding; children; sociodemographic factors sociodemographic factors associated with bottle feeding practices in infants under two years of age: a hospitalbased study in woldia, ethiopia yalew mihret1, fentanesh endalew1, hunegnaw almaw2, melese linger3* 1department of midwifery, college of health science, woldia university, woldia, ethiopia; 2department of public health nutrition, college of medicine and health science, bahir dar university, bahir dar, ethiopia; 3department of public health, college of health science, woldia university, woldia, ethiopia *corresponding author email: melselinger@gmail.com research bottle feeding is the practice of feeding an infant any substitute for breast milk with a bottle. based on world health organization (who) classification, a prevalence of exclusive breastfeeding below 50% is considered poor.1 the who recommends that 95% of infants younger than one month and 90% of those younger than six months should be exclusively breastfed, while 90% of those aged 6–23 months should be partly breastfed. however, in low and middle-income countries, only 37% of infants younger than six months of age are exclusively breastfed.2 in ethiopia, about 77% of infants scored low or medium on the breastfeeding performance index during the first six months of life,3 and only 58% of infants under age six months are exclusively breastfed.4 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu the period between birth up to two years of the child’s life is a “critical window period” because during this period, infants are vulnerable to malnutrition or any other illness.5 feeding exclusively breast milk within the first six months is considered a first vaccine for the infant.6 despite breastfeeding recommendations, the prevalence and duration of breastfeeding is declining rapidly and is being replaced by bottle feeding, particularly among urban residents in developing countries.7 bottle feeding is generally not recommended as it can lead to an increased incidence of excessive weight gain, diarrhea, infection, malnutrition, increased mortality, iron depletion, and decreased birth spacing.8-15 even the expressed breast milk could increase infant weight gain if it is fed by the bottle.16 globally, 45%, or 3.1 million, of child deaths are attributable to undernutrition annually; this problem is severe in low income countries.14 increasing appropriate complementary feeding has the potential to prevent 6% of all under-5 deaths, particularly in the developing countries.5 numerous studies in various countries have shown that being an urban resident,17,18 not being counseled on bottle feeding education,18,19 the infant being hospitalized,18 low infant age,19 being a homemaker, not obtaining postnatal care, lower mother’s age,19 being an employed mother, hospital delivery, high infant age,9,17 higher maternal education level, high wealth index,17,20,21 as well as workload and short maternity leave20,21 were contributing factors for bottle feeding. previous research inconsistently reported factors associated with bottle feeding practice, especially sociodemographic variables, infant age, and mothers’ educational and occupational status. the government of ethiopia adopted infant and young child feeding guidelines in 200422 and the national nutrition program in 201323 to unlock the lifesaving potential of optimal breastfeeding practices. the guideline is based on who recommendations that emphasizes exclusive breastfeeding. furthermore, the health extension program in ethiopia aims at improving proper infant and young child nutrition, including promotion of exclusive breastfeeding. 22 although the government put forth the efforts mentioned above, the prevalence of bottle feeding practice among infants under two years was 11.9 %24 in 2011 and increased to 14% in 2016,25 according to ethiopia demographic and health survey report. therefore, this study was aimed to assess factors associated with bottle feeding practices among mothers with infants in woldia general hospital, ethiopia, 2019. methods study setting and population this hospital-based cross-sectional study was conducted among mothers with infants (children less than 24 months of age) who attended the immunization clinic in woldia general hospital, woldia, ethiopia. the town is located 521 kilometers away from addis ababa, the capital city of ethiopia, and 360 kilometers away from bahir dar, the regional city of amhara. according to the national census of 2008, the town of woldia had a total population of 75,496, of whom 38,167 were men, and 37,279 were women. woldia has one general hospital and two health centers. this study was conducted from february to april 2019 at woldia general hospital. sample size and sampling technique the sample size was calculated using a single population proportion formula: n=(za/2)2p(1-p)/w2 with the assumptions za/2=1.96 (95% confidence level), p=0.196 (19.6% as the prevalence of bottle feeding practice in holeta town19) and w=0.05 (5% margin of error). the estimated sample size was 243. we accounted for a non-response rate of 10%, so our final sample size estimate increased to 267. a systematic random sampling technique was conducted to select a representative population in the immunization clinic. the sampling interval (k) was mihret this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.440|http://cajgh.pitt.edu established by dividing the average number of women who visited the immunization clinic in the previous three months before data collection (average n=900) by the sample size, which produced k=900/267=3. women were recruited daily by simple random sampling technique using the lottery method, and the next respondent was selected by adding a sampling interval to the number of the selected women. the same procedure was done on subsequent days until the required sample size was reached. exposure and outcome variables the exposure variables were sociodemographic factors and obstetric factors. the definition and measurements standards of the variables were adopted from the ethiopian demographic and health survey 2016.25 the outcome variable was bottle feeding practice, which was categorized as yes/no. bottle feeding practice was measured based on who definition of this indicator: "proportion of children 0–23 months of age that were fed any liquid (including breastmilk) or semisolid from a bottle with nipple/teat in previous 24 hours prior to data collection period".25 data collection tools and procedures data were collected by using a structured standard questionnaire through face-to-face interview. the questionnaire was adopted from the ethiopian demographic and health survey 2016.25 it has two parts: sociodemographic information and obstetric information. first, the english version of the questionnaire was prepared. it was translated to the local language of amharic and then translated back to english. the data collectors were five graduate class midwifery students who had received one day of training before starting the data collection. the quality of the data collection process was monitored, and clear uniform instructions were given to all data collectors. all data collected as a part of this research were checked by the principal investigator. data processing and analysis data were entered and cleaned in epidata version 3.1, and spss version 20.0 was used for data analysis. descriptive statistical analyses were employed. binary logistic regression analysis models were used to assess the association between dependent and independent variables. variables with p-value of < 0.2 in bivariable logistic regression analysis were entered to multivariable logistic regression analysis. finally, variables with p-value < 0.05 with 95% ci in multivariable logistic regression were taken as independent predictors for bottle feeding practice. cor and aor were used to show the strength of association between the dependent and independent variables ethical consideration ethical clearance was obtained from the ethical review committee from the college of health science, woldia university. the purpose of the study was explained, and confidentiality was secured by omitting any identifiers. verbal consent was obtained from each study participant over 18 years of age. for mothers under 18 years of age, verbal consent was obtained from both, the participant and her guardian. results sociodemographic characteristics from the estimated sample size, 255 participants responded to survey, (95.5% response rate). among the study participants, 222 (87.1%) were married, 155 (60.8%) were 15-24 years of age, 138 (54.1%) were orthodox by religion, and 165 (64.7%) of mothers were urban residents (table 1). obstetric related factors in this study, 241 (94.5%) mothers had antenatal care in their previous pregnancy. during their antenatal care follow up, 209 (87.1%) of women did not receive counseling about bottle feeding practice. from the total central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu study participants, 218 (85.5%) received postnatal health care services for the current child (table 2). child feeding practices the overall rate of bottle feeding was 42.7% (95%ci: 35.8, 48.2) and the magnitude was 12.7%, 46.6% and 55.7% respectively when disaggregated into age categories of 0-5 months, 6-11 months and 12-24 months, respectively. among the respondents who were asked about the reason why they practiced bottle feeding, around 42 (38.5%) respondents reported that they practiced bottle feeding due to work. seventy (44.9%) anticipated practicing bottle feeding up to two years, and 176 (69.0%) previously obtained information on the benefits of breastfeeding from health professional (table 3). health status of an infant among respondents who used bottles for feeding, 103 (58.9%) used formula, 18 (10.3%) of the mothers cleaned the bottle once daily, 39 (15.3%) of the infants had history of recurrent diarrhea in the past one month, and only 90 (51.4%) of the mothers cleaned the bottle through boiling (table 4). factors associated with bottle feeding practice in multivariable logistic regression analysis, infants aged 0-5 months old, mothers aged 35-50 years old, having 2-5 children and being a farmer as mother’s occupation showed significant association with bottle feeding practice. other factors like father’s occupation, father’s education, antenatal care follow up, postnatal follow up, place of delivery, mother’s education level, sex of the child, parity and gravidity had no association with infant bottle feeding practices. infants 0-5 months old were 84% less likely to be bottle fed than infants 12-23 months old [aor=0.16; 95%ci: 0.06, 0.4]. furthermore, mothers who were between 35-50 years old were 57% less likely to practice bottle feeding than those who were in between ages 1524 [aor=0.43; 95%ci: 0.22, 0.85]. mothers who had 25 children were six times as likely to practice bottle feeding as compared to mothers who have 6-10 children [aor=6.37; 95%ci: 1.33, 30.44]. being a farmer as mother’s occupation increased the odds of bottle feeding by 2.7 times as compared to a mother who were homemakers [aor=2.7; 95%ci: 1.30, 5.67] (table 5). variables frequency percentage age of mother 15-24 40 15.7% 25-34 155 60.8% 35+ 60 23.5% residence urban 165 64.7% rural 90 35.3% marital status married 222 87.1% divorced 18 7.1% single 8 3.1% widowed 7 2.7% mother’s occupation homemaker 128 50.2% farmer 32 12.5% daily laborer 15 5.9 % merchant 39 15.3 % government employee 41 16.1% educational status of mother unable to read and write 64 25.1 % primary 76 29.8% secondary 68 26.7% higher education 47 18.4% religion of mother orthodox 138 54% muslim 91 36.2 protestant 20 7.8% others 6 2% occupation of husband farmer 72 28.2% daily laborer 21 8.2% merchant 86 33.7% government employee 76 29.8% educational status of husband illiterate 38 14.9% primary 73 28.6% secondary 60 23.5% higher education 84 32.9% note: other religions=adventist table 1. sociodemographic characteristics of mothers with infants less than 24 months of age in woldia general hospital, ethiopia, 2019 (n=255) mihret this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu variables frequency percent gravidity of mother primigravida 70 27.5% multigravida 185 72.5% number of children 1 75 29.4% 2-5 160 62.7% 6-10 20 7.8% age of youngest child in months 0-5 55 21.6% 6-11 103 40.4% 12-23 97 38% sex of infant male 163 63.9% female 92 36.1% attended pnc for the current child yes 218 85.5% no 37 14.5% attended anc for the last pregnancy yes 241 94.5% no 14 5.5% counseling about bottle feeding obtained no 209 87.1% yes 31 12.9% place of delivery health institution 179 70.2% home 76 29.8% note: pnc=postnatal care, anc=antenatal care table 2. obstetric related factors of mothers with infants less than 24 months of age in woldia general hospital, ethiopia, 2019 (n=255) mihret this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu variables frequency percent source of information on the advantage of breast feeding mass media 28 11% health professional 176 69% family 51 20% type of feeding for the youngest children now only breast milk 100 39.2 only bottle feeding 32 12.5 breast and other foods with cup and spoon 116 45.5% other food with cup and spoon 7 2.7% duration of bottle feeding practice up to 6 months 30 19.2% up to 1 year 37 23.7% up to 2 year 70 44.9% until the baby discontinues 19 12.2% child bottle fed presently yes 109 42.7% no 146 57.3% reasons to start bottle feeding mothers return to work 42 38.5% inadequate breast milk 30 27.5% availability of formula milk 14 12.8% pregnancy 3 2.8% mother is ill 20 18.3% time of initiation of breast feeding immediately after birth 218 85.5% after 1 year 23 9% when the mother feels comfortable 10 3.9% i don’t know 4 1.6% breast feedings per day 1-7 107 42% ≥ 8 148 58% table 3. child feeding practices among mothers with infants less than 24 months of age in woldia general hospital, ethiopia, 2019 (n=255) mihret this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu variables frequency percent source of water for drinking pipe 205 80.4% river 13 5.1% spring (protected) 35 13.7% other 2 0.8% history of recurrent diarrhea in the past one month yes 39 15.3% no 216 84.7% history of illness in the past one month yes 20 7.9% no 235 92.1% type of illness diarrhea 5 25% weight loss 4 20% vomiting 3 15% abdominal pain 5 25% respiratory infection 3 15% number of bottles one 60 34.3% two 73 41.7% more than two 42 24% frequency of bottle cleaning every feeding pattern 91 52% only when spoiled 34 19.4% once daily 18 10.3% every 6 hours 32 18.3% techniques of cleaning the bottle boiling 90 51.4% rinsing with water and soap 64 36.6% only rinsing with water 21 12% additional food with bottle feeding yes 105 60% no 70 40% kind of fluid offering to the baby with bottle feeding cow’s milk 63 36% formula milk 103 58.9% tea 2 1.1% expressed breast milk 7 4% note: other water source=unprotected spring table 4. health status of infants less than 24 months of age in woldia general hospital, ethiopia, 2019 (n=255) central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu variable bottle feeding cor (95% ci) aor (95% ci) yes no mother’s age in years 15-24 18 22 1 1 25-34 74 81 0.89(0.446,1.800) 0.46(0.19,1.10) 35-50 17 43 2.07(0.896,4.787) 0.43(0.22,0.85) child’s age in months 0-5 7 48 0.17(0.07,0.4) 0.16(0.06,0.4) 6-11 48 55 0.89(0.51,1.55) 0.96 (0.51,1.8) 12-24 54 43 1 1 number of children 1 30 42 7.07 (1.53,32.66) 4.12(0.8,21.19) 2-5 70 86 7.7(1.73,34.48) 6.37(1.33,30.44) 6-10 9 18 1 1 mother’s occupation homemaker 48 80 1 1 farmer 12 20 11(0.45,2.23) 2.72(1.3,5.67) daily laborer 6 9 0.9(0.3,2.69) 2.29(0.87,6.04) merchant 18 21 0.7(0.34,1.44) 2.75(0.79,9.24) government employee 25 16 0.38(0.19,0.79) 1.79(0.72,4.42) mother’s educational status unable to read and write 20 44 0.36(0.19,0.69) 4.12(0.8,21.19) primary 25 51 0.39(0.21,0.71) 0.27(0.64,1.01) secondary and above 64 51 1 1 note: p-value significant at level of p<0.05, backward lr method, hosmer lemeshow p-value=0.98 table 5. multivariable logistic regression analyses among mothers with infants less than 24 months of age in woldia general hospital, ethiopia, 2019 discussion the aim of this study was to assess the magnitude of bottle feeding practice and associated factors among infants less than two years old in woldia general hospital. in the current study, the prevalence of bottle feeding practice was 42.7% (95%ci: 35.8, 48.2). age of the child, age of the mother, mother's occupation, and number of children in the family were found to be associated with bottle feeding practice. the magnitude of bottle feeding in the current study was consistent with the studies conducted in sudan and namibia.17,18 the magnitude of bottle feeding in this study was higher compared to the national prevalence reported in the 2016 edhs,25 holeta town,19 bahir dar26 and nigeria.27 the possible reason for this difference might be attributed to study period variation, as there has been increasing advocacy for using formula in this region recently. mihret this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.440|http://cajgh.pitt.edu the practice of bottle feeding from the current findings was lower than in the study conducted in ethiopia.21 there might also be differences due to variations in socio-cultural aspects among study participants regarding feeding practices. mothers in the age group of 35-50 were less likely to practice bottle feeding as compared to mothers in the age range of 15-24 years old. this finding is also supported by another study conducted in southern nation nationality of people regional state, ethiopia, 2016.28 the possible explanation could that as mothers age increases, her experiences in childcare increase as well, and more appropriate care and feeding patterns are adopted. infants in the age group of 0-5 months old were less likely to be bottle fed than infants 12-23 months old; this finding has also been reported elsewhere19 and inconsistent in studies conducted in namibia17 and kenya.9 infants, especially those less than 6 months of age, have gastrointestinal systems that are not well matured. bottle feeding at this age may be associated with problems in digestion and absorption, which in turn may lead to diarrhea, vomiting, and infections. if mothers had experienced this previously, they may not start bottle feeding their child within the first year. being a farmer as the mother’s occupation increased the likelihood of bottle feeding as compared to mothers who were homemakers. this result is consistent with a study conducted in brazil, in which women who worked outside of home practiced bottle feeding more often.29 this pattern may be attributed to challenging workload among mothers who are working in farming. this study had some limitations. the crosssectional nature of the study may be subject to recall bias, and social desirability bias might influence the determinants of bottle feeding. for future researchers, conducting the studies with large sample size and incorporating factors such as media exposure and social media utilization will help to identify other important predictors of bottle feeding practices. the study’s strength is that it used primary data and included infants up to the age of two, which helps to estimate the magnitude of bottle feeding appropriately. designing special nutrition intervention program for mothers who are working in farming, as well as developing a strategy to increase mothers' education in the area of nutrition and infant health, could contribute to lower bottle feeding use and improved infant outcomes. references 1. batista clc, ribeiro vs, nascimento m, rodrigues vp. association between pacifier use and bottle-feeding and unfavorable behaviors during breastfeeding. j pediatr (rio j). 2018;94(6):596-601. 2. victora cg, bahl r, barros aj, et al. breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. the lancet. 2016;387(10017):475-490. 3. haile d, biadgilign s. higher breastfeeding performance index is associated with lower risk of illness in infants under six months in ethiopia. international breastfeeding journal. 2015;10(1):32. 4. central statistical agency., the dhs program icf. ethiopian demographic and health survey 2016 addis ababa, ethiopia, and rockville, maryland, usa: csa and icf2017. 5. shukure r. assessment of knowledge, attitude and practice on initiation of complementary feeding among under two years children in fiche town, north showa zone, ethiopia. international journal of biomedical engineering and clinical science. 2017;3(6):103-109. 6. jabbar ns, bueno ab, silva pe, scavone-junior h, ines ferreira r. bottle feeding, increased overjet and class 2 primary canine relationship: is there any association? braz oral res. 2011;25(4):331-337. 7. lakshman r, ogilvie d, ong kk. mothers' experiences of bottle-feeding: a systematic review of qualitative and quantitative studies. archives of disease in childhood. 2009;94(8):596-601. 8. ventura ak, mennella ja. an experimental approach to study individual differences in infants' central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.440 | http://cajgh.pitt.edu intake and satiation behaviors during bottle-feeding. child obes. 2017;13(1):44-52. 9. matanda dj, mittelmark mb, kigaru dm. breast-, complementary and bottle-feeding practices in kenya: stagnant trends were experienced from 1998 to 2009. nutr res. 2014;34(6):507-517. 10. sutcliffe tl, khambalia a, westergard s, jacobson s, peer m, parkin pc. iron depletion is associated with daytime bottle-feeding in the second and third years of life. arch pediatr adolesc med. 2006;160(11):11141120. 11. olatosi oo, sote eo. association of early childhood caries with breastfeeding and bottle feeding in southwestern nigerian children of preschool age. j west afr coll surg. 2014;4(1):31-53. 12. avila wm, pordeus ia, paiva sm, martins cc. breast and bottle feeding as risk factors for dental caries: a systematic review and meta-analysis. plos one. 2015;10(11):e0142922. 13. krogh c, biggar rj, fischer tk, lindholm m, wohlfahrt j, melbye m. bottle-feeding and the risk of pyloric stenosis. pediatrics. 2012;130(4):e943-949. 14. li r, magadia j, fein sb, grummer-strawn lm. risk of bottle-feeding for rapid weight gain during the first year of life. arch pediatr adolesc med. 2012;166(5):431-436. 15. mcateer jp, ledbetter dj, goldin ab. role of bottle feeding in the etiology of hypertrophic pyloric stenosis. jama pediatr. 2013;167(12):1143-1149. 16. kim hy, han y, pyun y, kim j, ahn k, lee si. prolonged bedtime bottle feeding and respiratory symptoms in infants. asia pac allergy. 2011;1(1):3035. 17. berde as. factors associated with bottle feeding in namibia: findings from namibia 2013 demographic and health survey. j trop pediatr. 2018;64(6):460-467. 18. hassan aa, taha z, abdulla ma, ali aa, adam i. assessment of bottle-feeding practices in kassala, eastern sudan: a community-based study. open access maced j med sci. 2019;7(4):651-656. 19. kebebe t, assaye h. intention, magnitude and factors associated with bottle feeding among mothers of 0-23 months old children in holeta town, central ethiopia: a cross sectional study. bmc nutr. 2017;3:53. 20. yngve a, sjöström m. breastfeeding determinants and a suggested framework for action in europe. public health nutrition. 2001;4(2):729-739. 21. sheka shemsi seid, elsa muluneh, ismael ahmed sinbirro, tolasa takele moga, tura koshe haso, shamsedin amme ibro. utilization of bottle feeding practices and associated factors among mothers who have infant less than 12 months of age in agaro town, jimma zone south west ethiopia, 2018. health science journal. 2019;13(1):630. 22. fetene n, linnander e, fekadu b, et al. the ethiopian health extension program and variation in health systems performance: what matters? plos one. 2016;11(5):e0156438. 23. kim ss, rawat r, mwangi em, et al. exposure to large-scale social and behavior change communication interventions is associated with improvements in infant and young child feeding practices in ethiopia. plos one. 2016;11(10):e0164800. 24. central statistical agency [ethiopia], icf international. ethiopia demographic and health survey 2011. in: central statistical agency , icf international, eds. addis ababa, ethiopia. calverton, maryland, usa, 2012. 25. croft, n. t, marshall amj, allen ck, al. e. 2018. guide to dhs statistics. rockville, maryland, usa: icf; 2018. 26. demilew ym, tafere te, abitew db. infant and young child feeding practice among mothers with 0 – 24 months old children in slum areas of bahir dar city, ethiopia. international breastfeeding journal. 2017;12(26). 27. ogbo fa, agho ke. determinants of suboptimal breastfeeding practices in nigeria: evidence from the 2008 demographic and health survey bmc public health. 2015;15(259). 28. kelaye t. assessment of prevalence of exclusive breast feeding practice and associated factors among under six-month-old children selected woreda south nation nationality of people regional state, ethiopia, 2016. journal of nutritional health & food science. 2016. 29. buccini gdos s, benicio mh, venancio si. determinants of using pacifier and bottle feeding. rev saude publica. 2014;48(4):571-582. microsoft word izguttinov.docx new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. community readiness for increasing older adult physical activity levels in kazakhstan aniyar izguttinov1*, assel ainabekova2, miruna petrescuprahova3, suzanne j. wood3 1department of health policy and management, university of north carolina at chapel hill, chapel hill, north carolina, usa; 2center for global health, republican center for health development, ministry of healthcare of the republic of kazakhstan, nur-sultan, kazakhstan; 3department of health services, university of washington, seattle, washington, usa *corresponding author email: aniyar@email.unc.edu vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.447 | http://cajgh.pitt.edu izguttinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.447 | http://cajgh.pitt.edu abstract introduction: physical activity is proven to be a significant element of successful aging, but many seniors worldwide fail to achieve the recommended levels. this study aimed to assess the readiness of the community in nur-sultan, kazakhstan, to act on the issue of physical inactivity among older adults. methods: in order to achieve this purpose, we conducted qualitative interviews with key informants in the community and applied a validated community readiness tool. results: the results suggest that the local community is at early stages of readiness to act on the issue of older adult physical inactivity. we identified a number of barriers that prevented seniors from leading active lifestyles, which included community misconceptions about older adult physical activity, family centeredness in older adulthood, scarcity of resources, passive support from the leadership, and lack of efforts in the community. research findings also highlighted the importance of conducting indepth analysis of key informant responses in addition to calculating readiness scores, when using the community readiness tool. conclusion: community-specific strategies for enhancing the level of physical activity among seniors are required to offset the disease burden associated with aging and to prolong life expectancy in kazakhstan, and it is of paramount importance to tailor potential efforts as to address the current readiness of the community and its needs. keywords: community readiness; physical activity; older adults; healthy aging community readiness for increasing older adult physical activity levels in kazakhstan aniyar izguttinov1*, assel ainabekova2, miruna petrescuprahova3, suzanne j. wood3 1department of health policy and management, university of north carolina at chapel hill, chapel hill, north carolina, usa; 2center for global health, republican center for health development, ministry of healthcare of the republic of kazakhstan, nur-sultan, kazakhstan; 3department of health services, university of washington, seattle, washington, usa *corresponding author email: aniyar@email.unc.edu research physical activity is proven to be a significant element of successful aging.1 apparent benefits of physical activity for older adults include an increase in functional ability and reduction in the risk of cognitive decline.2 scientific evidence also suggests that physical activity prevents onset of diabetes and stroke, improves sleep and life satisfaction, and helps to build social networks in older adulthood.3 despite these benefits, many seniors fail to achieve the recommended levels of physical activity.4-6 one clear finding in the literature is that inactivity increases substantially with age across nations.3,7 the kazakhstan of today has improved in many health status measures relative to the 1990s, when the country obtained its independence. in 2017, the average life expectancy was 72.9 years, which indicates a threeand-a-half-year gain compared to the 1980s.8 however, cardiovascular diseases in particular place the greatest burden on the population of kazakhstan, accounting for 53% of mortality in the nation.9 an analysis across age central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.447 | http://cajgh.pitt.edu groups demonstrates an even more alarming picture, with cardiovascular diseases estimated to be the single leading cause of deaths for the age groups of 45-59 and 60-74 years.9 given the high prevalence of cardiovascular diseases, especially in older age, and relatively short life expectancy in kazakhstan, increasing physical activity levels among older adults in the country appears to be a very promising public health measure.3 however, little is known about the readiness of communities in kazakhstan to implement older adult physical activity initiatives, and the design of successful programs will have to consider current community norms and activities. therefore, the purpose of this study was to systematically assess the community readiness to act on the issue of physical inactivity among older adults aged 60 and over in the city of nur-sultan (formerly astana), kazakhstan. we believe the study findings will help inform locally tailored initiatives to enhance older adult physical activity levels and will facilitate the adoption of evidence-based public health programs in the region. methods a cross-sectional community readiness assessment was carried out to achieve the purpose of the study. the community was defined by the geographical area of the city of nur-sultan. community readiness tool community readiness (cr) is defined as the degree to which a certain community is willing and prepared to take action on a specific health problem.10 we chose the community readiness tool (crt) developed by edwards et al.11 as the assessment tool for our study because it (1) offered flexibility in tailoring the approach to a particular health issue and a community; (2) has been used successfully to analyze potential dissemination of older adult physical activity programs in the us, germany, and china;12-14 and (3) previous studies have reported the validity and high consistency of the tool.15 the crt provides a step-by-step protocol for the assessment of five dimensions of cr: (1) community knowledge of issue, (2) community knowledge of efforts, (3) community climate, (4) leadership, and (5) resources. all dimensions are scored separately using a nine-point anchored rating scale before an overall numeric value is calculated. each score on the scale corresponds to one of the nine stages of cr,10 which are described in table 1. participant recruitment the purposeful sampling was used to recruit key informants from a diverse range of community sectors.16 through online search and personal connections, we identified and contacted seventeen potential interviewees. the crt suggests interviewing 6-12 key informants depending on the size of the community. in this study, the final sample included ten (n=10) individuals representing five different sectors: (1) older adult organizations, (2) public health agencies, (3) fitness/sports facilities, (4) healthcare providers, and (5) social service organizations. the team did not offer any incentives for participation. interview guide and procedures the interview instrument was developed in accordance with the crt and directly addressed all five dimensions. the final version of the guide was translated into the kazakh and russian languages and pilot-tested. all interviews were held in-person between june and december 2018 and followed a semi-structured format.17 the team obtained a written consent from each informant. while interviewees were given a choice of three languages (russian, kazakh, and english), all of them preferred to answer the questions in russian. each interview, which lasted 45-70 minutes, was audio recorded with permission, and then transcribed using the online transcription software happyscribe®. izguttinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.447 | http://cajgh.pitt.edu stages title description 1 no awareness issue is not generally recognized by the community or leaders as a problem (or it may truly not be an issue). 2 denial/resistance at least some community members recognize that it is a concern, but there is little recognition that it might be occurring locally. 3 vague awareness most feel that there is a local concern, but there is no immediate motivation to do anything about it. 4 preplanning there is clear recognition that something must be done, and there may even be a group addressing it. however, efforts are not focused or detailed. 5 preparation active leaders begin planning in earnest. community offers modest support of efforts. 6 initiation enough information is available to justify efforts. activities are underway. 7 stabilization activities are supported by administrators or community decision makers. staff are trained and experienced. 8 confirmation/ expansion efforts are in place. community members feel comfortable using services, and they support expansions. local data are regularly obtained. 9 community ownership/ professionalization detailed and sophisticated knowledge exists about prevalence, causes, and consequences. effective evaluation guides new directions. model is applied to other issues. table 1. stages of community readiness analysis although ten interviews were conducted, we excluded one from the analysis due to lack of analyzable responses and failure to provide information for scoring two of the crt dimensions. hence, a total of nine (n=9) interview transcripts were subject to analysis. we first assessed participant characteristics and cr scores closely following the crt and using the anchored rating scales that are part of the tool.10 two authors independently scored each interview before discussing individual assessment discrepancies and producing a final table with consensus scores. as recommended by kostadinov et al.,18 we also calculated standard deviations of cr scores. for the purposes of qualitative data analysis, we developed an a-priori list of codes to conduct a deductive assessment based on the crt and the interview guide. then, using an inductive approach,19 we coded two previously translated interview transcripts in order to identify any emergent codes. the final codebook, containing 29 a-priori and four emergent codes, was used to code the entire dataset. qualitative coding results were then discussed with the whole research team and eventually the themes were mapped onto one of the five cr dimensions. dedoose® version 8.1 was used for qualitative data analysis. results participant characteristics all participants were directly involved in the provision of services to senior citizens or were actively engaged in policy issues that potentially affected older adult physical activity levels. seven informants were female (78%) and two were male (22%). while the majority of interviewees were between 30 and 50 years old, two participants were over 60 years old. table 2 describes the sample characteristics. central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.447 | http://cajgh.pitt.edu characteristic n (%) gender male female 2 (22) 7 (78) age category 30-44 years 45-59 years >60 years 5 (56) 2 (22) 2 (22) representative from: older adult organization public health agency fitness / sports facility hospital / healthcare provider social service organization 1 (11) 2 (22) 3 (34) 2 (22) 1 (11) representative job title: director / deputy director head of the department / unit fitness instructor cardiologist 2 (22) 3 (34) 3 (34) 1 (11) table 2. key informant characteristics (n=9) community readiness scores the overall readiness score was 3.28 (sd=0.30), which corresponded to the vague awareness stage of cr. the range of individual scores for each dimension of each interview was between 1.0 and 5.0. the highest average score of 3.72 (sd=0.79) was observed in the knowledge of issue dimension, whereas the knowledge of efforts domain received the lowest score of 2.92 (sd=1.59). table 3 represents consensus scores across each dimension based on all key informant interviews. the results suggested that four out of five dimensions were at vague awareness phase of cr. the only exception was the knowledge of efforts dimension, which was assessed to be at denial/resistance stage. qualitative assessment of community readiness dimension 1— community knowledge of issue: this dimension addressed the scope of community members’ knowledge and understanding of the issue of physical inactivity among senior citizens. there was a common general understanding that physical activity was important in preserving physical and mental wellbeing, and hence was a significant factor in prolonging one’s lifespan. however, when asked specifically about the issue of physical inactivity among seniors, informants (8 of 9) cited that there was lack of awareness. healthy lifestyle and physical activity in particular were attracting the attention of younger generations but not among older adults. “they know very little about it. now there is a tendency that young people are interested in healthy nutrition and physical activity, but they do not inform their moms and dads, other adults.” head of physical therapy unit, hospital 2 dimension mean ± sd (readiness stage) community knowledge of issue 3.72 ± 0.79 (vague awareness) community knowledge of efforts 2.92 ± 1.59 (denial/resistance) community climate 3.31 ± 1.22 (vague awareness) leadership 3.11 ± 0.86 (vague awareness) resources 3.33 ± 0.45 (vague awareness) overall readiness 3.28 ± 0.30 (vague awareness) table 3. domain specific and overall community readiness scores izguttinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.447 | http://cajgh.pitt.edu according to three informants, older adults in the community may consider physical activity too risky or inappropriate for older age. “as they have more health concerns, they become less active. they believe that physical movement can damage their joints, allocated time for each exercise might not be enough, and as if from the side they will look funny doing those activities.” deputy director, social services center one interviewee believed this view was shared by younger generations as well when they thought that engagement in physical activities might exacerbate their parents’ and grandparents’ current conditions and lead to complications. a number of participants (3 of 9) including representatives from a hospital and fitness facilities pointed out that physical activity was often seen by older adults only as a supplement to medications and conventional medicine. seniors may have underestimated the importance of exercise, for example, compared to following a medication regime. two informants noted that this misconception was also present among healthcare professionals. main discussion during a patient visit was around clinical concepts of disease, its symptoms, and conventional treatment methods. a respondent went on to explain: “doctors are not particularly familiar with sports either. to someone who has been living a sedentary life for 40 years they say, ‘you need to be physically active,’ and expect him/her to go straight into running.” instructor of nordic walking, independent provider dimension 2— community knowledge of efforts: this dimension was comprised of how much community members knew about local efforts, if any, their effectiveness, and accessibility for older adults. efforts from the government, private, and nonprofit sectors aimed at increasing older adult physical activity were fragmented and rarely present. three out of nine informants could not name any physical activity programs offered specifically for seniors. nordic walking was the only example of a structured physical activity program mentioned by several interviewees (5 of 9). “i have not seen a separate program specifically designed for the elderly not from the private, nor from the public sector. a lot of different activities are carried out all around the city during summer months, but nothing is specific to older adults.” instructor of physical exercise class, fitness center some fitness centers provided discounts for senior citizens to encourage the use of sports and leisure facilities. however, informants (3 of 9) believed that older adults often thought that fitness centers were for younger people, and it might be challenging for the elderly. those who were involved in designing or delivering services or heard about physical activity opportunities for senior citizens were uncertain of how widespread those activities were and if they were popular among older adults. according to informants (4 of 9), majority of community members were unaware or had limited knowledge about current and future efforts. “we can see this by the way people call and come to us. they say, ‘we have elderly parents, and we do not know what to do with them.’ they ask for some kind of activities and events, but we are not aware of anything like that.” director, older adult organization dimension 3— community climate: this dimension included the prevailing attitude of community members towards older age and the role of physical activity in older adulthood. informants indicated that older adult life was traditionally considered as a period to be spent with family, grandchildren, and relatives where older adult physical activity was of little value to seniors themselves and their children. after the age of 60, people may have become more heavily centered on family and household needs. hence, their physical activity has been limited to central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.447 | http://cajgh.pitt.edu everyday chores, such as grocery shopping and housekeeping. according to informants, older adults were respected in the family and community. their rare participation in physical activities was usually welcomed, but they were not seen as active members of society. as cited by one key informant, tv commercials portrayed older people as barely moving individuals. another respondent suggested to think about common gifts that seniors received on birthdays and other occasions, and explained it in the following way: “in our society, people very often present handkerchiefs, slippers, pajamas to older adults all these gifts indicate that our view of the elderly is of an isolated and closed person. so even with our gifts we push them in the corner. if the community members saw them as an active part of society, then they would be given sports shoes, a sports bag, ice skating gear, active outfit.” director, older adult organization informants acknowledged community concern about the issue of physical inactivity among older adults was limited to a group of enthusiasts and certain professionals, whereas the community as a whole expressed no concern and considered it to be an individual level problem. informants (5 of 9) were skeptical about the problem becoming a real concern for city residents in near future. “our society is not ready to act on it yet. now fitness is experiencing some kind of a boom and maybe involvement of older adults will somehow be a priority in the future, but it is not happening now. probably, not going to happen soon.” instructor of nordic walking, independent provider dimension 4— leadership: this dimension aimed to understand the position of the appointed leaders and influential community members in relation the issue and assessed their willingness to support current as well as future community actions. informants indicated that while the issue may have been a concern for the leadership, they showed no immediate motivation to act. due to many other pressing issues needing attention and funding, older adult physical activity was not a priority. a respondent pointed out that the government’s view of senior population was limited to pension reforms. “when you ask about what is being done in relation to senior citizens, they [government officials] start explaining pension reforms. an elderly person is equal to pension affairs, and no one notices other aspects of older adult life.” director, older adult organization dimension 5— resources: the last dimension of the crt explored the availability of local resources – human, money, and space – for community members to use in support of efforts now and in the future. informants (6 of 9) cited lack of financial resources as one of the most common barriers for seniors to engage in physical activities. free opportunities had been accessible on a limited or seasonal basis, whereas fitness center memberships were unaffordable for the elderly for whom pension was usually the single source of income. government funding was very scarce, and most of older adult physical activities were self-funded or supported by family members. when asked about alternative means of funding from grants and businesses, key informants (7 of 9) were unable to provide examples and explained that very limited financial support was available for promotion of older adult physical activity. while not readily available, informants suggested that volunteers could be found among community members. to them, youth were especially involved in volunteering, which might help in activating older adults. in order to direct volunteer efforts towards effective promotion of physical activity among seniors, informants indicated that someone needed to train, organize, and mobilize them in a structured way. izguttinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.447 | http://cajgh.pitt.edu “it seems to me that the problem lies precisely in the absence of an organizer or a leader who will be able to take the ownership of the problem, advocate for a solution, and use his/her skills as well as networks for the benefit of seniors… volunteers can be easily recruited if there is a leader.” head of physical therapy unit, hospital 2 in terms of expert help, there appeared to be a sufficient number of knowledgeable and skilled healthcare workers, public health practitioners, and fitness instructors in the community. yet, they may not all be trained to work specifically with older adult population. two key informants mentioned that special training, expertise, and desire were needed to successfully accomplish such work. informants explained that during summer months, outdoor spaces could easily be used for physical activity sessions, but indoor spaces may not be readily available free of charge. availability would also depend on the size of a required space. throughout colder periods of the year, lack of indoor facilities in close proximity was thought to be a substantial barrier to physical activity. discussion we anticipated that the local community might score low in its readiness to challenge the current situation in relation to physical inactivity among senior citizens. in fact, quantitative assessment suggests that cr in nur-sultan is equal to the score of 3.28 on a nine-point scale, which is equivalent to the stage of vague awareness. according to the crt, this means that most people recognize the issue as a local concern, but there is no immediate motivation to act on it. qualitative analysis, however, indicates that community awareness might even be more limited and only certain groups such as fitness instructors and gerontologists express genuine concern regarding the issue. such qualitative research findings suggest a denial/resistance stage of cr and highlight the importance of conducting in-depth analysis of interviewee responses in addition to calculating readiness scores when using the crt. this also suggests that a broader assessment of cr with a greater number of key informants is needed in the future. the literature points to many factors affecting engagement of older adults in physical activity.21,22 while identification of barriers was not a specific goal of the study, through qualitative analysis we identified a number of obstacles that prevent seniors from leading active lifestyles. physical activity is often perceived by community members, including the elderly, as a pursuit of younger people, which could be risky or inappropriate for older adults. there is also an emphasis on conventional treatment of health problems and a diseasecentric view of aging. such beliefs, coupled with lack of information about the issue, appear to contribute to high levels of physical inactivity among seniors in nur-sultan. another common barrier is unaffordability of physical activity classes in the capital city. as evidenced by the results of the world values survey,20 only around 16% of older adults in kazakhstan are able to save money and the rest “just get by” or “borrow money”. this fact may justify a low priority of physical activity among seniors. likewise, the country and city leadership do not recognize the problem as a priority and have been passive in offering a solution. lack of concern about the issue in the community and among the leadership could explain the scarcity of efforts. however, it is important to examine the current situation while taking into account the broader country profile. as a developing nation, kazakhstan’s government seems to be focusing on improving and diversifying the economy, and people are still driven by survival values of ensuring financial and physical security.20 in addition, the proportion of seniors in the country (7.4%) is significantly lower than in europe (20%) and the us (16%),23 which could be distancing attention from the issues of older age, including physical inactivity. at the same time, high mortality and morbidity rates from cardiovascular central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.447 | http://cajgh.pitt.edu diseases may in the near future incentivize the government to invest more resources in preventative initiatives. the authors of the crt suggest directing the efforts at increasing awareness, empowering community groups, and acquiring local support in order to move the readiness beyond the stage of vague awareness. for that purpose, studies from the us and china12,14 have recommended disseminating information about the benefits of physical activity through various printed and electronic media. in this regard, the government of kazakhstan can use its vast network of state owned or regulated media channels to inform the community about the issue and to promote greater involvement of seniors in physical activity. in the key informant interviews, nordic walking was a commonly mentioned physical activity program. while it is not targeted at older adults, the program has been proven to be effective in improving heart rate, oxygen consumption, and quality of life.24 promoting this program further may be a valid strategy to increase physical activity among older adults. alternatively, evidence-based older adult activity programs such as enhance®fitness may be introduced in the community.25 however, implementation in kazakhstan would first require a study of feasibility and necessary adaptations. given that the country’s governance structure is highly centralized,26 national policies are likely to be more effective in changing the current situation. for instance, inclusion of older adult physical activity promotion as one of the priorities in the next state healthcare development program27 may facilitate the promotion of older adult physical activity and the adoption of evidence-based programs throughout the country. this in turn could aid the transition from a disease-centric clinical paradigm towards a more prevention-centric, whole-person view of health care. to our knowledge, this was the first effort to conduct a systematic evaluation of cr in central asia. therefore, the concepts and methods of the study could be used by local researchers to conduct readiness assessments for other health and social problems in the communities of the region. furthermore, in the vast majority of studies the crt was used exclusively in a quantitative manner, whereas we went beyond that approach and included a qualitative assessment of key informant responses, which is a major strength of the study. our final sample, however, included only 9 respondents. although we ensured inclusion of representatives from a diverse range of fields, the study would have benefited from a larger sample size and a greater number of participants aged over 60. in addition, the concept of cr is community-specific, which limits the generalizability of the findings. references 1. arem h, matthews ce, lee im. physical activity is key for successful aging-reply: even a little is good. jama intern med. 2015;175:1863. 2. paterson dh, warburton de. physical activity and functional limitations in older adults: a systematic review related to canada’s physical activity guidelines. int j behav nutr phys act. 2010;7:38. 3. bauman a, merom d, bull fc, buchner dm, fiatarone singh ma. updating the evidence for physical activity: summative reviews of the epidemiological evidence, prevalence, and interventions to promote “active aging”. gerontologist. 2016;56(s2):s268–s280. 4. keadle s, mckinnon r, graubard b., troiano r. prevalence and trends in physical activity among older adults in the united states: a comparison across three national surveys. prev med. 2016;89:37-43. 5. townsend n, wickramasinghe k, williams j, bhatnagar p, rayner m. physical activity statistics 2015. british heart foundation: london; 2016. 6. zhu w, chi a, sun y. physical activity among older chinese adults living in urban and rural areas: a review. j sport health sci. 2016;5:281–286. izguttinov this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.447 | http://cajgh.pitt.edu 7. sun f, norman ij, while ae. physical activity in older people: a systematic review. bmc public health. 2013;13:449. 8. world bank. life expectancy at birth, total (years) – kazakhstan. c2017 https://data.worldbank.org/indicator/sp.dyn.le00.in? locations=kz accessed oct 25, 2019. 9. oecd. oecd reviews of health systems: kazakhstan 2018. oecd publishing: paris; 2018. 10. stanley lr, oetting er, plested ba, edwards rw, thurman pj, kelly kj, beauvais f. community readiness for community change. 2nd ed. tri-ethnic center for prevention research: fort collins, co, usa; 2014. 11. edwards rw, jumper-thurman p, plested ba, oetting er, swanson l. community readiness: research to practice. jcop. 2000;28(3):291-307. 12. jones dl, settipalli s, goodman jm, hootman jm, goins rt. community readiness for adopting a physical activity program for people with arthritis in west virginia. prev chronic dis. 2012;9:110-166. 13. gansefort d, brand t, princk c, zeeb h. community readiness for the promotion of physical activity in older adults a cross-sectional comparison of rural and urban communities. int j environ res public health. 2018;15:453. 14. liu m, zhang x, xiao j, ge f, tang s, belza b. community readiness assessment for disseminating evidence-based physical activity programs to older adults in changsha, china: a case for enhance®fitness. glob health promot. 2018. 15. oetting er, jumper-thurman p, plested b, edwards rw. community readiness and health services. subst use misuse. 2001;36(6-7):825-43. 16. palinkas la, horwitz sm, green ca, wisdom jp, duan n, hoagwood k. purposeful sampling for qualitative data collection and analysis in mixed method implementation research. adm policy ment health. 2015;42(5):533–544. 17. cohen d, crabtree b. qualitative research guidelines project. http://www.qualres.org/homesemi3629.html accessed nov 9, 2019. 18. kostadinov i, daniel m, stanley l, gancia a, cargo m. a systematic review of community readiness tool applications: implications for reporting. int j environ res public health. 2015;12:3453-3468. 19. boyatzis re. transforming qualitative information: thematic analysis and code development. thousand oaks, ca, us: sage publications, inc.; 1998. 20. inglehart r, moreno ha, welzel c, kizilova k, diez-medrano j, lagos m, norris p, ponarin e, puranen b. world values survey: round six country-pooled datafile. version: www.worldvaluessurvey.org/wvsdocumentationwv6. jsp. madrid: jd systems institute; 2014. 21. bethancourt hj, rosenberg de, beatty t, arterburn de. barriers to and facilitators of physical activity program use among older adults. clin med res. 2014;12(1-2):10-20. 22. gothe np, kendall bj. barriers, motivations, and preferences for physical activity among female african american older adults. ggm. 2016;2:1-8. 23. world bank. population ages 65 and above (% of total population). https://data.worldbank.org/indicator/sp.pop.65up.to. zs accessed oct 25, 2019. 24. tschentscher m, niederseer d, niebauer j. health benefits of nordic walking: a systematic review. am j prev med. 2013;44(1):76-84. 25. petrescu-prahova m, belza b, kohn m, miyawaki c. implementation and maintenance of a communitybased older adult physical activity program. gerontologist. 2015;56(4):677–686. 26. katsaga a, kulzhanov m, karanikolos m, rechel b. kazakhstan: health system review. health syst transit. 2012;14(4):1-154. 27. ministry of healthcare. healthcare development state programs. the official website of the ministry of healthcare of the republic of kazakhstan; c2019 http://dsm.gov.kz/en/kategorii/gosudarstvennyeprogrammy-0 accessed oct 19, 2019. cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. self-blame attributions of patients: a systematic review study yadollah jannati1, hamid sharif nia2, erika sivarajan froelicher3,4, amir hossein goudarzian5*, ameneh yaghoobzadeh6 1psychiatry and behavioral sciences research center, mazandaran university of medical sciences, sari, iran; 2amol school of nursing and midwifery, mazandaran university of medical sciences, sari, iran; 3department of physiological nursing, school of nursing, university of california san francisco, san francisco, california, usa; 4department of epidemiology & biostatistics, school of medicine, university of california san francisco, san francisco, california, usa; 5student research committee, mazandaran university of medical sciences, sari, iran; 6school of nursing and midwifery, tehran university of medical sciences, tehran, iran *corresponding author vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ jannati this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu abstract introduction: psychological aspects are important issues in patients that will have significant effects on disease progression. a new and important psychological concern is self-blame. this review was performed with the aim of systematic review on studies around patient’s self-blame. methods: this is a systematic review using international databases including pubmed (since 1950), scopus (since 2004), web of sciences (since 1900), and proquest (since 1938) and iranian databases including sid (since 2004) and magiran (since 2001). mesh terms including “patient,” “regret,” and “guilt” and non-mesh terms including “self-blame attribution,” “characterological self-blame,” “behavioral self-blame,” and “blame” were used in iranian and international databases with or and and operators. results: the review yielded 59 articles; 15 articles were included in the present study. the ages of patients ranged from 29-68.4 years. most of studies (86.6%) had cross-sectional design and use characterological self-blame and behavioral self-blame variables for assessing self-blame attributions. the results showed that in most studies, a significant relationship among self-blame and psychological distress, anxiety, and depression were reported. conclusion: a significant relation was reported between self-blaming and the degree of distress, anxiety, and depression in patients in most of the studies. keywords: self-blame; patient; anxiety; depression; systematic review self-blame attributions of patients: a systematic review study yadollah jannati1, hamid sharif nia2, erika sivarajan froelicher3,4, amir hossein goudarzian5, ameneh yaghoobzadeh6 1psychiatry and behavioral sciences research center, mazandaran university of medical sciences, sari, iran; 2amol school of nursing and midwifery, mazandaran university of medical sciences, sari, iran; 3department of physiological nursing, school of nursing, university of california san francisco, san francisco, california, usa; 4department of epidemiology & biostatistics, school of medicine, university of california san francisco, san francisco, california, usa; 5student research committee, mazandaran university of medical sciences, sari, iran; 6school of nursing and midwifery, tehran university of medical sciences, tehran, iran research vos et al. estimated about 95% of the world's populations are suffering from a variety of physical health problems1. cancer, cardiovascular disease, chronic obstructive pulmonary disease (copd), and diabetes are the most common health problems in the world. though at a lower incidence, populations also suffer from diseases such as acquired immunodeficiency syndrome (aids), kidney disease, and hypertension2. these are chronic conditions that typically require longterm care throughout life and often have many physical, psychological, and social challenges for the patient and their families3. psychological aspects are some of the most important problems these patients experience, and they have significant effects on the progression of their disease4. the psychological adaptation to these stressful life events needs to be assessed, including cognitive effects. cognitive assessments are important in determining these effects, explored/identified through factors like self-blame5. self-blame is a common reaction to stressful events and has certain effects on how http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu individuals adapt. types of self-blame are hypothesized to contribute to depression, and self-blame is a component of self-directed emotions like self-guilt and self-disgust. because of self-blame’s commonality in response to stress and its role in emotion, self-blame should be examined using psychology’s perspectives on stress and coping5,6. janoff-bulman suggested that behavioral self-blaming has a direct relation with the level of health and the ability to control stress. because these chronic conditions persist over many years and are often unstable, they have a damaging effect on psychological well-being6. many studies with patient samples other than cardiovascular disease confirmed the hypothesis that behavioral self-blaming is directly related to better health findings than characterological selfblaming5,7,8. numerous other studies have been conducted about self-blaming in patients5,9-12; though some contradictions are still presented. for example, the relationship between behavioral self-blaming and characterological self-blaming and psychological disorders was investigated in a study on cardiovascular patients receiving cardiac rehabilitation exercises12. the results indicated that behavioral self-blaming had a positive effect on the level of anxiety and depression at the beginning of exercise. characterological selfblaming, however, did not have any definite relationship with these variables. both types of self-blaming were good predictors of cardiac psychological symptoms in patients with cardiac rehabilitation in other studies10. the results of this study showed that both types of selfblaming initially had a positive relationship with the symptoms of heart disease, but only characterological self-blaming was a predictor of outcomes in the ensuing 21 months. therefore, studies on self-blaming of patients needed to be made comprehensively by means of an instrument that emphasizes both categories of blaming. considering the contradictory information across studies it seems necessary to do a review of all available literature on this topic to better understand the relationship between self-blaming and psychological disorders in different populations. therefore, considering the necessity of a comprehensive review, the present study was conducted with the aim of systemically reviewing studies in the field of self-blaming in patients, with the intent of exploring if self-blame is associated with any particular type of medical conditions. methods this systematic review was conducted in accordance with prisma guidelines 201913. this study reports on a systematic review of studies in the field of self-blaming. search strategy and studies’ criteria a systematic review of related studies conducted in the international databases in the english and farsi literature of pubmed (since 1950), scopus (since 2004), web of sciences (since 1900), and proquest (since 1938) and iranian databases of sid (since 2004) and magiran (since 2001). based on table 1, mesh terms including “patient”, “regret” and “guilt” and non-mesh terms including “self-blame attribution”, “characterological self-blame”, “behavioral self-blame” and “blame” were chosen to search using or and and operators in iranian and international databases, respectively. all original articles were collected and reviewed for inclusion in the study. first, the published articles related to the aim of the present study were reviewed by the two researchers (ahg and hsh). the initial list was then entered into endnote to eliminate duplicate studies if present. in the third stage, the articles were examined and filtered based on inclusion and exclusion criteria. inclusion criteria were: 1) the key words (including self-blame, characterological selfblame, behavioral self-blame, and blame) presented in title or abstract; 2) published in persian or english language; 3) self-blaming considered as the independent http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jannati this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu databases search strategy preliminary searches formal screening of search results against eligibility criteria pubmed [(self-blame attribution) or blame] or [regret or guilt) and patient 9,704 9 scopus 2,365 3 web of science 3,921 2 proquest 91,955 1 sid 67 0 magiran 280 0 table 1. database search stages variable; 4) only subjects with a physical diagnosis were included (due to the fact that there are differences between these patients and the ones with mental disorders, which makes it difficult to reach accurate conclusions). published studies in the form of dissertations, books, and abstracts of congresses and conferences were also excluded from the study, due to insufficient details and lack of peer review. review studies were also excluded from the study. also, articles with access limitation to the full text were received in correspondence with the author. based on table 1 and figure 1, from 108,292 articles that were found from all of databases, 51 articles were extracted. after across mentioned criteria, 36 articles were excluded. then, 15 articles were entered to quality assessment stage. quality assessment the quality of the methodology was verified by two researchers (ahg and yj) independently using the strobe checklist (for cross-sectional studies) and the coreq checklist (for qualitative studies). strobe consists of 22 sections and examines various aspects of the methodology, including the objectives of the study, sampling methods, variables measurements, statistical analysis, confounding modifications, and validity and reliability of the measures14. the minimum score was considered as 16 for this checklist. finally, qualified studies were entered to the research that obtained a minimum score14 using this checklist. moreover, coreq consists of 32 items, including the researcher's profile, the type of study design (sampling methods, sample size, type of interview and methodology), and the method of analyzing and reporting the results15. the minimum score was 23 to be included in the review. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jannati this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu figure 1. prisma flowchart data extraction and analysis the following information was extracted from each paper entered to the study: first author, year of publication, study type, number and mean age of participants, location of the study, type of population surveyed, type of instrument used, and most important findings. the validity of the tool was evaluated by 10 expert faculty members in mazandaran university of medical sciences. ethics statement this study was approved in ethic committee of mazandaran university of medical sciences (ir.mazums.rec.1398.453). http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jannati this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu results all articles entered into this study were reviewed by two checklists. overall, the quality of studies was acceptable. in the present study, 15 articles out of 59 articles were entered after various stages of screening5,8,16-28. most of them (86.6%) had cross-sectional designs and were conducted in the usa (73.3%). furthermore, most of the studies about self-blaming were among patients with cancer, but few studies have been conducted on patients with heart disease, copd, burns, major depressive disorders (mdd), type 2 diabetes, and irritable bowel syndrome (based on table 2). the patient ages ranged from 29 to 68.4. also, most studies used a two-part tool of characterological self-blame (csb) and behavioral self-blame (bsb) to evaluate self-blaming. based on the results, self-blaming had a significant relationship with the amount of distress, anxiety, and depression in patients. in other words, selfblaming was associated with mental disorders and patients’ quality of life. self-blame and distress some studies were carried out on cancer patients, cardiac patients and irritable bowel syndrome around the relationship of self-blame and psychological distress (table 2). malcarne in his study that was done on 72 cancer patients (near diagnosis) declared that characterological self-blame was related to higher levels of psychological distress in the first of study (time 1) and time 2 (4 months after) [r(70) = .38, p < .001] but behavioral self-blame not related to psychological distress in time 216. initial psychological distress was a significant predictor of characterological self-blame (sr 2 = .53, p < .001, β = .74), and the interaction of behavioral and characterological self-blame was significant (sr 2 = .02, p < .05, β = .18). bennett released that bsb in cardiac patients was predictive of baseline levels of anxiety symptoms (β=0.28, p<0.01, sr2=0.06), as well as time 2 (12 weeks later than cardiac rehabilitation program) symptoms after controlling for baseline levels (β=0.23, p<0.01, sr2=0.04)28. that is, blaming one’s behavior for a cardiac event was positively related to experiencing symptoms of anxiety concurrently and 12 weeks later. self-blame with anxiety and depression else-quest concluded that self-blame was negatively correlated with self-esteem (r = -0.26, p<0.001), but positively correlated with anxiety (r = 0.55, p<0.001), anger (r = 0.53, p<0.001) and depressed affect (r = 0.55, p<0.001)18. self-blame also has a mediating role on the effect of perceived stigma on adjustment. the bennett study on cardiac patients showed that bsb was positively related to baseline depressive symptoms (β=0.38, p<0.001, sr2=0.11), and it predicted symptoms of depression at time 2 after controlling for baseline levels (β=0.14, p<0.05, sr2=0.01)28. another research on newly diagnosed breast cancer patients declared that, at diagnosis, the regression equation was significant in predicting anxiety and depression symptoms, accounting for 20% of the variance8. level of distress was predicted by behavioral self-blame; greater behavioral self-blame was predictive of more anxiety and depression symptoms, accounting for 9% unique variance. characterological self-blame was not significantly associated with affective symptoms. when behavioral (β = .38, sr2 = .14) and characterological self-blame (β = .28, sr2 = .08) were entered separately, both were significant predictors of anxiety and depression symptoms8. in the kiecolt-glaser study, the burn patients’ self-blame had a significant relation with depression (r = 0.15, β = 0.32, p<0.05), but no significant relation was seen with anxiety20. phelan, in a study on colorectal cancer patients, also concluded that self-blame was significantly associated with depressive symptoms (b = 2.67, p<0.001). the perception that other people blame the individual with colorectal cancer for the disease remained non-significant (b = -0.58, p = 0.56)25. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu other related factors one of the important factors that was assessed by friedman on breast cancer patients was quality of life21. self-blame, spirituality, and employment status were significant predictors of quality of life, accounting for 47% of the variance (p<0.001). also the results from the multiple regression analyses show self-blame, selfforgiveness, and spirituality were significant predictors of mood disturbance, accounting for 50% of the variance (p<0.001)21. sholomskas stated that self-blaming had no significant relationship with coping skills in spinal injury patients17. also one concept that was focused in some studies was self-blaming rumination that effects on psychological distress and other related psychological diseases including depression29. author (year) study type place participants (n) mean age (sd) study tool important findings malcarne (1995) cross-sectional usa cancer patients (72) 45.46 (7.49) bsb and csb psychological distress was an important predictor of self-blame. bennett (2005) cross-sectional usa breast cancer patients (53) 53 (9.4) bsb and csb self-blame was an important predictor of anxiety and depression. sholomskas (1990) cross-sectional usa spinal damage (31) 29 causal dimension scale (cds) there was no relationship between self-blame and patient coping behaviors. else-quest (2009) cross-sectional usa lung, prostate and breast cancer patients (172) 66.9 (11.18) the state shame and guilt scale (ssgs) self-blame was an important predictor of anxiety, anger and depression. bennett (2013) cross-sectional usa cardiac patients (129) 64.1 (10.2) bsb and csb bsb was associated with mental distress at the beginning of the trainings. zahn (2015) cross-sectional england mdd (132) 32.8 (12.3) psychopathologybased instrument (amdp) self-blame was high in mdd patients, but it was not the cause of sin. glinder (1999) cross-sectional usa breast cancer patients (76) 54.8 (9.8) bsb and csb self-blame was an important predictor of anxiety and depression. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jannati this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu kiecolt-glaser (1987) cross-sectional usa burn patients (49) 35.87 (13.44) bsb and csb the higher bsb predicted depression and inconsistency. friedman (2007) cross-sectional usa breast cancer patients (123) 56.2 (11.5) bsb and csb self-blame was an important predictor of anxiety and depression. sheridan (2011) qualitative new zealand copd (29) interview self-blame has increased the sense of need. halding (2010) qualitative norway copd (18) interview self-blame was remarkable in these patients. phelan (2011) cross-sectional usa colorectal cancer (1109) 68.4 (10) researcher made self-blame was an important predictor of depression. friedman (2010) cross-sectional usa breast cancer patients (108) 52 bsb and csb self-blame was associated with quality of life. beverly (2012) qualitative usa type 2 diabetes (34) 59.8 (7.3) interview self-blame was responsible for poor achievement for medical purposes. alisha (2000) cross-sectional canada irritable bowel syndrome (25) bsb and csb self-blame was an important predictor of psychological distress. table 2. characterization of included articles discussion there are numerous studies about self-blaming; this is still an important and new subject throughout the world. one important conclusion of this review is that self-blaming is a significant predictor of psychological distress, anxiety, and depression in patients. it is problematic when it appears as self-blaming rumination30. self-blaming rumination is a form of intellectual rumination and negative recurring thinking with the purpose of underestimating oneself. moreover, researchers have suggested that it is associated with psychological problems such as depression, anxiety, and anger31. self-blaming is a form of inadequate self which is correlated with marital conflicts32. also, it is related to disappointment and indifference about others, that is, they feel apathy about them33. abi-habib and luyten found in their research that these kinds of people behaved in a hostile and biased manner against others34. they are anxious and hardly in control of their anger towards others, which often leads to conflicts in interpersonal relationships. so far, most of the studies about this phenomenon have been conducted in samples of us populations. cancer patients were the most emphasized http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu sample, cardiac and copd patients were the next grades. unfortunately, no attention has been paid to this very important issue on patients in iran. however, kochaki et al. conducted a study about the mediating role of selfblaming rumination in the relationship between disaffection and marital violence. they stated that selfblaming can’t predict marital violence35. it needs to consider that the sample population of this study was community samples who have different mental and physical conditions compared to populations of patients with medical diagnosis. patients are subjected to suffering from various psychological changes due to possible changes in their organs (because of the process of disease or surgical procedures) and the reductions of energy and activities associated with such illnesses. changes in their selfconcept is one of the most common and destructive changes36. patients with disrupted self-concept tend to blame themselves. it can lead to giving up against the disease in extreme cases, which can have adverse health effects for the patients. paying attention to this phenomenon will greatly contribute to the health and wellbeing of a community in terms of manpower and medical expenses. the hopelessness theory of depression proposes that depression is caused by two variables: attribution of negative events to stable and global causes, and other cognitive factors like low self-esteem37. csb attributes occurrence of events to stable aspects of the individual that are not controllable. csb attributions seem likely to cause helplessness, since individuals believe they are powerless to control the characteristics that lead to negative events38. on the other hand, bsb has an indeterminate effect under hopelessness theory, since bsb attributes events to behaviors that can be controlled to produce better outcomes38. these theories of attributional style and stress and coping have similar predictions to janoff-bulman’s bsb/csb distinction6. depression occurs when individuals feel that they cannot control the future. the csb/bsb distinction also corresponds to dweck’s distinction between ability and effort attributions39. effort attributions are when individuals assign success or failure to the hard work and other controllable factors, while ability attributions assign outcomes to internal, stable characteristics, like intelligence. dweck noted that individuals that believe outcomes are uncontrollable are more likely to be debilitated by setbacks, procrastinate or avoid stressors, and show greater stress responses39. in short, theorists believe that the type of cause to which events are attributed is a central factor of effectiveness of blame40. exploratory neuroscientific evidence has found a distinct sign of connectivity abnormality associated with general self-blame. evidence suggests that major depressive disorder creates vulnerability to depression that lasts years after the cessation of depressive episodes41. one of the mechanisms of this “scar theory” of depression is proposed to be increased likelihood to perform self-blame. self-blaming biases are present in patients with remitted depression, and these biases are associated with risk of recurrence of mdd41. researchers used functional magnetic resonance imaging (fmri) to examine brain regions and connections associated with self-blame. abnormal activation was demonstrated in subgenual cingulate cortex and septal area (scsr) in currently depressed individuals, but in other situations as well: previously-depressed individuals showed differences in brain activity while feeling guilt compared to always-healthy controls42. also, the amount of connection abnormality in these regions was predictive of depression recurrence42. these data suggest that depression episodes change the quality of self-blame, making individuals vulnerable to depression recurrence. the result of this systematic review reveals the fact that the issue of self-blaming is very important and is also a key for all groups of society, especially patients. unfortunately, this issue has not been adequately considered in iran. by emphasizing the use of specific tools to measure self-blaming for patients, some interventions can be initiated to treat these disorders. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jannati this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu moreover, the practice of using this tool and its necessity can be taught in the universities and especially in nursing schools (due to the high level of nurse-patient relationship). the collection of all these suggestions can be effective over time for the health of patients, as well as their families, which helps to reduce the burden of treatment on the country's side, in addition to promoting the country's health index in the world. this study had some limitations like other studies. one of the most important was the shortage of articles for more definitive and stable conclusions. also, no relevant studies were found on patients in iran that allowed us to compare our findings with other communities. most of the focus was on cancer patients, so a more accurate comparison between patient populations was not possible. given only seven databases were used in the study, the possibility exists that certain relevant publications containing self-blame measures were not identified, a common challenge when conducting systematic reviews. furthermore, given our initial review targeted article abstracts, it is plausible that information about the measures were included in the text of omitted articles. therefore, it is recommended that future studies be carried out on well-defined population of patients. of course, it is important to note that the tool to measure self-blaming has not been validated in iran. so, it needs to be validated in a farsi-speaking persian sample. now we know that self-blame had significant relation with some important psychological factors like depression and anxiety, so we can design and run some randomized clinical trial studies to assess the exact effects of reducing self-blame on those negative psychological factors. in summary, a significant relation was reported between self-blaming and the degree of distress, anxiety, and depression in patients in most of the studies. it is recommended to do further studies to evaluate this finding. references 1. vos t, barber rm, bell b, et al. global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the global burden of disease study 2013. the lancet. 2015;386(9995):743-800. 2. callebaut l, molyneux p, alexander t. the relationship between self‐blame for the onset of a chronic physical health condition and emotional distress: a systematic literature review. clinical psychology & psychotherapy. 2017;24(4):965-986. 3. health do. long term conditions compendium of information. department of health london; 2012. 4. dornelas ea, sears sf. living with heart despite recurrent challenges: psychological care for adults with advanced cardiac disease. american psychologist. 2018;73(8):1007. 5. bennett kk, compas be, beckjord e, glinder jg. self-blame and distress among women with newly diagnosed breast cancer. journal of behavioral medicine. 2005;28(4):313-323. 6. janoff-bulman r. characterological versus behavioral self-blame: inquiries into depression and rape. journal of personality and social psychology. 1979;37(10):1798. 7. plaufcan mr, wamboldt fs, holm ke. behavioral and characterological self-blame in chronic obstructive pulmonary disease. journal of psychosomatic research. 2012;72(1):78-83. 8. glinder jg, compas be. self-blame attributions in women with newly diagnosed breast cancer: a prospective study of psychological adjustment. health psychology. 1999;18(5):475. 9. vasconcelos e sa d, barrowclough c, hartley s, wearden a. self‐blame attributions in relatives of people with recent‐onset psychosis: associations with http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu relatives’ distress and behavioural control. british journal of clinical psychology. 2017;56(2):172-188. 10. harry km, bennett kk, clark jm, howarter ad, eways kr. self-blame attributions and cardiac symptom experiences in cardiac rehabilitation patients: a preliminary study. north american journal of psychology. 2015;17(3):541. 11. yang km, chae mj, so hs. stigma and distress among cancer patients: the mediating effect of selfblame. korean journal of adult nursing. 2018;30(1):89-97. 12. bennett kk, marte rm. patient attributions for cardiac events: predictors of physical and psychological recovery. journal of applied social psychology. 2013;43(3):660-672. 13. panic n, leoncini e, de belvis g, ricciardi w, boccia s. evaluation of the endorsement of the preferred reporting items for systematic reviews and meta-analysis (prisma) statement on the quality of published systematic review and meta-analyses. plos one. 2013;8(12):e83138. 14. von elm e, altman dg, egger m, et al. the strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies. international journal of surgery. 2014;12(12):1495-1499. 15. tong a, sainsbury p, craig j. consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups. international journal for quality in health care. 2007;19(6):349-357. 16. malcarne vl, compas be, epping-jordan je, howell dc. cognitive factors in adjustment to cancer: attributions of self-blame and perceptions of control. journal of behavioral medicine. 1995;18(5):401-417. 17. sholomskas de, steil jm, plummer jk. the spinal cord injured revisited: the relationship between self‐ blame, other‐blame and coping. journal of applied social psychology. 1990;20(7):548-574. 18. else-quest nm, loconte nk, schiller jh, hyde js. perceived stigma, self-blame, and adjustment among lung, breast and prostate cancer patients. psychology and health. 2009;24(8):949-964. 19. zahn r, lythe ke, gethin ja, et al. the role of selfblame and worthlessness in the psychopathology of major depressive disorder. journal of affective disorders. 2015;186:337-341. 20. kiecolt-glaser jk, williams da. self-blame, compliance, and distress among burn patients. journal of personality and social psychology. 1987;53(1):187. 21. friedman lc, barber cr, chang j, et al. selfblame, self-forgiveness, and spirituality in breast cancer survivors in a public sector setting. journal of cancer education. 2010;25(3):343-348. 22. friedman lc, romero c, elledge r, et al. attribution of blame, self-forgiving attitude and psychological adjustment in women with breast cancer. journal of behavioral medicine. 2007;30(4):351-357. 23. sheridan n, kenealy t, salmon e, rea h, raphael d, schmidt-busby j. helplessness, self blame and faith may impact on self management in copd: a qualitative study. primary care respiratory journal. 2011;20(3):307. 24. halding ag, heggdal k, wahl a. experiences of self‐blame and stigmatisation for self‐infliction among individuals living with copd. scandinavian journal of caring sciences. 2011;25(1):100-107. 25. phelan sm, griffin jm, jackson gl, et al. stigma, perceived blame, self‐blame, and depressive symptoms in men with colorectal cancer. psycho‐oncology. 2013;22(1):65-73. 26. beverly ea, ritholz md, brooks km, et al. a qualitative study of perceived responsibility and selfblame in type 2 diabetes: reflections of physicians and patients. journal of general internal medicine. 2012;27(9):1180-1187. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx jannati this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu 27. ali a, toner bb, stuckless n, et al. emotional abuse, self-blame, and self-silencing in women with irritable bowel syndrome. psychosomatic medicine. 2000;62(1):76-82. 28. bennett kk, howarter ad, clark jm. self-blame attributions, control appraisals and distress among cardiac rehabilitation patients. psychology & health. 2013;28(6):637-652. 29. ham s-m, hyun m-h. the mediating effects of self blame moderated by ruminative response style on the relationship between self-focused attention and depression: focused on gender differences. korean journal of stress research. 2015;23(4):225-235. 30. kolubinski dc, nikčević av, lawrence ja, spada mm. the role of metacognition in self-critical rumination: an investigation in individuals presenting with low self-esteem. journal of rational-emotive & cognitive-behavior therapy. 2016;34(1):73-85. 31. smart lm, peters jr, baer ra. development and validation of a measure of self-critical rumination. assessment. 2016;23(3):321-332. 32. martins tc, canavarro mc, moreira h. adult attachment insecurity and dyadic adjustment: the mediating role of self‐criticism. psychology and psychotherapy: theory, research and practice. 2015;88(4):378-393. 33. dinger u, barrett ms, zimmermann j, et al. interpersonal problems, dependency, and self‐criticism in major depressive disorder. journal of clinical psychology. 2015;71(1):93-104. 34. abi-habib r, luyten p. the role of dependency and self-criticism in the relationship between anger and depression. personality and individual differences. 2013;55(8):921-925. 35. kochaki amirhendeh m, karbalayi a, sabet m. the mediating role of anger rumination and self-criticism rumination in relationship between disaffection and marital violence. thoughts and behavior in clinical psychology. 2017;11(43):47-56. 36. sweegers mg, buffart lm, van veldhuizen wm, et al. how does a supervised exercise program improve quality of life in patients with cancer? a concept mapping study examining patients' perspectives. the oncologist. 2018:theoncologist. 2017-0613. 37. liu rt, kleiman em, nestor ba, cheek sm. the hopelessness theory of depression: a quarter‐century in review. clinical psychology: science and practice. 2015;22(4):345-365. 38. kaur m, kaur i. dysfunctional attitude and selfblame: effect on self-esteem and self-conscious emotions among adolescents. the international journal of indian psychology. 2015;3(1):112-127. 39. dweck cs. the role of expectations and attributions in the alleviation of learned helplessness. journal of personality and social psychology. 1975;31(4):674. 40. skinner ea, zimmer-gembeck mj. perceived control and the development of coping. the oxford handbook of stress, health, and coping. 2011:35-59. 41. kring am, johnson sl. abnormal psychology: the science and treatment of psychological disorders. wiley; 2018. 42. lythe ke, moll j, gethin ja, et al. self-blame– selective hyperconnectivity between anterior temporal and subgenual cortices and prediction of recurrent depressive episodes. jama psychiatry. 2015;72(11):1119-1126. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. patterns of physical activity and self-rated health among adult populations in south asia sanni yaya1*, ghose bishwajit1,2* 1faculty of social sciences, school of international development and global studies, university of ottawa, canada; 2institute of nutrition and food science, university of dhaka, bangladesh *equal contributors vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.347 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ yaya this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.347|http://cajgh.pitt.edu abstract introduction: although south asians are considered to be at high risk for cardiovascular diseases, research evidence on the health impacts of physical activity (pa) remains very limited. in this study we aimed to explore the patterns of pa and to investigate whether engaging in regular pa is associated with better self-rated health (srh) among south asians. methods: cross-sectional data on population health were drawn from the world health survey of who. subjects were 28,020 male and female south asians (from bangladesh, india, nepal, and sri lanka) aged 18 years and above. data were analysed using descriptive and multivariable logistic regression analyses. results: the proportion of the sample population reported good srh was 44.3%, 58.7%, 37.7%, and 73.7% in bangladeshis, indians, nepalese, and sri lankans, respectively. regular engagement in moderate pa was highest in nepal (69.7%) and lowest in bangladesh (37.4%). vigorous pa was highest in india (29.9%) and lowest in bangladesh (17.9%). in bangladesh, compared to those never engaged in mpa, those who engaged for 1-2, 3-4, 5-6, or 7 days a week were 30% [aor=1.306; 95%ci 1.0851.572], 33% [aor=1.326; 95%ci 1.093-1.609], 39% [aor=1.389; 95%ci 1.125-1.716], and 46% [aor=1.459; 95%ci 1.2491.705] more likely to report being in good health, respectively. conclusions: we found that self-reported engagement in physical activities varies in south asian countries. since engaging in pa may help improve subjective and objective health status, health policy makers need to focus on designing exercise-friendly neighbourhoods in an attempt to promote population health. keywords: moderate physical activity; vigorous physical activity; self-rated health; south asia; world health survey patterns of physical activity and selfrated health among adult populations in south asia sanni yaya1*, ghose bishwajit1,2* 1faculty of social sciences, school of international development and global studies, university of ottawa, canada; 2institute of nutrition and food science, university of dhaka, bangladesh research introduction the construct of self-rated health (srh) is an inclusive measure of public health, and it is used as a reliable predictor of quality of life, subjective well-being, disability, morbidity, and mortality1,2. srh is one of the most widely used predictors of health risk and prognosis compared with/to other objective measures3. possible explanations for the efficacy of self-assessments of health include its multifaceted representation of an individual’s general perception of health, including biological, psychosocial, and cultural dimensions of health and expressiveness4. srh has also been found to be related to clinical measures of health3, and it was proposed that general practitioners can utilize srh measures in clinical encounters5. moreover, srh can be regarded as a more inclusive measure of health status than clinical diagnosis, as it tends to be sensitive to social determinants of health such as education, socioeconomic status, and living conditions, which have direct influences on health and well-being and on shaping individuals perception of health and illness4,5. srh is therefore able to provide information above and beyond typical clinical evaluation and thus offers a http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.347|http://cajgh.pitt.edu comprehensive way of assessing a patients’ overall health status4,6. in recent years, there has been an increasing research interest on the impact of various lifestyle factors and health related behaviours on srh7,8. behavioural aspects, such as tobacco smoking, alcohol drinking, dietary habits, and engaging in physical activity (pa) are explored in relation to how they correlate with srh among people of different age groups and socioeconomic backgrounds. physical inactivity is regarded as a growing public health issue both in developed and developing countries. in europe and other industrialised societies, increasing sedentary lifestyle has been shown to be associated with worse health and all-cause mortality, independent of level of pa9-11. according to who, public health burden of physical inactivity is high and causes an estimated 600,000 deaths per year in europe alone11. worldwide, physical inactivity is responsible for 6% of the burden of coronary heart disease, 7% of type 2 diabetes, and 10% of breast and colon cancer12. it has also been identified as the fourth leading risk factor for global mortality in 2010, accounting for roughly 13.4 million disability adjusted life years (dalys)15 and 6% of all deaths13. there is a growing consensus that moderateto vigorousintensity pa has a key preventive role in noncommunicable diseases (ncds), including obesity, cardiovascular disease, type-2 diabetes, and some cancers9,10. lack of pa during adolescence was reported to be a significant predictor of abdominal obesity in young adulthood leading to a self-perpetuating vicious circle of obesity and physical inactivity14. in addition to its contribution to increased morbidity and mortality, physical inactivity is also responsible for a substantial economic burden. epidemiological evidence on the role of pa on srh is necessary for making informed health policies that can promote pa in the general population. south asians are people who identify with the cultures of bangladesh, india, sri lanka, and nepal, and account for about a quarter of the global population with a unique epidemiological and sociodemographic profile. though south asians are considered at-risk population for cardiovascular diseases, research evidence on the health impacts of pa in this population remains very limited. therefore, epidemiological evidence from other regions may not be applicable for the population in this region. this study was carried out to provide insights on the pattern of pa in south asians, and to investigate the association between frequency of pa and srh among the adult population. data used in this study were extracted from the world health survey program of who conducted during 2002-2004 that included four south asian countries: bangladesh, india, nepal, and sri lanka. methods data source this study was based on the data extracted from who world health survey conducted between 2002 and 2004, available from who upon request. objectives of the who-funded survey were to provide reliable and nationally comparable data on a wide range of health and socioeconomic indicators to facilitate evidence-based health policy making. these data are utilized by many researchers due to lack of more recent data on health behaviour and self-rated health in south asian population. the program is operational in 70 countries including four south asian countries: bangladesh, india, nepal, and sri lanka. further details regarding the original survey study are published elsewhere16. variables of interest self-rated health status was the outcome variable in this study. emerging evidence suggests predictability of srh for both non-clinical and clinical outcomes, and it is being proposed to family physicians as an efficient yet simple way for therapeutic decision making28,29. respondents were asked to rate their health on a scale from 1 to 5 with the following response http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx yaya this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.347|http://cajgh.pitt.edu variables bangladesh india nepal sri lanka (n=5462) (n=8853) (n=8031) (n=5674) age, mean (sd) 38.47 (14.81) 38.69 (15.07) 38.55 (15.33) 40.78 (15.22) 18-29 1688 30.9 2771 31.3 2666 33.2 1515 26.7 30-39 1502 27.5 2275 25.7 2008 25 1367 24.1 40-49 1103 20.2 1611 18.2 1462 18.2 1231 21.7 50-59 574 10.5 1054 11.9 867 10.8 823 14.5 60+ 595 10.9 1151 13 1028 12.8 743 13.1 sex female 2917 53.4 4515 51 4602 57.3 2968 52.3 male 2545 46.6 4338 49 3429 42.7 2706 47.7 currently married no 1218 22.3 2036 23 1413 17.6 1765 31.1 yes 4244 77.7 6817 77 6618 82.4 3909 68.9 educational attainment nil 2245 41.1 3400 38.4 4819 60 318 5.6 less than primary school 1000 18.3 832 9.4 883 11 431 7.6 primary complete 1360 24.9 44 0.5 1108 13.8 1430 25.2 secondary complete 404 7.4 1567 17.7 819 10.2 2236 39.4 high school/ equivalent complete 218 4 1142 12.9 257 3.2 1123 19.8 pre-university/ university 235 4.3 894 10.1 137 1.7 136 2.4 employment status govt. employee 197 3.6 336 3.8 249 3.1 511 9 private employee 333 6.1 974 11 169 2.1 647 11.4 employer 2081 38.1 3621 40.9 5381 67 1923 33.9 not working for payment 2851 52.2 3940 44.5 2225 27.7 2599 45.8 smoking habit daily 2021 37 2780 31.4 3212 40 726 12.8 yes. not daily 300 5.5 266 3 385 4.8 460 8.1 non-smoker 3141 57.5 5808 65.6 4433 55.2 4494 79.2 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.347|http://cajgh.pitt.edu table 1. sample characteristics. options: 1. very good; 2. good; 3. moderate; 4. bad; and 5. very bad. srh was analysed dichotomously as: 1) good srh (very good and good), and 2) poor srh (moderate, bad and very bad)30. the validity of the single-item tool to measure subjective health was mentioned in previous studies31,32. the predictor variable of primary interest was pa. the two types of pa used in this study were moderate pa (mpa) and vigorous pa (vpa). vpa was measured by the following question: “vigorous activities make you breathe much harder than normal and may include heavy lifting, digging, aerobics, or fast bicycling. think only about those physical activities that you performed for at least 10 minutes at a time. during the last 7 days, on how many days did you do vigorous physical activities?” mpa was measured by the following question: “moderate physical activities make you breathe somewhat harder than normal and may include carrying light loads, bicycling at a regular pace, or doubles tennis. do not include walking. again, think about only those physical activities that you performed for at least 10 minutes at a time. during the last 7 days, on how many days did you do moderate physical activities?” answers ranged from 0 to 7 days and were categorised as follows: 0 days (never), 1-2 days, 3-4 days, 5-6 days, and every day. the other potential predictor variables included in the study were: age (18-29/30-39/40-49/50-59/60+ years); sex (female/male); currently married (no/yes); educational attainment (nil/ less than primary school/ primary complete/ secondary complete/ high school/equivalent complete/ pre-university/ university); employment status (government employee/ private employee/ employer/ unemployed); smoking habit (daily/yes, but not daily/non-smoker); ever drank alcohol (yes/no). ethical considerations informed consent was obtained from the recruited participants before their participation in the survey. participation was completely voluntary, and the respondent had the choice to refuse to take part in the interview. the data used in this study were secondary, ever drank alcohol yes 360 6.6 965 10.9 2883 35.9 965 17 no 5102 93.4 7888 89.1 5148 64.1 4709 83 days of mpa 0 1262 23.1 1505 17 1108 13.8 1010 17.8 1-2 852 15.6 558 6.3 369 4.6 460 8.1 3-4 748 13.7 629 7.1 498 6.2 630 11.1 5-6 557 10.2 1062 12 450 5.6 755 13.3 7 2043 37.4 5099 57.6 5598 69.7 2820 49.7 days of vpa 0 2709 49.6 3824 43.2 3975 49.5 2582 45.5 1-2 754 13.8 735 8.3 771 9.6 545 9.6 3-4 606 11.1 646 7.3 899 11.2 499 8.8 5-6 410 7.5 1000 11.3 426 5.3 681 12 7 978 17.9 2647 29.9 1960 24.4 1367 24.1 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx yaya this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.347|http://cajgh.pitt.edu bangladesh india nepal sri lanka good srh (44.3) poor srh (55.7) good srh (58.7) poor srh (41.3) good srh (37.7) poor srh (62.3) good srh (73.7) poor srh (26.3) n % n % n % n % n % n % n % n % age 18-29 2092 38.3 1371 25.1 3444 38.9 1815 20.5 3100 38.6 1952 24.3 1838 32.4 607 10.7 30-39 1639 30 1393 25.5 2461 27.8 2010 22.7 2120 26.4 1831 22.8 1515 26.7 942 16.6 40-49 1005 18.4 1180 21.6 1478 16.7 1788 20.2 1446 18 1486 18.5 1265 22.3 1135 20 50-59 404 7.4 705 12.9 859 9.7 1328 15 747 9.3 1068 13.3 664 11.7 1265 22.3 60+ 322 5.9 814 14.9 611 6.9 1921 21.7 626 7.8 1687 21 392 6.9 1725 30.4 p <0.0001 <0.0001 <0.0001 <0.0001 sex female 2797 51.2 3015 55.2 4241 47.9 4905 55.4 4578 57 4642 57.8 2865 50.5 3257 57.4 male 2665 48.8 2447 44.8 4612 52.1 3948 44.6 3453 43 3389 42.2 2809 49.5 2417 42.6 p 0.002 <0.0001 0.175 <0.0001 currently married no 1191 21.8 1240 22.7 2125 24 1903 21.5 1333 16.6 1542 19.2 1765 31.1 1770 31.2 yes 4271 78.2 4222 77.3 6728 76 6950 78.5 6698 83.4 6489 80.8 3909 68.9 3904 68.8 p <0.0001 <0.0001 <0.0001 <0.0001 educational attainment nil 2103 38.5 2354 43.1 2939 33.2 4046 45.7 4634 57.7 5116 63.7 227 4 579 10.2 less than primary school 945 17.3 1043 19.1 691 7.8 1036 11.7 916 11.4 835 10.4 340 6 692 12.2 primary complete 1431 26.2 1305 23.9 35 0.4 44 0.5 1205 15 956 11.9 1316 23.2 1748 30.8 secondary complete 415 7.6 393 7.2 1470 16.6 1709 19.3 851 10.6 771 9.6 2326 41 1963 34.6 high school/ equivalent 262 4.8 186 3.4 1328 15 876 9.9 297 3.7 201 2.5 1305 23 613 10.8 preuniversity/ university 306 5.6 180 3.3 1142 12.9 531 6 137 1.7 145 1.8 159 2.8 74 1.3 p <0.0001 <0.0001 <0.0001 <0.0001 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.347|http://cajgh.pitt.edu employment status govt. employee 235 4.3 169 3.1 425 4.8 204 2.3 257 3.2 233 2.9 550 9.7 397 7 private employee 388 7.1 289 5.3 1107 12.5 779 8.8 177 2.2 161 2 721 12.7 437 7.7 employer 2687 49.2 2021 37 4621 52.2 3444 38.9 5590 69.6 5051 62.9 2480 43.7 1923 33.9 not working for payment 2157 39.5 2683 54. 6 3594 40.6 4427 50 2008 25 2586 32.2 1918 33.8 2916 51.4 p <0.0001 <0.0001 <0.0001 <0.0001 smoking habit daily 2092 38.3 2261 41.4 2470 27.9 3222 36.4 2883 35.9 3116 38.8 704 12.4 783 13.8 yes. not daily 262 4.8 257 4.7 257 2.9 274 3.1 418 5.2 482 6 443 7.8 494 8.7 non-smoker 3108 56.9 2944 53.9 6126 69.2 5356 60.5 4730 58.9 4433 55.2 4528 79.8 4397 77.5 p <0.0001 <0.0001 <0.0001 <0.0001 ever drank alcohol yes 328 6 388 7.1 983 11.1 956 10.8 2819 35.1 2980 37.1 993 17.5 891 15.7 no 5134 94 5074 92.9 7870 88.9 7897 89.2 5212 64.9 5051 62.9 4681 82.5 4783 84.3 p <0.0001 <0.0001 <0.0001 <0.0001 days of mpa 0 863 15.8 2807 51.4 505 5.7 1726 19.5 353 4.4 4538 56.5 448 7.9 1566 27.6 1-2 1010 18.5 787 14.4 1346 15.2 637 7.2 883 11 715 8.9 811 14.3 488 8.6 3-4 770 14.1 590 10.8 593 6.7 673 7.6 498 6.2 795 9.9 635 11.2 596 10.5 5-6 590 10.8 410 7.5 992 11.2 1151 13 385 4.8 450 5.6 817 14.4 596 10.5 7 2228 40.8 874 16 5409 61.1 4666 52.7 5903 73.5 1534 19.1 2956 52.1 2428 42.8 p <0.0001 <0.0001 <0.0001 <0.0001 days of vpa 0 716 13.1 1469 26.9 735 8.3 4241 47.9 811 10.1 1478 18.4 601 10.6 3387 59.7 1-2 2584 47.3 847 15.5 3523 39.8 744 8.4 3638 45.3 402 5 2292 40.4 386 6.8 3-4 634 11.6 726 13.3 664 7.5 629 7.1 956 11.9 498 6.2 499 8.8 511 9 5-6 415 7.6 530 9.7 930 10.5 1098 12.4 418 5.2 562 7 755 13.3 482 8.5 7 1114 20.4 1890 34.6 3001 33.9 2142 24.2 2217 27.6 5084 63.3 1532 27 908 16 p <0.0001 <0.0001 <0.0001 <0.0001 table 2. self-rated health (srh) results breakdown in bangladesh, india, nepal and sri lanka, whs 2002-03 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx yaya this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.347|http://cajgh.pitt.edu which are available in the public domain in anonymised form. additional approval was therefore was not necessary according to who regulations (https://www.who.int/healthinfo/survey/en/). statistical analysis datasets were checked for missing values and outliers. data were cleaned to retain the maximum number of observations. sample characteristics were analysed through univariate analysis. cross tabulation was used to measure the distribution of the sociodemographic variables across the outcome srh variable. chi-square tests were conducted to assess the group differences for good vs. poor self-rated health. variables that had a p-value below 0.25 were entered into the final regression analysis17. four separate regression models were run for each country. the outcomes of the regression (binary logistic) analyses were reported in terms of adjusted odds ratios (aor) and corresponding 95% confidence intervals. all analyses were performed with spss version 22. results descriptive sample characteristics were provided in table 1. in short, the mean age was highest in sri lankans (40.78, sd 15.22) and lowest in bangladeshis (38.47, sd 14.81). the majority of the participants were between 18 and 29 years of age, female, and currently married. rate of literacy was highest for sri lanka (94.4%) and lowest in nepal (40%). however, the rate of pre-university/university level education was highest in india (10.1%), followed by bangladesh (4.3%) and sri lanka (2.4%). regular engagement in mpa was highest for nepal (69.7%), followed by india (57.6%), sri lanka (49.7%), and bangladesh (37.4%), and that for vpa was highest in india (29.9%) followed by nepal (24.4%), sri lanka (24.1%), and bangladesh (17.9%). table 2 shows that the prevalence of good srh was highest in sri lanka (73.7%) and lowest in nepal (37.7%), while in bangladesh over two-fifth (44.3%) and in india (58.7%) a little less than three-fifth of the population reported being in good health. results of cross-tabulation also showed that people who reported good srh were more likely to be in the younger age groups, female, currently married, having no formal education (except for sri lanka), self-employed, nonsmoker, and never drinking alcohol. those who reported engaging in any type of physical activities were also more likely to report being in good health. results of multivariable regression are shown in table 3. results indicate that bangladeshis who engaged in 1-2, 3-4, 5-6, and 7 days a week were respectively 31% [aor=1.306; 95%ci 1.085-1.572], 33% [aor=1.326; 95%ci 1.093-1.609], 39% [aor=1.389; 95%ci 1.1251.716], and 46% [aor=1.459; 95%ci 1.249-1.705] more likely to report being in good health compared to those who never engaged in mpa. in sri lanka, the odds of being in good health were respectively 49% [aor=1.490; 95%ci 1.164-1.908], 80% [aor=1.802; 95%ci=1.433-2.266], 2.3 times [aor=2.255; 95%ci=1.805-2.817], and 86% [aor=1.854; 95%ci=1.579-2.177] higher among those who those who engaged in mpa for 1-2, 3-4, 5-6 and 7 days a week. in bangladesh, india, and nepal, those who engaged in vpa on daily basis were respectively 21% [aor=1.212; 95%ci 1.033-1.421], 34% [aor=1.340; 95%ci 1.186-1.512], 36% [aor=1.363; 95%ci 1.2011.547], 22% [aor=2.224; 95%ci 1.879-2.633] more likely to report being in good srh compared to those who never engaged in vpa. among sri lankans, the odds of being in good srh were respectively 2 times [aor=1.995; 95%ci 1.575-2.527], 25% [aor=1.255; 95%ci 1.007-1.564], 2.04 times [aor=2.036; 95%ci=1.644-2.521], and 2.22 times [aor=2.224; http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx https://www.who.int/healthinfo/survey/en/ central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.347|http://cajgh.pitt.edu 95%ci 1.879-2.633] higher among those who engaged in vpa for 1-2, 3-4, 5-6, and 7 days a week. discussion this is one of the first studies that reports on the association between pa and srh in a south asian sample population. findings of this study indicate a suboptimal level of pa among the adult population in variables bangladesh india nepal sri lanka odds ratio (95%ci) odds ratio (95%ci) odds ratio (95%ci) odds ratio (95%ci) days of mpa 0 1-2 1.306 0.913 1.186 1.490 (1.085-1.572) (0.654-1.010) (0.925-1.519) (1.164-1.908) 3-4 1.326 0.926 1.289 1.802 (1.093-1.609) (0.752-1.142) (1.028-1.615) (1.433-2.266) 5-6 1.389 0.894 0.930 2.255 (1.125-1.716) (0.693-1.004) (0.739-1.169) (1.805-2.817) 7 1.459 1.055 1.478 1.854 (1.249-1.705) (0.919-1.211) (1.283-1.702) (1.579-2.177) days of vpa 0 1-2 0.854 1.024 1.110 1.995 (0.721-1.012) (0.857-1.222) (0.939-1.313) (1.575-2.527) 3-4 1.025 1.103 1.178 1.255 (0.852-1.233) (0.922-1.343) (1.003-1.382) (1.007-1.564) 5-6 0.962 0.959 0.894 2.036 (0.772-1.198) (0.815-1.129) (0.722-1.106) (1.644-2.521) 7 1.212 1.340 1.363 2.224 (1.033-1.421) (1.186-1.512) (1.201-1.547) (1.879-2.633) table 3. multivariable analysis on the association between pa and srh in selected south asian countries, whs 2002-03. south asia. within subgroups, variations were observed in pa. findings showed that participants from bangladesh had the lowest proportion of engaging in any type of pa. similar results on low prevalence of pa were reported by previous studies from bangladesh33 and india34. findings suggest that the percentage of good srh decreased with age in all countries. female participants were more likely to report good srh compared to/with males in all countries except for in india. a noticeable variation was observed in the prevalence of srh among the four countries. another important disparity was that having higher frequency of participation in pa did not always relate to higher rate of good srh. for instance, compared to sri lanka, participants from nepal had lower rates of reporting good srh despite their higher frequency of involvement in both vpa and mpa. a possible connection might be higher living standards of sri lanka compared to the other countries measured in terms of human development index (hdi). the correlation between higher educational status and better health outcomes are well documented across countries18,19. our results further http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx yaya this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.347|http://cajgh.pitt.edu indicate that the rate of both moderate and vigorous type physical inactivity was highest in bangladesh, followed by sri lanka, and india. surprisingly, nepal had lowest srh despite its highest prevalence of mpa and second highest prevalence of vpa. as expected, engaging in regular pa was associated with higher odds of good srh for most of the countries. in bangladesh and nepal, those who participated in mpa on a daily basis, and in sri lanka, those took mpa 5-6 days a week, had the highest odds of reporting good srh. for vpa, highest odds of reporting good srh were reported among those who exercised on daily basis, compared with those who exercised at a lesser frequency. among all the countries, the strongest associations between srh and pa in both categories was observed in sri lanka. a major barrier to reporting association between srh and pa is the lack of comparable studies reporting prevalence at the national level and the absence of standardised and validated instruments in studied countries24. previous studies based on usa (86.2%)20 and canada (89.9%)21 concluded that participants who rated their health as poor to average were less likely to take pa compared with those who rated their general health as good to excellent21. similar findings were observed in south korea, where an independent association between lower level of pa and poor srh was reported22. regarding the prevalence of pa, a study encompassing 76 countries reported that the prevalence of physical inactivity among individuals aged 15 years or older ranged from 3 to 62%23, which varied substantially from the worldwide prevalence of physical inactivity in adults of 31%24. this study has some important limitations. number of days of vpa and mpa (at least 10 minutes at a time) was used as a proxy for level of pa instead of exact duration. however, similar methodology was used in some other studies21,26. another limitation is the absence of several necessary covariates which are commonly correlated with the level of pa, such as presence of disease conditions (diseased people are less likely to engage in pa), place of residency (urban and rural residences have differing patterns of engaging in pa), and other community level variables (e.g. neighbourhood cleanliness, safety, availability of public spaces for exercise). as the data were secondary, we had no control over the choice of selecting the covariates and the ways they were measured. for instance, we could not distinguish between work and leisure physical activity, which could have affected the associations. with the data being self-reported, there remains a possibility of under and over-reporting, as well as the recall bias. moreover, there are also differences in the way in which men and women describe their health. women are more likely to report poorer functioning and worse overall health than men27. last but not least, the results cannot be generalised to all age groups, since no data were available on participants below 18 years of age. further research is needed to better understand subgroup variations with larger sample sizes to address the heterogeneity found within south asian groups in this study, who may have different motivations to undertaking and increasing their pa levels. at policy making level, attempts should be taken to encourage pa by improving the provision of necessary infrastructure and environment for exercise. this should be facilitated by developing national pa guidelines for people of different ages. further studies should investigate the predictive factors of pa in the population and monitor the trends in pa to improve public health. references 1. jennifer beam dowd, anna zajacova. does selfrated health mean the same thing across socioeconomic groups? evidence from biomarker data. ann epidemiol. 2010 oct; 20(10): 743–749. 2. lee s, mcclain c, webster n, han s. question order sensitivity of subjective well-being measures: focus on life satisfaction, self-rated health, and http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.347|http://cajgh.pitt.edu subjective life expectancy in survey instruments. qual life res. 2016 oct;25(10):2497-510. 3. irina l.g. todorova, katherine l. tucker, marcia pescador jimenez et al. determinants of self-rated health and the role of acculturation: implications for health inequalities. ethn health. 2013 dec; 18(6): 10. 4. jylhä m. what is self-rated health and why does it predict mortality? towards a unified conceptual model. soc sci med. 2009 aug; 69(3):307-16. 5. göran waller. self-rated health in general practice: a plea for subjectivity. br j gen pract. 2015 mar; 65(632): 110–111. 6. undén al, elofsson s. health from the patient's point of view. how does it relate to the physician's judgement? fam pract. 2001 apr; 18(2):174-80. 7. kwaśniewska m, kaleta d, dziankowskazaborszczyk e, drygas w, makowiec-dabrowska t. lifestyle index and self-rated health status. int j occup med environ health. 2007;20(4):349-56. 8. sargent-cox k, cherbuin n, morris l, butterworth p, anstey kj. the effect of health behavior change on self-rated health across the adult life course: a longitudinal cohort study. prev med. 2014 jan;58:75-80. 9. warburton, d.e.; nicol, c.w.; bredin, s.s. health benefits of physical activity: the evidence. can. med assoc. j.2006,174, 801–809. 10. humphreys, b.r.; mcleod, l.; ruseski, j.e. physical activity and health outcomes: evidence from canada health econ. 2014,23, 33–54. 11. morris, j.n.; heady, j.a.; raffle, p.a.; roberts, c.g.; parks, j.w. coronary heart-disease and physical activity of work. lancet1953,265, 1111– 1120. 12. i-min lee, mbbs, scd, eric j shiroma, msc, felipe lobelo et al. impact of physical inactivity on the world’s major non-communicable diseases. lancet. 2012 jul 21; 380(9838): 219–229. 13. global recommendations on physical activity for health. geneva: world health organization; 2010. bookshelf id: nbk305049. 14. pietiläinen kh1, kaprio j, borg p, plasqui g et al. physical inactivity and obesity: a vicious circle. obesity (silver spring). 2008 feb;16(2):409-14. 15. ding d, lawson kd, kolbe-alexander tl et al. the economic burden of physical inactivity: a global analysis of major non-communicable diseases. lancet. 2016 sep 24;388(10051):1311-24. 16. who world health survey, survey manual, world health organization 2002. 17. yaya s, bishwajit g, danhoundo g, shah v, ekholuenetale m. trends and determinants of hiv/aids knowledge among women in bangladesh. bmc public health. 2016 aug 17;16(1):812. 18. baker dp, leon j, smith greenaway eg, collins j, movit m. the education effect on population health: a reassessment. population and development review. 2011;37(2):307–332. 19. goesling b. the rising significance of education for health? social forces. 2007;85(4):1621–1644. 20. james tsai, earl s ford, chaoyang li, guixiang zhao and lina s balluz. physical activity and optimal self-rated health of adults with and without diabetes. bmc public health 2010, 10:365. 21. catherine hudon, hassan soubhi and martin fortin. relationship between multimorbidity and physical activity: secondary analysis from the quebec health survey. bmc public health 2008, 8:304. 22. m.a. han, k.s. kim, j. park, m.g. kang, s.y. ryu. association between levels of physical activity and poor self-rated health in korean adults: the third korea national health and nutrition examination survey (knhanes), 2005. public health. october 2009 volume 123, issue 10, pages 665–669. 23. dumith sc, hallal pc, reis rs, kohl iii hw. worldwide prevalence of physical inactivity and its http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx yaya this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.347|http://cajgh.pitt.edu association with human development index in 76 countries. prev med2011;53(1e2):24e8. 24. bauman a, bull f, chey t, craig c, ainsworth b, sallis j, et al. the international prevalence study on physical activity: results from 20 countries. int j behav nutr phys activity 2009;6(1):21. 25. m. moniruzzamana, m. mostafa zamana, m.s. islalm, h.a.m.n. ahasanc, h. kabird, r. yasmin. physical activity levels in bangladeshi adults: results from steps survey 2010. public health 137 (2016) 131e138. 26. adrian bauman, fiona bull, tien chey, cora l craig et al. the international prevalence study on physical activity: results from 20 countries. int j behav nutr phys act. 2009; 6: 21. 27. hosseinpoor ar, stewart williams j, amin a, araujo de carvalho i, beard j, boerma t, kowal p, naidoo n, chatterji s. social determinants of selfreported health in women and men: understanding the role of gender in population health. plos one. 2012; 7(4):e34799. 28. gilles ambresin, physical activitytty chondros, christopher dowrick, helen herrman, jane m. gunn. self-rated health and long-term prognosis of depression. ann fam med. 2014 jan; 12(1): 57– 65. 29. bishwajit g, tang s, yaya s, he z, feng z. lifestyle behaviors, subjective health, and quality of life among chinese men living with type 2 diabetes. am j mens health. 2017 mar;11(2):357364. 30. carin warnoff, mats lekander, tomas hemmingsson et al. is poor self-rated health associated with low-grade inflammation in 43 110 late adolescent men of the general population? a cross-sectional study. bmj open. 2016; 6(4): e009440. 31. mucci la, wood pa, cohen b, clements km, brawarsky p, brooks dr. validity of self-reported health plan information in a population-based health survey. j public health manag pract. 2006 nov-dec;12(6):570-7. 32. fosse ne, haas sa. validity and stability of selfreported health among adolescents in a longitudinal, nationally representative survey. pediatrics. 2009 mar;123(3):e496-501. 33. moniruzzaman m, mostafa zaman m, islalm ms, ahasan ha, kabir h, yasmin r. physical activity levels in bangladeshi adults: results from steps survey 2010. public health. 2016 aug;137:131-8. . 34. ranjit m anjana, rajendra pradeepa, ashok k das et al. physical activity and inactivity patterns in india – results from the icmr-indiab study (phase-1) [icmr-indiab-5]. int j behav nutr phys act. 2014; 11: 26. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx microsoft word labana.docx new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. online game addiction and the level of depression among adolescents in manila, philippines ryan v. labana1*, jehan l. hadjisaid2, adrian r. imperial2, kyeth elmerson jumawid2, marc jayson m. lupague2, daniel c. malicdem2 1department of biology, college of science, polytechnic university of the philippines, manila, philippines; 2senior high school, polytechnic university of the philippines, manila, philippines *corresponding author vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.369 | http://cajgh.pitt.edu labana this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.369 | http://cajgh.pitt.edu abstract introduction: world health organization recognizes online game addiction as a mental health condition. the rise of excessive online gaming is emerging in the philippines, with 29.9 million gamers recorded in the country. the incidence of depression is also increasing in the country. the current correlational analysis evaluated the association between online game addiction and depression in filipino adolescents. methods: a paper-and-pencil self-administered questionnaire assessing depression and online game addiction was distributed from august to november, 2018. the questionnaire included socio-demographic profiles of the respondents, and the 14-item video game addiction test (vat) (cronbach's α=0.91) and the patient health questionnaire-9 (cronbach's α=0.88) to determine levels of online game addiction and depression, respectively. multiple regression analyses were used to test the association between depression and online game addiction. results: three hundred adolescents (59% males, 41% females) participated in the study. fifty-three out of 300 respondents (12.0% males, 5.7% females) had high level of online game addiction as reflected in their high vat scores. in this study, 37 respondents (6.7% males, 5.7% females) had moderately severe depression and 6 (2.0%) females had severe depression. online game addiction was positively correlated with depression in this study (r=0.31; p<0.001). when multiple regression analysis was computed, depression was found to be a predictor of online game addiction (coefficient=0.0121; 95% ci-8.1924 0.0242; p=0.05). conclusion: depression, as associated with online game addiction, is a serious threat that needs to be addressed. high level of online game addiction, as positively correlated to the rate of depression among adolescents in manila, could potentially be attributed to the booming internet industry and lack of suffiicent mental health interventions in the country. recommended interventions include strengthening depression management among adolescents and improving mental health services for this vulnerable population groups in schools and within the communities. keywords: mental health; public health; addiction; video games; depression; neuroscience online game addiction and the level of depression among adolescents in manila, philippines ryan v. labana1*, jehan l. hadjisaid2, adrian r. imperial2, kyeth elmerson jumawid2, marc jayson m. lupague2, daniel c. malicdem2 1department of biology, college of science, polytechnic university of the philippines, manila, philippines; 2senior high school, polytechnic university of the philippines, manila, philippines research based on the report of the european mobile game market in 2016, there were more than 2.5 billion video gamers across the globe.1 several studies have found that the majority of these players were adolescents aged 12-17 years,2-5 with more usage among males than females.6 in 2017, newzoo.com reported that the active gamers in the philippines were 52% males and 48% females.7 in the us, 60% of the video gamers were males and 40% are females.6 studies have shown that there are similarities between males and females in regard to choice of games, behavior toward video gaming, and motives for engaging in this activity.8 some of the reported reasons to engage in video games include having fun and for recreation,9-10 to de-stress,11-12 and to avoid real life issues.13-14 the prevalence of video gaming central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.369 | http://cajgh.pitt.edu addiction varies from region to region based on the sociocultural context and the criteria used for the assessment.15 however, it is well established that video gaming is addictive,16-18 and there is clinical evidence for the symptoms of biopsychosocial problems among video game addicts.19 it is a serious threat to the mental and psychosocial aspects of an individual, as it lead to stress, loss of control, aggression, anxiety, and mood modification.20-21 in the philippines, online gaming is an emerging industry. the country ranks 29th in game revenues across the globe. in 2017, there were more than 29.9 million gamers recorded in the country. most of the gamers were 21-35 years of age, followed by the adolescents 10-20 years of age.7 adolescents accounted for 30.5% of the total population in the country.22 in general, this age group is already facing mental health issues, such as anxiety, mood disorders, and depression. this concern gets more alarming as rates of suicide among high school and college students are growing worldwide.23 world health organization lists video game addiction as a mental health problem.24 psychiatric research reported evidence on the links between depression and video game addiction. among the findings are mri scans of video game addicts showing disruption of some brain parts and overriding of the 'emotional' part with the 'executive' part.25 a study in china has also reported that gamers are at increased risk of being depressed in comparison to those who did not play video games.26 in the field of neuroscience, depression caused by online game addiction is explained as a reduction of synaptic activities due to permanent changes in the dopaminergic pathways. this means that long exposure to online gaming causes changes in a person’s sense of natural rewards, often making activities less pleasurable. this neuroadaptation is also associated with chronic depression.27 there is a paucity of studies on video game addiction in the philippines, making its implications not well understood. there are reports of the impact of video game addiction on the academic performance of the gamers,28-30 but no study has been found associating video game addiction and depression in the philippine setting. based on the 2004 report from the department of health in the philippines, over 4.5 million cases of depression were reported in the country. recently, world health organization reported that 11.6% of the 8,761 surveyed young filipinos considered committing suicide; 16.8% of them (of 8,761) had attempted it.31 this phenomenon is said to be instigated by several factors, including the individual’s exposures to technology. video game addiction and depression are two emerging public health issues among adolescents in the philippines.31-32 this small-scale study aims to understand the association between these two factors and produce baseline information that can be used in formulating evidence-based public health policies in the country. methods research site and participants this study was conducted in the months of august-november 2018 in the city of manila, the capital of the philippines. manila is situated on the eastern shores of manila bay, on the western edge of luzon (14o35’45”n 120o58’38”e). it is one of the most urbanized areas and the center of technological innovation in the country. it has a population of 1.78 million, based on 2016 census.33 manila covers 896 barangays (villages), which are grouped into six districts. based on the 2010 census, the total population of filipino adolescents, regardless of sex, was 166,391.34 this population estimate was used for computing the sample size needed for this study. sample size calculation was estimated using the online calculator from openepi.35 the completion rate of the questionnaires was 78.13%, for a total of 300 consenting respondents who were all online video gamers. they were selected if they were residents of manila city and reported playing video games on the regular basis. labana this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.369 | http://cajgh.pitt.edu figure 1. map of manila from the national capital region of the philippines instruments the study used a paper-and-pencil selfadministered questionnaire. to determine the level of online game addiction of the respondents, the study used the video game addiction test (vat) developed by van rooij et al.36 from the 14-item version of the compulsive internet use scale (cius).37 vat was utilized in several studies among adolescents in the past, and it has demonstrated excellent reliability and validity. the scale outcomes were found to be comparable across gender, ethnicity, and learning year, making it a helpful tool in studying video game addiction among various subgroups.36 the survey contains questions in five categories: loss of control, conflict, salience, mood modification, and withdrawal symptoms. each question was measured on a 5-point scale: 0–never to 4–very often. the results were then used as an indicator of the level of addiction. this study adapted the calculations conducted by van rooij et al.38 wherein the average scale scores of all the respondents were arranged from 0-4 and then were divided into two groups. the first group had an average of 0-2 or 'never' to 'sometimes', while the second group had an average of 3-4 or 'often' to 'very often'. the latter group was considered to have the highest level of problematic gaming or, in this study, with online game addiction.38 the internal reliability of the vat in this study was excellent at cronbach's α of 0.91. the level of depression of the respondents was determined by using the patient health questionnaire-9 (phq-9).39 it is a 9-item depression module taken from the full phq. the questionnaire allows the respondents to rate their health status in the past six weeks. there are 9 diagnostic questions in which the respondents rated 0 for 'not at all', 1 for 'several days', 2 for 'more than half the days', and 3 for 'nearly every day'. the total of the phq-9 scores was used to measure severity of depression. since there are 9 items in the questionnaire and each question can be rated from 0-3, the phq-9 scores can range from 0-27. the score was interpreted as ‘no depression’ (0-4 points), ‘mild depression’ (5-9 points), ‘moderate depression’ (10-14 points), ‘moderately severe depression’ (15-19 points), and ‘severe depression’ (20-27 points).39 in this study, the internal reliability of phq-9 had a cronbach's α of 0.88. central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.369 | http://cajgh.pitt.edu data gathering procedure the study randomly surveyed gamers in various parts of manila. since there are no reliable records of the gamers in the area available for research, various sampling techniques were utilized. a convenience sampling was done by visiting internet cafes in the city and requesting the gamers to answer the questionnaire during their time-out (from the game). a verbal consent was provided by each respondent after hearing a brief explanation of the research objectives and the necessary instructions. while answering the questionnaire, the respondents were assisted by the investigator for any clarifications and questions. the questionnaire was completed by the respondents in approximately 2.5 minutes. other procedures included snowball sampling, accidental, and voluntary response sampling after the distribution of invitation to respond among internet cafes, gamers’ social media groups/sites, and online gamers’ organizations. the study was approved by the ethical board of the polytechnic university of the philippines. statistical analysis all the responses from the questionnaires were inputted into ms excel and into spss version 23.0 (ibm corp., armonk, ny, usa). descriptive statistics of responses were computed and included the frequencies (f), percentages (%), averages (x̄) and standard deviations (sd). the association between online game addiction and depression was analyzed using pearson's correlation and was further analyzed using a multiple regression analysis. the study hypothesized that there is no significant correlation between online game addiction and level of depression among adolescents in the city of manila, philippines. all statistical results were considered significant at the p value <0.05. results profile of the respondents a total of 300 consenting adolescents participated in the study. there were more males (n=176; 59%) than females (n=124; 41%) who participated in the study. most of the respondents were adolescents (aged less than 19 years), except for the six respondents who were already 20 years old during the data gathering. the mean age of the participants was 17 years old (sd=0.90). figure 2 presents the profiles of the respondents based on their gender and age characteristics. the vat analysis shows that there were more males (12.0%) who were addicted to online games than females (5.7%). meanwhile, 15-, 17-, and 18-year old respondents had the highest vat scores among the six age groups. figure 2. profiles of the respondents based on gender and age labana this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.369|http://cajgh.pitt.edu level of online game addiction the 14-item vat was ranked from the highest to the lowest mean score to understand the common conditions experienced by the respondents. the item with the highest mean was no. 13: do you game because you are feeling down? (x̄=2.1, sd=1.40). this question had the third greatest number of “4-very often” ratings (n=46/300). it was followed by the item no. 3: do others (e.g., parents or friends) say you should spend less time on games? (x̄=2.06, sd=1.41). the third item with the highest mean score was item no. 7: do you look forward to the next time you can game? (x̄=2.0, sd=1.27). the item with the highest number of “4-very often” rating was item no. 14: do you game to forget about problem? (n=67/300). items 12 and 2 also had high mean scores: do you neglect to do your homework because you prefer to game? (item 12; x̄=1.98, sd=1.34); and do you continue to use the games despite your intention to stop? (item 2; x̄=1.84, sd=1.20). profiles overall profile respondents with high vat scoresa respondents with high vat scoresb n % n % n % gender male 176 58.7 36 12.0 36 20.5 female 124 41.3 17 5.7 17 13.7 age 15 years old 12 4.0 3 1.0 3 25.0 16 years old 42 14.0 3 1.0 3 7.1 17 years old 168 56.0 34 11.3 34 22.0 18 years old 60 20.0 12 4.0 12 20.0 19 years old 12 4.0 1 0.3 1 8.3 20 years old 6 2.0 0 0.0 0 0.0 apercentage was computed against the overall number of participants (n=300) bpercentage was computed against n of each profile of the respondents table 1. levels of online game addiction based on gender and age level of depression the phq-9 was used to quantify the symptoms of depression of the respondents and identify its severity. the majority of the respondents demonstrated no depression (47%), followed by having mild depression (22%), and moderate depression (17%). of note, the current study revealed 12% of the respondents had moderately severe depression and 2% had severe depression. we found that higher phq-9 scores were associated with decreased functional status. the most common symptoms reported by the respondents based on the mean scores of each item in phq-9 include …feeling tired or having little energy (x̄=1.89, sd=1.30), …poor appetite or overeating (x̄=1.87, sd=1.37), … feeling down, depressed or hopeless (x̄=1.81, sd=1.18), …trouble falling or staying asleep, or sleeping too much (x̄=1.78, sd=1.33), and …trouble concentrating on things, such as reading newspaper or watching television (x̄=1.75, sd=1.40). interestingly, the six respondents who were identified to have “severe” depression were all females, and four of them had high vat scores. labana this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.369 | http://cajgh.pitt.edu profiles no depression n (%) mild n (%) moderate n (%) moderately severe n (%) severe n (%) gender male 87 (29.0) 38 (12.7) 31 (10.3) 20 (6.7) 0 (0.0) female 54 (18.0) 28 (9.3) 19 (6.3) 17 (5.7) 6 (2.0) age 15 years 5 (1.7) 1 (0.3) 2 (0.7) 2 (0.7) 0 (0.0) 16 years 24 (8.0) 9 (3.0) 3 (1.0) 7 (2.3) 0 (0.0) 17 years 77 (25.7) 34 (11.3) 31 (10.3) 22 (7.3) 5 (1.7) 18 years 26 (8.7) 17 (5.7) 10 (3.3) 5 (1.7) 1 (0.3) 19 years 5 (1.7) 4 (1.3) 3 (1.0) 1 (0.3) 0 (0.0) 20 years 4 (1.3) 1 (0.3) 1 (0.3) 0 (0.0) 0 (0.0) table 2. level of depression of the respondents based on the phq-9 scores association between online game addiction and depression the association between online game addiction based on the vat scores and the level of depression among the respondents was evaluated through pearson's correlation analysis. results (table 3) show that the level of online game addiction was positively correlated with the level of depression (r=0.31, p<0.001) but was not significantly correlated with age or gender (r=-0.80, p<0.171 and r= 0.10, p<0.097, respectively). a multiple linear regression was calculated to predict online game addiction based on gender and depression. this regression analysis was performed with all participants and with the subset of participants with high vat scores, which indicated online game addiction. a significant regression equation was found (f(2.50)= 2.247, 0.10), with an r2 of 0.082. table 4 shows that depression was a significant predictor of online game addiction. variables gender age online game addiction depression gender 1 -.080 .100 .070 .171 .097 .212 age -.080 1 -.080 -.020 .171 .171 .739 online game addiction .100 -.080 1 .310 .097 .171 .000* depression .070 -.020 0.310 1 .212 .739 .000* *significant at p ≤0.001 in correlation matrix table 3. pearson’s correlation coefficient among gender, age, online game addiction, and depression of the adolescents in manila labana this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.369 | http://cajgh.pitt.edu variables regression coefficient 95% ci p value adolescents playing online games (n=300) age -0.0224 -0.1298 0.0850 0.68 depression 0.0418 0.0271 0.0565 0.47 adolescents with addiction playing online games (n=54) age -0.0443 -0.1305 0.0417 0.30 depression 0.0121 -8.1924 0.0242 0.05* *significant at p<0.05 table 4. multiple regression analysis for prediction of online game addiction based on age and level of depression discussion the correlation between online game addiction and the levels of depression in this study was weak but statistically significant. this positive correlation was previously reported in other research studies across the globe.40-41 in a study conducted by rikkers et al.40 among children and adolescents (11-17 years old) in australia, electronic gaming was positively associated with emotional and behavioral problems including depression. longer gaming hours were also associated with severe depressive symptoms, somatic symptoms, and pain symptoms among young people in taiwan.41 online game addiction was associated by zamani et al.42 not only with depression but also with sleep disorder, physical complaints, and social dysfunctions of students in iran. in a study conducted by dong et al.,43 depression came out as one of the outcomes of the internet addiction disorder. in the current study, most of the respondents looked forward to the next time they would game, with the most common reason of engaging in games reported to be easing the moments of feeling down. another reason of the respondents’ addiction to online games was that they want to forget about problems. it is considered as one of the core symptoms of addiction as described by brown.44 the second most common experience of the respondents was the 'inability to voluntarily reduce the time spent on online games', which is another core symptom of addiction.45 most of the respondents admitted that they were getting advice from their parents or friends to spend less time on games, but they could not control it, despite their intention to stop. in fact, gaming negatively affected homework completion among many study participants. this effect was previously studied among high school students in los baños, philippines, where the video gamers had 39% probability to fail in school. in this previously published study, 6 out of 10 video gamers spent their daily allowances on computer games, giving them access to continuously spend their time playing.29 the addiction of the adolescents in manila could have been influenced by the ubiquitous nature of internet in the city. internet cafes are very accessible in the country, and they are thriving in almost all corners of the city. in addition, the rent for internet and online games in metro manila costs 10 to 20 pesos per hour only (us $0.19 to us $0.38 per hour), making playing video games affordable. some internet hubs are even offering discounts and promotions for longer stays of 10-12 straight hours of playing online games. central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.369 | http://cajgh.pitt.edu based on the most cited symptoms of the respondents in this study, it could be implied that adolescents cope with their emotional distress by playing online games. this means that the high occurrence of online game addiction goes along with the high occurrence of depression among the same group. in regard to depression, most respondents in this study were feeling tired, having poor appetite, feeling hopeless, having trouble falling asleep, or having trouble concentrating on things that require enough attention, like reading books. these symptoms were also reported by schmit et al.45 as related to online game addiction, where the people who spent longer hours playing online games got higher scores for loneliness and isolation. this study did not capture the number of hours spent by the respondents in online games, which could be incorporated in the next study for further analysis. depression, as associated to online game addiction, may lead to anxiety, compulsion, and suicide ideations.46 this is a serious threat to the population health that needs to be addressed. interventions may include strengthening depression management among adolescents, either in school or in the community. there are several ways to manage depression. the schools and the community should reinforce sports by making it more challenging, engaging, and motivating. in the philippines, numerous factors make receiving mental health care a challenge. there is only one psychiatrist for every 250,000 mentally ill patients, budget dedicated to mental health interventions is limited,47 a guidance and counseling system has not yet matured,48 and there was even a report that online counseling was preferred by the students than its face-to-face counterpart.49 the poor availability of the mental health interventions in the country may lead to upsurge of depression cases among adolescents. meanwhile, the booming online game industry in the country leads to the increased numbers of addicted adolescents to online game addiction. policy makers, the government, and its stakeholders should start addressing these issues before it becomes an even bigger health concern, especially in the face of ongoing covid19 pandemic. the philippine government should also assess their existing intervention programs in mental health issues. in 2016, "hopeline" was launched in the philippines. it was a national hotline for mental health assistance for the prevention of depression and suicide cases in the country. the hotline is equipped with a professional team of counselors as responders.50 no study has been found to assess the effectiveness of this intervention for depression. national trainings and workshop programs have been implemented in other countries to empower the people in dealing with the stigma of depression which includes mental health literacy campaign, peer services, and advocacies.51 this is an essential step to correct various misconceptions on depression, especially among adolescents. this study was cross-sectional and cannot determine causality. this is the first report on the association between online game addiction and the levels of depression among adolescents in the city of manila, philippines. despite the small sample and the limited scope of the research, the current study has shown interesting preliminary results that could be instrumental in the conduct of a bigger scale study in the country. to facilitate participation of the larger number of respondents, the future investigators are suggested to coordinate with various high schools in metro manila and use these schools as a sampling frame for a robust sampling technique. in this study, the level of online game addiction has no statistically significant association with age and gender. the association between age and online game addiction could have been improved by including older age groups in this study. data from a group of young adults (college students), who are also exposed to online gaming, could be compared to these data for further analysis. gender is commonly associated with the level of online game addiction in many studies, but it is not statistically significant in this present study. the sample size in this study was only 300 and may not have been representative enough of a general population. also, our sample size was not large enough to capture distinctions between males and females. this could also be addressed by a wider scale of surveys in the future research. labana this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.369|http://cajgh.pitt.edu references 1. epc. 2019 video game industry statistics, trends & data [accessed 2020 june 15]. available from https://www.wepc.com/news/video-gamestatistics/. 2. griffiths md, davies mn, & chappell d. online computer gaming: a comparison of adolescent and adult gamers. j adolesc 2004; 27: 87–96. doi: 10.1016/j.adolescence.2003.10.007. 3. barnett j & coulson m. virtually real: a psychological perspective on massively multiplayer online games. review of general psychology 2010; 14: 167-179. doi: 10.1037/a0019442. 4. elson m & ferguson cj. gun violence and media effects: challenges for science and public policy. the british journal of psychiatry 2013; 203: 322324. doi: 10.1192/bjp.bp.113.128652. 5. ferguson cj, coulson m, & barnett j. a metaanalysis of pathological gaming prevalence and comorbidity with mental health, academic and social problems. journal of psychiatric research 2011; 45: 1573-1578. doi: 10.1016/j.jpsychires.2011.09.005. 6. statista. distribution of computer and video gamers in the united states from 2006 to 2019, by gender. [accessed 2020 june 15]. available from https://www.statista.com/statistics/232383/gendersplit-of-us-computer-and-video-gamers/ 7. newzoo. the filipino gamer, 2017 [accessed 2020 june 15]. available from https://newzoo.com/insights/infographics/thefilipino-gamer/. 8. veltri nf, krasnova h, baumann a, & kalayamthanam n. gender differences in online gaming: a literature review. proceedings of the 20th americas conference on information systems, savannah, 2014 [accessed 2020 june 15]. available from http://citeseerx.ist.psu.edu/viewdoc/download?doi= 10.1.1.667.4530&rep=rep1&type=pdf. 9. griffiths md & hunt n. computer game playing in adolescence: prevalence and demographic indicators. journal of community & applied social psychology 1995; 5: 189-193. doi: 10.1002/casp.2450050307 10. kuss dj & griffiths md. internet gaming addiction: a systematic review of empirical research. international journal of mental health and addiction 2012; 10: 278-296. doi: 10.1007/s11469-011-9318-5 11. grusser sm, thalemann r, albrecht u, & thalemann cn. excessive computer usage in adolescents-a psychometric evaluation. wiener klinischewochenschrift 2005; 117: 188-195. doi: 10.1007/s00508-005-0339-6. 12. wood rta & griffiths md. a qualitative investigation of problem gambling as an escape based coping strategy. psychology and psychotherapy: theory, research and practice 2007; 80: 107-125. doi: 10.1348/147608306x107881. 13. wan, cs & chiou wb. why are adolescents addicted to online gaming? an interview study in taiwan. cyber psychology& behavior 2006; 9: 762-766. doi: 10.1089/cpb.2006.9.762. 14. wood rta, griffiths md, & parke a. experiences of time loss among videogame players: an empirical study. cyberpsychology& behavior 2007; 10: 38-44. doi: 10.1089/cpb.2006.9994. 15. fu kw, chan wsc, wong pwc, & yip psf. internet addiction: prevalence, discriminant validity and correlates among adolescents in hong kong. br. j. psychiatry 2010; 196: 486–492. doi: 10.1192/bjp.bp.109.075002. 16. griffiths m. does internet and computer "addiction" exist? some case study evidence. cyber psychology & behavior 2004;3(2): 211-218. doi: 10.1089/109493100316067. 17. griffiths md, kuss dj, & king dl. video game addiction: past, present, and future. current psychiatry review, 2012; 8:0000-000. doi: 10.2174/157340012803520414 . 18. griffiths md. online games, addiction, and overuse of. inthe international encyclopdia of digital communication and society.1st ed. john wiley & central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.369 | http://cajgh.pitt.edu sons, inc.; 2015. doi: 10.1002/9781118290743.wbiedcs044. 19. beutel me, hoch c, woelfing k, mueller kw. clinical characteristics of computer game and internet addiction in persons seeking treatment in an outpatient clinic for computer game addiction. z. psychosom. med. psychother. 2011, 57, 77–90. doi: 10.13109/zptm.2011.57.1.77. 20. kuss dj & griffiths md. internet and gaming addiction: a systematic literature review of neuroimaging studies. brain sci 2012; 2: 347-374. doi: 10.3390/brainsci2030347. 21. anderson ca, funk jb, & griffiths md. contemporary issues in adolescent video game playing: brief overview and introduction to the special issue. j adolesc 2004; 27(1), 1–3. doi: 10.1016/j.adolescence.2003.10.001. 22. unicef. at a glance: philippines [accessed 2020 june 15]. available from https://www.unicef.org/infobycountry/philippines_s tatistics.html#123. 23. lee yj, cho sj, cho ih, & kim sj. insufficient sleep and suicidality in adolescents. sleep2012; (4):455-60. doi: 10.5665/sleep.1722. 24. keaten j & cheng m. cumpolsive video-game playing could be mental health problem [accessed 2020 june 15]. available from https://medicalxpress.com/news/2018-06compulsive-video-game-mental-healthproblem.html. 25. hymas c & dodds l. addictive video games may change children's brains in the same way as drugs and alcohol, study reveals [accessed 2020 june 15] available from https://www.telegraph.co.uk/news/2018/06/12/addi ctive-video-games-may-change-childrens-brainsway-drugs/. 26. peng w & liu m. online gaming dependency: a preliminary study in china. cyberpsycholbehav soc netw 2010; 13 (3). doi: 10.1089=cyber.2009.0082. 27. craven r. targeting neural correlates of addiction. nat rev neurosci 2006;7:1. doi: 10.1038/nrn1840. 28. verecio r. online gaming addiction among bsit students of leyte normal university philippines its implication towards academic performance. indjsrt 2018; 11(47): 1-4. doi: 10.17485/ijst/2018/v11i47/137972. 29. cortes mds, alcalde jv, & camacho jv. effects of computer gaming on high school students' performance in los baños, laguna, philippines. 国 際公共政策研究 (international public policy research). 2012; 16(2):7588. [accessed december 2020]. available from: https://ir.library.osaka.ac.jp/repo/ouka/all/24497/osi pp_030_075.pdf. 30. lumbay c, larisma ccm, centillas jr. cl. computer gamers'academic performance in a technological state college in leyte, philippines. journal of social sciences 2017; 6(2):41-49. doi: 10.25255/jss.2017.6.2s.41.49. 31. rappler. mental illness, suicide cases rising among youth [accessed 2020 june 15]. available from https://www.rappler.com/newsbreak/indepth/211671-suicide-cases-mental-health-illnessyouth-rising-philippines. 32. rappler. how does the ph fare in mental health care? [accessed 2020 june 15]. available from https://www.rappler.com/newsbreak/iq/184754philippines-mental-health-care. 33. world population review. manila population 2019 [accessed 2020 june 15]. available from http://worldpopulationreview.com/worldcities/manila-population/. 34. philippine statistics authority. population of the city of manila climbed to 1.7 million (results from the 2010 census of population and housing) [accessed 2020 june 15]. available from https://psa.gov.ph/content/population-city-manilaclimbed-17-million-results-2010-censuspopulation-and-housing. 35. openepi. open source epidemiologic statistics for public health. [accessed 2020 june 15]. available from http://openepi.com/samplesize/sspropor.htm. 36. van rooij aj, schoenmakers tm, van den eijnden rj, vermulst aa, & van de mheen d. video game labana this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.369|http://cajgh.pitt.edu addiction test: validity and psychometric characteristics. cyber psychol behav soc netw2012; 15(9):507-11. doi: 10.1089/cyber.2012.0007. 37. meerkerk gj, van den eijnden rj, vermulst aa, & garretsen hf. the compulsive internet use scale (cius): some psychometric properties. cyber psychol behav 2009; 12(1):1-6. doi: 10.1089/cpb.2008.0181. 38. van rooij aj, kuss dj, griffiths md, shorter gw, shoenmakers tm, van de mheen d. the (co occurrence of problematic video gaming, substance use, and psychosocial problems in adolescents. journal of behavioral addictions 2014; 3(3):157– 165. doi: 10.1556/jba.3.2014.013. 39. kroenke k, spitzer rl, williams jb. the phq-9: validity of a brief depression severity measure. j gen intern med 2001; 16(9):606-13. pmcid: pmc1495268. 40. rikkers w, lawrence d, hafekost j, zubrick sr. internet use and electronic gaming by children and adolescents with emotional and behavioral problems in australia –results from the second child and adolescent survey of mental health and wellbeing. bmc public health 2016; 16:399. doi: 10.1186/s12889-016-3058-1. 41. weigh h-t, chen m-h, huang p-c, bai y-m. the association between online gaming, social phobia, and depression: an internet survey. bmc psychiatry 2012; 12:92 doi: 10.1186/1471-244x-12-92. 42. zamani e, chashmi m, & hedayati n. effect of addiction to computer games on physical and mental health of female and male students of guidance school in city of isfahan. addict health 2009.; 1(2): 98-104. pmcid: pmc3905489. 43. dong g, lu q, zhou h, zhao x. precursor or sequela: pathological disorders in people with internet addiction disorder. plos one 2011; 6(2):e14703. doi:10.1371/journal.pone.0014703. 44. brown i. a theoretical model of the behavioral addictions—applied to offending. in. hodge je, mcmurranm,hollins cr. eds. chichester, uk: john wiley; 1997, p. 13-65. 45. schmit s, chauchard e, chabrol h, & sejourne n. evaluation of the characteristics of addiction to online video games among adolescents and young adults. encephale 2011; 37 (3): 217-223. doi: 10.1016/j.encep.2010.06.006. epub 2010 aug 17. 46. wenzel t, rushiti f, aghani f, diaconu g, maxhuni b, & zitterl w. suicidal ideation, posttraumatic stress and suicide statistics in kosovo. an analysis five years after the war. suicidal ideation in kosovo. torture 2009; 19(3):238-47. pmid: 20065542. 47. newman c. minding the gap in philippines’ mental health. [accessed 2020 june 15] available from https://www.bworldonline.com/minding-gapphilippines-mental-health/. 48. lagon hm. guidance and counseling in the philippines: a journey to maturity. [accessed 2020 june 26]. available from https://archive.dailyguardian.com.ph/guidance-andcounseling-in-the-philippines-a-journey-tomaturity/. 49. teh la, acosta ac, hechanova mrm, alianan as. attitudes of psychology graduate students toward face-to-face and online counseling. philippine journal of psychology 2014; 47 (2): 6597. 50. rappler. national hotline for mental health assistance now open [accessed 2020 june 15]. available from https://www.rappler.com/nation/146077-dohhotline-mental-health-assistance-open-suicideprevention. 51. national academies of sciences, engineering, and medicine. (2016). ending discrimination against people with mental and substance use disorders: the evidence for stigma change. washington, dc: the national academies press. doi: 10.17226/23442. microsoft word jafari-koulaee.docx new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. a systematic review of the effects of aromatherapy with lavender essential oil on depression azar jafari-koulaee1, forouzan elyasi2,3, zohreh taraghi3,4,5, ehteram sadat ilali4,*, mahmood moosazadeh5 1student research committee, mazandaran university of medical sciences, sari, iran; 2department of psychiatry, school of medicine, mazandaran university of medical sciences, sari, iran; 3addiction institute, mazandaran university of medical sciences, sari, iran; 4department of geratric nursing, school of nursing and midwifery, mazandaran university of medical sciences, sari, iran; 5health science research center, mazandaran university of medical sciences, sari, iran *corresponding author vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu jafari-koulaee this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu abstract introduction: depression is considered as one of the most serious health issues worldwide, and the search for the most effective and safe treatments for depression is essential. aromatherapy with lavender have attracted the attention of many researchers due to their low cost and ease of use, so this study was conducted to review of the effects of aromatherapy with lavender essential oil on depression. methods: this systematic review study was conducted by searching the databases (sid, magiran, google-scholar, medline via pubmed, scopus, and web of science) by using the keywords such as depression, lavandula, lavender, and aromatherapy, as well as applying or and and operators to the end of january 1, 2020 a.d. the inclusion criteria were: 1) interventional studies that determined keywords were in the title or keywords of the article, 2) aromatherapy was conducted through inhalation or massage, 3) the full text of paper was accessible, and 4) published in english or persian. finally, the information obtained from articles was extracted using a checklist. results: out of 278 studies, 9 studies were included to the systematic review process after screening and eliminating duplicate papers according to the purpose of the study. aromatherapy with lavender essential oil was conducted on the patients suffering from migraine, patients with the acute coronary syndrome, patients undergoing hemodialysis, community-dwelling older adult, and postpartum depression. the results obtained from some studies showed the positive effect of aromatherapy with lavender essential oil on depression whereas some studies did not report the effect of aromatherapy with lavender on depression significantly. conclusion: it seems that aromatherapy with lavender probably can be used as a complementary, simple, and inexpensive method to improve mild and moderate depression. it is recommended to earmark using a collaborative approach and make use of interdisciplinary and psychology specialists as well as complementary medicine in applying aromatherapy with lavender essential oil. keywords: aromatherapy; lavender; depression; complementary medicine a systematic review of the effects of aromatherapy with lavender essential oil on depression azar jafari-koulaee1, forouzan elyasi2,3, zohreh taraghi3,4,5, ehteram sadat ilali4,*, mahmood moosazadeh5 1student research committee, mazandaran university of medical sciences, sari, iran; 2department of psychiatry, school of medicine, mazandaran university of medical sciences, sari, iran; 3addiction institute, mazandaran university of medical sciences, sari, iran; 4department of geratric nursing, school of nursing and midwifery, mazandaran university of medical sciences, sari, iran; 5health science research center, mazandaran university of medical sciences, sari, iran research depression is considered as one of the most serious healthcare problems, and the statistics of individuals suffering from it is increasing. according to statistics, over 264 million suffer from depression throughout the world.1 in a review study, the prevalence of depression in iran was reported 6% to 73%.2 the pathogenesis of depression is complicated, and numerous risk factors can impact depression affection. these factors include the medical chronic condition, stress, chronic pain, familial history, female gender, economic conditions, joblessness, drug abuse, low self-esteem, lack of social support, marital status, brain injury, and age.3-6 furthermore, obesity, malnutrition, physical inactivity, lack of sunlight, lack of sleep, and social problems in modern societies influence the rate of depression central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu affection.6 unfortunately, suffering from depression is followed by unpleasant consequences; for example, a decrease in a patient's performance in personal, social, and familial dimensions and even suicide.7,8 indeed, depression is the source of many somatic disorders,9,10 insomnia,11 sexual disorders,12,13 and disorders in biologic rhythms.14 hence, it seems necessary to seek the best, most effective, and least hazardous therapies and approaches to improve depression. in this respect, numerous pharmacological and non-pharmacological therapies are offered for depression improvement.15,16 concerning the pharmacological therapies, it seems that many drugs play significant roles in treating psychological disorders; however, with respect to the presence of many complaints regarding the uselessness of these drugs for all patients, along with the emergence of diverse side effects and tolerance (if they are used in the long-run), numerous researchers have noticed using non-pharmacological therapies.17-19 several studies have addressed the positive effect of some non-pharmacological therapies, including art therapy,20 music,21,22 and aromatherapy,23,24 on the improvement in depression and anxiety. in the meantime, aromatherapy, as a non-pharmacological method, has been exploited in many studies owing to its hazardless and convenient usage.25 aromatherapy employs the fragrant oils extracted from flowers and herbs to treat varying diseases. essential oils can be used by inhaling, taking bath, or during massages.25,26 lavender is of those herbs that are used in aromatherapy.27 this herb is from the lamiaceae family with the scientific name of lavandula angustifolia.28 many studies have addressed the anti-pain,29,30 antianxiety and anti-depressant,27,31,32 and sleep improvement33 effects. also, some researchers have believed that lavender exerts its psychological effects through the effects on the limbic system, especially the amygdala and hippocampus. mechanism of this plant on the cell surface is not completely known, but it has been reported that this plant probably had a similar function to benzodiazepines and increased gaba (gamma aminobutyric acid) in the amygdala.34 on the other hand, the review of the available databases showed that although some studies have reported the positive effects of aromatherapy with lavender on depression,27, 35-40 but some others have reported reverse results.41,42 thus, considering the presence of contradictions in this field, lavender’s application to improving depression is still being argued. hence, to access more precise and comprehensive evidence, this study reviewed the effect of aromatherapy with lavender on depression. methods this systematic review study was conducted based on the preferred reporting items for systematic reviews and meta-analysis (prisma)43 in 2020. to review the studies, we considered the components of the population intervention comparison outcome (pico) structured review as a part of the research process.44 pico is one of the most suitable methods in discovering different literature for systematic review studies regarding diseases, therapeutic interventions, and consequences.45 at first, some factors, including the intervention type, kind of applied study, titles, and databases of concern are inserted in the standard pico checklist for initial information estimation. to search more comprehensively, we searched the informational databases of sid, magiran, google-scholar, medline via pubmed, scopus, and web of science by using the mesh and non-mesh keywords such as depression, lavandula, lavender, and aromatherapy, as well as applying or and and operators, with no time limitation since establishment of databases to the end of january 1, 2020 a.d. also, the final references of searched articles, were evaluated as additional resources. the details of how keywords and operators were used to search the database are described below: • scopus:(title-abs-key (lavender) or title-abs key (lavandula) and title-abs jafari-koulaee this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu key (aromatherapy) and title-abs-key (depression)) • wos:(ts=(aromatherapy and (lavender or lavandula) and depression)) and language: (english or persian) and document types: (article) • pubmed:(((lavender[title/abstract]) or lavandula[title/abstract]) and aromatherapy[title/abstract]) and depression[title/abstract] • google scholar:(lavender or lavandula) and aromatherapy and depression • sid:(lavender or lavandula) and aromatherapy and depression figure 1. flowchart of article selection using prisma records identified through database searching (n = 277 ) sc re en in g in cl ud ed el ig ib ili ty id en tif ic at io n additional records identified through other sources (n = 1 ) total records (n =278) records screened (n = 254 ) records excluded (n=239), with reasons such as: no interventional study (n=87) not related to the depression (n=99) lavender was not used through aromatherapy (inhalation or massage) (n=15) the full text of article was not accessible (n=28) published in other langugages (no english or persian) (n=10) full-text articles assessed for eligibility (n = 15 ) records excluded (n=6), with reasons such as: poor quality (n=3) insufficient and ambiguous information (n=3) studies included in qualitative synthesis (n = 9 ) records excluded (n=24): duplicate cases (n=24) jafari-koulaee this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu two researchers (a.j. & e.i.) reevaluated and reinvestigated the resources and databases to warrant the sufficiency and inclusiveness of information and article searching. after primary screening and removing duplicate cases, the articles were reviewed on the basis of inclusion and exclusion criteria, and finally eligible articles were included in the systematic review process. the inclusion criteria were: 1) interventional studies that determined keywords were in the title or keywords of the them, 2) aromatherapy was conducted through inhalation or massage, 3) the full text of article was accessible, and 4) published in english or persian. the studies with poor qualities, insufficient and ambiguous information were excluded from the process. the quality evaluation of the studies was conducted by the jadad checklist. the jadad checklist includes the three items of randomization, blinding, and withdrawals and dropouts that are in direct relationship with bias control in interventionist studies. the quality of studies was ranked as low-quality and high-quality studies if they were scored 1-2 and 3-5, respectively.46,47 in the present study, we eliminated the scores that were below 3 based on the checklist after the quality evaluation, and the scores above 3 were included in the review process. finally, a checklist was used to extract the information of the papers imported to the review. this checklist consisted of items such as the author’s name, year of publication, type of study, sample size, type of variable, instrument, type of intervention, and results. results out of 278 studies, 9 studies were included to the systematic review process after screening and eliminating duplicate articles according to the purpose of the study. the details related to the stages of study selection are represented in figure 1. the intervention in these studies was inhalation aromatherapy27,36-42 or aromatherapy massage35,40 with lavender. aromatherapy with lavender essential oil was conducted on the patients suffering from migraine,41 patients with the acute coronary syndrome,35 patients undergoing hemodialysis,27,39 community-dwelling older adults,36,40 and postpartum depression.37,38,40 depression was measured by different scales, including hospital anxiety and depression scale (hads), geriatric depression scale (gds), beck depression inventory (bdi), depression anxiety stress scales-21, center for epidemiological studies depression (ces-d) scale, and edinburgh anxiety questionnaire and stress scale. the results obtained from studies showed the positive effect of aromatherapy with lavender essential oil on depression,27,35-40 whereas some studies did not report the positive effect of aromatherapy with lavender on depression significantly.41, 42 other details are presented in table 1. discussion the present study aimed to review the effect of aromatherapy with lavender on depression. in this regard, the results of the review showed that the depression of patients undergoing hemodialysis significantly improved in the study of tayebi et al.39 compared to the study of bagheri nesami et al.27 perhaps, one of the possible reasons for the difference between the results of these two studies is the duration of every aromatherapy session; i.e., a session lasted one hour in the study of tayebi et al.,39 while it was 15 minutes in the study of bagheri nesami et al.27 longer aromatherapy periods may have better effects on depression reduction. of course, the presence of other factors such as differences in the personal and cultural characteristics of individuals, the patients’ inclinations to use complementary medicine, and many other cases should be considered. xiong et al.,40 in their study on older adults, reported that depression significantly decreased in the jafari-koulaee this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu author (year) study design sample size (n) / type of sample of the study type of intervention / follow-up period variable/ instruments results conclusion quality of study bagherinesami1 et al. (2017) randomized control trial ni=36; nc=36 / hemodialysis patients intervention group: aromatherapy with 3 drops of lavender essential oil 5% for 10 minutes every time they underwent hemodialysis for a period of one month control group: routine care follow-up period: 4 weeks anxiety and depression/ hospital anxiety and depression scale (hads) before intervention (control group): mean±sd= 4.05 ±4.48 two weeks after intervention (control group): mean±sd= 5.00 ± 5.13 four weeks after intervention (control group): mean±sd= 4.27 ± 5.04 p = 0.221 before intervention (experimental group): mean±sd= 4.54 ± 4.11 two weeks after intervention (experimental group): mean±sd= 3.11 ± 3.06 four weeks after intervention (experimental group): mean±sd= 3.82 ± 4.07 p = 0.019 between the two groups: p = 0.005 significant differences existed between the two groups with respect to depression levels before, two and four weeks after the intervention. 3 tayebi et al. (2015) randomized control trial ni=30; nc=30 / hemodialysis patients interventional group: inhale the lavender essential oil smeared on a piece of cloth (three drops of oil) for one hour during the hemodialysis control group: routine care follow-up period: 4 weeks depression, anxiety, stress / depression anxiety stress scales-21 pre-test (interventional group): mean±sd= 6.7±4.9 pre-test (control group): mean±sd= 7.4 ± 6.9 post-test (interventional group): mean±sd= 4.9±5.55 post-test (control group): mean±sd= 7.4 ± 7.3 between the two groups: p<0.001 aromatherapy with lavender essential oil might reduce depression and stress among hemodialysis patients. 3 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu bahrami et al. (2016) randomized control trial ni=45; nc=45 / patients with acute coronary syndrome intervention group received reflexology with lavender essential oil control group: routine care follow-up period: 4 weeks depression / hospital's anxiety and depression scale pre-test (experimental group): mean±sd = 12.51 ± 5.40 pre-test (control group): mean±sd = 8.04 ± 4.71 p = 0.439 post-test (experimental group): mean±sd = 8.04 ± 4.71 post-test (control group): mean±sd = 11.11 ± 3.42 p = 0.001 aromatherapy massage can be considered by clinical nurses an efficient therapy for alleviating psychological and physiological responses among older women suffering from acute coronary syndrome. 3 xiong et al. (2017) randomized control trial ni=20; ni=20; nc=20 / chinese communitydwelling older adults aromatherapy massage group: 30 min of aromatherapy massage with 5ml oil lavender (diluted in sweet almond oil to a concentration of 1%), twice weekly for 8 weeks aromatherapy inhalation group: 30 min of nasal inhalation of 50ml of the compound essential oils blended in 10ml of purified water, twice weekly for 8 weeks control group: no intervention follow-up period: 10 weeks depression/ geriatric depression scale short form (gdssf) & patient health questionnaire-9 (phq-9) pre-test (massage group): mean±sd = 6.70 ± 1.92 pre-test (inhalation group): mean±sd = 7.00 ± 1.34 pre-test (control group): mean±sd = 6.80 ± 1.47 post-test (massage group): mean±sd = 3.25 ± 2.15 post-test (inhalation group): mean±sd = 3.75 ± 1.68 post-test (control group): mean±sd = 6.65 ± 1.23 6-week follow-up (massage group): mean±sd = 3.95 ±2.07 6-week follow-up (inhalation group): mean±sd = 4.35 ±1.56 6-week follow-up (control group): mean±sd = 6.95 ±1.25 10-week follow-up (massage group): mean±sd = 3.63 ±2.00 10-week follow-up (inhalation group): mean±sd = 4.55 ±1.29 10-week follow-up (control group): mean±sd = 6.70 ±1.61 after intervention, the aromatherapy massage and inhalation groups demonstrated significantly lower gdssf than control participants. 3 jafari-koulaee this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu janizadeh et al. (2016) quasi experimental ni=20; ni=20; ni=20; nc=20 / elderly women interventional group 1: yoga practice interventional group 2: yoga practice combined with lavender use in the first month of training interventional group 3: yoga practice combined with lavender use in the second month of training all three interventional groups practiced yoga for 2 months. control group: routine care follow-up period: 8 weeks depression/ beck depression inventory (bdi) pre-test (interventional group 1): mean±sd= 24.40 ±12.72 post-test (interventional group 1): mean±sd= 21.20 ± 12.12 p= 0.001 pre-test (interventional group 2): mean±sd=23.10±11.77 post-test (interventional group 2): mean±sd= 14 ±7.65 p= 0.001 pre-test (interventional group 3): mean±sd=19.50±8.42 post-test (interventional group 3): mean±sd= 13.40 ± 7.73 p= 0.001 pre-test (control group): mean±sd= 21.30±8.55 post-test (control group): mean±sd= 20.80± 8.63 greater reduction in depression in the combined groups compared to the yoga practice group. however, there was no significant difference between the two combined groups 3 jafarikoulaee et al. (2018) randomized control trial ni=30; nc=30 / migraine patients interventional group: inhaled 2-3 drops of lavender essence for 15 min, three times a week for 4 consecutive weeks control group: routine care follow-up period: 4 weeks depression / beck depression inventory (bdi-13) pre-test (interventional group): mean±sd= 10.93±0.56 pre-test (control group): mean±sd= 9.70±2.33 post-test (interventional group): mean±sd= 5.23±0.57 post-test (control group): mean±sd= 5.10 ± 0.53 p=0.13 lavender essential oil can be useful for reducing depression and headache disability in migraine patients. 3 kianpour et al. (2016) randomized control trial ni=25; nc=34; np=31 / women in the postpartum period interventional group: 7 drops of lavender oil and 1cc rose water at the concentration of 100%, postpartum depression / edinburgh questionnaire before intervention (interventional group): mean±sd= 10.37 ±3.21 before intervention (control group): mean±sd= 10.61±4.21 before intervention (placebo group): mean±sd= 9.71 ±4.20 the use of aromatherapy can be recommended in high-risk women. 4 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu placebo group: 7 drops of odorless sesame seed oil, with 1 cc of musk willow sweat at the concentration of 100% control group: routine care follow-up period: 6 weeks p>0.05 2 weeks after delivery (interventional group): mean±sd= 7.80 ±3.90 2 weeks after delivery (control group): mean±sd= 8.51 ±3.61 2 weeks after delivery (placebo group): mean±sd= 11.70±4.10 p>0.001 6 weeks after delivery (interventional group): mean±sd= 6.80 ±3.61 6 weeks after delivery (control group): mean±sd= 9.50 ±3.03 6 weeks after delivery (placebo group): mean±sd= 7.90 ±3.30 p=0.01 kianpour et al. (2016) randomized control trial ni=70; nc=70 / women in the postpartum period interventional group: aromatherapy consisted of inhaling three drops of lavender essential oil every 8h with for 4 weeks control group: no aromatherapy follow-up period: 12 weeks postpartum depression / 21-item depression, anxiety, and stress scale and the edinburgh stress, anxiety, and depression scale 2 weeks after intervention (interventional group): mean±sd=5.31±4.42 2 weeks after intervention (control group): mean±sd= 7.34 ±5.16 p=0.003 1 month after intervention (interventional group): mean±sd= 4.10 ±3.92 1 month after intervention (control group): mean±sd= 7.59 ±5.14 p < 0.0001 3 months after intervention (interventional group): mean±sd= 3.81 ±3.48 3 months after intervention (control group): mean±sd= 7.27 ±5.11 p < 0.0001 inhaling the scent of lavender for 4 weeks can prevent stress, anxiety, and depression after childbirth. 3 sehhatie et al. (2015) controlled doubleblinded random clinical trial ni=158; nc=162/ women in the postpartum period interventional group: showering, being in upright posture, aromatherapy with lavender (1ml solution of mothers’ postpartum depression / edinburgh questionnaire pre-test (experimental group): mean±sd= 6.1±3.2 post-test (experimental group): mean±sd= 7.8±4.6 pre-test (control group): mean±sd= 6.3±3.2 post-test (control group): the results show the decrease of depression in the intervening group as compared to 4 jafari-koulaee this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu 20% lavender essence), and soft music without words control group: the interventions were customary according to delivery interventions. follow-up period: 8 weeks mean±sd= 8.8±5.4 mean difference (95% ci) = (-0.2-1.8)-0.8 p=0.124 the control group which could be due to the effect of nonpharmacologi cal methods of pain relief in labor. table 1. summary of data extracted from the reviewed articles (n=9) inhalation and massage aromatherapy group compared to the control group. furthermore, it was observed that the long-term effects of aromatherapy with lavender on depression reduction lasted for 10 weeks after the intervention.38 in line with the mentioned study, kianpour et al.37,38 conducted a study on postpartum depression that the long-tern effect of aromatherapy with lavender on depression reduction was found 6 weeks, one month, and even three months after delivery. on the other hand, in another study,49 although the positive effects of aromatherapy lasted up to six weeks after the intervention, there was not a significant difference between the experimental and control groups in their depression scores after 10 weeks. perhaps, one of the possible reasons for the difference in results is that the patients of this study49 were suffering from cancer, and the kind of aroma applied to aromatherapy was not specified, whereas the participants in the study of xiong et al.40 and kianpour et al.37,38 were the community dwelling older adult and women in postpartum period, respectively, and they utilized lavender essential oil. in a study conducted on postpartum depression, kianpour et al.37,38 found that women’s depression significantly decreased after aromatherapy with lavender. however, sehatti et al.42 reported that aromatherapy with lavender essential oil did not significantly decrease the depression of women after their delivery. one of the reasons for the difference between results may be the kind of utilized lavender essential oil. kianpour et al.37 and another study38 employed a pure lavender essential oil and the one diluted by rose essential oil, respectively, while sehatti et al.42 employed lavender essential oil 20% diluted by distilled water. moreover, the difference in the time of depression measurement may be another reason. it is because kianpour et al.37 and another study38 measured depression 2, 4, and 12 weeks and 2 and 6 weeks after delivery, respectively. however, in another study, depression was assessed 8 weeks after delivery. janizadeh et al.36 showed that if the lavender essential oil were applied along with yoga, it would have positive effects on the depression reduction of depressed women. therefore, we can state that aromatherapy with lavender essential oil combined with other nonpharmacological interventions that impact depression, including yoga, may be more effective in improving depression. of course, it is worth to mention that some factors such as the type and severity of depression, as well as individuals’ personal and physical conditions and inclinations, should be taken into account. hence, the conduction of more large-scale studies is necessary for acquiring more comprehensive and precise evidence in this regard. overall, the possible reasons for the differences in the results of the studies in terms of severity of central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu decreasing depression may be related to the differences in definition of cases, randomization, blinding and sample size determination. in the reviewed studies, participations were not homogeneous (migraine patients,41 acute coronary syndrome patients,35 hemodialysis patients,27,39 community-dwelling older adults,36,40 and postpartum depression).37,38,40 also, randomization was done in almost all studies,27,35-42 whereas blinding was performed in only two studies.38,42 on the other hand, although according to the review of the studies, sample size calculation in most of the studies was done based on the sample size formula or an acceptable method for estimating the sample size, but sample size in some of the studies was small or moderate thus, it seems that further large clinical trials with larger sample size are needed to provide more accurate evidence. the results of the most studies revealed that probably, lavender aromatherapy can improve the depression of patients undergoing hemodialysis, patients suffering from acute coronary syndrome, community dwelling older adults, and postpartum depression. furthermore, the results showed that probably, aromatherapy can improve depression if it is mixed with other non-pharmacological interventions, including physical exercises and yoga, but available studies are not sufficient. although, it seems that lavender aromatherapy as a complementary, simple, and inexpensive method can be used by clinical nurses to improve depression (mild to moderate), along with other measures, in patients with chronic diseases or undergoing diagnostic and therapeutic measures and postpartum depression, but further high-quality rcts studies are needed to confirm these findings and to achieve the best level of evidence in this field. high-quality rcts studies can provide more reliable findings so that we can use their findings in evidence-based practice. also, a collaborative and interdisciplinary approach is recommended for applying lavender aromatherapy. despite the strengths of this study, one of the limitations of this study is inaccessibility to some of the studies because of publishing in non-english or nonpersian language. a relatively low sample size in some of the studies and lack of high-quality rcts are other limitations. meanwhile, the impossibility of metaanalysis due to the heterogeneity of the design of studies and research population is another limitation of the study. depression is a major contributor to the overall global burden of disease, and it is essential to support those who are suffering from this mental disorder by applying easy and safe methods. in this regard, it is recommended that future research be conducted focusing on the evaluation of the effect of complementary medicine interventions (e.g. aromatherapy) and the importance of applying them in combination with other interventions to reduce depression and its psychological and social burden of this debilitating disease in the world. references 1. james sl, abate d, abate kh, abay sm, abbafati c, abbasi n, et al. global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the global burden of disease study 2017. the lancet. 2018;392(10159):1789-858. 2. ali montazeri, seyed javad mousavi, sepideh omidvari, mahmood tavousi, akram hashemi, tahereh rostami. depression in iran: a systematic review of the literature (2000-2010). health monitor journal of the iranian institute for health sciences research. 2013;12(6):567-94. 3. maurer dm. screening for depression. american family physician. 2012;85(2):139-44. 4. madsen ie, nyberg st, hanson lm, ferrie je, ahola k, alfredsson l, et al. job strain as a risk factor for clinical depression: systematic review and meta-analysis jafari-koulaee this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu with additional individual participant data. psychological medicine. 2017;47(8):1342-56. 5. shi y, yang d, zeng y, wu w. risk factors for poststroke depression: a meta-analysis. frontiers in aging neuroscience. 2017;9:218-24. 6. al balawi mm, faraj f, al anazi bd, al balawi dm. prevalence of depression and its associated risk factors among young adult patients attending the primary health centers in tabuk, saudi arabia. open access macedonian journal of medical sciences. 2019;7(17):2908-12. 7. szczepańska-gieracha j, morka j, kowalska j, kustrzycki w, rymaszewska j. the role of depressive and anxiety symptoms in the evaluation of cardiac rehabilitation efficacy after coronary artery bypass grafting surgery. european journal of cardio-thoracic surgery. 2012;42(5):e108-e14. 8. ribeiro jd, huang x, fox kr, franklin jc. depression and hopelessness as risk factors for suicide ideation, attempts and death: meta-analysis of longitudinal studies. the british journal of psychiatry. 2018;212(5):279-86. 9. olver js, hopwood mj. depression and physical illness. medical journal of australia. 2013;199:9-12. 10. katon w, lin eh, kroenke k. the association of depression and anxiety with medical symptom burden in patients with chronic medical illness. general hospital psychiatry. 2007;29(2):147-55. 11. bao y-p, han y, ma j, wang r-j, shi l, wang ty, et al. cooccurrence and bidirectional prediction of sleep disturbances and depression in older adults: metaanalysis and systematic review. neuroscience & biobehavioral reviews. 2017;75:257-73. 12. raso v, tolea mi, casseb jsdr, duarte ajds, greve jmda. depression is inversely associated with sexual satisfaction and physical function in men living with hiv/aids. medicalexpress. 2016;3(6):158-65. 13. kugler c, meng m, rehn e, morshuis m, gummert jf, tigges-limmer k. sexual activity in patients with left ventricular assist devices and their partners: impact of the device on quality of life, anxiety and depression. european journal of cardio-thoracic surgery. 2018;53(4):799-806. 14. wittmann m, schreiber w, landgrebe m, hajak g. circadian rhythms and depression. fortschritte der neurologie-psychiatrie. 2018;86(5):308-18. 15. habibzadeh h, milan zd, radfar m, alilu l, cund a. effects of peer-facilitated, video-based and combined peer-and-video education on anxiety among patients undergoing coronary angiography: randomised controlled trial. sultan qaboos university medical journal. 2018;18(1):e61-7. 16. sharif f, shoul a, janati m, kojuri j, zare n. the effect of cardiac rehabilitation on anxiety and depression in patients undergoing cardiac bypass graft surgery in iran. bmc cardiovascular disorders. 2012;12(1):40-6. 17. unützer j, klap r, sturm r, young as, marmon t, shatkin j, et al. mental disorders and the use of alternative medicine: results from a national survey. american journal of psychiatry. 2000;157(11):1851-7. 18. cohen zd, derubeis rj. treatment selection in depression. annual review of clinical psychology. 2018;14-9. 19. akil h, gordon j, hen r, javitch j, mayberg h, mcewen b, et al. treatment resistant depression: a multi-scale, systems biology approach. neuroscience & biobehavioral reviews. 2018;84:272-88. 20. ciasca ec, ferreira rc, santana cla, forlenza ov, dos santos gd, brum ps, et al. art therapy as an adjuvant treatment for depression in elderly women: a randomized controlled trial. revista brasileira de psiquiatria (sao paulo, brazil : 1999). 2018;40(3):25663. central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu 21. petrovsky d, cacchione pz, george m. review of the effect of music interventions on symptoms of anxiety and depression in older adults with mild dementia. int psychogeriatr. 2015;27(10):1661-70. 22. costa f, ockelford a, hargreaves dj. does regular listening to preferred music have a beneficial effect on symptoms of depression and anxiety amongst older people in residential care? the qualitative findings of a mixed methods study. music and medicine. 2018;10(2):54-62. 23. tang sk, tse mym. aromatherapy: does it help to relieve pain, depression, anxiety, and stress in community-dwelling older persons? biomed research international. 2014;2014:12-8. 24. babakhanian m, ghazanfarpour m, kargarfard l, roozbeh n, darvish l, khadivzadeh t, et al. effect of aromatherapy on the treatment of psychological symptoms in postmenopausal and elderly women: a systematic review and meta-analysis. journal of menopausal medicine. 2018;24(2):127-32. 25. cooke b, ernst e. aromatherapy: a systematic review. br j gen pract. 2000;50(455):493-6. 26. maddocks‐jennings w, wilkinson jm. aromatherapy practice in nursing: literature review. journal of advanced nursing. 2004;48(1):93-103. 27. bagheri-nesami m, shorofi sa, nikkhah a, espahbodi f. the effects of lavender essential oil aromatherapy on anxiety and depression in haemodialysis patients. pharmaceutical and biomedical research. 2017;3(1):8-13. 28. yaghoobi k, kaka gr, davoodi sh, ashayeri h. therapeutic effects of lavandula angustifolia. journal of gorgan university of medical sciences. 2015;17(4):1-9. 29. bagheri-nesami m, espahbodi f, nikkhah a, shorofi sa, charati jy. the effects of lavender aromatherapy on pain following needle insertion into a fistula in hemodialysis patients. complementary therapies in clinical practice. 2014;20(1):1-4. 30. ghods a, abfroosh n, ghorbani r, asgari m. effect of lavender inhalation on pain intensity during insertion of vascular needles in hemodialysis patients. journal of babol university of medical sciences. 2014;16(10):7-14. 31. beyliklioğlu a, arslan s. effect of lavender oil on the anxiety of patients before breast surgery. j perianesth nurs. 2019;34(3):587-93. 32. franco l, blanck tjj, dugan k, kline r, shanmugam g, galotti a, et al. both lavender fleur oil and unscented oil aromatherapy reduce preoperative anxiety in breast surgery patients: a randomized trial. j clin anesth. 2016;33:243–9. 33. özkaraman a, ö d, yılmaz h. aromatherapy: the effect of lavender on anxiety and sleep quality in patients treated with chemotherapy. clinical journal of oncology nursing. 2018;22(2):203-10. 34. cavanagh hm, wilkinson jm. biological activities of lavender essential oil. phytother res. 2002 jun;16(4):301-8. 35. bahrami t, rejeh n, heravi‐karimooi m, vaismoradi m, tadrisi sd, sieloff c. effect of aromatherapy massage on anxiety, depression, and physiologic parameters in older patients with the acute coronary syndrome: a randomized clinical trial. international journal of nursing practice. 2017;23(6):e12601-6. 36. janizadeh e, badami r, torkan a. comparison of the effectiveness of yoga and lavender on symptoms of depression in elderly women. j res behav sci. 2016;14(4):421-7. 37. kianpour m, mansouri a, mehrabi t, asghari g. effect of lavender scent inhalation on prevention of stress, anxiety and depression in the postpartum period. iranian j nursing midwifery res. 2016;21:197-201. jafari-koulaee this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.442 | http://cajgh.pitt.edu 38. kianpour m, moshirenia f, kheirabadi g, asghari g, dehghani a, dehghani-tafti a. the effects of inhalation aromatherapy with rose and lavender at week 38 and postpartum period on postpartum depression in high-risk women referred to selected health centers of yazd, iran in 2015. iranian. j nursing midwifery res. 2018;23:395-401. 39. tayebi a, kasra dehkordi a, ebadi a, sahraei h, einollahi b. the effect of aromatherapy with lavender essential oil on depression, anxiety and stress in hemodialysis patients: a clinical trial. journal of evidence-based care. 2015;15(5):65-74. 40. xiong m, li y, tang p, zhang y, cao m, ni j, et al. effectiveness of aromatherapy massage and inhalation on symptoms of depression in chinese community-dwelling older adults. the journal of alternative and complementary medicine. 2018;24(7):717-724. 41. jafari-koulaee a, khenarinezhad f, sharifi razavi a, bagheri-nesami m. the effect of aromatherapy with lavender essence on depression and headache disability in migraine patients: a randomized clinical trial. journal of medicinal plants. 2019;2(70):162-72. 42. sehhatie f, mirgafourvand m, niri zv. the effect of non-pharmaceutical methods of labor pain relief on mothers’ postpartum depression: a randomized controlled trial. international journal of women's health and reproduction sciences. 2015;3(1):48-55. 43. asar s, jalalpour s, ayoubi f, rahmani m, rezaeian m. prisma; preferred reporting items for systematic reviews and meta-analyses. journal of rafsanjan university of medical sciences. 2016;15(1):68-80. 44. sayers a. tips and tricks in performing a systematic review. the british journal of general practice. 2008;58(547):136-9. 45. schardt c, adams mb, owens t, keitz s, fontelo p. utilization of the pico framework to improve searching pubmed for clinical questions. bmc medical informatics and decision making. 2007;7(1):1-6. 46. jadad ar, moore ra, carroll d, jenkinson c, reynolds dj, gavaghan dj, et al. assessing the quality of reports of randomized clinical trials: is blinding necessary? controlled clinical trials. 1996;17(1):1-12. 47. ali m, oderuth e, atchia i, malviya a. the use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review. j hip preserv surg. 2018;5(3):209-19. 48. fahimeh sehhatie, mozhgan mirgafourvand, zhaleh vn. the effect of non-pharmaceutical methods of labor pain relief on mothers’ postpartum depression: a randomized controlled trial. international journal of women’s health and reproduction sciences. 2015;3(1):48–55. 49. wilkinson sm, love sb, westcombe am, gambles ma, burgess cc, cargill a, et al. effectiveness of aromatherapy massage in the management of anxiety and depression in patients with cancer: a multicenter randomized controlled trial. journal of clinical oncology. 2007;25(5):532-9. microsoft word khafaie&rahim.docx new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. estimating case fatality and case recovery rates of covid-19: is this the right thing to do? morteza abdullatif khafaie1 and fakher rahim2* 1social determinants of health research center, ahvaz jundishapur university of medical sciences, ahvaz, iran; 2thalassemia & hemoglobinopathy research center, health research institute, ahvaz jundishapur university of medical sciences, ahvaz, iran; *corresponding author email: bioinfo2003@gmail.com vol. 10, no. 1 (2021) | issn 2166-7403 (online) doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu abstract introduction: case fatality rates (cfrs) and case recovery rates (crrs) are frequently used to define health consequences related to specific disease epidemics, including the covid-19 pandemic. this study aimed to compare various methods and models for calculating cfr and crr related to covid-19 based on the global and national data available as of april 2020. methods: this analytical epidemiologic study was conducted based on detailed data from 210 countries and territories worldwide in april 2020. we used three different formulas to measure cfr and crr, considering all possible scenarios. results: we included information for 72 countries with more than 1,000 cases of covid-19. overall, using first, second, and third estimation models, the cfr were 6.22%, 21.20%, and 8.67%, respectively; similarly, the crr was estimated as 23.21%, 78.86%, 32.23%, respectively. we have shown that cfrs vary so much spatially and depend on the estimation method and timing of case reports, likely resulting in overestimation. conclusion: even with the more precise method of cfrs estimation, the value is overestimated. case fatality and recovery rates should not be the only measures used to evaluate disease severity, and the better assessment measures need to be developed as indicators of countries’ performance during covid-19 pandemic. keywords: coronavirus; covid-19; case fatality rates; cfrs; case recovery rates; crrs estimating case fatality and case recovery rate of covid-19: is this the right thing to do? morteza abdullatif khafaie1 and fakher rahim2* 1social determinants of health research center, ahvaz jundishapur university of medical sciences, ahvaz, iran; 2thalassemia & hemoglobinopathy research center, health research institute, ahvaz jundishapur university of medical sciences, ahvaz, iran; *corresponding author email: bioinfo2003@gmail.com research in late december 2019, a series of unexplained pneumonia cases were reported in wuhan, china, which led government and researchers in china to take quick action to control its spread and start a large number of etiologic studies.1 on january 30, 2020, who declared the epidemic of the virus as a public health emergency with international concern (pheic).2 covid-19 has spread to more than 210 countries and territories around the world, and as of december 2020, nearly 1.7 million lives have been lost.3 the virus spreads through droplets after infected persons cough or sneeze, which may enter the body through inhalation or contact with contaminated surfaces, and then touching the eyes, nose, and mouth.5 according to scientists, the average time required for symptoms to appear is 5 days, but in some cases and situations, it may take much longer, as the virus' incubation period lasts up to 14 days.6 case fatality rates (cfrs) and case recovery rates (crrs) are frequently used to define health consequences related to certain disease epidemics, as well as for the covid-19 outbreak.7 cfr is the central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu proportion of deaths due to a specified health condition compared to total infected cases.8 calculations are based on the controversial assumption that all of patients were tested. covid-related cfr might be either overestimated or underestimated depending on if calculations are based on every confirmed case or only those cases who have recovered or died. specialists in epidemiology have proposed different scenarios for calculating cfr, each with its advantages and disadvantages.9-11 crr is the proportion of recovered or discharged individuals with a specified health condition compared to total infected cases.12 the absence of reliable numbers of infected cases for the entire population could lead to inaccurate calculation of the cfr and crr due to lack of a valid denominator. there has been an urgent need for these reported data to be openly available, so estimates of cfr and crr can be estimated as accurately as possible. this study aimed to compare various introduced methods and models for the calculation of cfr and crr related to covid-19 over a time based on the recent global and national data. methods design and setting this analytical epidemiologic study was conducted using detailed data from 210 countries and territories available around the world as of april 17, 2020. the current survey was approved by the ahvaz jundishapur university of medical sciences ethical committee. source of data and procedure we used a method that our research team recently published to retrieve data and estimate cfr and crr.13 in brief, the data about total cases, total deaths, and total recovered cases, alongside total screening tests used to diagnose covid-19, were collected from the world’s most acceptable and accurate data repositories, including who14, worldometer4, the centers for disease control and prevention, and the morbidity and mortality weekly report series (provided from centers for disease control and prevention)15, consistent with the user’s guide of data sources for patient registries.16 the data analyses were performed between april 17-19, 2020. data were measured and analyzed for each country, and cfr and crr for countries with ≥1,000 cases (n=72) are presented in the main tables. data for the remaining countries with <1,000 cases (n=138) are accessible in the supplementary tables. measuring the cfr and crr given the difficulty of estimating cfr and crr accurately during the ongoing covid-19 pandemic, we used three different methods to estimate cfr and crr, considering all possible scenarios (figure 1). formula i according to battegay et al., we used the proportion of total deaths and recovered cases of covid-19 disease to total cases of disease at global and national levels to estimate cfrs and crrs, respectively.17 cfr= (total deaths attributed to covid-19/ total cases of covid-19) * 100 crr= (total recovered individuals attributed to covid-19/total cases of covid-19) * 100 formula ii another method, proposed by ghani et al., to estimate cfrs and crrs is merely considering the summation of the current total deaths plus current total recovered as the denominator.18 cfr= total deaths attributed to covid-19/(deaths+recovered) crr= total recovered individuals attributed to covid-19/(deaths+recovered) khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489|http://cajgh.pitt.edu formula iii this formula accounts for the lag time between an individual’s disease onset and death/recovery.4 t is the average time from emerging symptoms until the onset of death (or recovery). since most countries had not adopted well-performing detection systems, to avoid overestimating the rates, t was considered 7 days, which is the difference of the minimum reported time between the onset of symptom to outcomes and the maximum incubation period.19 cfr=deaths at day x/total cases at day x–t crr=recovered at day x/total cases at day x–t statistical analysis data management and calculation were conducted in microsoft excel, and results (cf and cr rates) were tabulated for the three standard methods of rate estimation by countries. we reported information for the 72 countries in the body of the paper with more than 1,000 cases of covid-19 in the main paper, and the estimates of the remaining countries (n=138) were provided as supplementary tables. overall rates for the world were also calculated. figure 1. schematic illustration of three different conceivable models for cfr and crr calculation khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu results the total number of reported cases from the beginning of the epidemic until april 17, 2020 was 1,925,179. the usa had the highest number of covid19 cases detected (n=578,155; 30.5% of global cases), followed by spain and italy with 170,099 (8.84%) and 159,516 (8.29%) cases, respectively. table 1 shows global as well as national data on the covid-19 healthrelated consequences. global cfrs for covid-19 estimated by first, second, and third methods were 6.22%, 21.20%, and 8.67%, respectively. similarly, crrs were estimated as 23.21%, 78.86%, 32.23%. the third method, which is the more precise and widely accepted method, shows that algeria (19.17%), belgium (18.39%), and the uk (18.38%) account for the highest cfrs. data about all countries with confirmed cases less than 1,000 were presented in table s1. considering the first estimation model, the highest crrs were in china, south korea, and iran. given the second estimation model, most countries such as germany, china, iran, switzerland, canada, and austria had crr above 90%. based on the third estimation model, several countries, including china, turkey, russia, sweden, and peru, had crrs higher than 90% (table 1). the overall lowest and highest cfr and crr in the european continent were estimated by model 1 and model 2, respectively (table 2). the highest cfr was observed in the european continent using models 1 and 3; model 2 highlighted the north american continent as the region with the highest cfr (table 2). moreover, the highest crr was observed in oceania in all three models (table 2). the impact of important contributing factors affecting cfr and crr such as the country’s population, gdp, number of hospital beds per 1,000 people, number of icu beds per 100,000 people, and number of ventilators were assessed in the three different proposed models of estimation (table s2). comparison among countries with high, moderate, and low cfr was illustrated in figure 2. though the analysis showed a statistically nonsignificant pattern for all variables of interest, models 1 and 2 potentially provide more accurate estimates of cfr and crr (table 3). the who reported cfr for covid19 as 2%20; other calculated values are shown based on data and available literature in countries and at the global level (table 4). country total recovered total deaths total cases active cases model 1 model 2 model 3 cfr1 crr1 cfr2 crr2 cfr3 crr3 usa 3,950,354 198,128 6,676,601 2,528,119 2.97% 59% 4.78% 95.22% 0.85% 57.09% india 3,702,595 78,614 4,754,356 973,147 1.65% 78% 2.08% 97.92% 0.49% 75.34% brazil 3,553,421 131,274 4,315,858 631,163 3.04% 82% 3.56% 96.44% 0.63% 80.79% russia 873,535 18,484 1,057,362 165,343 1.75% 83% 2.07% 97.93% 2.20% 78.31% peru 559,321 30,593 722,832 132,918 4.23% 77% 5.19% 94.81% 0.85% 61.54% colombia 592,820 22,734 708,964 93,410 3.21% 84% 3.69% 96.31% 2.98% ----- mexico 467,525 70,604 663,973 125,844 10.63% 70% 13.12% 86.88% 0.44% 65.32% south africa 576,423 15,427 648,214 56,364 2.38% 89% 2.61% 97.39% 0.90% 77.98% spain n/a 29,747 576,697 n/a 5.16% --------------0.14% ----- argentina 409,771 11,263 546,481 125,447 2.06% 75% 2.68% 97.32% 0.85% 60.79% chile 404,919 11,895 432,666 15,852 2.75% 94% 2.85% 97.15% 1.06% 86.39% iran 344,516 23,029 399,940 32,395 5.76% 86% 6.27% 93.73% 0.68% 81.57% france 89,059 30,910 373,911 253,942 8.27% 24% 25.76% 74.24% 1.93% 20.91% uk n/a 41,623 365,174 n/a 11.40% ---------------1.24% ------ khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489|http://cajgh.pitt.edu country total recovered total deaths total cases active cases model 1 model 2 model 3 cfr1 crr1 cfr2 crr2 cfr3 crr3 bangladesh 238,271 4,702 336,044 93,071 1.40% 71% 1.94% 98.06% 0.28% 68.78% saudi arabia 301,836 4,240 325,050 18,974 1.30% 93% 1.39% 98.61% 0.51% 86.03% pakistan 289,429 6,379 301,481 5,673 2.12% 96% 2.16% 97.84% 0.26% 93.21% turkey 257,731 6,999 289,635 24,905 2.42% 89% 2.64% 97.36% 0.32% 88.52% iraq 221,283 7,941 286,778 57,554 2.77% 77% 3.46% 96.54% 0.23% 76.62% italy 213,191 35,603 286,297 37,503 12.44% 74% 14.31% 85.69% 0.38% 71.24% germany 235,300 9,427 260,546 15,819 3.62% 90% 3.85% 96.15% 0.87% 89.92% philippines 187,116 4,292 257,863 66,455 1.66% 73% 2.24% 97.76% 0.06% 71.58% indonesia 152,458 8,650 214,746 53,638 4.03% 71% 5.37% 94.63% 0.09% 67.64% israel 113,496 1,103 152,722 38,123 0.72% 74% 0.96% 99.04% 0.94% 68.37% ukraine 68,346 3,148 151,859 80,365 2.07% 45% 4.40% 95.60% 0.36% 36.87% canada 120,075 9,170 136,141 6,896 6.74% 88% 7.10% 92.90% 0.01% 87.39% bolivia 82,796 7,297 125,982 35,889 5.79% 66% 8.10% 91.90% 0.23% 63.32% qatar 118,475 205 121,523 2,843 0.17% 97% 0.17% 99.83% 0.16% 91.46% ecuador 91,242 10,864 116,451 14,345 9.33% 78% 10.64% 89.36% 0.33% 76.72% kazakhstan 100,615 1,634 106,803 4,554 1.53% 94% 1.60% 98.40% 0.53% 91.90% dominican republic 76,531 1,953 103,092 24,608 1.89% 74% 2.49% 97.51% 0.62% 71.19% romania 42,811 4,127 102,386 55,448 4.03% 42% 8.79% 91.21% 0.07% 40.11% panama 73,476 2,155 101,041 25,410 2.13% 73% 2.85% 97.15% 0.01% 71.66% egypt 83,261 5,627 100,856 11,968 5.58% 83% 6.33% 93.67% 0.08% 80.48% kuwait 84,404 558 94,211 9,249 0.59% 90% 0.66% 99.34% 0.26% 80.19% belgium 18,709 9,923 92,478 63,846 10.73% 20% 34.66% 65.34% 0.83% 18.99% oman 83,325 762 88,337 4,250 0.86% 94% 0.91% 99.09% 0.25% 93.35% sweden n/a 5,846 86,505 n/a 6.76% ----100.00% ----0.49% ---- china 80,399 4,634 85,184 151 5.44% 94% 5.45% 94.55% 0.19% 92.96% morocco 65,867 1,553 84,435 17,015 1.84% 78% 2.30% 97.70% 0.61% 76.91% guatemala 70,403 2,949 81,658 8,306 3.61% 86% 4.02% 95.98% 0.25% 86.18% netherlands n/a 6,253 81,012 n/a 7.72% ----100.00% ----0.28% ---- uae 68,983 399 78,849 9,467 0.51% 87% 0.58% 99.42% 0.11% 80.38% japan 66,280 1,423 74,544 6,841 1.91% 89% 2.10% 97.90% 0.38% 87.58% belarus 72,547 744 73,975 684 1.01% 98% 1.02% 98.98% 0.23% 97.45% poland 59,725 2,182 73,650 11,743 2.96% 81% 3.52% 96.48% 0.21% 80.92% honduras 17,760 2,065 67,136 47,311 3.08% 26% 10.42% 89.58% 0.15% 20.56% ethiopia 24,493 996 63,888 38,399 1.56% 38% 3.91% 96.09% 0.40% 36.44% portugal 43,894 1,860 63,310 17,556 2.94% 69% 4.07% 95.93% 0.14% 67.01% venezuela 47,729 477 59,630 11,424 0.80% 80% 0.99% 99.01% 0.57% 77.97% bahrain 53,192 211 59,586 6,183 0.35% 89% 0.40% 99.60% 0.32% 85.07% singapore 56,699 27 57,357 631 0.05% 99% 0.05% 99.95% 0.28% 97.64% nigeria 44,088 1,078 56,177 11,011 1.92% 78% 2.39% 97.61% 0.35% 76.45% costa rica 20,928 590 55,454 33,936 1.06% 38% 2.74% 97.26% 0.16% 32.11% nepal 37,524 336 53,120 15,260 0.63% 71% 0.89% 99.11% 0.81% 67.71% algeria 33,875 1,605 48,007 12,527 3.34% 71% 4.52% 95.48% 0.21% 68.64% uzbekistan 43,511 386 46,850 2,953 0.82% 93% 0.88% 99.12% 0.05% 90.71% switzerland 38,500 2,020 46,704 6,184 4.33% 82% 4.99% 95.01% 0.11% 76.85% armenia 41,605 911 45,675 3,159 1.99% 91% 2.14% 97.86% 0.05% 89.51% central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu country total recovered total deaths total cases active cases model 1 model 2 model 3 cfr1 crr1 cfr2 crr2 cfr3 crr3 ghana 44,342 286 45,434 806 0.63% 98% 0.64% 99.36% 0.02% 94.92% kyrgyzstan 40,779 1,063 44,828 2,986 2.37% 91% 2.54% 97.46% 0.62% 89.86% moldova 30,437 1,117 42,714 11,160 2.62% 71% 3.54% 96.46% 0.32% 69.91% afghanistan 31,234 1,420 38,641 5,987 3.67% 81% 4.35% 95.65% 0.03% 79.89% azerbaijan 35,607 559 38,172 2,006 1.46% 93% 1.55% 98.45% 0.15% 90.23% kenya 22,771 619 35,969 12,579 1.72% 63% 2.65% 97.35% 0.02% 60.83% czechia 21,205 453 35,401 13,743 1.28% 60% 2.09% 97.91% 0.25% 56.27% austria 26,579 754 32,696 5,363 2.31% 81% 2.76% 97.24% 0.09% 78.70% serbia 31,100 731 32,300 469 2.26% 96% 2.30% 97.70% 0.03% 91.26% ireland 23,364 1,783 30,730 5,583 5.80% 76% 7.09% 92.91% 0.19% 73.41% palestine 19,979 210 29,906 9,717 0.70% 67% 1.04% 98.96% 0.19% 66.07% paraguay 13,679 514 27,324 13,131 1.88% 50% 3.62% 96.38% 0.08% 45.81% el salvador 17,874 782 26,851 8,195 2.91% 67% 4.19% 95.81% 0.19% 65.70% world 20,811,464 924,577 28,943,657 7,207,616 3.19% 72% 4.25% 95.75% 0.73% 68.72% table 1. the comparison of case fatality rate (cfr) and case recovery rate (crr) by model between 72 different countries with at least 1,000 total cases. data retrieved 13 september 2020. continents number of countries total recovered total deaths total cases active cases model 1 model 2 model 3 cfr1 crr1 cfr2 crr2 cfr3 crr3 europe 48 2,239,376 212,327 4,053,217 1,601,514 5.24% 55% 8.66% 55% 2.47% 47.72% north america 39 4,835,653 289,160 7,950,455 2,825,642 3.64% 61% 5.64% 61% 0.52% 59.77% asia 49 6,843,427 162,543 8,485,682 1,479,712 1.92% 81% 2.32% 81% 0.17% 78.56% south america 14 5,771,324 227,166 7,073,893 1,075,403 3.21% 82% 3.79% 82% 0.05% 81.19% africa 57 1,096,779 32,556 1,352,693 223,358 2.41% 81% 2.88% 81% 0.08% 80.68% oceania 7 25,940 843 29,967 3,184 2.81% 87% 3.15% 87% 0.27% 69.35% world 210 20,813,150 924,610 28,946,628 7,208,868 3.19% 72% 4.25% 72% 0.41% 70.36% table 2. continental comparison of cfrs and crrs using three various proposed estimation methods khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu figure 2. comparison between countries with low, moderate, and high cfr variables model 1 model 2 model 3 rs p rs p rs p population with cfr 0.088 0.597 -0.078 0.637 0.124 0.457 population with crr 0.098 0.556 0.078 0.637 -0.082 0.622 gdp with cfr 0.152 0.361 -0.029 0.859 0.266 0.106 gdp with crr 0.121 0.467 0.029 0.859 0.005 0.974 nhb with cfr -0.167 0.315 -0.149 0.637 0.192 0.247 nhb with crr 0.124 0.457 0.149 0.371 0.121 0.468 nib with cfr 0.112 0.501 0.014 0.933 0.029 0.073 nib with crr 0.122 0.462 -0.014 0.933 0.217 0.188 number of ventilators with cfr -0.221 0.181 -0.009 0.953 0.041 0.803 number of ventilators with crr -0.109 0.511 0.009 0.953 -0.088 0.0595 note: nhb: number of hospital beds per 1000 people; nib: number of icu beds per 100,000 people; cfr: case fatality rate; crr: case recovery rate; rs: pearson correlation coefficient; p: p-value table 3. the estimated cfrs and crrs against the county’s population, gdp, number of hospital beds per 1,000 people, number of icu beds per 100,000 people, and number of ventilators between the three different proposed models of estimation. khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu study id (reference) country population method cfr estimation level change et al, 2020 (19) china >30 chinese locations and other countries/regions model 1 (computational using bayes theorem) 3.7% local yang et al., 2020 (20) china 205 patients with cancer and laboratory-confirmed sarscov-2 infection model 1 hematological malignancies: 41% solid tumors: 3.28 local turk et al., 2020 (21) usa 474 people with intellectual and developmental disabilities (idd) model 1 (cfr within 30 days) 5.1% local capalbo et al., 2020 (22) italy 182 patients with laboratoryconfirmed sars-cov-2 infection model 2 12.1% local dongarwar and salihu, 2020 (23) usa a total of 213 countries had been affected by the disease as of may 6, 2020 model 1 asia: 3.5 australia: 1.4% global peng et al., 2020 (24) china 82,836 patients with covid19 were confirmed in mainland china model 1 5.6% local abdollahi et al., 2020 (3) canada and usa using data for covid-19 confirmed cases model 1 (cfr within 30 days) canada: 4.9% usa: 5.4% local undela and gudi, 2020 (25) india 2,761,121 confirmed cases model 1 7.0% global mi et al, 2020 (26) china 82,735 confirmed cases model 1 5.7% local khafaie and rahim, 2020 (12) iran 33,570 confirmed cases model 1 (cfr within 30 days) 3.61 global table 4. reported values and methods to calculate cfr from the literature on covid-19 discussion we have presented a global consequence of covid-19 in terms of cfrs and crrs using three different estimation methods. by april 18, 2020, deceased cases reached 119,699, according to data from worldometer.20 we have shown that the cfr varies greatly geographically and even depends on the method of estimation implemented and case reports' timing. as a clear example of this, a cfr of 0.31 was estimated in singapore and 98.82 in the uk. even with the more precise cfr estimation method,4 we hypothesize that the value is still overestimated. other factors that could contribute to varying estimations are the pandemic stage, number and types of tests performed, strategies of diagnostics, capability of the healthcare system, and the reporting system. for example, the usa had a significant increase in testing capacity, but the preliminary estimates of cfrs did not change dramatically (cfr=3.07 on khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489|http://cajgh.pitt.edu march 12, 2020 vs. 4.03 on april 18, 2020).13 as of april 2020, most countries were testing people with severe symptoms, mainly those needing hospitalization. the important point is that it is still unclear how many cases of covid-19 were asymptomatic, or whether similar standards for testing are being performed between countries. cross-country comparisons cannot be reliable indicators, unless countries are comparable or important factors are adjusted for. however, if all these possible limitations are carefully acknowledged, cfr may help better appreciate the severity of covid-19 and required mitigation steps. given the impossibility of accurately estimating cfr and crr while the covid-19 pandemic has not yet ended, using different methods to estimate cfr and crr, considering all possible scenarios, could help us to better estimate disease severity across different countries. some researchers prefer to use the proportion of total deaths and recovered cases of covid-19 disease to total disease cases at global and national levels to estimate cfrs and crrs. after the end of the pandemic, observing cfr and crr using this method can be done, but while the pandemic is still ongoing, this method is naïve and could be misleading. the immune response to covid-19 is not fully understood yet. studies suggested the possible likelihood of relapse in recovered patients and existing models do not account for that. however, method iii highly depends on the selected time period from where total cases are considered as the denominator.18 the estimation of cfr using method iii (6.22%) is similar to the method i (8.67%). however, because all the cases have not been resolved, method iii can still be assumed to be the more precise.18 otherwise, we suggest merely extracting the active cases from the denominator while using method i. undiagnosed cases are important for the disease spread, so detecting asymptomatic/undiagnosed cases is critical for the covid-19 pandemic control. to this end, new methods based on mathematical models have been recently proposed to accurately calculate the healthrelated consequences of the covid-19.21 one of these models is the susceptible–exposed–infectious– recovered–dead (seird) model, which could be applied to better estimate the covid-19 transmission rate and case fatality risk worldwide.22 cfr is used as a measure of disease severity and ideally, should be estimated by direct follow-up of cases and ascertainment of their outcome.23 we have alternatively estimated the risk in a population within a specified period by dividing the number of deaths associated with the disease by the number of cases of that disease using different methods. in this current report, we have presented risk instead of “rate” because the numerator cases were not a subset of the denominator's population. all three methods of cfr estimation have their limitations. common limitations of the methods are the undiagnosed cases and delays in reporting data. another limitation of this research is removing countries with a relatively small number of covid-19 confirmed cases in the main analyses, since cfr is a flawed metric of mortality risk when the sample size is small or very limited. cfr is commonly used to measure disease severity and is often used to predict the course or outcome of a disease. it can also be used to evaluate the effectiveness of new therapies by reducing measures and improving methods. in the covid-19 outbreak, widespread changes in cfr estimates can be misleading, which may lead to underestimating the potential threat of covid-19 in symptomatic patients. it is difficult to compare estimates across the countries, as different countries use different definitions and various testing strategies that may or may not include some cases. changes in cfr may also be impacted by testing delays, dealing with delays, and differences in the quality of care or interventions at diverse stages of the disease. moreover, gender, ethnicity, and underlying diseases may vary by country. cross-sectional comparisons of cfr values may be biased because the disease duration may potentially vary from country to central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu country during the epidemic. to avoid this bias, timeadjusted estimates between the onset of symptoms and death should be recommended to compare cfrs across countries.13 therefore, the estimation of cfr in response to covid-19 pandemic disease is a high priority, but its interpretation must be done using evidence-based strategies. though each model has its disadvantages and pitfalls, we recommend estimating cfr using corrected model i by dividing the number of deaths on a given day by the number of patients with confirmed covid-19 infection 14 days before, based on the assumed maximum incubation period of up to 14 days. the who announced that the fatality rate of the covid-19 is 10 times higher than that of influenza, making this research timely and relevant.14 due to high mortality cases around the world, accurate calculations and clear estimates of cfr for covid-19 can inform public health interventions and policies to improve health locally and globally. cfr and crr are not the only measures of severity of the disease, and better estimators could be explored in future research. references 1. zhou p, yang xl, wang xg, et al. a pneumonia outbreak associated with a new coronavirus of probable bat origin. nature. 2020;579(7798):270273. doi: 10.1038/s41586-020-2012-7 2. sun p, lu x, xu c, sun w, pan b. understanding of covid-19 based on current evidence. j med virol. 2020. doi: 10.1002/jmv.25722 3. dong e, du h, gardner l. an interactive webbased dashboard to track covid-19 in real time. lancet infect dis. 2020;20(5):533-544. doi: 10.1016/s1473-3099(20)30120-1 4. abdollahi e, champredon d, langley jm, galvani ap, moghadas sm. temporal estimates of casefatality rate for covid-19 outbreaks in canada and the united states. cmaj. 2020. doi: 10.1503/cmaj.200711 5. kampf g, todt d, pfaender s, steinmann e. persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. j hosp infect. 2020;104(3):246-251. doi: 10.1016/j.jhin.2020.01.022 6. lauer sa, grantz kh, bi q, et al. the incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application. annals of internal medicine. 2020;172(9):577-582. doi: 10.7326/m20-0504 7. bulut c, kato y. epidemiology of covid-19. turk j med sci. 2020;50(si-1):563-570. doi: 10.3906/sag-2004-172 8. antunes jl. a dictionary in the dynamics of epidemiology. rev bras epidemiol. 2016;19(1):219-223. doi:10.1590/1980/5497201600010020 9. rajgor dd, lee mh, archuleta s, bagdasarian n, quek sc. the many estimates of the covid-19 case fatality rate. the lancet infectious diseases. 2020;20(7):776-777. doi: 10.1016/s14733099(20)30244-9 10. lipsitch m, donnelly ca, fraser c, et al. potential biases in estimating absolute and relative casefatality risks during outbreaks. plos negl trop dis. 2015;9(7):e0003846. doi: 10.1371/journal.pntd.0003846 11. atkins ke, wenzel ns, ndeffo-mbah m, altice fl, townsend jp, galvani ap. under-reporting and case fatality estimates for emerging epidemics. bmj. 2015;350:h1115. doi: 10.1136/bmj.h1115 12. national academies of sciences, engineering, and medicine; health and medicine division; board on health care services; committee on health care utilization and adults with disabilities. health-care utilization as a proxy in disability determination. washington (dc): national academies press (us); march 1, 2018. 13. khafaie ma, rahim f. cross-country comparison of case fatality rates of covid19/sars-cov-2. osong public health res perspect. 2020;11(2):74-80. doi: 10.24171/j.phrp.2020.11.2.03 14. world health organization (who). coronavirus disease 2019 (covid-19) situation report –43. khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489|http://cajgh.pitt.edu world health organization. march 3, 2020. accessed december 2020. https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200303sitrep-43-covid-19.pdf. 15. centers of disease control and prevention (cdc). united states covid-19 cases and deaths by state. centers for disease control and prevention. 2020. accessed march 10, 2020, https://www.cdc.gov/coronavirus/2019ncov/cases-in-us.html. 16. (us) rmafhraq. registries for evaluating patient outcomes: a user's guide [internet]. data sources for registries. 2014; https://www.ncbi.nlm.nih.gov/books/nbk208611/ 17. battegay m, kuehl r, tschudin-sutter s, hirsch hh, widmer af, neher ra. 2019-novel coronavirus (2019-ncov): estimating the case fatality rate a word of caution. swiss med wkly. 2020;150:w20203. doi: 10.4414/smw.2020.20203 18. ghani ac, donnelly ca, cox dr, et al. methods for estimating the case fatality ratio for a novel, emerging infectious disease. am j epidemiol. 2005;162(5):479-486. doi: 10.1093/aje/kwi230 19. baud d, qi x, nielsen-saines k, musso d, pomar l, favre g. real estimates of mortality following covid-19 infection. the lancet infectious diseases. 2020;20(7):773. doi: 10.1016/s14733099(20)30195-x 20. covid tc, stephanie b, virginia b, et al. geographic differences in covid-19 cases, deaths, and incidence-united states, february 12april 7, 2020. mmwr morb mort wkly rep. 2020;69(15);465-471. doi: 10.15585/mmwr.mm6915e4 21. li r, pei s, chen b, et al. substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2). science. 2020;368(6490):489-493. doi: 10.1126/science.abb3221 22. maugeri a, barchitta m, battiato s, agodi a. estimation of unreported novel coronavirus (sars-cov-2) infections from reported deaths: a susceptible-exposed-infectious-recovereddead model. j clin med. 2020;9(5):1350. doi: 10.3390/jcm9051350 23. kelly h, cowling bj. case fatality: rate, ratio, or risk? epidemiology. 2013;24(4):622-623. doi: 10.1097/ede.0b013e318296c2b6 khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu table s1. the comparison of case fatality rate (cfr) and case recovery rate (crr) between different countries (n = 210 countries and territories around the world and 2 international conveyances). data retrieved on september 13, 2020. country total recovered total deaths total cases active cases cfr1 crr1 cfr2 crr2 cfr3 crr3 usa 3,950,354 198,128 6,676,601 2,528,119 2.97% 59% 4.78% 95.22% 0.85% 57.09% india 3,702,595 78,614 4,754,356 973,147 1.65% 78% 2.08% 97.92% 0.49% 75.34% brazil 3,553,421 131,274 4,315,858 631,163 3.04% 82% 3.56% 96.44% 0.63% 80.79% russia 873,535 18,484 1,057,362 165,343 1.75% 83% 2.07% 97.93% 2.20% 78.31% peru 559,321 30,593 722,832 132,918 4.23% 77% 5.19% 94.81% 0.85% 61.54% colombia 592,820 22,734 708,964 93,410 3.21% 84% 3.69% 96.31% 2.98% --- mexico 467,525 70,604 663,973 125,844 10.63% 70% 13.12% 86.88% 0.44% 65.32% south africa 576,423 15,427 648,214 56,364 2.38% 89% 2.61% 97.39% 0.90% 77.98% spain n/a 29,747 576,697 n/a 5.16% ---100.00% ---0.14% --- argentina 409,771 11,263 546,481 125,447 2.06% 75% 2.68% 97.32% 0.85% 60.79% chile 404,919 11,895 432,666 15,852 2.75% 94% 2.85% 97.15% 1.06% 86.39% iran 344,516 23,029 399,940 32,395 5.76% 86% 6.27% 93.73% 0.68% 81.57% france 89,059 30,910 373,911 253,942 8.27% 24% 25.76% 74.24% 1.93% 20.91% uk n/a 41,623 365,174 n/a 11.40% ---100.00% ---1.24% --- bangladesh 238,271 4,702 336,044 93,071 1.40% 71% 1.94% 98.06% 0.28% 68.78% saudi arabia 301,836 4,240 325,050 18,974 1.30% 93% 1.39% 98.61% 0.51% 86.03% pakistan 289,429 6,379 301,481 5,673 2.12% 96% 2.16% 97.84% 0.26% 93.21% turkey 257,731 6,999 289,635 24,905 2.42% 89% 2.64% 97.36% 0.32% 88.52% iraq 221,283 7,941 286,778 57,554 2.77% 77% 3.46% 96.54% 0.23% 76.62% italy 213,191 35,603 286,297 37,503 12.44% 74% 14.31% 85.69% 0.38% 71.24% germany 235,300 9,427 260,546 15,819 3.62% 90% 3.85% 96.15% 0.87% 89.92% philippines 187,116 4,292 257,863 66,455 1.66% 73% 2.24% 97.76% 0.06% 71.58% indonesia 152,458 8,650 214,746 53,638 4.03% 71% 5.37% 94.63% 0.09% 67.64% israel 113,496 1,103 152,722 38,123 0.72% 74% 0.96% 99.04% 0.94% 68.37% ukraine 68,346 3,148 151,859 80,365 2.07% 45% 4.40% 95.60% 0.36% 36.87% canada 120,075 9,170 136,141 6,896 6.74% 88% 7.10% 92.90% 0.01% 87.39% bolivia 82,796 7,297 125,982 35,889 5.79% 66% 8.10% 91.90% 0.23% 63.32% qatar 118,475 205 121,523 2,843 0.17% 97% 0.17% 99.83% 0.16% 91.46% ecuador 91,242 10,864 116,451 14,345 9.33% 78% 10.64% 89.36% 0.33% 76.72% kazakhstan 100,615 1,634 106,803 4,554 1.53% 94% 1.60% 98.40% 0.53% 91.90% dominican republic 76,531 1,953 103,092 24,608 1.89% 74% 2.49% 97.51% 0.62% 71.19% romania 42,811 4,127 102,386 55,448 4.03% 42% 8.79% 91.21% 0.07% 40.11% panama 73,476 2,155 101,041 25,410 2.13% 73% 2.85% 97.15% 0.01% 71.66% egypt 83,261 5,627 100,856 11,968 5.58% 83% 6.33% 93.67% 0.08% 80.48% kuwait 84,404 558 94,211 9,249 0.59% 90% 0.66% 99.34% 0.26% 80.19% belgium 18,709 9,923 92,478 63,846 10.73% 20% 34.66% 65.34% 0.83% 18.99% oman 83,325 762 88,337 4,250 0.86% 94% 0.91% 99.09% 0.25% 93.35% sweden n/a 5,846 86,505 n/a 6.76% ---100.00% ---0.49% --- china 80,399 4,634 85,184 151 5.44% 94% 5.45% 94.55% 0.19% 92.96% morocco 65,867 1,553 84,435 17,015 1.84% 78% 2.30% 97.70% 0.61% 76.91% guatemala 70,403 2,949 81,658 8,306 3.61% 86% 4.02% 95.98% 0.25% 86.18% khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489|http://cajgh.pitt.edu country total recovered total deaths total cases active cases cfr1 crr1 cfr2 crr2 cfr3 crr3 netherlands n/a 6,253 81,012 n/a 7.72% ---100.00% ---0.28% --- uae 68,983 399 78,849 9,467 0.51% 87% 0.58% 99.42% 0.11% 80.38% japan 66,280 1,423 74,544 6,841 1.91% 89% 2.10% 97.90% 0.38% 87.58% belarus 72,547 744 73,975 684 1.01% 98% 1.02% 98.98% 0.23% 97.45% poland 59,725 2,182 73,650 11,743 2.96% 81% 3.52% 96.48% 0.21% 80.92% honduras 17,760 2,065 67,136 47,311 3.08% 26% 10.42% 89.58% 0.15% 20.56% ethiopia 24,493 996 63,888 38,399 1.56% 38% 3.91% 96.09% 0.40% 36.44% portugal 43,894 1,860 63,310 17,556 2.94% 69% 4.07% 95.93% 0.14% 67.01% venezuela 47,729 477 59,630 11,424 0.80% 80% 0.99% 99.01% 0.57% 77.97% bahrain 53,192 211 59,586 6,183 0.35% 89% 0.40% 99.60% 0.32% 85.07% singapore 56,699 27 57,357 631 0.05% 99% 0.05% 99.95% 0.28% 97.64% nigeria 44,088 1,078 56,177 11,011 1.92% 78% 2.39% 97.61% 0.35% 76.45% costa rica 20,928 590 55,454 33,936 1.06% 38% 2.74% 97.26% 0.16% 32.11% nepal 37,524 336 53,120 15,260 0.63% 71% 0.89% 99.11% 0.81% 67.71% algeria 33,875 1,605 48,007 12,527 3.34% 71% 4.52% 95.48% 0.21% 68.64% uzbekistan 43,511 386 46,850 2,953 0.82% 93% 0.88% 99.12% 0.05% 90.71% switzerland 38,500 2,020 46,704 6,184 4.33% 82% 4.99% 95.01% 0.11% 76.85% armenia 41,605 911 45,675 3,159 1.99% 91% 2.14% 97.86% 0.05% 89.51% ghana 44,342 286 45,434 806 0.63% 98% 0.64% 99.36% 0.02% 94.92% kyrgyzstan 40,779 1,063 44,828 2,986 2.37% 91% 2.54% 97.46% 0.62% 89.86% moldova 30,437 1,117 42,714 11,160 2.62% 71% 3.54% 96.46% 0.32% 69.91% afghanistan 31,234 1,420 38,641 5,987 3.67% 81% 4.35% 95.65% 0.03% 79.89% azerbaijan 35,607 559 38,172 2,006 1.46% 93% 1.55% 98.45% 0.15% 90.23% kenya 22,771 619 35,969 12,579 1.72% 63% 2.65% 97.35% 0.02% 60.83% czechia 21,205 453 35,401 13,743 1.28% 60% 2.09% 97.91% 0.25% 56.27% austria 26,579 754 32,696 5,363 2.31% 81% 2.76% 97.24% 0.09% 78.70% serbia 31,100 731 32,300 469 2.26% 96% 2.30% 97.70% 0.03% 91.26% ireland 23,364 1,783 30,730 5,583 5.80% 76% 7.09% 92.91% 0.19% 73.41% palestine 19,979 210 29,906 9,717 0.70% 67% 1.04% 98.96% 0.19% 66.07% paraguay 13,679 514 27,324 13,131 1.88% 50% 3.62% 96.38% 0.08% 45.81% el salvador 17,874 782 26,851 8,195 2.91% 67% 4.19% 95.81% 0.19% 65.70% australia 23,340 810 26,651 2,501 3.04% 88% 3.35% 96.65% 0.23% 85.10% lebanon 7,936 239 23,669 15,494 1.01% 34% 2.92% 97.08% 0.05% 32.87% bosnia and herzegovina 15,922 690 23,138 6,526 2.98% 69% 4.15% 95.85% 0.08% 63.57% libya 12,100 354 22,348 9,894 1.58% 54% 2.84% 97.16% 0.18% 52.02% s. korea 18,226 358 22,176 3,592 1.61% 82% 1.93% 98.07% 0.37% 81.19% cameroon 18,837 415 20,009 757 2.07% 94% 2.16% 97.84% 0.32% 91.38% denmark 16,247 630 19,557 2,680 3.22% 83% 3.73% 96.27% 0.29% 80.39% ivory coast 17,960 119 18,916 837 0.63% 95% 0.66% 99.34% 0.10% 92.82% bulgaria 12,758 717 17,891 4,416 4.01% 71% 5.32% 94.68% 0.32% 70.16% madagascar 14,349 210 15,737 1,178 1.33% 91% 1.44% 98.56% 0.25% 89.56% north macedonia 13,128 646 15,694 1,920 4.12% 84% 4.69% 95.31% 0.09% 80.47% senegal 10,373 295 14,237 3,569 2.07% 73% 2.77% 97.23% 0.05% 71.13% sudan 6,731 834 13,470 5,905 6.19% 50% 11.02% 88.98% 0.03% 44.13% zambia 12,007 312 13,466 1,147 2.32% 89% 2.53% 97.47% 0.01% 85.62% croatia 10,721 218 13,368 2,429 1.63% 80% 1.99% 98.01% 0.40% 79.47% central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu country total recovered total deaths total cases active cases cfr1 crr1 cfr2 crr2 cfr3 crr3 greece 3,804 302 13,036 8,930 2.32% 29% 7.36% 92.64% 0.30% 27.04% norway 10,371 265 12,079 1,443 2.19% 86% 2.49% 97.51% 0.12% 84.63% hungary 4,058 633 11,825 7,134 5.35% 34% 13.49% 86.51% 0.11% 32.06% albania 6,494 330 11,185 4,361 2.95% 58% 4.84% 95.16% 0.36% 54.62% drc 9,719 262 10,385 404 2.52% 94% 2.62% 97.38% 0.27% 89.52% guinea 9,251 63 10,020 706 0.63% 92% 0.68% 99.32% 0.09% 89.49% malaysia 9,189 128 9,868 551 1.30% 93% 1.37% 98.63% 0.13% 86.58% namibia 5,811 98 9,604 3,695 1.02% 61% 1.66% 98.34% 0.25% 59.00% french guiana 9,132 63 9,521 326 0.66% 96% 0.69% 99.31% 0.30% 91.87% maldives 7,055 31 9,052 1,966 0.34% 78% 0.44% 99.56% 0.07% 74.77% tajikistan 7,782 72 9,014 1,160 0.80% 86% 0.92% 99.08% 0.09% 81.95% gabon 7,706 53 8,643 884 0.61% 89% 0.68% 99.32% 0.71% 88.24% finland 7,500 337 8,557 720 3.94% 88% 4.30% 95.70% 0.49% 82.17% haiti 6,120 219 8,478 2,139 2.58% 72% 3.45% 96.55% 0.18% 67.63% zimbabwe 5,675 224 7,508 1,609 2.98% 76% 3.80% 96.20% 0.09% 73.91% mauritania 6,804 161 7,274 309 2.21% 94% 2.31% 97.69% 0.56% 92.66% luxembourg 6,397 124 7,194 673 1.72% 89% 1.90% 98.10% 0.21% 88.24% tunisia 1,991 107 6,635 4,537 1.61% 30% 5.10% 94.90% 0.53% 24.70% montenegro 4,491 118 6,530 1,921 1.81% 69% 2.56% 97.44% 0.09% 66.39% malawi 3,724 177 5,678 1,777 3.12% 66% 4.54% 95.46% 0.46% 65.41% slovakia 3,114 38 5,453 2,301 0.70% 57% 1.21% 98.79% 0.51% 56.19% djibouti 5,327 61 5,394 6 1.13% 99% 1.13% 98.87% 0.07% 93.46% eswatini 4,188 98 5,050 764 1.94% 83% 2.29% 97.71% 0.14% 76.16% mozambique 2,905 35 5,040 2,100 0.69% 58% 1.19% 98.81% 0.12% 51.88% equatorial guinea 4,490 83 4,996 423 1.66% 90% 1.82% 98.18% 0.00% 83.87% hong kong 4,613 100 4,939 226 2.02% 93% 2.12% 97.88% 0.47% 91.11% congo 3,887 88 4,928 953 1.79% 79% 2.21% 97.79% 0.08% 75.95% nicaragua 2,913 144 4,818 1,761 2.99% 60% 4.71% 95.29% 0.15% 59.86% car 1,825 62 4,749 2,862 1.31% 38% 3.29% 96.71% 0.29% 36.03% cabo verde 4,104 44 4,711 563 0.93% 87% 1.06% 98.94% 0.04% 85.35% uganda 1,998 52 4,703 2,653 1.11% 42% 2.54% 97.46% 0.21% 36.06% cuba 3,878 108 4,653 667 2.32% 83% 2.71% 97.29% 0.21% 80.29% suriname 3,788 93 4,579 698 2.03% 83% 2.40% 97.60% 0.17% 80.78% rwanda 2,544 22 4,565 1,999 0.48% 56% 0.86% 99.14% 0.15% 51.59% jamaica 1,072 40 3,623 2,511 1.10% 30% 3.60% 96.40% 0.55% 22.74% slovenia 2,699 135 3,603 769 3.75% 75% 4.76% 95.24% 0.28% 73.58% syria 827 152 3,506 2,527 4.34% 24% 15.53% 84.47% 0.63% 22.99% thailand 3,312 58 3,473 103 1.67% 95% 1.72% 98.28% 0.00% 88.89% gambia 1,617 102 3,376 1,657 3.02% 48% 5.93% 94.07% 0.03% 47.63% somalia 2,791 98 3,376 487 2.90% 83% 3.39% 96.61% 0.27% 79.86% mayotte 2,964 40 3,374 370 1.19% 88% 1.33% 98.67% 0.00% 87.34% angola 1,289 132 3,335 1,914 3.96% 39% 9.29% 90.71% 0.09% 37.36% lithuania 2,070 86 3,296 1,140 2.61% 63% 3.99% 96.01% 0.24% 62.23% sri lanka 2,983 12 3,195 200 0.38% 93% 0.40% 99.60% 0.00% 90.45% guadeloupe 837 24 3,080 2,219 0.78% 27% 2.79% 97.21% 0.00% 21.40% jordan 2,156 22 3,062 884 0.72% 70% 1.01% 98.99% 0.46% 67.90% khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489|http://cajgh.pitt.edu country total recovered total deaths total cases active cases cfr1 crr1 cfr2 crr2 cfr3 crr3 aruba 1,542 18 2,994 1,434 0.60% 52% 1.15% 98.85% 0.40% 48.76% trinidad and tobago 766 51 2,993 2,176 1.70% 26% 6.24% 93.76% 0.17% 25.06% bahamas 1,319 67 2,928 1,542 2.29% 45% 4.83% 95.17% 0.00% 40.57% mali 2,276 128 2,916 512 4.39% 78% 5.32% 94.68% 0.03% 73.80% myanmar 676 16 2,796 2,104 0.57% 24% 2.31% 97.69% 0.57% 23.28% réunion 1,313 14 2,723 1,396 0.51% 48% 1.06% 98.94% 0.00% 45.46% estonia 2,252 64 2,655 339 2.41% 85% 2.76% 97.24% 0.11% 82.94% south sudan 1,290 49 2,578 1,239 1.90% 50% 3.66% 96.34% 0.00% 45.42% guinea-bissau 1,127 39 2,275 1,109 1.71% 50% 3.34% 96.66% 0.35% 46.95% malta 1,850 15 2,274 409 0.66% 81% 0.80% 99.20% 0.04% 77.53% botswana 546 10 2,252 1,696 0.44% 24% 1.80% 98.20% 0.27% 22.29% benin 1,793 40 2,242 409 1.78% 80% 2.18% 97.82% 0.04% 79.93% iceland 2,085 10 2,162 67 0.46% 96% 0.48% 99.52% 0.09% 93.06% sierra leone 1,634 72 2,096 390 3.44% 78% 4.22% 95.78% 0.29% 75.00% georgia 1,363 19 2,075 693 0.92% 66% 1.37% 98.63% 0.19% 63.66% yemen 1,211 582 2,009 216 28.97% 60% 32.46% 67.54% 0.20% 59.78% guyana 1,191 54 1,812 567 2.98% 66% 4.34% 95.66% 0.17% 63.41% new zealand 1,676 24 1,797 97 1.34% 93% 1.41% 98.59% 0.06% 90.21% uruguay 1,502 45 1,780 233 2.53% 84% 2.91% 97.09% 0.62% 83.15% togo 1,189 37 1,555 329 2.38% 76% 3.02% 96.98% 0.39% 73.95% cyprus 1,281 22 1,523 220 1.44% 84% 1.69% 98.31% 0.00% 81.02% burkina faso 1,127 56 1,514 331 3.70% 74% 4.73% 95.27% 0.40% 73.91% latvia 1,248 35 1,464 181 2.39% 85% 2.73% 97.27% 0.00% 84.43% belize 458 19 1,458 981 1.30% 31% 3.98% 96.02% 0.89% 29.15% andorra 943 53 1,344 348 3.94% 70% 5.32% 94.68% 0.60% 69.05% liberia 1,210 82 1,316 24 6.23% 92% 6.35% 93.65% 0.08% 90.58% lesotho 528 33 1,245 684 2.65% 42% 5.88% 94.12% 0.08% 41.77% niger 1,100 69 1,178 9 5.86% 93% 5.90% 94.10% 0.08% 92.53% chad 938 80 1,083 65 7.39% 87% 7.86% 92.14% 0.09% 83.56% vietnam 910 35 1,060 115 3.30% 86% 3.70% 96.30% 0.19% 84.15% french polynesia 642 2 953 309 0.21% 67% 0.31% 99.69% 0.00% 62.85% martinique 98 18 939 823 1.92% 10% 15.52% 84.48% 0.00% 8.73% sao tome and principe 866 15 906 25 1.66% 96% 1.70% 98.30% 0.00% 93.93% san marino 662 42 722 18 5.82% 92% 5.97% 94.03% 0.00% 87.26% diamond princess 651 13 712 48 1.83% 91% 1.96% 98.04% 0.42% 88.76% turks and caicos 270 5 641 366 0.78% 42% 1.82% 98.18% 0.00% 40.09% channel islands 575 48 633 10 7.58% 91% 7.70% 92.30% 0.47% 87.05% sint maarten 430 19 533 84 3.56% 81% 4.23% 95.77% 0.00% 78.80% tanzania 183 21 509 305 4.13% 36% 10.29% 89.71% 0.59% 35.17% papua new guinea 232 5 508 271 0.98% 46% 2.11% 97.89% 0.79% 44.69% taiwan 475 7 498 16 1.41% 95% 1.45% 98.55% 0.40% 94.18% burundi 374 1 471 96 0.21% 79% 0.27% 99.73% 0.64% 77.07% comoros 415 7 456 34 1.54% 91% 1.66% 98.34% 0.00% 90.57% faeroe islands 410 418 8 0.00% 98% 0.00% 100.00% 0.24% 98.09% mauritius 335 10 361 16 2.77% 93% 2.90% 97.10% 0.00% 90.03% eritrea 304 361 57 0.00% 84% 0.00% 100.00% 0.00% 82.27% central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu country total recovered total deaths total cases active cases cfr1 crr1 cfr2 crr2 cfr3 crr3 isle of man 312 24 337 1 7.12% 93% 7.14% 92.86% 0.59% 90.80% gibraltar 294 327 33 0.00% 90% 0.00% 100.00% 0.00% 86.24% mongolia 298 311 13 0.00% 96% 0.00% 100.00% 0.00% 93.57% cambodia 274 275 1 0.00% 100% 0.00% 100.00% 0.00% 93.45% saint martin 107 6 256 143 2.34% 42% 5.31% 94.69% 0.39% 37.50% bhutan 159 244 85 0.00% 65% 0.00% 100.00% 0.00% 59.84% cayman islands 204 1 208 3 0.48% 98% 0.49% 99.51% 0.00% 94.23% barbados 158 7 180 15 3.89% 88% 4.24% 95.76% 0.00% 86.67% bermuda 161 9 177 7 5.08% 91% 5.29% 94.71% 0.00% 82.49% monaco 123 1 169 45 0.59% 73% 0.81% 99.19% 0.00% 68.05% brunei 139 3 145 3 2.07% 96% 2.11% 97.89% 2.07% 91.03% curaçao 56 1 145 88 0.69% 39% 1.75% 98.25% 0.00% 31.03% seychelles 136 139 3 0.00% 98% 0.00% 100.00% 0.72% 94.24% liechtenstein 105 1 111 5 0.90% 95% 0.94% 99.06% 0.90% 90.99% antigua and barbuda 91 3 95 1 3.16% 96% 3.19% 96.81% 1.05% 93.68% british virgin islands 37 1 66 28 1.52% 56% 2.63% 97.37% 0.00% 39.39% st. vincent grenadines 61 64 3 0.00% 95% 0.00% 100.00% 0.00% 85.94% macao 46 46 0 0.00% 100% 0.00% 100.00% 2.17% 82.61% fiji 24 2 32 6 6.25% 75% 7.69% 92.31% 3.13% 53.13% saint lucia 26 27 1 0.00% 96% 0.00% 100.00% 7.41% 96.30% timor-leste 25 27 2 0.00% 93% 0.00% 100.00% 0.00% 85.19% new caledonia 26 26 0 0.00% 100% 0.00% 100.00% 0.00% 100.00% caribbean netherlands 7 25 18 0.00% 28% 0.00% 100.00% 4.00% 4.00% dominica 18 24 6 0.00% 75% 0.00% 100.00% 0.00% 58.33% grenada 24 24 0 0.00% 100% 0.00% 100.00% 4.17% 87.50% laos 21 23 2 0.00% 91% 0.00% 100.00% 0.00% 65.22% st. barth 13 21 8 0.00% 62% 0.00% 100.00% 0.00% 61.90% saint kitts and nevis 17 17 0 0.00% 100% 0.00% 100.00% 0.00% 70.59% greenland 14 14 0 0.00% 100% 0.00% 100.00% 0.00% 100.00% montserrat 11 1 13 1 7.69% 85% 8.33% 91.67% 0.00% 84.62% falkland islands 13 13 0 0.00% 100% 0.00% 100.00% 0.00% 76.92% vatican city 12 12 0 0.00% 100% 0.00% 100.00% 0.00% 100.00% saint pierre miquelon 5 11 6 0.00% 45% 0.00% 100.00% 0.00% 36.36% western sahara 8 1 10 1 10.00% 80% 11.11% 88.89% 0.00% 80.00% ms zaandam 2 9 7 22.22% 0% 100.00% 0.00% 0.00% 0.00% anguilla 3 3 0 0.00% 100% 0.00% 100.00% 0.00% 100.00% total 20,811,464 924,577 28,943,657 7,207,616 3.19% 72% 4.25% 95.75% 0.73% 68.72% khafaie & rahim this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu table s2. the estimated cfrs and crrs for each included country (n=38) against the county’s population, gdp, number of hospital beds per 1,000 people, number of icu beds per 100,000 people, and number of ventilators between the three different proposed models of estimation. country total recovered total deaths total cases active cases population (million) gdp (trillion) number of hospital beds per 1,000 people number of icu beds per 100,000 people number of ventilators model 1 model 2 model 3 cfr1 crr1 cfr2 crr2 cfr3 crr3 usa 36,948 23,644 587,155 526,563 327.2 19.39 2.77 34.7 177,000 4.03 6.29 39.02 60.98 6.96 12.18 spain 64,727 17,756 170,099 87,616 46.66 1.311 2.97 9.7 nr 10.44 38.05 21.53 78.47 12.37 44.83 italy 35,435 20,465 159,516 103,616 60.48 1.935 3.18 12.5 3,000 12.83 22.21 36.61 63.39 14.85 28.73 france 27,718 14,967 136,779 94,094 66.99 2.583 5.98 11.6 30,000 10.94 20.26 35.06 64.94 14.57 27.14 germany 64,300 3,194 130,072 62,578 82.79 3.677 8.00 29.2 25,000 2.46 49.43 4.73 95.27 3.55 66.79 uk 135 11,329 88,621 76,948 66.44 2.622 2.54 6.6 8,175 12.78 0.15 98.82 1.18 18.35 ---- china 77,738 3,341 82,249 1,170 1,386 12.24 4.34 3.6 nr 4.06 94.52 4.12 95.88 5.64 93.80 iran 45,983 4,585 73,303 22,735 81.16 0.4395 1.5 4.8 nr 6.25 62.73 9.07 90.93 2.64 14.58 turkey 3,957 1,296 61,049 55,796 80.81 0.8511 2.81 47.1 17,000 2.12 6.48 24.67 75.33 8.83 98.30 belgium 6,707 3,903 30,589 19,979 11.4 0.4927 5.76 15.9 nr 12.76 21.93 36.79 63.21 18.39 28.16 netherlands 250 2,823 26,551 23,478 17.18 0.8262 3.32 6.4 nr 10.63 0.94 91.86 8.14 9.27 54.82 switzerland 13,700 1,138 25,688 10,850 8.57 0.6789 4.53 11.0 nr 4.43 53.33 7.67 92.33 1.23 12.03 canada 7,756 780 25,680 17,144 37.59 1.653 2.52 13.5 nr 3.04 30.20 9.14 90.86 6.03 45.96 brazil 173 1,355 23,723 22,195 209.3 2.056 2.3 nr nr 5.71 0.73 88.68 11.32 16.13 1.12 russia 1,470 148 18,328 16,710 144.5 1.578 8.05 8.3 40,000 0.81 8.02 9.15 90.85 8.25 103.11 portugal 277 535 16,934 16,122 10.29 0.2176 3.39 4.2 1,400 3.16 1.64 65.89 34.11 4.36 3.87 austria 7,343 368 14,041 6,330 24.6 1.323 3.84 9.1 1,314 2.62 52.30 4.77 95.23 3.74 17.66 israel 1,855 116 11,586 9,615 8.712 0.3509 3.02 nr nr 1.00 16.01 5.89 94.11 5.12 0.69 sweden 381 919 10,948 9,648 10.12 0.538 2.22 5.8 nr 8.39 3.48 70.69 29.31 4.20 96.93 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 10, no. 1 (2021) | issn 2166-7403 (online) | doi 10.5195/cajgh.2021.489 | http://cajgh.pitt.edu ireland 25 365 10,647 10,257 4.83 0.3337 2.96 6.5 nr 3.43 0.23 93.59 6.41 3.32 63.76 s. korea 7,534 222 10,564 2,808 51.4 1.531 12.27 10.6 9,795 2.10 71.32 2.86 97.14 15.65 5.70 india 1,181 358 10,453 8,914 1,339 2.597 0.53 5.2 40,000 3.42 11.30 23.26 76.74 1.78 37.54 peru 2,642 216 9,784 6,926 32.17 0.2114 1.6 nr nr 2.21 27.00 7.56 92.44 3.11 96.101 japan 799 143 7,645 6,703 126.8 4.872 13.05 7.3 32,586 1.87 10.45 15.18 84.82 2.97 14.32 ecuador 597 355 7,529 6,577 16.62 0.1031 1.50 nr nr 4.72 7.93 37.29 62.71 1.71 54.75 chile 2,367 82 7,525 5,076 18.05 0.2771 2.2 2.11 nr 1.09 31.46 3.35 96.65 6.32 13.97 poland 487 245 6,934 6,202 37.98 0.5245 6.62 6.9 10,100 3.53 7.02 33.47 66.53 5.20 14.70 romania 914 331 6,633 5,388 19.53 0.2118 6.3 21.4 nr 4.99 13.78 26.59 73.41 6.45 26.51 norway 32 134 6,605 6,439 5.368 0.3988 3.6 8 800 2.03 0.48 80.72 19.28 1.46 21.02 australia 3,494 61 6,394 2,839 24.6 1.323 3.84 9.1 1,314 0.95 54.64 1.72 98.28 2.27 29.08 denmark 2,235 285 6,318 3,798 5.603 0.3249 2.61 6.7 nr 4.51 35.38 11.31 88.69 10.53 42.55 czech republic 519 143 6,059 5,397 10.65 0.2157 6.63 11.6 3,529 2.36 8.57 21.60 78.40 5.78 64.21 pakistan 1,097 96 5,707 4,514 197 0.305 0.6 nr 34,000 1.68 19.22 8.05 91.95 3.14 0.61 mexico 1,964 332 5,014 2,718 129.2 1.15 1.38 1.2 2,050 6.62 39.17 14.46 85.54 3.87 26.20 saudi arabia 805 65 4,934 4,064 32.94 0.6838 2.7 nr nr 1.32 16.32 7.47 92.53 1.50 89.40 philippines 242 315 4,932 4,375 104.9 0.3136 1.0 nr nr 6.39 4.91 56.55 43.45 0.80 25.56 malaysia 2,276 77 4,817 2,464 31.62 0.3145 1.9 nr nr 1.60 47.25 3.27 96.73 11.99 14.14 indonesia 380 399 4,557 3,778 264 1.016 1.2 nr nr 8.76 8.34 51.22 48.78 9.36 12.17 world 445,023 119,699 1,925,179 1,360,457 --------------------6.22 23.12 21.20 78.80 8.67 32.23 cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. recommendations for mental health reforms in uzbekistan: a policy report akmal alikhan aliev1*, tatiana taylor salisbury1 1centre for global mental health, health service and population research department, institute of psychiatry, psychology and neuroscience, king’s college london, london, uk *corresponding author vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ aliev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu abstract introduction: there are large differences in the development of mental health systems of the west and the countries of the former eastern bloc. the latter is characterized by a more biological approach to mental health and reliance on psychiatric hospitals. in 2018, uzbekistan authorities showed interest in reforming mental health care of the country. the policy report provides an overview of progress towards the provision of community mental health (cmh) care across eastern europe and recommendations for this transition within uzbekistan. methods: a literature search on mental health care in uzbekistan was conducted to understand its strengths and weaknesses. progress towards the provision of cmh care across eastern europe was assessed using data on the number of psychiatric beds and availability of mental health services in community settings reported within the published literature. countries identified as making the greatest progress towards cmh care were reviewed in detail to better understand the process of reform assets and barriers. results: mental health care in uzbekistan is highly institutionalized, underfunded and understaffed. social care services are poorly developed. however, current leadership has kindled the promise of mental health reform. georgia, lithuania and poland have made the most progress in terms of cmh care availability. however, due to various obstacles such as dual financial burden, high stigma and lack of political will, their programs lack social integration and/or uniform availability and underfunding along with scarcity of mental health specialists are common. on the other hand, research and evaluation, involvement of service users into service planning and cooperation with donors facilitated reform implementation. conclusion: uzbekistan may develop into a modern mental health system and avoid the setbacks encountered by other countries in the region, through careful financial planning, stigma reduction, improving mental health literacy, human resources strategic development and civil society engagement. keywords: deinstitutionalization; policy report; uzbekistan recommendations for mental health reforms in uzbekistan: a policy report akmal alikhan aliev1, tatiana taylor salisbury1 1centre for global mental health, health service and population research department, institute of psychiatry, psychology and neuroscience, king’s college london, london, uk research the reform of mental health care in eastern europe (i.e. the 23 countries of the united nations eastern european group1) has not been as swift as in western europe. in the west, mental health care reform began in earnest in the mid-20th century with closures of mental asylums and psychiatric hospitals in response to financial, treatment and societal shifts2,3 which resulted in major policy shifts favoring community-based mental health care and deinstitutionalization4. community mental health (cmh) is based on the principle that treatment is provided in the least confined environment and aimed at rehabilitating the person for returning to the society5. the process of downsizing psychiatric hospitals while expanding mental health services within the community is known as deinstitutionalization6. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu while deinstitutionalization was commonplace across western europe during the end of the 20th century, a more biological approach to mental health held across eastern europe (ee) supported the institutionalization of mental health care in the region7. although progress towards deinstitutionalization in europe varies significantly from country to country8, across ee it is generally hampered by insufficient numbers of mental health professionals, a significant reliance on inpatient care and a lack of funding9. uzbekistan, a middle-income country in central asia with a population of 32.4 million people10, gained independence after the collapse of soviet union and has experienced a long period of stagnation with mental health services concentrated primarily in old overcrowded psychiatric institutions with poor sanitary conditions11. recently the country has shown signs of openness for wide-ranging reforms, including in mental health. a revised psychiatric care law is planned to be issued in the near future with a focus on human rights. the presidential decree on mental health published in 2018 aimed at reducing the treatment gap, improving the quality of care in hospitals and increasing the psychiatric workforce12. however, the country’s new mental health policy does not include a commitment to developing cmh care, which could contribute to bridging the health gap between uzbekistan and western europe13. the aim of this paper is to provide evidencebased recommendations for the reform of the uzbekistan’s mental health care. this policy report provides (1) a description of the current mental health system in uzbekistan, and (2) a discussion of reforms in mental health systems of ee countries. based on these findings, recommendations for deinstitutionalization in uzbekistan are proposed. methods review of uzbekistan’s mental health system a literature search on the uzbekistan’s mental health system published between 1991 (year of uzbekistan’s independence) and april 2019 was conducted across four databases (medline, embase, psychinfo and web of science). the search strategy (appendix) was based on a previous review of mental health systems in ee14. literature on the epidemiology of severe mental disorders (icd-10 diagnosis: f20–f22, f24, f25, f28– f31, f32.3, and f33.3), available mental health services and staff, policy and legislation, financing of mental health care, stigma and service users’ involvement was included. severe mental disorders were selected due to their high socio-economic burden15. the inclusion criteria were extended to include opinion papers, reports and editorials. all literature published in english or russian languages were included. clinical, biological, psychometric research papers, case studies, conference abstracts were excluded. after title and abstract screening, studies that did not meet inclusion criteria were excluded as not relevant and the rest were screened for full-text. identified studies were complemented with world health organization (who) reports (e.g. health systems in transition, who-aims and mental health atlas). state websites (e.g. lex.uz and minzdrav.uz) were used to obtain documents on mental health law, legal acts and presidential decrees concerning mental health. data from included articles were coded and extracted according to topics mentioned above. a narrative synthesis was used to summarize the information. the impact of mental health reforms on deinstitutionalization in eastern europe mental health care transition from institutes to cmh in ee was evaluated through psychiatric beds reduction and availability of community services. mental health atlas16–19 was used for psychiatric beds change calculation and availability of community mental health services was analyzed through 23 country profiles in the lancet’s review of mental health systems in ee20. georgia, lithuania and poland were identified as http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aliev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu countries which had achieved the most progress in the transition to cmh in ee for their significant inpatient bed reduction and commitment to scale-up community services. details with tables on the process of identification of these three countries can be found in the appendix. selected countries were then further examined by literature referenced in the corresponding country profiles in the lancet review14. key milestones in the development of mental health policies and systems were extracted for each of the identified countries as a particular focus on the factors that contributed to reform and cmh and challenges experienced. activities, milestones and barriers common across identified countries were explored. triangulation of information identified through the literature review was used to develop a set of recommendations for mental health reform in uzbekistan. results mental health care in uzbekistan one hundred and forty unique records were identified through the search strategy (figure 1). following title and abstract screening, eight full-text articles were reviewed. two articles did not meet inclusion criteria and one article could not be found. an additional three legislation and policy documents and three national reports were included. figure 1. screening and selection of articles http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aliev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu uzbekistan adopted its first mental health law, on psychiatric care, in the year 2000, which ensures the rights of people with mental disorders and outlines involuntary hospitalization procedures21. in july 2018, a draft of the amended law was published for public consultation. this included more thorough regulation of involuntary hospitalization, including court appeal process and state supervision over the activities of psychiatric care provision22. a national mental health policy and plan, which focused on shifting services from hospitals to the community was also introduced in 2000. however, it was not accompanied by an increase in funding and remains largely unenacted23. a number of legal acts were published in 2013-2014. these aimed to improve psychiatric provision through incentivizing mental health workers and ameliorating patient quality of life24. the proportion of mental health expenditure has varied and declined since independence. the latest available data from 2012 reports 2.1% of the total health budget is spent on mental health25. additional funds have been allocated to mental health care since 2013 by the ministry of finance together with loans and grants from foreign states for the reconstruction of psychiatric facilities and purchase of medical equipment12,25. before independence, primary care was neglected in favor of secondary and tertiary care provision26. this was and still is particularly true for mental health. most (89%) of the mental health budget is spent on psychiatric hospitals while integration of mental health into primary care remains poor23,27. outpatient care is provided by 22 psychiatric dispensaries located across the country, including day treatment in some regions28. although psychiatric hospitals continue to receive the majority of the mental health budget, the number of beds in mental hospitals and psychiatric dispensaries has declined nearly two-fold since 199128. however, the associated savings from reduced bed numbers were not reallocated to create community-based services but, instead, diverted to other health care concerns28. today, the number of beds in psychiatric hospitals is 26 per 100,000 population but it does not fully reflect the institutionalization of people with mental disorders in uzbekistan. an additional 890 beds are located in forensic inpatient departments and 6,500 beds for people with mental disabilities across 20 social care homes26. in addition, tens of thousands of children with special education needs are placed in more than 200 special boarding schools in the country25. it is not clear whether reduction of psychiatric beds is associated with transinstitutionalization of people from hospitals to other institutions since information on these facilities is not publicly available. due to the stigmatization of the field of psychiatry, relatively low salaries and poor working conditions, the number of psychiatrists working in uzbekistan has declined nearly two-fold since 1991 to 2.8 per 100,000 population25. however, the country retains a high number of psychiatric nurses, with nine per 100,000. social workers and psychologists are not integrated into the health system. there are only 0.08 psychologists per 100,000 population and no social workers or occupational therapists involved in mental health care17. to address the lack of human resources for mental health, the 2018 presidential decree identified increasing access to psychiatric care as a priority and promotes the inclusion of social workers within the mental health care system12. quotas for postgraduate studies and medical residencies in psychiatry have increased in each medical school and scholarships are now provided. stigma associated with mental disorders within the country has been related to a decrease in help-seeking from medical professionals and greater demand for traditional healers26,29. mundt et al.11 suggest this finding is partly a result of the integration of muslim spiritual and russian biological traditions in uzbekistan’s psychiatry. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aliev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu mental health care development in georgia, lithuania and poland apart from showing tangible commitment to the provision of mental health in the community by developing services integrated into state health system, georgia, lithuania and poland have substantially downsized inpatient capacities and provide the best examples of cmh care in the region. in lithuania and poland, a number of consecutive policy documents developed in the 1990’s onwards set the direction of a new mental health policy30,31. new community services began as a result, but these were sporadic and largely unavailable. new strategies in 2007, in lithuania, and in 2010, in poland, supported the development of networks of nation-wide cmh centers to provide care for those who would have previously been cared for in hospitals. unfortunately, they never provided an appropriate quality of care, largely lacking psychosocial elements20,32. reform failure can be explained by low prioritization of mental health among policy-makers, which led to the underfinancing of reform programs31,33. the inability to ensure appropriate resourcing of cmh care was experienced in both countries. poland was unable to address financial challenges during reform. new community services were poorly integrated and found themselves in competition with hospitals where the majority of funds were still allocated and used for their renovation. reforms also lacked sufficient monitoring mechanisms to assess the efficacy and quality of implementation activities. low prioritization of mental health in georgia and lithuania was partly associated with prevalent societal stigma towards mental illness, which discourages policy-makers from implementing plans to make services for people with mental disorders closer to communities33. another barrier for new community services to operate is significant lack of qualified staff that could deliver psychosocial services20,32,34. under financial assistance from eu funds lithuania built a network of community facilities but faced with absence of specialists who could deliver quality psychosocial help, instead treatment remained pharmacological. reform implementation is also aggravated by bureaucratic challenges of interagency cooperation between different government structures like ministry of health and ministry of social welfare that are both responsible for new program implementation20. georgia, which was devastated by civil war in the early 1990’s, presents a slightly different case of mental health care development. after change of government in 2004, a window of opportunity for reforms was opened35. it took several years of preparatory work to provide policymakers with evidence on poor quality of psychiatric care available within the country and cost-effectiveness of psychosocial interventions prior to adoption of the mental health reform in 201035,36. investment for mental health gradually increased and plans and programs were supported by foreign experts. deinstitutionalization within the country was comprehensive including not only establishment of services in the community such as crisis teams and residential facilities (this is referred by georgian experts as a “real” deinstitutionalization, emphasizing that the process is not just about the reduction of psychiatric beds), but also investing into capacity building and education20,35. modern psychiatric literature was translated into the georgian language and treatment guidelines were updated. mental health workers received evidence-based training and a mental health research center was established. georgian national ngos were directly involved in mental health reform by piloting psychosocial interventions that were later scaledup to the state level and participating in development of policy and legislation as stakeholders. despite significant investment into cmh care, the reforms did not affect the psychiatric hospitals, which still consume most of the mental health budget (69% in 2014) and remain in poor condition with treatment being purely pharmacological37, emphasizing, again, importance of addressing dual financial burden during reform implementation. table 1 presents a summary of the findings in three countries. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aliev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu poland lithuania georgia strong and weak characteristics of cmh • day clinics • centers for mental health • substantial reduction (40%) of beds in psychiatric hospitals • availability and organization of services is very poor • 115 multidisciplinary mental health teams in primary care clinics • 40 day-care centers opened • substantial reduction (40%) of beds in psychiatric hospitals • multidisciplinary teams are not utilized for people with smi • drug treatment prevails over the psychosocial treatment • lack of social workers and psychologists in the teams • one of the largest psychiatric hospitals closed and beds relocated into general hospitals • new residential facilities opened in a number of towns • crises teams started functioning across country • mental health education reformed • inpatient care deteriorated and treatment became more aggressive in order to discharge patients quickly to comply with new rules. policy and/or plans and their outcomes in terms of access to community care mental health protection act (1994) mental health programme(1994) -access to psychiatric care worsened national programme on mental health 20112015 -care mostly provided in 51 large psychiatric hospitals with unsatisfactory conditions -centers for mental health do not meet criteria of the programme state programme on the prevention of mental disorders 1999-2009 mental health strategy (2007) -investments took place into hospital and pharmaceutical care -deinstitutionalization and destigmatization targets were not prioritized -community care remained underfunded national health care strategy 2011-2015 the national strategy and action plan for 20152020 -care mostly relies on psychiatric hospitals with unsatisfactory conditions key facilitating factors • user organizations participate in policy formulating and organization of psychiatric care • eu structural funds assisted in opening new day-care centers • state funding for mental health substantially increased after 2004 • new funding model (2008) • evidence of positive outcomes of cmh provided to policy-makers • civil society involvement is substantial • international donors financial support key obstacles • major health reform that changed financial scheme of health care and diluted responsibility of mental health policy • lack of funding • inadequate funding of community services • shortage of mental health staff • no mechanisms to assess efficacy and quality of implementation were in place • lack of political will • economic constrains • stigma among general population • passive user movement • shortage of mental health staff • lack of funding • lack of state funding • shortage of mental health staff table 1. community mental health development in poland, lithuania, and georgia http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aliev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu discussion most countries in ee have made failed attempts to introduce nation-wide cmh care. most patients continue to be treated in psychiatric hospitals despite adoption of mental health policies and implementation plans focused on deinstitutionalization. commitments to reform mental health care remain primarily on paper. path dependency and historical institutionalism theories help to explain these phenomena38. for policymakers it is extremely difficult for a radically different approach such as cmh care to be introduced, when the previous system had been developing for decades with different priorities and political meaning7. petrea suggests that it is likely that availability of often ambitious plans and policies might be merely symbolic gestures to comply with international norms with little intention of enforcing them39. significant societal mental health stigma, insufficient funding and scarce human resources make further challenges the reform process. mental health care in uzbekistan shares many of the same characteristics as other ee countries at the start of their mental health reforms. while each country’s attempts at deinstitutionalization have resulted in mixed outcomes, their experiences provide valuable information on the reasons why they failed to radically change the system despite ambitious plans and steady reduction of psychiatric beds. based on the experience of other countries in the region and the history of mental health care within uzbekistan, we recommend the following actions to increase the success of continuing mental health reform: 1. embed financial planning for reform implementation. lack of funding is the primary obstacle every country faces when cmh care is attempted. uzbekistan’s average allocation of the health budget to mental health is considerably lower than in ee, which is itself twice lower than in western europe9. lack of investment in mental health services during the 1990s led to the deterioration psychiatric hospitals and much of the current funding is spent on their maintenance, leaving little for cmh to develop. based on the experiences of georgia, lithuania, poland and uzbekistan, as well as the global experience of deinstitutionalization, it is vital that adequate funds are made available to support mental health care in the community and psychiatric hospitals at the beginning of reforms with the majority of financial allocations shifting to community-based care as its coverage and treatment capabilities increase and reliance on psychiatric hospitals decreases. one can expect that after substantial economic reforms in the country and market liberalization10, uzbekistan will have more financial capacity to increase expenditure on mental health care in the near future. collaboration with international donors will also likely increase, which as in the cases of georgia and lithuania, will play an important role in scaling-up cmh services. however, it is important that increases in funding are thoughtfully spent in line with best evidence and existing resources. a review of the local context, strengths, needs and capacities of uzbekistan should precede the planning and implementation of any reforms40. financial planning will also address the dual financial burden of funding the old and new systems during the transitional period. 2. address knowledge gap and increase research capacity to assess reforms. there is a significant gap in research on the impact of mental health reform across ee14. it is a particular problem for uzbekistan as our study has highlighted the substantial lack of published literature on uzbekistan’s mental health care within international journals. a mental health research body, which does not exist currently in uzbekistan, should be established to obtain http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu local evidence to support implementation plans and disseminate implementation outcomes. a standardized data collection system should be in place to assist policymaking and advocacy. failing to introduce robust assessment mechanisms and lack of prioritization contributed to the failure of lithuanian reforms. this issue, however, was addressed in georgia, where extensive training and educational support was made available for local professionals to challenge the old psychiatric model and an entire research center was established to support reforms and their implementation. collaboration with international institutions will be crucial to the introduction of contemporary approaches to scientific research and strengthening of research capacity within the country. 3. reduce stigma associated with mental health. high stigma towards mental illness is prevalent among general population and policymakers across ee and is related to a long period of institutionalization of mental health7. in lithuania, the authorities, although aware of deinstitutionalization policy and the notion of liberalization of mental health, were unwilling to introduce changes because of their concerns about losing the voters33. to avoid this in uzbekistan, the overriding institutional culture should be challenged by national anti-stigma campaigns along with or prior to shifting care to community. such campaigns based on local educational initiatives aiming at replacing myths and stereotypes together with massmedia advertising have reported positive outcomes both in increasing public knowledge on mental illness and in diminishing experienced discrimination reported by people with mental disorders in england, japan, new zealand, egypt and brazil41. 4. create favorable conditions for civil society groups to evolve and take part in development of mental health agenda as an equal stakeholder. if civil society, which is comprised of charities, ngos, service user associations and other groups united by the same goal, is not considered as a competent stakeholder, mental health care reforms are not likely to progress42. this is a particular problem for uzbekistan, where our study was unable to identify a single ngo working in the field of mental health. in contrast, civil society in ee is active and raises concerns about mental health system on the political level. the lack of visibility of civil society groups within uzbekistan may be partly due to excessively bureaucratic and opaque politics with little openness and trancparency43. these shortcomings have contributed to the suppression of civil initiatives and limited international aid involvement in healthcare44,45. the current uzbekistan government, which has demonstrated openness to new ideas and reform, should start with creating favorable conditions for ngos to evolve and international aid organizations to work in the country. furthermore, civil society should be accepted as an equal stakeholder by the government to improve national mental health outcomes46. 5. improve the country’s human resources for mental health. scarcity of mental health professionals is a global challenge. no strategies used by the studied countries were identified to tackle this issue. significant efforts are needed in health workforce policy, education and financing to address the problem of labor migration and stigma among medical community to prevent the shortage to worsen47. in other low and middle-income countries, strategies including task-shifting and integration of mental health care with general health care already proved to be effective to compensate http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aliev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu limited human resources47. uzbekistan has addressed this issue by investing into psychiatric education and introducing new specialties such as social worker and occupational therapist. to capitalize further on the government’s actions, uzbekistan should define where these specialists will be based and in what form they will operate (e.g. multidisciplinary teams, primary care) and develop national training plans. given uzbekistan’s cultural context, engaging traditional healers in mental health care delivery48 is another strategy to address this issue. this study was initiated in light of increasing attention towards mental health care in uzbekistan and drew on knowledge transfer from experience of other countries in the similar political context. based on revealed obstacles and facilitators during reforms in three countries a set of recommendation was developed for uzbekistan’s policymakers. to the best of our knowledge, no such work has been conducted before. it was not possible to evaluate the quality of policies and community services. countries were chosen on the basis of the reported availability of mental health policies and access to community services, but not necessarily having a quality care. this is a major subject to study further in the future. mental health atlas was used as a primary evidence for the assessment of a country’s psychiatric hospital capacities because it is the most complete source of information on national mental health systems currently available. because of different approaches to collect data in different years and a large number of missing data, change only in psychiatric beds in psychiatric and general hospitals was analyzed to assess progress towards cmh. this could potentially impact the results as beds in community settings such as in residential facilities were not taken into account. since the initial analysis for this study was conducted, country profiles for the who mha 2017 have been made available. there are no significant deviations from the data obtained from previous years’ reports, except for estonia, which reduced psychiatric bed capacity by ten-fold and increased the number of beds in general hospitals by 2.8 per 100,000 since 2005. future studies should evaluate estonia’s mental health policies and cmh services and their success. uzbekistan is standing on the same path of mental health system development with other ee countries. the country was closed from external influence and had never introduced community care before. today, when it is on the verge of reforms, it is very likely that uzbekistan will experience the same obstacles that other countries faced with: low prioritization of mental health and persistent shortage of finances, resistance to change from medical community and general population, knowledge gap, lack of mental health and social care staff, passive civil society – these are all barriers that hinder development of community care in ee. with the change of political power, a window of opportunity in uzbekistan was opened, where reforms started to take place and it is important to address these issues now to avoid challenges other countries had to experience. through the creation of a financial plan, reducing the local mental health knowledge gap, tackling stigma associated with mental disorders, supporting civil society and increasing the numbers of mental health professionals, we believe uzbekistan can give itself the best chance to find success through deinstitutionalization. references 1. un. united nations regional groups of member states. accessed february 02, 2019. http://www.un.org/depts/dguzauacm/regionalgroup s.shtml http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu 2. knapp m, mcgrother c, haverman mj. balance of care (deinstitutionalisation in europe). results from the mental health econonomics european network mheen. int j integr care. 2009;9. 3. koyanagi c. learning from history: deinstitutionalization of people with mental illness as precursor to long-term care reform. henry j. kaiser family foundation; 2007. 4. parker c. developing mental health policy: a human rights perspective1. ment health policy pract eur. published online 2006:308. 5. freeman m, pathare s. who resource book on mental health, human rights and legislation. world health organization; 2005. 6. bachrach ll. deinstitutionalization: an analytical review and sociological perspective. published online 1976. 7. tomov t, van voren r, keukens r, puras d. mental health policy in former eastern bloc countries. ment health policy pract eur future dir ment health care. published online 2006:397–426. 8. salisbury tt, killaspy h, king m. an international comparison of the deinstitutionalisation of mental health care: development and findings of the mental health services deinstitutionalisation measure (mendit). bmc psychiatry. 2016;16(1):54. 9. krupchanka d, winkler p. state of mental healthcare systems in eastern europe: do we really understand what is going on? bjpsych int. 2016;13(4):96–99. 10. the world bank. the world bank in uzbekistan.; 2017. accessed february 03, 2019. https://www.worldbank.org/en/country/uzbekistan/over view 11. mundt a, heinz a, ströhle a. uzbekistan: psychiatry in transition. eur psychiatry. 2009;24(8):526–528. 12. postanovleniye prezidenta respubliki uzbekistan o merakh po korennomu sovershenstvovaniyu psikhiatricheskoy pomoshchi [decree of the president of the republic of uzbekistan on measures for fundamental improvement of psychiatric care]; 2018. accessed february 02, 2019 http://lex.uz/ru/docs/3588132 13. thornicroft g, alem a, drake re, et al. community mental health: putting policy into practice globally. vol 29. john wiley & sons; 2011. 14. winkler p, krupchanka d, roberts t, et al. a blind spot on the global mental health map: a scoping review of 25 years’ development of mental health care for people with severe mental illnesses in central and eastern europe. lancet psychiatry. 2017;4(8):634–642. 15. gustavsson a, svensson m, jacobi f, et al. cost of disorders of the brain in europe 2010. eur neuropsychopharmacol. 2011;21(10):718-779. doi:10.1016/j.euroneuro.2011.08.008 16. world health organisation. atlas: country profiles of mental health resources 2001. geneva; 2001. 17. world health organisation. mental health atlas; 2011. 18. world health organisation. mental health atlas 2014. 19. world health organisation. mental health atlas 2005. 20. winkler p, krupchanka d, roberts t, et al. appendix. a blind spot on the global mental health map: a scoping review of 25 years’ development of mental health care for people with severe mental illnesses in central and eastern europe. lancet psychiatry. 2017;4(8):634–642. 21. zakon respubliki uzbekistan o psikhiatricheskoy pomoshchi [law of the republic of uzbekistan on http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aliev this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu psychiatric care]. 2000. accessed august 15, 2018. http://lex.uz/ru/docs/14460 22. o vnesenii izmeneniy i dopolneniy v zakon respubliki uzbekistan o psikhiatricheskoy pomoshchi [on the amendments to the law of the republic of uzbekistan on psychiatric care]. published online july 26, 2018. accessed august 15, 2018. http://minzdrav.uz/documentation/discussion.php?id=5 5101 23. world health organisation. who-aims report on mental health system in uzbekistan.; 2007. 24. kurbanova sm, harabara gi. about the measures taken to improve the mental health service in the republic of uzbekistan for 2013-2016. zh nevrol psikhiatr im s s korsakova. 2017;117(5):114. 25. kharabara g, khodjaeva n. state of mental health care in the republic of uzbekistan. in: routledge handbook of psychiatry in asia. routledge; 2015:49– 54. 26. ahmedov m, azimov r, mutalova z, huseynov s, tsoyi e, rechel b. uzbekistan: health system review. health syst transit. 2014;16(5):1-137, xiii. 27. mundt ap, fakhriddinov s, fayzirahmanova m, et al. use of psychiatric inpatient capacities and diagnostic practice in tashkent/uzbekistan as compared to berlin/germany. soc psychiatry psychiatr epidemiol. 2011;46(12):1295–1302. 28. gazizova d, mazgutov a, kharabara g, tsoyi e. mental health in uzbekistan. int psychiatry. 2011;8(1):10-11. doi:10.1192/s1749367600006160 29. yеshimbetova s, chembaev b. clinical and sociocultural characteristics of individuals with schizophrenia who commited serious assualtive acts in uzbekistan. eur med health pharm j. 2014;7(2). 30. puzynski s, moskalewicz j. evolution of the mental health care system in poland. acta psychiatr scand. 2001;104:69–73. 31. puras d, germanavicius a, povilaitis r, veniute m, jasilionis d. lithuania mental health country profile. int rev psychiatry. 2004;16(1-2):117–125. 32. puras d. lithuania, in international perspectives on mental health. in: h. ghodse, ed. international perspectives on mental health. royal college of psychiatrists: cambridge; 2011:343-347. 33. puras. evidence-based mental health policy in lithuania. mental health reforms . 11(1-2): 5-7. 2011;(11(1-2)):5-7. 34. bomba j. poland, in international perspectives on mental health. in: ghodse h, ed. international perspectives on mental health. royal college of psychiatrists: cambridge; :363-347. 35. makhashvili n, van voren r. balancing community and hospital care: a case study of reforming mental health services in georgia. plos med. 2013;10(1):e1001366. 36. zavradashvili n, donisi v, grigoletti l, et al. is the implementation of assertive community treatment in a low-income country feasible? the experience of tbilisi, georgia. soc psychiatry psychiatr epidemiol. 2010;45(8):779–783. 37. ombudsman of georgia. report on the monitoring of mental health institutions.; 2015. 38. smith ke, katikireddi sv. a glossary of theories for understanding policymaking. j epidemiol community health. 2013;67(2):198–202. 39. petrea i. mental health in former soviet countries:from past legacies to modern practices. public health rev. 2012;34(2):1-21. doi:10.1007/bf03391673 40. world health organisation | the who mental health policy and service guidance package. who. accessed may 31, 2020. http://www.who.int/mental_health/policy/essentialpacka ge1/en/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.513 | http://cajgh.pitt.edu 41. thornicroft g, mehta n, brohan e, kassam a. stigma and discrimination. princ soc psychiatry. published online 2010:331. 42. almeida hw, mahoney j. 13 mental health policy development and implementation. glob ment health princ pract. published online 2013:190. 43. martini m. overview of corruption and anticorruption: uzbekistan. transparency international; 2015. accessed february 11, 2019. https://www.transparency.org/files/content/corruptionqa s/country_profile_uzbekistan_2015.pdf 44. ulikpan a, mirzoev t, jimenez e, malik a, hill ps. central asian post-soviet health systems in transition: has different aid engagement produced different outcomes? glob health action. 2014;7(1):24978. 45. abramson dm. a critical look at ngos and civil society as means to an end in uzbekistan. hum organ. published online 1999:240–250. 46. swarbrick m. expertise from experience: mental health recovery and wellness. in eds. graham, g., thornicroft, g., szmukler, g. mueser, kt., & drake, re. oxford textbook of community mental health. oxford univresity press. in: ; 2011. 47. kakuma r, minas h, dal poz mr. 10 strategies for strengthening human resources for mental health. glob ment health princ pract. published online 2013:104. 48. nortje g, oladeji b, gureje o, seedat s. effectiveness of traditional healers in treating mental disorders: a systematic review. lancet psychiatry. 2016;3(2):154–170. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. interval hysterectomy for placenta percreta – a case report mohammad sazzadul huque1, mini ravi2 1college of medicine, gulf medical university, united arab emirates; 2mafraq hospital, united arab emirates vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.345 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ huque this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.345|http://cajgh.pitt.edu abstract introduction: placenta percreta is an abnormality of placentation where it invades the serosa and can go beyond it. complications include massive hemorrhage, bladder dysfunction, and severe infections during delivery. the aim of this study is to report a complex case of placenta percreta managed by interval hysterectomy. case presentation: pre-operative: 34 years old patient with previous three cesarean sections was followed in antenatal clinic. she came with repeated bouts of vaginal bleeding at 30-31 weeks. at 32 weeks and 4 days classical cesarean section was done with placenta left in situ. prophylactic bilateral internal iliac artery balloon was inserted. post cesarean section, uterine artery embolization was performed. post-operative: clinical features of pulmonary embolism (pe) developed about 4 hours later. postoperative day 13: total abdominal hysterectomy was done. after few days of discharge, the patient presented to the emergency department with shortness of breath. she was consequently diagnosed with chronic pulmonary embolism and treated with warfarin. conclusion: this is a case of placenta percreta managed by interval hysterectomy. however, the most widely accepted method of management is cesarean hysterectomy. in this case, interval hysterectomy was done due to the possibility of bladder invasion by placenta, to decrease the amount of blood loss and to reduce the number of days stayed in hospital. appropriate management for the patient must be personalized, whether it is by cesarean hysterectomy or interval hysterectomy, as each has risks and benefits. keywords: placenta percreta; interval hysterectomy; case report; complications of placenta percreta interval hysterectomy for placenta percreta – a case report mohammad sazzadul huque1, mini ravi2 1college of medicine, gulf medical university, united arab emirates; 2mafraq hospital, united arab emirates research introduction placenta accreta comes under a broad category of abnormal adherent placenta and is classified into three different entities: (1) placenta accreta vera, where placenta invades the decidual layer of the myometrium. (2) in placenta increta, placental villi invade more deeply within the myometrium.1 (3) placenta percreta is diagnosed when the placenta invades up to the serosa and can go beyond it.2 placenta accreta is diagnosed in about 1:533 pregnancies where 75%-80% are placenta accreta vera, 17% placenta increta, and remaining 5% are placenta percreta. overall, the incidence of placenta percreta is extremely low but the appearance of this rare disorder is increasing due to increase number of cesarean deliveries being performed in the past few years globally.3,4 placenta percreta is considered one of the most severe forms of placenta accreta. it is a potentially lifethreatening condition with the risk of severe maternal http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.345|http://cajgh.pitt.edu morbidity and mortality. in cases where placenta precreta is complicated by bladder invasion, mortality rates can be as high as 9.5% in mothers and 24% in newborn.5 both diagnostic methods, sonography and mri, have good sensitivity and specificity for prenatal diagnosis of placenta accreta.4 according to american college of obstetricians and gynecologists, widely acknowledged method to manage placenta accreta spectrum is by performing cesarean hysterectomy, in which the placenta is left in situ after delivery of the fetus because any attempts to remove the placenta is associated with substantial danger of hemorrhage.6. another method of management that can be considered for placenta percreta is interval hysterectomy. in general, patients who have placenta accreta are more likely to have a caesarean section (aor: 4.6). they are at an increased risk for being admitted to intensive care unit (icu)/high dependency unit (aor: 46.1) and to have a hysterectomy (aor: 209.0). births are expected to be preterm with a high level neonatal icu admission and resuscitation needs.7 the median expected blood loss at time of cesarean hysterectomy for patients with placenta accreta has been reported to be 3 liters and the mean transfusion requirement of 5 units of packed red blood cells.8 in addition to higher estimated blood loss, placenta percreta patients are also at an increased risk of bladder and ureteral injury.9 conservative management where the uterus and the placenta are left in-situ at time of cesarean delivery was shown to be associated with a reduction in blood loss in patients with placenta percreta, decreased need for transfusion, and less incidence of disseminated intravascular coagulation through uterus involution.8,10 we are reporting this rare case to increase the awareness about placental percreta and to share our experiences with the interval hysterectomy as a treatment modality. this is a very interesting case because it shows the complete picture of the case from antepartum history to operative details and discharge information. it also includes information of treatment that took place after discharge. it highlights the list of complication one can anticipate in a case of placenta percreta. case presentation antepartum history 34 years old patient, gravida 6 parity 3, previous 2 miscarriages (18 weeks & 12 weeks), was seen first at 23 weeks 4 days of pregnancy. she had undergone previous 3 cesarean sections and an evacuation of retained products of conception by curettage in 2013 for partial hydatidiform mole. at 27 weeks 5 days, she was admitted for vaginal bleeding. on further evaluation by ultrasound (figure 1), the diagnosis of placenta percreta was made (later confirmed by mri). at 29 weeks, she had constipation with 2 episodes of urinary retention and she was put on continuous bladder drainage. she developed urinary tract infection and treated with appropriate antibiotics based on culture sensitivity. she continued to have repeated bouts of vaginal bleeding of varying amounts and severe constipation from 31 weeks of gestation. operative history at 32 weeks 4 days, patient underwent cystoscopy, which had shown signs of cystitis with no definite infiltration. she underwent classical cesarean section under combined anesthesia (epidural + general). the umbilical cord was tied near insertion and the placenta was left in situ because there was no spontaneous separation. then, the uterus was closed. prophylactic temporary bilateral internal iliac artery balloons were inserted and inflated earlier. uterine artery embolization was performed post cesarean section and selective angiograms confirmed adequate positioning. the patient required large volume of particles and still had incomplete embolization with the lower part of the uterus still showing some unblocked branches on both sides. post-operative course post-operatively, she was transferred to labor ward and within 4 hours, she developed clinical features of pulmonary embolism (pe). some of her symptoms http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx huque this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.345|http://cajgh.pitt.edu figure 1. clinical images: a. doppler ultrasound and b. ultrasound of the uterine lower segment included drop in o2 saturation to 81%, tachycardia, chest pain, peripheral cyanosis, and signs of respiratory distress. then, she was transferred to icu and was initiated on heparin infusion. on chest x-ray, she had no atelectasis, pneumothorax, or pleural effusion. an immediate ct scan did not show any pe. there was no doppler evidence of venous thrombosis in the femoral and popliteal venous systems. later on day 1 postoperative, she had focal patchy consolidation left base and was started on parenteral meropenem, linezolid and fluconazole for the next 5 days. she had two consecutive ct scans on post-operative on days 2 and 3, which were negative. on ecg, there was right heart strain. she was now on enoxaparin. on the post-operative day 5, she was prescribed parenteral piperacillin-tazobactam for 5 days and she was shifted out of icu next day. she had 500ml vaginal bleeding on the 9th post-operative day. 2 units prbc were transfused. she was switched to oral cefuroxime and metronidazole and planned to continue on long-term low dose antibiotic. on post-operative day 11, she received methotrexate. on day 12, the mra had shown the placenta was still enhancing with some areas of infarct and separation, fluid collection in the uterine cavity (present from day 1 post op, not increasing), with large ovarian veins, hugely distended and extensive pelvic varices, r>l, extensive collaterals. her crp was 12.7 mg/l. operative details on post-operative day 13, she underwent total abdominal hysterectomy. intraoperatively, the bladder was densely adherent, drawn up, with large vessels in the broad ligament. the lower segment was bulging due to the presence of the placenta. the uterus was about 24 weeks’ size with adherent omentum. there was 100 ml of old blood in the cavity and the placenta was partially infarcted. the total blood loss was 2000 ml. post-hysterectomy period post-operatively, she was in icu for 2 days receiving anticoagulation treatment (bridging treatment with enoxaparin + warfarin) and patient controlled analgesia. she had a bout of severe cough on day 4 and loose motions on day 5. she was diagnosed with vault hematoma, which was retro-vesical, about 120 ml in volume, treated conservatively. on day 10 she had been discharged from the hospital. she presented to the er on the post-operative day 16 and was diagnosed with chronic pulmonary embolism. patient had a pulmonary embolus within the right middle lobe pulmonary artery; areas of subsegmental embolus within the right lower lobe pulmonary arteries. she had no pleural effusions or consolidation and no mediastinal lymphadenopathy. she was readmitted for 4 days. she was started on therapeutic enoxaparin + warfarin. she was continued on 6 mg warfarin for 4 weeks after discharge. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.345|http://cajgh.pitt.edu discussion in the field of abnormal placentation, placenta percreta is the most uncommon and most dangerous among them. the diagnosis of this condition can be achieved during pregnancy by ultrasound and/or magnetic resonance imaging. the main aim of the therapy should be to minimize the blood loss by doing a hysterectomy, or by preventing the elimination of the placenta at the time of delivery, or via methotrexate regiment for the ablation of the remaining placenta in the post-delivery period.11 in usa, the most common method of threatment for placenta accreta is cesarean hysterectomy. the complications of cesarean hysterectomy are bladder and/or ureters injury, severe hemorrhage and maternal demise. placental retention with uterine conservation during the time of delivery and interval hysterectomy are the other options available for stable patient. these techniques can result in decreased amount of blood loss and bladder/other organs resection.12 previous studies report cases of invasive placentation that were managed by interval hysterectomy. one case had placental invasion up to the anterior abdominal wall. by delaying patient’s hysterectomy and using uterine artery embolization, patient was able to undergo the hysterectomy and bladder resection with less morbidity when compared to the scenario when procedure would have been performed during cesarean delivery, which was already made difficult by the immense hemorrhage.12 in the case series by wong et al, eight suspected cases of abnormal placentation were managed. in three cases, the placentas were separated from the uterus with minimal difficulty. in two cases of placenta percreta without invasion of bladder, cesarean hysterectomy was done. in the remaining three cases of percreta with bladder invasion, the entire placenta was left in-situ. resolution occurred in two of them, over a period of 8 and 12 months respectively. the last one had post-operative course complication with deep vein thrombosis and disseminated intravascular coagulation. this patient underwent hysterectomy with preoperative uterine artery embolization, inferior vena cava filter placement and ureteric stenting. hence, the conservative management is potentially safe and attractive alternative to the other modalities. however, cautious and vigilant patient selection with individualized assessment is needed.13 in our case, we chose interval hysterectomy because of possible bladder invasion by placenta, to decrease the amount of blood loss, and to reduce the hospital stay. in another study of 93 patients with abnormal placentation, 20 patients have been diagnostically confirmed to have placenta percreta. out of these women, 11 underwent immediate hysterectomy; 9 underwent interval hysterectomy. median approximate blood loss for women who underwent immediate hysterectomy (2.8l) was significantly higher compared to interval hysterectomy (1l). median duration of stay for the immediate hysterectomy was 15 days compared to 7 days for the interval hysterectomy. however, there was a trend towards increased rate of infection with interval hysterectomy.14 in conclusion, this case highlights the need to investigate various management options for patients with placenta percreta. while it is a rare diagnosis, it is increasing in incidence. it should be highlighted that cesarean section should be reserved to the patients for whom it is indicated. in addition, it is difficult, risky, and expensive to manage such cases. nevertheless, proper management for the patients must be individualized whether it is cesarean hysterectomy or interval hysterectomy, as each option has its own risk and benefits, and must be performed with caution. references 1. fitzpatrick ke, sellers s, spark p, kurinczuk jj, brocklehurst p, knight m. incidence and risk factors for placenta accreta/increta/percreta in the uk: a national http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx huque this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.345|http://cajgh.pitt.edu case-control study. plos one. 2012;7(12):e52893. 2. ibrahim ma, liu a, dalpiaz a, schwamb r, warren k, khan sa. urological manifestations of placenta percreta. curr urol. 2015;8(2):57-65. 3. hudon l, belfort ma, broome dr. diagnosis and management of placenta percreta: a review. obstet gynecol surv. 1998;53:509– 517. 4. wu s, kocherginsky m, hibbard ju. abnormal placentation: twenty-year analysis. am. j. obstet. gynecol. 2005;192(5):1458– 1461. 5. price fv, resnik e, heller ka, christopherson wa. placenta previa percreta involving the urinary bladder: a report of two cases and review of the literature. obstet gynecol. 1991;78:508-511. 6. placenta accreta spectrum. obstetric care consensus. 2018;132(6):259-17. available from: https://www.acog.org/-/media/obstetriccare-consensusseries/occ007.pdf?dmc=1&ts=20181129t1453 250701. accessed on january 28, 2019. 7. farquhar cm, li z, lensen s et al. incidence, risk factors and perinatal outcomes for placenta accreta in australia and new zealand: a case– control study. bmj open. 2017;7(10):e017713. 8. rajkumar b, kumar n, sowmya s. placenta percreta in primigravida, an unsuspected situation. int jour of reprod, contracept, obs & gyn [internet]. 2014;3(1). available from: http://www.ijrcog.org/index.php/ijrcog/article/ view/830. accessed on january 28, 2019. 9. wright jd, pri-paz s, herzog tj. predictors of massive blood loss in women with placenta accreta. am. j. obstet. gynecol. 2011;205(38):1-6. 10. sentilhes. maternal outcome after conservative treatment of placenta accreta. obstet. gynecol. 2010;115(3):526–534. 11. konijeti r, rajfer j, askari a. placenta percreta and the urologist. rev urol. 2009;11(3):173–176. 12. fay ee, norquist b, jolley j, hardesty m. conservative management of invasive placentation: two cases with different surgical approaches. ajp rep. 2016;6(2):212–215. 13. wong vv1, burke g. planned conservative management of placenta percreta. j obstet gynaecol. 2012;32(5):447-52. 14. emily w, stephanie c, noelle b, yongmei h, william b, annette p. surgical management of placenta percreta: outcomes of immediate versus interval hysterectomy. obstetrics & gynecology. 2018;131(117s). available from: https://journals.lww.com/greenjournal/abstract /2018/05001/surgical_management_of_placen ta_percreta__.406.aspx. accessed on january 28, 2019. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.acog.org/-/media/obstetric-care-consensus-series/occ007.pdf?dmc=1&ts=20181129t1453250701 https://www.acog.org/-/media/obstetric-care-consensus-series/occ007.pdf?dmc=1&ts=20181129t1453250701 https://www.acog.org/-/media/obstetric-care-consensus-series/occ007.pdf?dmc=1&ts=20181129t1453250701 https://www.acog.org/-/media/obstetric-care-consensus-series/occ007.pdf?dmc=1&ts=20181129t1453250701 https://www.ncbi.nlm.nih.gov/pubmed/?term=farquhar%20cm%5bauthor%5d&cauthor=true&cauthor_uid=28982832 https://www.ncbi.nlm.nih.gov/pubmed/?term=li%20z%5bauthor%5d&cauthor=true&cauthor_uid=28982832 https://www.ncbi.nlm.nih.gov/pubmed/?term=lensen%20s%5bauthor%5d&cauthor=true&cauthor_uid=28982832 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5640005/ http://www.ijrcog.org/index.php/ijrcog/article/view/830 http://www.ijrcog.org/index.php/ijrcog/article/view/830 https://journals.lww.com/greenjournal/abstract/2018/05001/surgical_management_of_placenta_percreta__.406.aspx https://journals.lww.com/greenjournal/abstract/2018/05001/surgical_management_of_placenta_percreta__.406.aspx https://journals.lww.com/greenjournal/abstract/2018/05001/surgical_management_of_placenta_percreta__.406.aspx interval hysterectomy for placenta percreta – a case report abstract keywords: placenta percreta; interval hysterectomy; case report; complications of placenta percreta interval hysterectomy for placenta percreta – a case report research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. factors influencing salt-reducing behavior in young adults: a pilot cross-sectional study from kazakhstan mina aubakirova1, marat sultanov1, aidarkhan izimov1, yesbolat sakko1, torekhan bex1, anuar mussagazin1, raushan alibekova1* 1school of medicine, nazarbeyev university, nur-sultan, kazakhstan *corresponding author: raushan alibekova md, mph, phd school of medicine, nazarbayev university 5/1 kerei and zhanibek khans street, nur-sultan 010000, kazakhstan telephone: +7 (7172) 70-67-02 email: raushan.alibekova@nu.edu.kz vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ aubakirova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu abstract introduction: in kazakhstan, a post-soviet country in central asia, salt intake is estimated as high, potentially contributing to the morbidity and mortality from cardiovascular diseases. the aim of this study was to explore salt intake in residents of the capital of kazakhstan, nur-sultan. methods: an online cross-sectional survey of knowledge, attitudes, and behaviors on salt intake among young adult residents of the capital city of kazakhstan was conducted (n = 237). bivariate and multivariate linear regression analyses were performed. results: although 95% (n=225) reported knowledge on the adverse health effects of high salt intake, older respondents were more aware of its association with high blood pressure (p = 0.007), heart disease (p = 0.037), and heart attack (p = 0.002). only one-third (n=79) correctly identified the recommended level of daily salt intake. females reported more awareness of kazakhstani people consuming salt more than recommended (p = 0.0027) and that processed products constituted the major source of salt in diet (p = 0.007). general dietary concern (p < 0.001), high self-assessment of salt intake (p < 0.001), and older age (p = 0.012) were found to be adjusted predictors of salt-reducing behavior. conclusion: lack of reported knowledge on salt-health relationship is of concern, especially among young males. a greater dietary concern and individual awareness of the excessive salt consumption is likely to assist in reducing salt intake. further studies are required to validate the findings of this pilot study on a bigger population level in order to provide a basis for future salt related interventions and policy changes in kazakhstan. keywords: attitudes; behaviors; kazakhstan; knowledge; salt factors influencing salt-reducing behavior in young adults: a pilot cross-sectional study from kazakhstan mina aubakirova1, marat sultanov1, aidarkhan izimov1, yesbolat sakko1, torekhan bex1, anuar mussagazin1, raushan alibekova1 1school of medicine, nazarbeyev university, nur-sultan, kazakhstan research central asia has been reported as one of the regions with the highest burden of cardiovascular diseases (cvd) in the world1. in kazakhstan, incidence of cvds increased from 8,600 cases per 100,000 in 2005 to 15,500 cases per 100,000 in 20162, 3. diet has been identified as one of the preventive measures for decreasing risk of chronic illnesses along with exercising and avoiding smoking and consuming alcohol 4. among dietary practices, excessive salt intake is commonly recognized as the factor associated with cardiovascular diseases5-7. excessive salt intake has been determined to be a risk factor for high blood pressure, and a related global target of 30% reduction has been included in the global action plan for the prevention and control of noncommunicable diseases for 2013-20208. the world health organization (who) advises the daily intake of salt not to exceed five grams9. multiple http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu studies report that this threshold is crossed in numerous regions,10, 11 including central asia region12. according to the who, in kazakhstan, the daily intake of salt surpasses the who recommended limit by nearly fourfold13. studies vary with regard to how awareness of the negative impact of salt on health and attitudes toward salt consumption in general influence dietary behaviors. some have found that the higher the knowledge, the more conscientious food choices are7, while other studies have observed absence of willingness of people to change their eating habits, even when they realize the negative sideeffects of high amounts of salt consumption14. given the high incidence of cvds and the higher than recommended levels of salt consumption among the kazakhstani population, we have conducted a survey of knowledge, attitudes, and behaviors (kabs) related to salt intake among young residents of the city of nur-sultan. the city was chosen because it is the capital, so it attracts, and therefore represents, residents from all over the country. methods study design and participants since knowledge, attitudes, and behaviors are more easily altered in young people, the study population of the research was chosen to be young people aged 18 and above residing in nur-sultan. the younger generation has widespread access to the internet. according to the department of statistics of the republic of kazakhstan, in 2018, 90.1% of nur-sultan population in the 16-44 age group had access to the internet, while among all internet users of nur-sultan, 13.4% and 67.9% fell in the 16-24 and 25-64 age groups, respectively15. lack of a common sampling frame for mobile phone users, as well as the unpopularity of landline phones among the target group, made random digit dialing an unfeasible means of data collection. therefore, an internet survey was decided to be conducted. data collection a survey was devised and pilot tested on 20 participants. after collecting feedback from the respondents, appropriate amendments were implemented, and the final survey was launched using qualtrics platform, where it was accessible during 15 30 march 2018. snowball sampling was used to recruit participants through ads on social network pages relevant to the target demographic, outlining the survey aims and offering interested young adults to participate. such pages included those related to local universities and leisure activities in social media, namely vkontakte and whatsapp. since no individual invitations were sent, estimating the response rate was not possible. a small number of responses were excluded from the final sample due to completion of only the initial questions related to demographic information. before proceeding to the questionnaire, the participants were presented with information on the survey’s purposes and their right to withdraw from completing the survey at any point; therefore, informed consent was assumed for all participants that completed the survey. it also stated that by filling out the survey, they confirmed that they were over the age of 18. no personal identifiable information was collected from the participants. the respondents could choose to complete the questions either in russian or kazakh language. no requirement was imposed on the participants to complete all the questions. ethical approval for the study was obtained from nazarbayev university institutional research ethics committee. questionnaire a questionnaire containing 18 questions was adapted from a questionnaire of kabs related to dietary salt used in the study by grimes et al16. some alterations to the original survey instrument were introduced. then, the survey was translated into russian and kazakh by http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aubakirova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu two independent translators, and discrepancies in the translations were further assessed by a third translator. the demographic questions included gender, age, region of origin, education level, and level of involvement in cooking. age was categorized into four groups (18-20, 21-23, 24-26, and 27-30), which was aimed at facilitating usage of mobile devices. the two questions related to country of birth and language spoken at home were substituted with a question on the region of origin within the country to potentially compare regional dietary differences. the options provided in the question related to education level, which apart from directly reflecting level of education also serves as a proxy to socio-economic status, were redesigned to represent the local education system’s specifics. several questions similar to the ones in the original survey instrument were used to assess the knowledge related to dietary salt intake. the questions were concerned with the knowledge on: (a) the relationship between sodium and salt, (b) the recommendations related to salt intake, (c) the level of salt consumption in kazakhstan (in comparison to recommendations), (d) the main source(s) of salt in the diet of kazakhstan’s population, (e) health risks associated with high salt intake, and (f) association of high salt intake with several health outcomes. categorical response options were provided for each question. for the purposes of multivariate analysis, a knowledge score variable was constructed. a score of 1 was assigned for each correct answer, while 0 was given for wrong responses and if the respondent chose the ‘i don’t know’ option. thus, the knowledge score ranged from 0 to 9. the correct responses for the question related to the level of salt consumption in kazakhstan were assumed to be ‘more than needed’ and ‘too much’, since sodium intake for kazakhstan and the central asia region as a whole has been ranked among the highest in the world12, 13. for the question related to the main sources of salt in the diet, the correct response was assumed to be ‘processed foods’, which is consistent with a who report from kazakhstan13. two questions assessed the participants’ attitudes regarding salt intake. a block question was used to assess the participants’ level of concern for several food-related issues (healthy eating and sugar/salt/fat/saturated fat/calorie content). scores were assigned for each answer on a likert type scale with 1 to 5 assigned to answers from ‘not at all concerned’ to ‘very concerned’. the concern score was created by combining response scores and used in the multivariate model. the other question in this section was related to the participants’ own assessment of their salt intake levels in view of the recommendations. if a respondent indicated that their personal consumption of salt was higher than the recommended level, then the response was assigned a score of 1, with all the other response categories given a score of 0. this variable was used in the regression analysis as a binary predictor variable. these questions were concerned with the participants’ past and current behaviors regarding salt intake. three questions were designed with a 5-point frequency scale from ‘never’ to ‘always’, asking participants about their habits of (a) adding salt during cooking, (b) adding salt while eating, and (c) placing a saltshaker during meals. scores were assigned from 1 to 5, with 1 representing the lowest salt-reduction behavior (e.g. if the respondent reported always adding salt while cooking). the next four questions assessed several behaviors related to salt reduction strategies that the participants may have employed in the past month on a 5-point frequency scale from ‘never’ to ‘always’. if a person reported to have never engaged in a particular behavior related to salt reduction, the response was assigned a score of 1, while the highest score was given for the highest salt-reducing behavior. all the scores from 1 to 5 for the seven questions on salt-reduction behavior were combined to form a http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu behavior score ranging from 7 to 35 for the multivariate model. data analysis the data collected through the qualtrics survey system17 were exported into spreadsheet format. chisquare test of independence and fisher’s exact test were used for bivariate analyses. multivariate linear regression models were constructed with salt reduction behavior score as the outcome and knowledge score as the primary predictor, adjusted for dietary concern score, perception of personal salt consumption, gender, age, and region. statistical analysis was performed using stata software version 14.218. statistical significance was reported at  = 0.05. results knowledge related to salt intake the majority of the respondents (62.87%, n=149) correctly indicated that salt contains sodium (table 2). females were better informed than male respondents that kazakhstani people consumed salt more than recommended (p = 0.0027) and that processed meat and other processed products constituted the major sources of salt in diet (p = 0.007) (supplementary table 1). almost 95% (n=225) of the participants replied that eating too much salt could damage health. however, older age groups were more aware than the younger age groups of the association between excessive salt consumption and high blood pressure (p = 0.007), heart disease (p = 0.037), and heart attack (p = 0.002). similarly, respondents with general secondary education had lower awareness than those with higher levels of education of the association of excess in salt with heart disease (p = 0.007) and heart attack (p=0.013). attitudes related to salt intake roughly half of the participants were concerned about the salt content in their diet (figure 1). women, however, showed higher concern regarding salt content in food compared to men, although this finding was not significant (p = 0.064). with regard to concern on other dietary contents, the respondents with general secondary education had lower levels of concern about the amount of fat in food (p = 0.013), whereas female respondents were concerned with the amount of saturated fat in products more than males (p = 0.018) (supplementary table 2). behaviors related to salt intake more than 90% of the sample reported never or rarely asking to have a meal prepared without salt when eating out (figure 2). among the respondents, the oldest age group (27-30 years old) was more likely than the other age groups to avoid eating at fast food restaurants as a salt-reducing practice (p = 0.002) (supplementary table 3). respondents with higher and general secondary education levels were more likely to avoid adding salt to food during meals than those with professional secondary education (p = 0.007). multivariate analysis level of knowledge was not associated with saltreducing behavior at p = 0.069, adjusting for age, gender, region of birth, and level of dietary concern variables. on the other hand, dietary concern score was found highly associated with salt reduction behavior at p < 0.001, as was the variable of self-assessment of salt intake. among demographic predictors, a statistically significant difference in salt reducing behavior was observed between the 18-20 and 27-30 age groups (p = 0.012). neither gender nor region of origin was significantly associated with the person’s salt-related behavior. discussion the main findings of the study suggest that level of knowledge is not a significant predictor of salt-reducing behavior, adjusting for age, gender, region of birth, and http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aubakirova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu characteristic n % gender male 84 35.44 female 153 64.56 age group 18-20 78 32.91 21-23 42 17.72 24-26 74 54.02 27-30 43 18.14 region of origin nur-sultan 46 19.41 almaty 25 10.55 central kazakhstan 28 11.81 east kazakhstan 14 5.91 north kazakhstan 50 21.09 south kazakhstan 44 18.57 west kazakhstan 30 12.66 language of survey completion kazakh 11 4.6 russian 226 95.4 level of education higher 188 79.32 professional secondary 10 4.22 general secondary 39 16.46 level of involvement in cooking always 46 19.41 often 76 32.07 sometimes 57 24.05 rarely 48 20.25 never 10 4.22 table 1. socio-demographic characteristics of participants (n=237) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu question n % salt may be defined in the product’s contents as ‘salt’ and as ‘sodium’. what is the relationship between salt and sodium? they are exactly the same 39 16.46 salt contains sodium 149 62.87 sodium contains salt 9 3.80 don't know 40 16.88 health professionals recommend that we should eat no more than a certain amount of salt each day. how much salt do you think it is? 3 grams 94 39.66 5 grams 79 33.33 8 grams 17 7.17 10 grams 13 5.49 15 grams 5 2.11 don’t know 29 12.24 do you think eating too much salt could damage your health? yes 225 94.94 no 3 1.27 don’t know 9 3.8 which, if any, of the following do you think is linked to eating too much salt? high blood pressure yes 145 61.18 no 20 8.44 don’t know 72 30.38 kidney disease yes 198 83.54 no 9 3.80 don’t know 30 12.66 heart disease yes 139 58.65 no 27 11.39 don’t know 71 29.96 heart attack yes 108 51.05 no 30 13.08 don’t know 83 35.86 in your opinion, how much salt do kazakhstani people consume? too much 19 8.02 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aubakirova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu more than needed 146 61.6 normal amount 62 26.16 less than needed 2 0.84 don't know 8 3.38 which of the following do you think is the main source of salt in the diet of kazakhstan’s population? salt added during cooking or at the table 101 42.62 salt contained in processed meat products and in other processed products 124 52.32 salt contained in natural food products 4 1.69 don't know 8 3.38 how do you think your daily salt intake compares to the amount of salt recommended by health professionals? less than recommended 25 10.55 about the right amount 124 52.32 more than recommended 69 29.11 don’t know 19 8.02 *correct responses for knowledge questions are in bold table 2. knowledge & attitudes related to salt intake level of dietary concern variables. young adults who were concerned in general about their diet and those who self-assessed their salt intake level as high reported saltreducing behaviors more frequently. participants aged 27-30 reported higher engagement in salt-reducing behavior than those aged 18-20. the local relevance of the research topic is set to increase in the coming years as the burden of cardiovascular diseases continues to exacerbate, thereby increasing the demand for preventive population-wide interventions. although an overwhelming majority were aware of the increased health risk as a result of high salt intake, which is consistent with similar studies conducted in other cities of kazakhstan13 and internationally16, 19, younger participants were less aware of the association of salt with specific cardio-vascular health outcomes. educating on these relationships could be the purpose of salt-related local interventions, especially given the morbidity and mortality rates associated with cvd in kazakhstan, and should specifically target younger populations. yet the effectiveness of purely educational interventions may be debatable. for example, a kabs study in australia revealed that despite a decent level of awareness of adverse health impacts of excess salt consumption, the respondents were not willing to reduce these consumption amounts due to abundant promotion of inexpensive products high in salt and the lack of proper food labelling6. therefore, public health programs should target these aspects apart from focusing on awarenessraising. in the current study, the main perceived sources of salt (added during cooking or at the table and salt contained in processed products) were also among the identified leading sources of salt in a study of salt intake in turkey20. again, awareness of the main sources of salt is not sufficient for encouraging salt-decreasing behaviors and an emphasis on practical skills may be necessary19. thus, specific interventions targeting http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu predictor variables coefficient 95% ci p knowledge score 0.263 -0.021; 0.547 0.069 concern score 0.269 0.142; 0.396 <0.001 assessment of own level of salt consumption compared to recommendations* -3.023 -4.211; -1.834 <0.001 gender** -0.518 -0.169; 0.653 0.385 age*** 21-23 0.759 -0.873; 2.392 0.361 24-26 0.535 -0.808; 1.878 0.433 27-30 2.079 0.452; 3.705 0.012 region of origin**** central kazakhstan 0.772 -1.066; 2.610 0.409 west kazakhstan 0.409 -1.329; 2.146 0.644 south kazakhstan 1.273 -0.054; 2.600 0.060 east kazakhstan 0.193 -2.229; 2.614 0.876 *binary variable with all responses except for ‘more than recommended’ combined as reference group **females as reference group ***18-20 as reference group ****north kazakhstan as reference group table 3. multivariate model: predictors of salt-reducing behavior cooking practices may be useful. in kazakhstan, such practical interventions should target women, who are better informed about the primary sources of salt in food and are usually the primary cooks in traditional kazakh families. among the respondents, those generally concerned with food contents reported higher engagement in saltdecreasing behaviors. specifically, women were more concerned with the amount of saturated fat in food; therefore, interventions on salt-reduction practices for women could be integrated into saturated-fat reduction or into general healthy diet interventions. higher selfassessed salt intake level in our study was associated with frequent salt-reducing behavior, similarly to the findings of a previous study from australia16. a recent report on a who study of salt-related kabs in two regions of kazakhstan did not examine specifically the association between attitudes and behaviors; however, it claims that only 10% of the respondents evaluate their consumption of salt as excessive13. salt-reduction behaviors were higher in the oldest participants than in the younger ones. these findings are similar to results of a cohort study by vega-vega et al. (2018), measuring sodium in urine and through dietary recall, which also observed associations of age (p = 0.03) and male gender (p < 0.001) with sodium intake, adjusting for intake of calories, median urinary iodine excretion, and body-mass index21. a study from two kazakhstani regions also shows that males have higher sodium concentration in urine than females13. the study is subject to coverage bias due to the selected data collection mode. however, our target population of young adults are predominantly active http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu figure 1. level of concern for food-related issues figure 2. behavioral practices to reduce salt intake performed in the past month 107 112 141 115 133 171 74 86 69 92 81 60 56 39 27 30 23 6 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% calorie content sat. fat content fat content salt content sugar content healthy eating extremely or very concerned somewhat concerned not very or not at all concerned 100 74 92 12 69 59 64 13 68 104 81 212 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% avoided using packaged, ready-to-eat foods? used spices/herbs instead of salt during cooking? avoided eating food from fast food restaurants? when eating out, asked to have your meal prepared without salt? proportion always or often sometimes rarely or never http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu internet users; moreover, the anonymous online data collection may have reduced the possibility of social desirability bias. the results have limited generalizability because of the sampling technique and given that the majority of the respondents had higher education, younger age, and urban status. furthermore, there is a possibility of answering the questionnaire twice or multiple times in the internet survey. finally, due to the cross-sectional design study, results need to be interpreted with caution. future research could use other methodology to address the limitations of the current paper and add to the validity of the present results. also, further studies will be required to evaluate the effectiveness of salt-related interventions. references 1. moran ae, roth ga, narula j, mensah ga. 1990-2010 global cardiovascular disease atlas. global heart. 2014 mar;9(1):3–16. 2. ministry of health of the republic of kazakhstan. zdorovye naseleniya respubliki kazakhstan i deyatelnost organizatsiy zdravookhraneniya v 2005 godu [health of the population of the republic of kazakhstan and activities of healthcare organizations in 2005]. almaty. 2006. 3. ministry of health of the republic of kazakhstan. zdorovye naseleniya respubliki kazakhstan i deyatelnost organizatsiy zdravookhraneniya v 2016 godu [health of the population of the republic of kazakhstan and activities of healthcare organizations in 2016]. almaty. 2017. 4. hyseni l, elliot-green a, lloyd-williams f, kypridemos c, o’flaherty m, mcgill r, et al. systematic review of dietary salt reduction policies: evidence for an effectiveness hierarchy? shankar b, editor. plos one. 2017 may 18;12(5):e0177535. 5. ha sk. dietary salt intake and hypertension. electrolyte blood press. 2014;12(1):7. 6. land m-a, webster j, christoforou a, johnson c, trevena h, hodgins f, et al. the association of knowledge, attitudes and behaviours related to salt with 24-hour urinary sodium excretion. international journal of behavioral nutrition and physical activity. 2014;11(1):47. 7. nasreddine l, akl c, al-shaar l, almedawar m, isma’eel h. consumer knowledge, attitudes and saltrelated behavior in the middle-east: the case of lebanon. nutrients. 2014 nov 13;6(11):5079–102. 8. world health organization. global action plan for the prevention and control of noncommunicable diseases 2013-2020. 2013. geneva, switzerland: who document production services. 9. word health organization. salt reduction. retrieved from http://www.who.int/en/news-room/factsheets/detail/salt-reduction. 2016 10. temme e, hendriksen m, milder i, toxopeus i, westenbrink s, brants h, et al. salt reductions in some foods in the netherlands: monitoring of food composition and salt intake. nutrients. 2017 jul 22;9(7):791. 11. johnson c, mohan s, rogers k, shivashankar r, thout sr, gupta p, et al. mean dietary salt intake in urban and rural areas in india: a population survey of 1395 persons. journal of american heart association 2017 jan 6;6(1):e004547. 12. powles j, fahimi s, micha r, khatibzadeh s, shi p, ezzati m, et al. global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. bmj open. 2013 dec;3(12): e003733. 13. world health organization. better nutrition in kazakhstan. retrieved from http://www.euro.who.int/__data/assets/pdf_file/0010/39 6190/who-nutrition-kazakhtsan-en.pdf?ua=1. 14. zhang j, wu t, chu h, feng x, shi j, zhang r, et al. salt intake belief, knowledge, and behavior: a cross-sectional study of older rural chinese adults. medicine. 2016 aug;95(31): e4404. 15. ministry of national economy of the republic of kazakhstan. statistics committee. statistics of information and communication technologies. astana. 2018. retrieved from http://stat.gov.kz 16. grimes ca, kelley s-j, stanley s, bolam b, webster j, khokhar d, et al. knowledge, attitudes and behaviours related to dietary salt among adults in the http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx aubakirova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu state of victoria, australia 2015. bmc public health. 2017 dec;17(1):532. 17. qualtrics. provo, utah, usa: qualtrics. 2018 18. statacorp. stata. college station, tx: statacorp llc. 2015 19. sarmugam r, worsley a. current levels of salt knowledge: a review of the literature. nutrients. 2014 dec 1;6(12):5534–59. 20. erdem y, akpolat t, derici ü, şengül ş, ertürk ş, ulusoy ş, et al. dietary sources of high sodium intake in turkey: salturk ii. nutrients. 2017 aug 24;9(9):933. 21. vega-vega o, forseca-correa ji, mendoza-de la garza a, rincon-pedrero r, espinosa-cuevas a, baeza-alias a, et al. contemporary dietary intake: too much sodium, not enough potassium, yet sufficient iodine: the salmex cohort results. nutrients. 2018 jun 25;10(7):816. http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. microbiological and susceptibility profile of clinical gram positive isolates at a tertiary pediatric and maternity hospital in ulaanbaatar, mongolia susanna felsenstein1, sarantsetseg bira2, narangerel altanmircheg2, enkhtur shonkhuuz3, ariuntuya ochirpurev4, david warburton5,6 1cork university hospital university college cork, wilton, cork, republic of ireland; 2central laboratory department, national center for maternal and child health, ulaanbaatar, mongolia; 3critical care medicine, national center for maternal and child health, ulaanbaatar, mongolia; 4health emergencies and food safety, office of the who representative in mongolia, ulaanbaatar, mongolia; 5keck school of medicine, university of southern california, usa; 6ostrow school of dentistry, university of southern california, usa vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.380 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.380|http://cajgh.pitt.edu abstract introduction: information on microbiological and susceptibility profiles of monoglian bacterial isolates is scarce. resistance profiles, patient demographics and microbiological work-up of gram positive isolates were analyzed in order to develop infection control activities and policies at the national center for maternity and children’s health (ncmch) in ulaanbataar, mongolia. methods: all gram positive isolates of specimens submitted to the microbiology laboratory at ncmch between january 2014 and august 2017 were included. data collected included demographic data, specimen type, in-/outpatient status, hospital ward of sample origin, and antimicrobial susceptibility testing profile. susceptibility testing was performed by trained microbiologists at the ncmch microbiology laboratory. t-test, mann-whitney, chi-square and fisher exact tests were used as appropriate. results: of 11,889 isolates, 4012 (33.7%) were gram positive, with most identified as s. aureus (62.6%, n=2512). rates of methicillin resistance (mrsa) remained stable at a quarter, but was significantly higher among inpatients (inpatients: 630/2002, 31.5%; outpatients 67/290, 23.1%; p≤0.05) and sterile site isolates (sterile: 83/171, 48.5%; non-sterile: 416/1678, 24.8%; p≤0.01). the vast majority of s. pneumoniae isolates (12/14; 85%) was found to be penicillin resistant by oxacillin disk diffusion. while identification of group b streptococci was rare (n=137) due to of lack of diagnostic measures available, the number of enterococcal isolates identified increased signifi-cantly due to implementation of improved microbiological work-up (2015: n=7; 2016: n=26; 2017: n=83). conclusion: compared with published studies from neighboring nations, the rates of antimicrobial resistance among gram positive isolates at ncmch, particularly with respect to s. aureus and s. pneumoniae, were much higher. further improvement of microbiological diagnostics and collabo-ration of stakeholders is required to address the pressing infection control and stewardship issues and to ensure reliable identification of relevant pathogens in mongolia. keywords: child health; women health; communicable diseases; epidemiology; maternal and child health; mongolia microbiological and susceptibility profile of clinical gram positive isolates at a tertiary pediatric and maternity hospital in ulaanbaatar, mongolia susanna felsenstein1, sarantsetseg bira2, narangerel altanmircheg2, enkhtur shonkhuuz3, ariuntuya ochirpurev4, david warburton5,6 1cork university hospital university college cork, wilton, cork, republic of ireland; 2central laboratory department, national center for maternal and child health, ulaanbaatar, mongolia; 3critical care medicine, national center for maternal and child health, ulaanbaatar, mongolia; 4health emergencies and food safety, office of the who representative in mongolia, ulaanbaatar, mongolia 5keck school of medicine, university of southern california, usa; 6ostrow school of dentistry, university of southern california, usa research introduction gram positive organisms (gpo) include some of the most clinically relevant bacteria, such as s. aureus, s. pneumoniae and enterococci, which can cause a wide array of serious infections among hospitalized and community patients1. http://www.library.pitt.edu/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.380|http://cajgh.pitt.edu the who estimates that globally, 700,000 deaths each year are directly attributable to antimicrobial resistance (amr), based on amr data from asian countries of the western pacific region of the who (wpro), including china, south korea, and malaysia2,3. this report emphasizes the need for the development of the national action plans for all nations, while underscoring the importance of the multidimensional one health approach encompassing health care sector, public, veterinary, agricultural, environmental, and food sectors, as well as financial stakeholders4. a national action plan for mongolia was approved in 20175. amr in asia is increasing at alarming rates6-9, with little data availible on the susceptibility patterns of gram positive organisms in mongolia. mongolia is a vast country with an area of 1,500 million km2 and just over three million inhabitants featuring one of the lowest population densities worldwide. half of the population lives in the capital ulaanbaatar, while the rest inhabits rural areas, many following the traditional nomadic lifestyle of mongolian herders10. in recent years, mongolia has experienced rapid economic growth and modernization, especially in ulaanbaatar. contrasting this, many parts of the country remain extremely remote and difficult to access. this poses significant challenges to the introduction of antimicrobial surveillance and infection control, staff education and diagnostic tools, enforcement of drug regulation and auditing of prescription practices10,11. in a community-based survey, over 70% of children had received antibiotics in the preceding six months, more than half of which had not been prescribed by a healthcare professional12. in 2018, the who released its first global report on the consumption and use of antibiotics, and mongolia recorded the highest consumption among the six western pacific region countries that submitted the data. a high burden of infectious diseases, such as respiratory and genitourinary infections, tuberculosis and sexually transmitted diseases, high usage of over-the-counter antibiotics, and widely prevalent antibiotic use based on self-diagnosis are among the contributing factors12,13. multidrugresistant gpos are a growing concern in other central asian countries14. the paucity of data on susceptibility patterns of gpos in mongolia impacts the development of infection control practices, antimicrobial stewardship, and poses a significant public health concern. the national center for maternal and child health (ncmch), ulaanbaatar, is the country’s largest governmentrun pediatric and maternity hospital, and national tertiary referal center. the pediatric hospital accommodates 19 medical and surgical subspecialties, 320 inpatient beds, and provides treatment for approximately 40,000 inpatients and over 175,000 outpatients per year. the adjacent maternity hospital has 250 inpatient beds providing gynecological and obstetric care, with just under 12,000 deliveries annually15. the ncmch is the first mongolian center to publish its data on gram positive amr internationally. the goal of this study was to identify areas in need of further improvement in diagnostic microbiological work-up, surveillance of resistant organisms, enabling development of antimicrobial treatment guidelines, and improvement of infection control practices. methods data collection all gram positive isolates of specimens submitted to the microbiology laboratory at ncmch between january 2014 and august 2017 were included. data collection began with the introduction of routine electronic data collection in 2014. data were collected retrospectively (2014-2017) and prospectively (2017) using whonet vs. 516, an electronic laboratory http://www.library.pitt.edu/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.380|http://cajgh.pitt.edu organism 2014 2015 2016 2017 total s. aureus 414 (47.0%) 1036 (64.7%) 750 (70.6%) 312 (66.5%) 2512 (62.6%)* coagulase negative staphylococci 267 (30.2%) 432 (27%) 252 (23.7%) 45 (8.9%) 996 (24.8%)* group b streptococci 19 (2.2%) 116 (7.2%) 3 (0.3%) 0 138 (3.4%)* viridans streptococci 102 (11.6%) 8 (0.5%) 10 (0.9%) 3 (0.6%) 123 (3%)* enterococcus spp., unidentified 4 (0.5%) 4 (0.2%) 22 (2.1%) 83 (17.7%) 113 (2.8%)* group a streptococci 58 (6.6%) 1 (0.1%) 10 (0.9%) 18 (3.8%) 87 (2.2%) s. pneumoniae 4 (0.5%) 4 (0.2%) 10 (0.9%) 8 (1.7%) 26 (0.6%) micrococcus spp. 11 (1.3%) 0 0 0 11 (0.3%) e. faecalis 1 (0.1%) 0 4 (0.4%) 0 5 (0.1%) e. avium 0 0 1 (0.1%) 0 1 (0.0%) total 880 1601 1062 472 4012 (100%) *significant differences in annual isolation frequency (p≤0.05), for the five most frequently identified organisms per year table 1. species identification of gram positive isolates. database made available by the who. data collected included demographic data, specimen type, in-/outpatient status, hospital ward of sample origin, and antimicrobial susceptibility testing (ast) profile. organisms identified by means other than culture (ie. latex agglutination) were not included (n=13). in cases of an identical organism being isolated from a patient within 30 days, only the first isolate was included. susceptibility testing susceptibility testing was performed by trained microbiologists at the ncmch microbiology laboratory. instances where ncmch laboratory ast differed from clinical laboratory standards institute (clsi) guidelines are specifically indicated17-19. additions or omissions to standard test panels are indicated separately. susceptibility interpretation is reported as per clsi 2016 guidelines17. fully resistant and intermediately susceptible isolates (%i/r) are reported as one category. only species with a minimum of 30 isolates annually were used to test for antimicrobial succeptability18. reports on isolates with less than 30 isolates per year are explicitly specified. molecular detection of organisms or susceptibility status was unavailable. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.380|http://cajgh.pitt.edu figure 1. the prevalence of methicillin-resistant staphylococcus aureus in 2014-2917 while both clsi and the european committee on antimicrobial susceptibility testing (eucast) now recommend induction of the meca gene with cefoxitin19 23, the ncmch relies on oxacillin disk diffusion (dd) for diagnosis of methicillin resistant s. aureus (mrsa); hence these results were interpreted as per clsi 2006 guidelines22. vancomycin resistance testing was done by dd. as no broth microdilution data was available, organism rates with dd diameters ≥15 mm on a 30 mcg vancomycin disk were reported as susceptible (vssa), the remaining as vancomycin resistant s. aureus (vrsa)22-23. in s. pneumoniae isolates, penicillin susceptibility was tested on 1 mcg oxacillin disks. as no broth dilution was done, meningitis breakpoints and cephalosporin susceptibilities are not reported20,22,24. the ethics committee at ncmch approved this study. statistical analysis quantitative variables were reported as absolute numbers and percentages. for continuous variables, comparisons between groups to test equality were performed using the t-test or mann-whitney test when appropriate. tests of association between categorical variables were based on chi-square and fisher exact tests. all p values reported are two-sided and were considered statistically significant if p<0.05. statistical computations were performed using spss 22.0 (spss inc. chicago, illinois). results of 11,889 isolates, 4012 (33.7%) were gram positive (table 1). neonatal samples accounted for n=951 (23.8%); pediatric samples for n=2,010 (50.2%), and adult samples from patients ages ≥18 years for n=1,043 (26.0%) of isolates. three quarters of specimens originated from wound and surface swabs (26.3%), genital swabs (28.2%), urine (21.2%); and 598 (5%) from blood cultures. the remaining samples (7.6%) were obtained from respiratory secretions, cerebrospinal fluid, http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.380|http://cajgh.pitt.edu s. pneumoniae (n, non-meningitis breakpoints) 2014 2015 2016 2017 total oxacillin 1mcg disk, zone diameter in mm not done 3 4 3 2 12 resistant 8 0 0 0 1 1 10 0 0 0 1 1 14 0 0 1 0 1 ≤19 1 0 5 3 9 susceptible 23 0 0 0 1 1 25 0 0 1 0 1 total 4 4 10 8 26 vancomycin 30mcg disk, zone diameter in mm not done 2 2 0 0 4 resistant 16 0 0 1 0 1 17 0 0 1 0 1 susceptible ≥17 2 0 0 0 2 18 0 0 0 1 1 20 0 0 2 3 5 22 0 0 0 3 3 25 0 0 3 1 4 26 0 2 2 0 4 29 2 0 1 0 3 total 4 4 10 8 26 table 2. interpretation of susceptibility data by non-meningitis breakpoints of s. pneumoniae isolates. joint and pericardial aspirates, and stool samples. the source of specimen could not be determined in 11.7% of cases. two thirds of isolates (n=2,512; 62.6%) were identified as s. aureus; mostly from inpatients (86%, 2,171/2,478). oxacillin susceptibility was available in 92.5% (2,320/2,512) of isolates; two thirds (69.8%, 1,620/2,320) were methicillin susceptible (mssa), the remainder resistant (mrsa). whilst in 2014 high rates of mrsa (60%, 224/377) were observed, they remained stable thereafter at approximately one quarter (figure 1). mrsa was significantly more common among inpatients compared to outpatients (mrsa inpatients: n=630/2,002, 31.5%; outpatients: n=67/290, 23.1%; p=0.04). mssa predominated on surface swabs (78.3%, 875/1,117) and other non-sterile site cultures (82.0%, 128/156); whereas s. aureus positive blood cultures grew http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.380|http://cajgh.pitt.edu mrsa in 44.5% (23/53). the mrsa rate among sterile samples was overall higher (sterile: n=83/171, 48.5%; non-sterile: n=416/1,678, 24.8%; p=0.01; figure 1) and increased significantly over the study period (p=0.02). the exception were swabs taken from burns, where mrsa accounted for 78% (40/51) of staphylococcal isolates. vancomycin susceptibility was available for 88.1% (n=661/750) of s. aureus isolates in 2016 and 97.4% (n=304/312) in 2017. resistance was reported in six instances, originating from the maxillofacial (n=4/6) and pediatric intensive care units (n=2/6). non-reliable vancomycin susceptibility was more frequently documented in 2014/15 when staff had just started to undergo training, and quality control was being established for vancomycin susceptibility testing. hence, vancomycin susceptibilities from 2014-2015 were not used for clinical management and are therefore not reported. teicoplanin and daptomycin were not included in the test panel. susceptibilities to clindamycin, rifampicin, or cotrimoxazole were only tested in a minority of isolates. isolates of coagulase negative staphylococci (cons) (n=996) were comprised of s. epidermidis (85.5%, n=851), s. xylosus (n=12), s. saprophyticus (n=1), s. auricularis (n=1), s. sciuri (n=4), s. hominis (n=1), s. hemolyticus (5.3%, n=53), s. lugdunensis (n=1), s. warneri (n=1) and other, not further identified cons spp. (6.7%, n=71). sample origin was available for 75% (744/996) of isolates. of those, 9% (n=67/744) were sterile sites isolates, mostly (n=52/67) from blood cultures. most originated from pediatric patients (75.8%), mainly from wound swabs. a substantial proportion (16.8%, n=167/996) did not undergo susceptibility testing. cefazolin susceptibilities were available for 88.8% (n=884/996), 10.9% of which were resistant. vancomycin susceptibilities were available for 83.2% (n=829/996), of which 11% (n=12/829) were resistant, all identified between 2014 and 2015. since 2016, no vancomycin resistant cons were identified. despite identification of group b streptococci (gbs) being mostly outsourced to another facility, 137 gbs isolates were identified; 66 in children, 47 in adults, only twelve from neonatal isolates. in adults, gbs was mostly isolated from respiratory tract or wounds. among n=716 urinary and n=3,313 genital tract samples from adults, only three uterine and one urinary sample were identified as gbs, the majority of isolates from these sites were gram negatives. group a streptococcus (gas) isolates were mainly found in nasopharyngeal specimens (59.8%; n=52/87); a quarter (n=10/46) of pediatric gas isolates had been sampled from burns. all gas isolates tested (n=48/60) were penicillin susceptible. viridans streptococci or not further identified streptococcus spp. originated mainly from respiratory and oral specimens. penicillin susceptibility was tested by oxacillin disk diffusion, which is not recommended for viridans streptococci and hence not reported. however, disk diffusion is acceptable for testing of cephalosporin susceptibilities: 16.5% (n=15/91) were reported as not susceptible to cefotaxime, 0.7% (n=6/86) as not susceptible to ceftriaxone. among 26 isolates of s. pneumoniae, five were blood streamand six cerebrospinal fluid (csf) isolates, the remainder originated from wound and eye swabs, all in children. approximately half (n=14/26) underwent pencillin susceptibility testing by oxacillin disk diffusion. the majority 85.7% (n=12/14) were identified as resistant by this method, confirmation by minimum inhibitory concentrations (mic) testing was not available. nearly all s. pneumoniae tested for vancomycin (n=20/22) were found to be susceptible with the exception of a neonatal eye swab and a pediatric wound isolate. among csf isolates, susceptibilities could not be retrieved in 4/6 instances, the remaining two were penicillin resistant per oxacillin disk when considering non-meningitis break points. vancomycin susceptibilities however were available for all, and http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.380|http://cajgh.pitt.edu vancomycin susceptibility with zone diameters exceeding 17 mm was universal. while in 2014 and 2015 only ten enterococcal isolates were identified, there were 26 in 2016 and 83 in 2017, reflecting that standardized diagnostic measures for enterococcal identification were introduced in october 2016. most (n=113/119) were reported as enterococcus spp. and not further identified, five as e. faecalis, and one as e. avium. they originated equally from children (n=64) and adults (n=52). six of 97 isolates that underwent vancomycin susceptibility testing were resistant, all of them sampled from adult outpatients. ampicillin susceptibility was not documented even though it constitutes the antibiotic of choice. gentamicin susceptibility was universal for all available (n=25/119), though specific testing for high-level enterococcal resistance was not done. discussion this study is the largest report on the susceptibility profile of gram positive isolates from clinical specimens in mongolia to date. the results highlight important points on the epidemiology of gram positive pathogens in mongolia. rates of mrsa remained stable at approximately one quarter overall. methicillin resistance in s. aureus isolates from inpatients and sterile site specimens howvere increased. hence, mrsa spread appears to be mainly nosocomially driven. the isolation of enterococci increased dramatically, reflecting improved diagnostic means. s. pneumoniae was frequently identified as penicillin resistant, a finding that bears important clinical relevance. in addition to the large sample size and a patient cohort representing patients of all ages and given the ncmch is a tertiary referral center for patients from across all of the mongolia, data were collected consecutively over several years, thereby enabling an observation over time. during the data collection period, several changes were implemented in order to improve diagnostic processes, quality control, and staff training. however, this also means that the study has important limitations. adjustments made to microbiological diagnostics are reflected in a changing species and susceptibility profile over the study period. susceptibility panels remained dependent on locally available equipment and antimicrobials used in clinical practice18,20. it is recognized that this will require ongoing adjustments, which are often subject to financial constraints. the study identified a need for further implementation of improved diagnostics through modernized equipment and staff training, in order to enable accurate identification of a wider range of gram positive pathogens. this need is currently being addressed. as a country at the threshold of developing into a modern state, mongolia’s health care system has a unique opportunity to apply modern technology and therapeutic options, while facing new challenges in surveillance, governance, and stewardship policies. this situation is exemplified by the increasing use of antimicrobial agents for nosocomial infections in intensive care settings and the resulting spread of multidrug resistant organisms. clinicians are increasingly confronted with the complications of modern intensive care medicine, expansion of intensive neonatal care, and surveillance of changing epidemiology of childhood infections as vaccination schedules are changing. an important gram positive vaccine preventable pathogen, s. pneumoniae, was not commonly identified. however, the majority of isolates available for analysis were penicillin resistant on oxacillin disk testing. this method may underestimate non-reliable penicillin susceptibility18,24. mics to penicillin and vancomycin were unavailable, and while reliable conclusions regarding penicillin susceptibility cannot be drawn based on this data alone, the results should caution mongolian clinicians against the use of http://www.library.pitt.edu/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.380|http://cajgh.pitt.edu beta-lactam monotherapy in pneumococcal meningitis, especially in the absence of universal and reliable cephalosporin susceptibilities 24,25. these findings are in agreement with recent reports from the russian federation, where a survey identified 28% of pneumococcal isolates as penicillin resistant26. by contrast, among s. pneumoniae isolates in kazakhstan27, penicillin susceptibility was almost universal. pneumococcal vaccination of infants has recently been introduced to targeted populations in mongolia but is not universal yet28. in the coming years, more widespread pneumococcal vaccination is likely to change the epidemiology of pneumococcal infections in mongolia. therefore, reliable identification, susceptibility testing and serotyping of s. pneumoniae in order to monitor vaccination impact must be ensured. a gbs screening program is not currently performed in mongolia, hence the data presented is not representative of gbs carrier or infection prevalence among women or neonates in mongolia. the lack of laboratory exposure to gbs diagnostics may explain the unusual susceptibility patterns, including the report of seven cephalosporin resistant isolates. misidentification cannot be ruled out, however it should be noted that penicillin and cephalosporin susceptibility is no longer universal for gbs, particularly in asia29,30. more data on gbs epidemiology in mongolia is currently being assimilated and molecular testing will become part of the ncmch’s laboratory strategy by the end of 2019. once in place, a guideline for risk stratification of fetomaternal and neonatal management will be introduced. enterococcal identification was introduced in 2016, and universal testing for aminopenicillin, gentamicin, and vancomycin susceptibility is currently being introduced. the increase in enterococcal identification underscores the significant impact of improved diagnostics on the accuracy of institutional species composition and treatment considerations. in previous years, limited data available on s. aureus in mongolia identified a rate of 9% of methicillin resistance and of 28% of multidrug resistance in 2007 and 201131. sample origin was only known for 21% of isolates in this study. our data shows a much higher rate of mrsa, possibly as a result of a greater number of sterile samples from hospitalized patients, though a comparison of the two studies is difficult. our findings may also be indicative of a significant rise in the proportion of mrsa among s. aureus isolates in mongolia over time. comparison with a similar institution in the neighboring nation of kazakhstan shows that rates of mrsa in mongolia are strikingly higher. in kazakhstan, 95 to 100% of s aureus isolates were reported as oxacillin susceptible32, of our isolates, one third were methicillin resistant. in russian siberia, nosocomial mrsa rates among s. aureus are more comparable at a rate of 22%, though community rates of mrsa in siberia were reportedy much lower (2.9%) than we identified in outpatients attending the ncmch. in relation to the community acquired infections, mongolia’s unique position as country where animal husbandry and nomadic herders’ lifestyle applies to much of the population remains to be investigated. over 700 drugs are registered and commonly used in livestock production. amr monitoring in the livestock and food supply is critical in order to control amr development. laboratories routinely examine food for food borne pathogens, however amr testing is not yet systematically conducted throughout the food chain32. a mongolian food chain amr monitoring system piloted in 2016 with who support revealed that food borne pathogens found in animal products and animal production facilities were commonly resistant to antimicrobials with a high proportion of multidrugresistance. in another study, almost half of food items tested mrsa positive33. this highlights that in addition to infection control in the hospital environment, amr is an issue that requires an integrative and collaborative approach of multiple agencies34. susceptibility testing for gram positive isolates at ncmch is now performed http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.380|http://cajgh.pitt.edu following a more standardized approach, and staff training is ongoing. cefoxitin disk testing for mrsa identification has been introduced at ncmch and follow-up data is being collected. vancomycin susceptibility testing has been included from 2016. of the six s. aureus isolates exhibiting non-reliable vancomycin susceptibility, all but one were methicillin susceptible, contrasting the fact that most studies have identified that the majority of vana or vanb positive s. aureus isolates to be also methicillin resistant. vana/b/c acquisition is increasingly recognized to occur irrespective of methicillin susceptibility33,35. in the future, isolates found to be vancomycin resistant will be tested for extended antimicrobial susceptibilities. susceptibility testing will aim to include vancomycin susceptibility by mic into testing of all invasive s. aureus isolates, with an implementation deadline by the end of 2019. our study constitutes the largest published record of clinical gram positive isolates in mongolia. the results emphasize the importance of consequent surveillance and urgent attention to strategies that that allow rapid diagnosis of gram positive infections; a difficult task mongolia shares with other countries in the area experiencing rapid and profound societal and economic change. compared with studies from neighboring nations, the rates of amr among gram positive isolates at ncmch, particularly s. aureus and s. pneumoniae, were much higher. as a nation with significant livestock populations, amr monitoring must be embedded in an approach that involves both the public and veterinary sector as well as healthcare facilities. international collaboration is critical to address these issues. references 1. david mz, daum rs. community-associated methicillin-resistant staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic. clin microbiol rev. 2010;23(3):616-87. 2. review on antimicrobial resistance. antimicrobial resistance: final report and recommen-dations. 2016. https://amrreview.org/sites/default/files/160525_final%20 paper_with%20cover.pdf. wellcome trust. jim o’neill (chair). accessed on 14 sepetmeber, 2019 3. global action plan for antimicrobial resistance. world health organization. isbn 978 92 4 150976 3. http://www.wpro.who.int/entity/drug_resistanc e/resources/global_action_plan_eng.pdf. accessed on 14 sepetmeber, 2019 4. batsukh z, tsolmon t, otgonbaatar d, undraa b, dolgorkhand a, ochirpurev a. one health in mongolia. 2016. pages 123-137. in mackenzie js, jeggo m, daszak p, richt ja ed-itors. one health: the human-animalenvironment interfaces in emerging infectious diseases. 5. national multi-sectorial action plan on combating antimicrobial resistance, 20172020. http://www.wpro.who.int/mongolia/en/. accessed on 14 sepetmeber, 2019 6. versporten a, zarb p, caniaux i, et al. antimicrobial consumption and resistance in adult hos-pital inpatients in 53 countries: results of an internet-based global point prevalence survey. lancet glob health. 2018; 6(6):e619-e629 7. van den hof s, woudt s, monen j, et al. central asian and eastern european surveillance of antimicrobial resistance (cesar). annual report 2018. isbn 978 92 890 5386 0 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://amr-review.org/sites/default/files/160525_final%20paper_with%20cover.pdf https://amr-review.org/sites/default/files/160525_final%20paper_with%20cover.pdf https://amr-review.org/sites/default/files/160525_final%20paper_with%20cover.pdf https://amr-review.org/sites/default/files/160525_final%20paper_with%20cover.pdf https://amr-review.org/sites/default/files/160525_final%20paper_with%20cover.pdf https://amr-review.org/sites/default/files/160525_final%20paper_with%20cover.pdf https://amr-review.org/sites/default/files/160525_final%20paper_with%20cover.pdf https://amr-review.org/sites/default/files/160525_final%20paper_with%20cover.pdf https://amr-review.org/sites/default/files/160525_final%20paper_with%20cover.pdf https://amr-review.org/sites/default/files/160525_final%20paper_with%20cover.pdf http://www.wpro.who.int/entity/drug_resistance/resources/global_action_plan_eng.pdf http://www.wpro.who.int/entity/drug_resistance/resources/global_action_plan_eng.pdf http://www.wpro.who.int/entity/drug_resistance/resources/global_action_plan_eng.pdf http://www.wpro.who.int/entity/drug_resistance/resources/global_action_plan_eng.pdf http://www.wpro.who.int/mongolia/en/ http://www.wpro.who.int/mongolia/en/ central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.380|http://cajgh.pitt.edu 8. antimicrobial resistance: global report on surveillance. geneva: world health organization; 2014. http://apps.who.int/iris/bitstream10665/112642 /1/9789241564748_eng.pdf. accessed on 14 sepetmeber, 2019 9. lee y, wakabayashi m. key informant interview on antimicrobial resistance (amr) in some countries in the western pacific region. global health. 2013; 26(9):34. 10. national statistics office of mongolia. social and economic situation of mongolia (october 2018). http://www.en.nso.mn/content/293. accessed on 14 sepetmeber, 2019 11. unicef multiple indicative cluster surveys, mongolia. http://mics.unicef.org/surveys. accessed on 14 sepetmeber, 2019 12. togoobaatar g, ikeda n, ali m, et al. survey of non-prescribed use of antibiotics for children in an urban community in mongolia. bull world health organ. 2010;88(12):930-6 13. who report on surveillance of antibiotic consumption: 2016-2018 early implementation. world health organization 2018. isbn 97892-4-151488-0 14. viderman d, brotfain e, khamzina y, kapanova g, zhumadilov a, poddighe d. bacterial resistance in the intensive care unit of developing countries: report from a tertiary hospital in kazakhstan. j glob antimicrob resist. 2018(15): s2213. 15. shonkuuz, e. et al. department of informatics and statistics, national center for maternal and child health, 2017. 16. whonet. http://www.whonet.org. accessed on 14 sepetmeber, 2019 17. clsi performance standards for antimicrobial susceptibility testing. 26th ed. clsi supplement m100s. wayne pa. clinical and laboratory standards institute, 2016. 18. clsi. analysis and presentation of cumulative antimicrobial susceptibility test data; approved guideline, 4th ed. clsi document m39-a4. wayne, pa: clinical and laboratory standards institute; 2014. 19. laboratory detection of: oxacillin/methicillinresistant staphylococcus aureus. https://www.cdc.gov/hai/settings/lab/lab_mrsa. html. accessed on 14 sepetmeber, 2019 20. giske cg, martinez-martinez l, cantón r. eucast subcommittee for detection of resistance mechanisms and specific resistances of clinical and/or epidemiological importance: 2013. version 1.0. http://www.amcli.it/wpcontent/uploads/2015/10/eucast_detection_r esistance_mechanisms_v1.pdf. accessed on 14 sepetmeber, 2019 21. dien bard j, hindler ja, gold hs, limbago b. rationale for eliminating staphylococcus breakpoints for β-lactam agents other than penicillin, oxacillin or cefoxitin, and ceftaroline. clin infect dis. 2014; 58(9): 1287–1296. 22. clinical and laboratory standards institute. performance standards for antimicrobial susceptibility testing; sixteenth informational supplement. clsi document m100-s16. isbn 1-56238-588-7. clinical and laboratory standards institute, 940 west valley road, suite 1400, wayne, pennsylvania 19087-1898 usa, 2006. 23. walters m, lonsway d, rasheed k, et al. investigation and control of vancomycinresistant staphylococcus aureus: a guide for health departments and infection control http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://apps.who.int/iris/bitstream10665/112642/1/9789241564748_eng.pdf http://apps.who.int/iris/bitstream10665/112642/1/9789241564748_eng.pdf http://apps.who.int/iris/bitstream10665/112642/1/9789241564748_eng.pdf http://apps.who.int/iris/bitstream10665/112642/1/9789241564748_eng.pdf http://www.en.nso.mn/content/293 http://www.en.nso.mn/content/293 http://mics.unicef.org/surveys http://mics.unicef.org/surveys http://www.whonet.org/ http://www.whonet.org/ https://www.cdc.gov/hai/settings/lab/lab_mrsa.html https://www.cdc.gov/hai/settings/lab/lab_mrsa.html https://www.cdc.gov/hai/settings/lab/lab_mrsa.html https://www.cdc.gov/hai/settings/lab/lab_mrsa.html http://www.amcli.it/wp-content/uploads/2015/10/eucast_detection_resistance_mechanisms_v1.pdf http://www.amcli.it/wp-content/uploads/2015/10/eucast_detection_resistance_mechanisms_v1.pdf http://www.amcli.it/wp-content/uploads/2015/10/eucast_detection_resistance_mechanisms_v1.pdf http://www.amcli.it/wp-content/uploads/2015/10/eucast_detection_resistance_mechanisms_v1.pdf http://www.amcli.it/wp-content/uploads/2015/10/eucast_detection_resistance_mechanisms_v1.pdf http://www.amcli.it/wp-content/uploads/2015/10/eucast_detection_resistance_mechanisms_v1.pdf felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.380|http://cajgh.pitt.edu personnel. atlanta, ga 2015. http://www.cdc.gov/hai/pdfs/vrsainvestigation-guide-05_12_2015.pdf. accessed on 14 sepetmeber, 2019 24. swenson j. m., hill b. c., thornsberry c. screening pneumococci for penicillin resistance. j. clin. microbiol. 1986; 24:749– 752. 25. choi s, chung jw, sung h, et al. impact of penicillin nonsusceptibility on clinical outcomes of patients with nonmeningeal streptococcus pneumoniae bacteremia in the era of the 2008 clinical and laboratory standards institute penicillin breakpoints. antimicrob agents chemother. 2012; 56(9): 4650–4655. 26. mayanskiy n, alyabieva n, ponomarenko o et al. serotypes and antibiotic resistance of noninvasive streptococcus pneumoniae circulating in pediatric hospitals in moscow, russia. int j infect dis. 2014; 20:58-62. 27. belyaev i, belyaev a. sensitivity study of antimicrobial pneumococci in central kazakhstan. georgian med news. 2017; (262):101-106. 28. sundaram n, chen c, yoong j, et al. costeffectiveness of 13-valent pneumococcal conju-gate vaccination in mongolia. vaccine. 2017; 35(7):1055–1063. 29. longtin j, vermeiren c, shahinas d, et al. novel mutations in a patient isolate of streptococcus agalactiae with reduced penicillin susceptibility emerging after long-term oral suppres-sive therapy. antimicrob agents chemother 2011;55:2983–2985. 30. seki t, kimura k, reid me, et al. high isolation rate of mdr group b streptococci with re-duced penicillin susceptibility in japan. j antimicrob chemother 2015;70:2725–2728. 31. nair r, hanson bm, kondratowicz k, et al. antimicrobial resistance and molecular epidemi-ology of staphylococcus aureus from ulaanbaatar, mongolia. peerj 2013;1:e176 32. khudaibergenova ms. antimicrobial use at a multi-disciplinary hospital. int j risk saf med. 2015;27 suppl 1:s13-4. 33. panesso d, planet pj, diaz l, et al. methicillin-susceptible, vancomycin-resistant staphylo-coccus aureus, brazil. emerg infect dis. 2015 oct; 21(10): 1844–1848. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.cdc.gov/hai/pdfs/vrsa-investigation-guide-05_12_2015.pdf http://www.cdc.gov/hai/pdfs/vrsa-investigation-guide-05_12_2015.pdf http://www.cdc.gov/hai/pdfs/vrsa-investigation-guide-05_12_2015.pdf http://www.cdc.gov/hai/pdfs/vrsa-investigation-guide-05_12_2015.pdf microbiological and susceptibility profile of clinical gram positive isolates at a tertiary pediatric and maternity hospital in ulaanbaatar, mongolia microbiological and susceptibility profile of clinical gram positive isolates at a tertiary pediatric and maternity hospital in ulaanbaatar, mongolia abstract abstract keywords: child health; women health; communicable diseases; epidemiology; maternal and child health; mongolia keywords: child health; women health; communicable diseases; epidemiology; maternal and child health; mongolia microbiological and susceptibility profile of clinical gram positive isolates at a tertiary pediatric and maternity hospital in ulaanbaatar, mongolia microbiological and susceptibility profile of clinical gram positive isolates at a tertiary pediatric and maternity hospital in ulaanbaatar, mongolia research research cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. a systematic review and metaanalysis of randomized controlled trials on the effect of transcranial magnetic stimulation on tinnitus management salma galal1*, naema ismail2, ghada niel3 1community and industrial medicine department, faculty of medicine; 2audiology department, faculty of medicine, al-azhar university, cairo, egypt; 3audiology department, mansoura international hospital, mansoura, egypt *corresponding author vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ galal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu abstract introduction: tinnitus occurs in 10-15% of the world’s population. it may lead to hearing loss, depression, and suicidal tendencies, as well as reduced quality of life. the aim of this study was to assess whether transcranial magnetic stimulation (tms) effectively reduces tinnitus handicapping after six months or more of follow-up. methods: a systematic review of randomized controlled trials with follow-up of six months was undertaken. the review took place through searching medline, science direct, and google scholar databases using the keywords “tinnitus” and “transcranial magnetic stimulation” and limiting the search results to randomized controlled trials (rcts) conducted on adults (19 years and older) published between 2005-2015. meta-analysis was performed on the similarly designed studies. results: five rcts with six month follow-up were found conforming to the inclusion criteria. in total, there were 119 patients in the tms arms and 115 in the placebo arms. however, designs were different between the studies and were therefore not all comparable. different parameters were used to measure the severity of tinnitus and depression scores. tinnitus handicapped inventory (thi) was the common measured outcome parameter used in all studies. thi score decreased after the tms in four studies. meta-analysis was performed on three similarly designed rcts with the overall effect being insignificant. conclusion: tms reduced the thi score and decreased the severity of tinnitus in 45% of patients and lead to a complete recovery in 32% of cases in one study. however, the meta-analysis demonstrated lack of significant effect of tms on tinnitus management. keywords:tinnitus; tms; transcranial magnetic stimulation; magnetic field therapy a systematic review and metaanalysis of randomized controlled trials on the effect of transcranial magnetic stimulation on tinnitus management salma galal1, naema ismail2, ghada niel3 1community and industrial medicine department, faculty of medicine; 2audiology department, faculty of medicine, al-azhar university, cairo, egypt; 3audiology department, mansoura international hospital, mansoura, egypt research tinnitus is the perception of sound in the ear or in the head without any external acoustic stimulation. numerous hypotheses have been developed for the pathophysiology of tinnitus. it has been suggested that tinnitus may arise from any abnormality of the neural pathway from the cochlear neural axis to the auditory cortex.1 the pathophysiological theory implies that the central nervous system is the source or “generator” of tinnitus.2 tinnitus is often a feature of ear disease and is usually associated with hearing loss, but it may also occur in patients with normal hearing.3 many cases of tinnitus have no identifiable cause. environmental exposure to recreational, urban, and occupational noise or ototoxic drugs can develop tinnitus.4 explosion or firing can cause damage to the peripheral auditory organs, which in turn causes the activation of neural plasticity and leads to tinnitus.5 in 39 studies done in belgium, italy, denmark, finland, norway, sweden, uk, scotland, usa, japan, china, south korea, australia, egypt, nigeria, and http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu brazil, the prevalence of tinnitus ranges from 5.1% to 42.7% and is higher in males than in females.6 the national health interview survey found that, within the us population, 11.2% of adults and 7.5% of adolescents suffer from tinnitus; tinnitus prevalence increases with age.7,8 in 1–2% of people who have tinnitus, tinnitus symptoms seriously reduce the quality of life, resulting in social isolation, depression, and even suicidal tendencies.5 in chronic cases, a variety of treatment approaches are available, including pharmacological treatment, complementary and alternative medicine therapies, sound treatment/associated technologies, psychological/behavioral treatment, and cochlear implants. there is no pharmacological treatment for tinnitus with long-term effect.9 talk therapy and sound therapy with little support of medication are the primary treatment in developed countries.10,11 there is little evidence on tinnitus management forms using chinese, alternative or complementary medicine. these therapy methods include ginkgo biloba, melatonin, zinc, diet modification, hyperbaric oxygen, temporo-mandibular joint therapy, and acupuncture, among others.12 tinnitus treatment can be reached by interrupting the abnormal activity and neuromodulation.13 repetitive magnetic fields generated by repetitive transcranial magnetic stimulation (rtms) can reduce neural overactivity in cortical areas and can potentially alleviate tinnitus.14 it is a non-invasive procedure.15 meng et al. review on tinnitus management with tms suggests addressing its long-term effectiveness.9 recent and ongoing research studies have attempted to assess whether rtms could be an effective tinnitus treatment for a longer duration. therefore, the aim of this study was reviewing rcts that addressed the effect of tms on tinnitus after at least six months. methods search strategy electronic searches on the medline (pubmed), science direct, and googlescholar databases were carried out in february 2016. english language articles published between 2005 and 2015 were selected. cochrane library was searched for systematic reviews on the topic. the search keywords used were either “unilateral or bilateral tinnitus”, “trans-cranial magnetic stimulation”, “tms”, “tms treatment”, “repetitive tms” and “rtms”. only rcts with adults at least 19 years old and at least six months follow-up were included. the authors independently searched the sites, reviewed the titles, abstracts, and keywords, and agreed on the studies included in the review. the decision for a final inclusion of the studies was made after reviewing the full articles. the authors resolved differences by discussing them together. the libraries of the faculties of medicine in some egyptian universities were searched on the same topic by another author. no thesis was found on the systematic review of rtms for tinnitus treatment. study inclusion and exclusion criteria any rct using rtms treatment (low/high frequency) with at least six months of follow-up was considered eligible. studies with children under the age of 19 or adults with total hearing loss. studies with combined therapy, where rtms treatment was used in conjunction with pharmacological therapy, diet modification, psychotherapy, hearing aids, or any metal appliances were also excluded. different tools are used in rcts to measure the severity of tinnitus. the authors tried to find one common primary or secondary tool for measuring severity, which was ultimately determined to be tinnitus handicapped inventory (thi). data extraction general information on publication, authors, article title, journal title, and publication year was extracted. the design of the trial was assessed in regard to trial arms, sample size, randomization process, allocation method, blinding of information, and statistical methods. the total number of intervention and http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx galal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu comparison groups of participants was registered with baseline characteristics, age, gender, inclusion and exclusion criteria. the intervention with tms pulse, stimulus frequency, and dropouts were reviewed. primary and secondary outcomes such as thi and depression or anxiety tests at baseline, at the end of the treatment and at follow-up were assessed. the number and type of adverse events were also extracted. the conclusion was considered. the review authors assessed the risk of bias in the included studies. the authors collected and extracted data from each rct study included and authors of the primary studies were contacted to clarify any questions about the data. data synthesis a descriptive data synthesis was done according to the reporting of the studies. in addition, meta-analysis of three studies with similar design was carried out in review manager 5. figure 1. flowchart of the review: rcts on tinnitus management with rtms records identified through database searching in english language (n=362) abstract records screened (n=329) records excluded (n =292) full-text primary articles assessed for eligibility (n=37) full-text articles excluded (n=32) 24 didn’t mention follow-up 1 author didn’t answer 7 studies had follow-up at less than 6 months studies included in systematic review (n=5) additional records identified through other sources (n=0) records after duplicates removed (n=330) http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu results the electronic search using the keywords for studies from 2005-2015 identified 362 articles: 240 from google scholar, 46 from medline, and 76 from science direct. after removing duplicates, the authors screened 329 studies— 292 by abstract and 37 by full text— according to the criteria of the search; 292 were excluded, 24 studies did not mention the follow-up, and seven studies had follow-ups less than six months. landgrebe et al. study had to be excluded, as the corresponding author did not respond to the authors’ questions.21 the five studies eligible for inclusion were: andres et al., hoekstra et al., khedr et al., kim et al., and marcondes et al.16-20 five included studies all five studies included in this review were randomized controlled double-blind trials from czech republic, netherlands, egypt, korea, and brazil investigating the efficacy of rtms for at least six months post treatment. khedr et al. followed up monthly for 10 months.18 studies were published in 2010-2014. all studies used low-frequency 1-hz rtms in 2-trial arms except khedr et al. who had 4-trial arms assessing 1-hz rtms versus 25-hz rtms and ipsilateral rtms against contralateral.18 three studies compared rtms with sham, unlike kim et al. and khedr et al.18,19 all studies enrolled 19 to 62 chronic tinnitus patients with different conditions. 17they were assigned randomly to the trial arms. diverse primary and secondary tools were used to measure the outcomes. the tinnitus handicapped inventory (thi) and the visual analogue rating scores (vas) were used to measure outcomes in all studies alongside diverse other tools at baseline, during followup, and after six months. analysis of studies random allocation was described in all studies except for marcondes et al. study.20 the blinding process was explained in all trials except for in kim et al.19 all studies had 3.8% (low risk) to 19.6% (high risk) dropouts except for khedr et al. with no dropouts.18 reasons for dropping out given by kim et al. were four patients received additional treatment during follow up and one patient had severe headaches.19 during the rtms treatment no serious side-effects were reported. nine patients from all studies experienced headache as adverse effects and only sporadic dizziness, pain at the site of stimulation, and sleep pattern changes. diverse scales were applied to measure the primary and secondary outcomes, however, tinnitus handicapped inventory (thi) was used in all studies. only two studies had scales for secondary outcome.17,18 the measurements were taken at baseline, after rtms treatment or placebo, 2-10 times during follow-up and six months after the intervention. only one study measured them after 10 months. andres et al. found significant reduction of the total score of basic scales that measure tinnitus severity.16 hoekstra et al. pointed out that tinnitus was unchanged.17khedr et al. revealed that 32.25% of all patients recovered completely from tinnitus and 27.4% improved in having tinnitus only at night before sleeping.18 kim et al reported improvement in 46.7% of the ipsilateral group and 51.6% of the contralateral group.19 for marcondes et al., 40% had a significant reduction of tinnitus severity after five days and for one to six months after treatment of active rtms.20 overall, more than 45% of patients experienced improvement. three of the studies assessing depression and anxiety with different scales did not find any differences between the groups during follow-up.16-18 khedr et al. used vas for loudness, awareness, and annoyance level of symptoms. after 10 months follow-up, the contralateral group showed more improvement regarding the annoyance level than the ipsilateral group.18 in the study of kim et al., the annoyance level did not show a significant difference.19 although the comparison between high and low rtms and ipsilateral and contralateral is of importance, the aim of our study implies the comparison of rtms versus ‘sham’ which was applied in three studies.16,17,20 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx galal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu comments time of measurement secondary outcome primary outcome site duration of intervention inclusion criteria patients’ number number of trial arms study design date pub lished authors significant reduction of the total score of basic scales that measure tinnitus severity. reduction was displayed in figures -before start -after 2 – 6 – 1426 weeks tq* modified thi** vas1*** vas2 goebel & hiller tinnitus questionnaire czech republic psychiatry otorhinolaryng ology, neurology, radiology charles university in prague 2 weeks chronic unior bilateral tinnitus patients of ~9 years duration normal hearing right handed 22 20 1hz rtms sham randomized, prospective, placebocontrolled 2010 andres et al.18 tinnitus unchanged. 25% improvement on the tq. -before start -after last session -after 1 week -after 1-3-6 months thi –vas stai**** beck depression inventory tq netherlands otorhinolaryng ology university medical center utrecht &brain center 5 consecutive days chronic nonfluctuating tinnitus of 8 months with some hearing loss 26 24 1 -hz rtms placebo rct block design per group of 8, double blind placebocontrolled 2013 hoekstra et al.19 32.25% of all patients recovered completely from tinnitus. 27.4% improved to the point where they only had tinnitus at night before sleeping. in the contralateral group 64.5% improved in comparison to 29% in the ipsilateral group. no different effect of 1hz or 25 hz frequency. -before start -after last session -monthly interval for 10 months ri and hamilton ratings of depression and anxiety thi vas egypt neuropsychiatr y, audiology assiut university hospital 2 weeks daily right or left ear tinnitus normal hearing & some hearing loss 15 16 15 16 1hz rtms: ipsilateral contralateral 25 -hz rtms: ipsilateral contralateral rct randomized to four groups 2010 khedr et al.20 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu 46.7% of patients having ipsilateral stimulation and 51.6% of contralateral showed improvement -before start -after last session -after 1-3-6 months thi vas: loudness awareness annoyance korea dept otorhinolaryng ology, research institute of rehabilitation for 5 days tinnitus localized to poor ear asymmetric hearing impairment at least 6months & treated for at least 2 months 30 31 1hz rtms : ipsilateral contralateral rct patients were assigned randomly to the ipsilateral orcontralater al 2014 kim et al.21 major changes in the physical & catastrophic domain 40% had a significant reduction of tinnitus severity after 5 days and 1, 6 months after treatment of active rtms -before start -after 71421days monthly interval for 6 months thi vas spect**** * brazil dept otolaryngology , radiology, psychiatry 5 consecutive days unior bilateral tinnitus of 3 months duration, normal hearing 10 9 1 -hz rtms placebo rct randomized double-blind controlled 2010 marcondes et al.22 *tq= tinnitus questionnaire **thi= tinnitus handicapped inventory ***vas= visual analogue rating scores ****stai=state-trait anxiety inventory *****spect= single photon emission computed tomography table 1. patients with tinnitus with rtms intervention for randomized controlled studies (rct) with at least 6 months of follow-up http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx galal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu thi was the common scale used for the comparison of outcomes at baseline, during follow-up, and six months after the intervention. there was improvement in the thi scores in the rtms group in the rcts of andres et al. and marcondes et al., but not in hoesksta et al.16,17,20 no significant differences were found between rtms and the sham group in all three studies at baseline, during followup, or six months after the intervention, except in the study of marcondes et al. directly after rtms.20 meta-analysis of the three studies with similar design was performed. two separate comparisons between the outcomes of the thi scores in rtms and sham group were set using data derived from the three studies. the first comparison at 1-4 weeks postintervention favored the rtms intervention over the sham but not to a statistically significant level (test of overall effect: z = 0.29, p = 0.77; fig. 2). the second comparison at six months post-intervention also favored the rtms intervention over the sham but not to a statistically significant level (test of overall effect: z = 0.93, p = 0.35; fig. 3). after 6 months thi after rtms baseline mean thi ± sd mean age (years) number of patients in trial arm studies 33.27±21.6 31.82±22.9 (2weeks) 37.09±21.7 48.09 rtms 22 andres et al. (2010) 27.7±23.2 23.1±19.5 26.5±20.4 50.05 sham 20 43 ±18 41 ±16(1week) 45 ±21 50 rtms 26 hoekstra et al. (2013) 52 ± 22 47 ±23 44± 22 55 sham 24 22.8 ± 18.2 19.4 ± 17.6* (1month) 29.8 ± 22.8 -rtms 10 marcondes et al. (2010) 29.6 ± 23.5 28.9 ± 25.9 28.9 ± 23.8 -sham 9 -patients were more than18 years of age * p=0.047 one sided (significant) table 2. mean tinnitus handicapped inventory (thi) in 3 studies with similar design at baseline, directly after rtms and after 6 months figure 2. forrest-plot showing the mean thi scores in rtms versus sham (1-4 weeks post-intervention) in the three studies http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu figure 3. forrest-plot showing the mean thi scores in rtms versus sham (6 months post-intervention) in the three studies discussion according to this systematic review, rtms reduced the severity of tinnitus in four rcts in over 45% of the patients for a duration of six months following the intervention. around one third of patients in one study were completely recovered from tinnitus.18 only one study did not find any changes.17 the outcome differences of the thi scores of the trials is due to diverse inclusion criteria of patients or technical application of rtms. two studies measuring depression and anxiety did not find any changes after rtms application despite reduction of tinnitus. it is likely that depression and anxiety take longer to improve, which explains the accompanying use of talk therapy in some regimens.10,11 as the primary aim of our review was to compare rtms with ‘sham’, only three studies matched.16,17,20 andres et al. reported significant reduction of the total score of basic scales that measure tinnitus severity, even for patients with a mean duration of nine years not responding to pharmacological treatment.16 for 40% of patients exposed to rtms in the marcondes et al. trial, the tinnitus severity decreased as measured with the thi.20 in contrast, the study of hoekstra et al. indicated no changes,17 likely due to this study including non-fluctuating tinnitus patients while the other two trials mentioned just unilateral and bilateral tinnitus patients. some other inclusion criteria such as hearing loss can have an effect on the outcome. marcondes et al.20 reported a positive effect of rtms on subjects with normal hearing. hearing loss might influence the effect of rtms. the trial of khedret al.18 reported that hearing impairment might exacerbate the plastic changes in neural function causing tinnitus, and that decreases the effect of rtms. this is in agreement with the study of kleinjung et al. and smith et al. reporting on the negative influence of hearing loss on the efficacy of rtms.13,22 in contrast, lehner et al. did not find a relationship between hearing loss and rtms efficacy.23 andres et al. included only normal hearing patients.16 the studies of hoekstra et al. and kim et al. did not report on this issue in their results, although they both included patients with impaired hearing.17,19 in addition, all studies included chronic tinnitus patients. duration of tinnitus is another one of the inclusion criteria that can affect the outcome. tinnitus duration should be considered when explaining the different outcomes between the five included studies. khedr et al.’s18 trial showed that there was a significant correlation between the duration of symptoms and change in thi (at baseline and 10 months after). this is substantiated through other studies that found patients who had the shortest history of tinnitus tended to respond the best to rtms therapy,13,24-26 though other studies did not find this effect.22, 23 andres et al. stated that their trial lowered the severity of tinnitus even in chronic patients who had it for nine years.16 the other three studies did not mention the effect of tinnitus duration on the outcome.17,19,20 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx galal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu another clinical implication of our review suggests that low-frequency rtms, ipsior contralateral positioning of the coil on the temporo-parietal cortex or auditory cortex reduces the severity of tinnitus. the auditory cortex is thought to play an important role in tinnitus, but there is strong evidence that the auditory cortex together with the limbic system, prefrontal and parietal cortex determines tinnitus distress.27-30 the parietal cortex and its connections to the auditory cortex could be involved in tinnitus through the mediating effect that the parietal cortex has on auditory attention.31, 32 repetitive tms of these areas could therefore decrease a patient’s reaction to tinnitus, leading to a reduction in the perception of tinnitus. another study reported that a combination of temporal and prefrontal stimulation showed a significant effect on tinnitus.13 repetitive tms works by interfering with baseline activity in the cortex and decreases tinnitus. this opinion is confirmed by smith et al. who found greater response of the contralateral stimulation using low-frequency rtms.22in contrast kim et al.’s trial found no significant difference between ipsilateral and contralateral stimulation, and tinnitus was reduced in half of the patients regardless of the side of stimulation.19 hoekstra et al. found no effect of bilateral stimulation of the auditory cortex.17marcondes et al. did not mention this point.20 the use of low-frequency rtms was applied by the five trials, which is contrary to meng et al. who found “very limited support for the use of low-frequency rtms for the treatment of patients with tinnitus” after four months of follow-up.9 the duration of rtms is another factor that might influence its effect. in andres et al. trial and khedr et al. the patients were treated for two weeks.16,18 in marcondes et al., hoekstra et al., and kim et al., the patients were treated for one week.17,19,20 it is reported that results may be better after a longer duration of treatment over two weeks.33 meta-analysis was not applied to all the rct studies as they differed in their design (table 1). kim et al. used ipsilateral versus contralateral.19khedr et al. had four trial arms comparing between highand lowfrequency and ipsilateral versus contralateral.18 three rcts abided to the primary aim of our study, using rtms versus sham in the trial arms: andres et al., hoekstra et al., and marcondes et al.16,17,20 the tinnitus handicapped inventory (thi) was used as the measurement for tinnitus severity by all studies. the meta-analysis was performed on those rcts with comparable design.16,17,20 the rtms intervention was favored, but without statistically significant effect. more than three identified rcts for the meta-analysis would have given stronger evidence. the limitations of this review were lack of funding, differences in protocols of the studies, its performance on limited database, and using only articles published in english. tinnitus handicapped inventory (thi) scores indicate that rtms has a role in decreasing the severity of tinnitus. it sustained the improvement and reduced handicapping for the duration of six months in three rcts or, as is the case in one trial, even 10 months. four studies reported reduction in tinnitus severity after rtms in over 45% of patients even after six months followup.16,18-20 one of the four studies had one third of patients completely recovered from tinnitus.18 only one study found rtms not effective on any outcome parameter.17 although the meta-analysis of the three studies with similar design of rtms and sham favored rtms intervention, the overall statistical effect showed no significant difference between the groups, regarding the tinnitus handicapped inventory (thi) scores. given the scarce number of rcts between 2005 and 2015, more studies in multi-centers with the same protocol of design, inclusion/exclusion criteria, technological procedure, and outcome measurements will provide stronger evidence. follow-up in future studies should preferably be longer than six months to accrue stronger evidence. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu references 1. crummer r, hassan g. diagnostic approach to tinnitus. american family physician. 2004; 69(1),1206. 2. atik a, pathophysiology and treatment of tinnitus: an elusive disease.indian j otolaryngol head neck surg. 2014 jan; 66(suppl 1): 1–5. 3. kehrle h, granjeiro r, sampaio a, bezerra r, almeida v, oliveira c. comparison of auditory brainstem response results in normal-hearing patients with and without tinnitus. arch otolaryngol head neck surg, 2008;134 (6), 647–651. 4. mazurek b, stöver t, haupt h, gross j, szczepek a. the role of cochlear neurotransmitters in tinnitus. hno 2007; 55(12):964–71. 5. moller a. pathophysiology of tinnitus. otolaryngol clin north am. 2003; 36, 249–266, v–vi. 6. mccormack a, edmondson-jones m , somerset s , hall d. a systematic review of the reporting of tinnitus prevalence and severity. hearing research 337 (2016) 70e79 7. zelaya ce, lucas jw, hoffman hj, mmwr quickstats: percentage of adults with selected hearing problems, by type of problem and age group—national health interview survey, united states, 2014. mmwr. 2015;64(37):1058. available from https://www.cdc.gov/mmwr/preview/mmwrhtml/ mm6437a8.htm. 8. mahboubi h, oliaei s, kiumehr s, dwabe s, djalilian hr. the prevalence and characteristics of tinnitus in the youth population of the united states. laryngoscope. 2013;123(8):2001–8. 9. meng z, liu s, zheng y, phillips js.repetitive transcranial magnetic stimulation for tinnitus (review). the cochrane collaboration. 2011. johnwiley & sons, ltd. 10.langguth b, kreuzer pm, kleinjung t, de ridder d.tinnitus: causes and clinical management.lancet neurol. 2013 sep;12(9):920-930. doi: 10.1016/s14744422(13)70160-1 11. baguley d, mcferran d, hall d. tinnitus. the lancet. 2013; 382, (9904),1600–1607. 12. li y, zeng rf, zheng d. acupuncture for tinnitus.cochrane database of systematic reviews2009, issue 4. art. no.:cd008149. doi: 10.1002/14651858.cd008149 13. kleinjung t, eichhammer p, landgrebe m, sand p, hajak g, steffens t. combined temporal and prefrontal transcranial magnetic stimulation for tinnitus treatment: a pilot study. otolaryngology head and neck surgery. 2008; 138(4), 497–501. 14. eichhammer p, hajak g, kleinjung t, landgrebe m, langguth b. functional imaging of chronic tinnitus: the use of positron emission tomography. prog brain res. 2007; 166, 83–88. 15. miller, m. magnetic stimulation: a new approach to treating depression? harvard health publications. 2012. 16. andres m, dvorakova j, rathova l, havrankova p, pelcova p, vaneckova m. efficacy of repetitive transcranial magnetic stimulation for the treatment of refractory chronic tinnitus: a randomized, placebo controlled study. neuro endocrinol lett. 2010; 31,238– 249. 17. hoekstra c, versnel h, neggers s, niesten m, van zanten g. bilateral low-frequency repetitive transcranial magnetic stimulation of the auditory cortex in tinnitus patients is not effective: a randomised controlled trial. audiol neurotol. 2013; 18,362–373. 18. khedr e, aboelfetoh n, rothwell j, el-atar a, sayed e, khalifa h. contralateral versus ipsilateral tms of temporoparietal cortex for the treatment of chronic unilateral tinnitus: a comparative study. european journal of neurology. 2010; 17, 976–983. 19. kim hj, kim dy, kim hi, hee s, sim ns, moon is. long-term effects of repetitive transcranial magnetic stimulation in unilateral tinnitus. the laryngoscope. 2014; 124, 2155-2160. 20. marcondes r, sanchez t, ono c, buchpiguel c, langguth b. (). repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study. european journal of neurology. 2010; 17, 38–44. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3918281/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3918281/ https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6437a8.htm https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6437a8.htm http://www.health.harvard.edu/blog/magnetic-stimulation-a-new-approach-to-treating-depression-201207265064 http://www.health.harvard.edu/blog/magnetic-stimulation-a-new-approach-to-treating-depression-201207265064 galal this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.356 |http://cajgh.pitt.edu 21. landgrebe m, binder h, koller m, eberl y, kleinjung t, eichhammer p. design of a placebocontrolled, randomized study of the efficacy of repetitive transcranial magnetic stimulation for the treatment of chronic tinnitus. bmc psychiatry. 2008; 8, 23–31. 22. smith j, mennemeier m, bartel t, chelette k, kimbrell t, triggs w, et al.repetitive transcranial magnetic stimulation for tinnitus: a pilot study. laryngoscope. 2007; 117(3), 529– 534. 23. lehner a, schecklmann m, landgrebe m, kreuzer p, poeppl t, frank e, et al. predictors for rtms response in chronic tinnitus. front syst neurosci. 2012; 6, 11. 24. de ridder d, vertraeten e, der kelen v. transcranial magnetic stimulation for tinnitus: influences of tinnitus duration on stimulation parameter choice and maximal tinnitus suppression. otol neurol, 2005; (26), 616–619. 25. plewnia c, reimold m, najib a, reischl g, plontke s, gerloff c. moderate therapeutic efficacy of positron emission tomographynavigated repetitive transcranial magnetic stimulation for chronic tinnitus: a randomised, controlled pilot study. j neurolneurosurg psychiatry. 2007; 78, 152–156. 26. khedr e, rothwell j, ahmed m, el-atar a. effect of daily repetitive transcranial magnetic stimulation for treatment of tinnitus: comparison of different stimulus frequencies. j neurol neurosurg psychiatry. 2008; 79, 212–215. 27. schlee w, hartmann t, langguth b, weisz n. abnormal resting-state cortical coupling in chronic tinnitus. bmc neurosci. 2009; feb 19,10,11. doi: 10.1186/1471-2202-10-11. 28. roberts l, eggermont j, caspary d, shore s, melcher j, kaltenbach j. ringing ears: the neuroscience of tinnitus. j neurosci. 2010; 30, 14972–14979. 29. de ridder d, elgoyhen a, romo r, langguth b. phantom percepts: tinnitus and pain as persisting aversive memory networks. proc natl acad sci usa. 2011; 108, 8075–8080. 30. leaver a, renier l, chevillet m, morgan s, kim h, rauschecker j. dysregulation of limbic and auditory networks in tinnitus. neuron. 2011; 69, 33–43. 31. cuny c, norena a, el massioui f, chéry-croze s. reduced attention shift in response to auditory changes in subjects with tinnitus. audiol neurotol. 2004; 9, 294– 302. 32. searchfield g, morrison-low j, wise k. object identification and attention training for treating tinnitus. prog brain res. 2007; 166, 441–460. 33. loo c, mitchell p. a review of the efficacy of transcranial magnetic stimulation (tms) treatment for depression, and current and future strategies to optimize efficacy. j affect disord, 2005; 88, 255–267. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. rapid emergence of multidrugresistance among gram negative isolates at a tertiary pediatric and maternity hospital in ulaanbaatar, mongolia susanna felsenstein1*, sarantsetseg bira2, narangerel altanmircheg2, enkhtur shonkhuuz3, ariuntuya ochirpurev4, david warburton5,6 1department of paediatric infectious diseases and immunology, liverpool, united kingdom; 2central laboratory department, national center for maternal and child health, ulaanbaatar, mongolia; 3critical care medicine, national center for maternal and child health, ulaanbaatar, mongolia; 4health emergencies and food safety, office of the who representative in mongolia, ulaanbaatar, mongolia; 5keck school of medicine, university of southern california, usa; 6ostrow school of dentistry, university of southern california, usa *corresponding author vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.371 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu abstract introduction: information on microbiological and susceptibility profiles of clinical isolates in mongolia is scarce, hampering infection control and clinical care. methods: species and resistance profiles of 6334 clinical gram negative isolates, collected at mongolia’s national center for maternal and child health between 2014 and 2017 were analyzed. results: annual proportion of multidrug-resistance among e. coli and enterobacter isolates increased from 2.8% to 16.6% and 3.5% to 22.6% respectively; klebsiella isolates exhibiting susceptibilities suggestive of extended spectrum beta-lactamase (esbl) production from 73% to 94%. by 2017, 60.6% of klebsiella isolates were multidrug-resistant, most originated from intensive care wards. enterobacteriaceae exhibiting susceptibility patterns suggestive of esbl production and multidrug-resistant organisms were common and their incidence increased rapidly. conclusion: these findings will serve to build strategies to strengthen microbiological surveillance, diagnostics and infection control; and to develop empiric therapy and stewardship recommendations for mongolia’s largest children’s and maternity hospital. keywords: gram negative bacterial infections; beta lactamases; drug resistance, multiple; intensive care units; mongolia; stewardship rapid emergence of multidrugresistance among gram negative isolates at a tertiary pediatric and maternity hospital in ulaanbaatar, mongolia susanna felsenstein1, sarantsetseg bira2, narangerel altanmircheg2, enkhtur shonkhuuz3, ariuntuya ochirpurev4, david warburton5,6 1department of paediatric infectious diseases and immunology, liverpool, united kingdom; 2central laboratory department, national center for maternal and child health, ulaanbaatar, mongolia; 3critical care medicine, national center for maternal and child health, ulaanbaatar, mongolia; 4health emergencies and food safety, office of the who representative in mongolia, ulaanbaatar, mongolia; 5keck school of medicine, university of southern california, usa; 6ostrow school of dentistry, university of southern california, usa research introduction antimicrobial resistance (amr) in asia increases at concerning rates1-6. the world health organization (who) projects an attributable cost of 700.000 lives annually and 1.35 trillion usd in countries of the western pacific region (wpro) alone for the next decade7. numerous, rapidly evolving and readily transmissible mechanisms of antimicrobial resistance in gram negatives, particularly the rise in carbapenem resistant enterobacteriaceae over the last two decades is of grave concern, and the cause of significant morbidity and mortality8,9. data on amr in mongolia is scarce, and the country is not part of transnational surveillance http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu networks6,10. a surveillance system at urban and rural level training health care providers in infectious diseases management and control is established but implementation is challenging10,11. however, the mongolian national statistical office and the united nations international children's emergency fund (unicef) report a four-fold reduction in infant and under 5's mortality over the last two decades, mainly by control of respiratory and vaccine-preventable diseases12,13, illustrating the major strides made in improving child and maternal health. mongolia features one of the lowest population densities worldwide. approximately half of the 3 million inhabitants reside in the capital ulaanbaatar, the remainder in provincial capitals, many of which follow a traditional nomadic lifestyle. the country’s economy is growing rapidly, mainly as a result of an expanding mining industry12. despite rapid modernization, especially in ulaanbaatar, many parts of the country are remote and not readily accessible. hence, challenges in combating the spread of amr are complex10,14. health care provision and access, development of diagnostic facilities, staff education, antimicrobial surveillance, auditing of prescription practices and enforcement of drug regulation remain a challenge. the national center for maternal and child health (ncmch) is the largest government-run pediatric and maternity hospital and only tertiary referral center. the pediatric hospital has 270 medical and 150 surgical beds accommodating 19 subspecialties and treats approximately 40.000 inpatients and over 175.000 outpatients each year. the adjacent 250-bedded maternity hospital provides gynecological and obstetric care, and manages approximately 12.000 deliveries per annum15. the aim of this study is to provide pathogen and susceptibility data for gram negative organisms (gnos) among inand outpatients of different ages in ulaanbaatar; allowing the development of evidencebased empirical antimicrobial treatment and infection control policies. methods data collection all gram negative isolates of cultured specimens submitted to the microbiology laboratory at ncmch between 01/2014 and 08/2017 were included. data was collected via the whonet database (version 5), retrospectively (2014-2016) and prospectively (2017), including demographic data, specimen type, in/outpatient status, hospital ward, species identification and antimicrobial susceptibility testing (ast) profile, and adequacy of microbiological work-up. the study was approved by the ncmch ethics committee (ncmchas2014). susceptibility testing at times, test panels differ from the clinical and laboratory standards institute (clsi) and the european committee on antimicrobial susceptibility testing (eucast) guidelines due to limitations of ast available. additions or omissions to standard test panels are specified in the text. organisms identified by means other than culture and stool samples are processed at another facility and were excluded. molecular detection of organisms and/or determination of susceptibility status was not available during the study period. of identical organisms isolated from a patient within 30 days, only the first isolate was included. only species with a minimum of 30 isolates per year, per specimen category and antimicrobial agent tested, were used for guiding empirical antimicrobial recommendations. susceptibility is interpreted as per clsi 2016 and cesar (central asian and eastern european surveillance of antimicrobial resistance) guidelines6,16. resistant and intermediately resistant isolates are reported as one category (%r/i). ast to antimicrobials not recommended for treatment of an http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu organism 2014 2015 2016 2017 total escherichia coli 1220 (67.3%) 1379 (57.1%) 602 (40.4%) 78 (12.6%) 3279 (51.8%) enterobacter 510 (28.1%) 873 (36.2%) 648 (43.5%) 417 (67.5%) 2450 (38.6%) e. cloacae 327 859 472 78 1736 enterobacter spp. (unidentified) 172 2 163 335 672 e. aerogenes 10 7 7 4 28 e. sakazakii 0 2 6 0 8 pantoea spp. 0 3 0 0 3 p. agglomerans 1 0 0 0 1 klebsiella 26 (1.4%) 70 (2.9%) 119 (8.0%) 67 (10.8%) 282 (4.5%) klebsiella spp. (unidentified) 5 1 65 62 133 k. pneumoniae 20 53 13 0 86 k. oxytoca 1 16 41 5 63 non-aer. pseudomonas spp., chryseobacterium, flavimonas 5 (0.3%) 10 (0.4%) 62 (4.2%) 38 (6.1%) 115 (1.8%) pseudomonas aeruginosa 17 (0.9%) 38 (1.6%) 11 (0.7%) 0 66 (1.0%) proteus mirabilis 34 (1.9%) 19 (0.8%) 24 (1.6%) 12 (1.9%) 89 (1.4%) raoultella spp 2 (0.1%) 12 (0.5%) 9 (0.6%) 1 (0.2%) 24 (0.4%) r. ornitholytica 1 4 7 1 13 r. terrigenica 0 8 2 0 10 r. planticola 1 0 0 0 1 serratia odifera 0 8 (0.3%) 0 0 8 (0.1%) serratia marescens 0 2 (0.1%) 1 2 (0.3%) 5 (0.1%) acinetobacter baumannii 0 0 6 (0.4%) 0 6 (0.1%) elizabethkingia meningoseptica 0 0 4 (0.3%) 1 5 burkholderia cepacia 0 0 1 1 2 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu organism 2014 2015 2016 2017 total kluyvera 0 0 1 0 1 chromobacterium violaceum 0 1 0 0 1 salmonella 0 1 0 0 1 pasteurella spp 0 0 1 0 1 moraxella 0 0 0 1 1 total 1814 2413 1489 618 6334 table 1. species identification of gram negative isolates. organism are excluded except for service utilization analysis. confirmation of phenotypical presence of extended spectrum betal lactamases (esbl) by double disk or minimal inhibitory concentration (mic) and confirmation of ampc status was not available. esbl status attribution relied on disk diffusion interpreted as per clsi, cdc and cesar recommendations6,14-19. species isolates assumed to be ampc-producers were excluded from esbl analysis. carbapenem susceptibility testing became available in july 2016. classification of carbapenem susceptibility used the most conservative estimate: if tested for one carbapenem only or if the test result was concordant, the report was analyzed as the final result. discordant carbapenem susceptibilities, with resistant or intermediate susceptibility for at least one, were reported as carbapenem resistant (cr)6,19. resistance to antibiotic classes was reported by combining the results of antibiotics representative for a class and the outcome based on the most resistant result. multidrug-resistance (mdr) was defined as resistance to three or more antimicrobial classes in isolates with a valid result for at least three, calculated as resistance or intermediate resistance to at least one antibiotic in each of class19, and documented by number of antimicrobial classes to which resistance was identified. statistical analysis quantitative variables were reported as absolute numbers and percentages. for continuous variables comparisons between groups to test equality were performed using the t-test when appropriate, or mannwhitney test when skewed. tests of association between categorical variables were based on chi-square and fisher-exact tests. all p values reported are two-sided and considered statistically significant if < .05. statistical computations were performed using spss 22.0 (spss inc. chicago, illinois). results epidemiology and origin of isolates: in total, 6334 (53.3%) gnos were included. e. coli and enterobacter spp. were most common, accounting for 90% of isolates (table 1). neonatal samples were dominated by wound (24.9%) and blood stream isolates (37.1%) (bsi); pediatric samples by wound (28.8%) and urinary (42.3%), isolates from adults by genital (63.5%) and urinary (30.8%) samples. predominant gnos differed considerably depending on age group (figure 1). sample numbers submitted from neonatal (nicu) and pediatric http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu figure 1. five most common species by age group: panel 1a: neonates (≤1month); panel 1b: children (1month to ≤18 years); panel 1c: adults (≥18 years). intensive care (picu) units increased over time, accounting for 45.8% of all isolates by 2017 (figure 2). enterobacter spp.: frequency of enterobacter spp. isolates increased over time. most were inpatient isolates (n=2051, 84%), almost half (n=1078, 44%) from neonates and children. the annual increase of enterobacter spp. among neonatal bsis was significant (p<0.001), contributing to a third of gram negative bsis (42/140; 30%) in 2017. whilst in 2014/15 enterobacter susceptibility to quinolones and aminoglycosides was reliable, resistance increased sharply from 2016 (supplemental figure 1a), especially among inpatients and bsis. from 2017, virtually all enterobacter spp. blood isolates were aminoglycoside resistant (46/47, 97.9%). in the first half of 2017 alone, 57/277 (20.6%) of enterobacter isolates tested were carbapenem resistant (cr), particularly blood (17/47; 36.2%) and urinary isolates (25/87; 28.7%). cr enterobacter isolates originated mainly from nicu (47/93; 50.5%) and picu (30/93; 32.3%). e. coli: among e. coli, adult samples accounted for 75.1% (n=2459/3274), predominantly from urine (n=1207, 36.8%) or genital tract (n=1498, 45.8%). the number of e. coli isolates fulfilling criteria for esbl confirmatory testing doubled over the study period from 27.0% to 60.3%; attributable to inpatient and nicu isolates (figure 3). aminoglycoside susceptibility remained stable at 75% whilst quinolone susceptibility decreased, one third of isolates were no longer susceptible by 2017 (supplemental figure 1b). only 5.3% (172/3246) of e. coli isolates underwent carbapenem susceptibility testing. the proportion of cr isolates increased from 12.8% (2016) to 28.2% (2017), almost all were inpatient samples (29/32), 72% (n=23/32) from icus (supplemental figure 1b). mdr increased between 2016 and 2017 among e. coli from 2.8% to 16.6% (figure 4). klebsiella spp.: almost all klebsiella isolates, 98.2% (277/282) originated from inpatients, most (208/282, 73%) from nicu, 66.3% of which were bsis (138/208); the remainder wound (9.2%) and urine isolates (6.7%). in nine instances, klebsiella was isolated http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu figure 2. ward attribution of samples (in %), by year http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu from neonatal csf. the majority showed susceptibility patterns suggestive of esbl production, most frequently among isolates from neonates (adults: 64%, 16/25; children: 83.1%, 49/59; neonates: 94.4%, 187/198), but increasing across all age groups from 73% in 2014 to 94% in 2017. most were gentamicin resistant by 2017 (53/64, 83%), as opposed to only 25% (6/24) in 2014. again, this was most pronounced among neonates, where aminoglycoside resistance increased from 26% (n=23; 2015) to 95.7% (n=46; 2017). quinolone resistance increased from 5.5% (3/55; 2015) to 60.6% (40/66; 2017) (supplemental figure 1c). only 135/282 (48%) underwent carbapenem susceptibility testing, 24.7% (19/77; 2016) and 28.1% (16/57; 2017) were identified as cr and originated mainly from nicu, where cr rates increased from 13.8% (8/58, 2016) to 32.5% (14/43, 2017). remaining gnos, including pseudomonas spp., raoultella spp., serratia spp., acinetobacter spp.: documentation of specimen origin was only available for 42/66 (63.6%) of p. aeruginosa isolates, urines and wound swabs predominated. reduced susceptibility to ceftazidime (13/54; 24%), gentamicin (12/62, 19.3%) and quinolones (8/55; 14.5%) occurred, however isolate numbers with susceptibility data available for all antimicrobials of interest were lower than 30 per year. all multidrug resistant isolates originated from nicu (n=3) and picu (n=2), carbapenem susceptibility was not documented. samples yielding isolates of the non-aeruginosa pseudomonas spp. group increased significantly (p<0.001) with picu (n=42) and nicu(n=42) contributing most isolates. the majority did not undergo susceptibility testing. raoultella spp. were mainly isolated in 2015/16, when 16/24 isolates, mainly r. terrigenica of identical susceptibility pattern, were isolated from specimens of multiple wards. most serratia isolates were identified in 2015 (10/13), mainly on neonatal wound swabs and bsis, and genital samples from maternity wards. quinolone susceptibility was universal (13/13; 100%), a quarter were aminoglycoside resistant. infections with chryseomonas luteola occurred exclusively in november/december 2015; isolated from urine (n=3), pleural (n=2) and peritoneal (n=2) fluid; and confined to nicu (n=5) and the pediatric nephrology ward (n=4). acinetobacter baumannii was isolated in six patients: four from neonatal bsis and one from neonatal csf and a joint aspirate of a young child all in november 2016. all were quinolone, aminoglycoside and carbapenem susceptible. esbl production and multidrug resistance across species over time: rates of esbl phenotype diverged when comparing inand outpatients in esbl producers (figure 3). in 2014, 29% of inand 19.5% of outpatient isolates would have required confirmatory testing, by 2017, this applied to 83% respectively 32% (p<0.001). mdr increased significantly more among inpatients, too (p<0.001, figure 4). in earlier years, only half of klebsiella and enterobacter isolates could be included, as the choice of antimicrobials tested for were not agents recommended for treatment, or susceptibilities for too few antimicrobials were documented, however adequate microbiological work up was achieved for almost all isolates by 2017. mdr among e. coli tested increased from 2.8% in 2014 to 17.2% by 2017; among enterobacter from 3.5% to 22.6%. the increase in mdr was most pronounced among klebsiella spp. where no multidrug-resistance was identified in 2014/15, affected a third in 2016 and doubled within a year to 60.6% of isolates by 2017. discussion this data represents the largest published dataset on pathogen and resistance profile of clinical gnos from mongolian patients. mongolia’s health care http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu figure 3. extended spectrum beta lactamase phenotype of organisms over time (in %). system has evolved to apply novel therapeutic options, that are associated with an increasing use of antimicrobials for nosocomial infections in intensive care settings and hence accompanied by new challenges in governance and stewardship. with esbl confirmation testing indicated for the majority of inpatient isolates, this study identified an urgent need for implementation of improved microbiological diagnostics enabling accurate identification of drug-resistant gnos; and steps are being taken to address it15. confirmatory testing is being introduced as a result of the here presented data, which illustrates an improvement in the detection of mdr and esbl status since 2017 as a result of these efforts. staff training supported by online resources and international collaborations is being undertaken9. more standardized susceptibility testing is being done, to first line antimicrobials initially, followed by second line testing where indicated, and esbl and carbapenemase testing is done where indicated. all klebsiella isolates will undergo ast for quinolones and aminoglycosides. it must be acknowledged that the present study has important limitations. first, a more detailed molecular and genotypic characterization of the organisms would have been of interest, at both local level impacting infection control and treatment options and http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu figure 4. multidrug-resistance status in enterobacter spp., e. coli, and klebsiella spp. (in %) on a transnational level, putting mongolian isolates into context within asia. financial restraints and the need for prioritization within the healthcare sector have hampered molecular diagnostics at ncmch to date, and diagnostic possibilities for ast remains limited. we found that the microbiological work up was not always in keeping with recommendations made by professional agencies 6,16-19. especially the lack of esbl confirmation posed difficulties, limiting treatment recommendations that could be inferred. the results of the available testing presented here however are concerning and serve as an opportunity to put amr in mongolia at the forefront of public health policies in the months and years to come. it is of utmost importance that data is made accessible to clinicians and to serve as an indicator for stakeholders that amr poses a clinical risk at ncmch, and in the mongolian capital at large. only a minority of e. coli and enterobacter spp. isolates underwent carbapenem susceptibility testing, the data may not reflect true susceptibility rates. a sizeable proportion of isolates underwent testing for less than three antimicrobials, disqualifying them from mdr analysis, particularly impacting enterobacter and klebsiella spp. isolates. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu whilst the representation of phenotypical esbl status may overestimate the true rate of esbl producers by 5-30%20, it is concerning to see such rapid increase in organisms of esbl phenotype. data on the resistance among uropathogenic e. coli in mongolia from 201621 supports our findings of a high burden of esbl and mdr, identifying resistance to beta-lactams in over 80%. susceptibility to nitrofurantoin and imipenem was relatively preserved, but 93.9% of e. coli isolates were multidrug resistant. while in this cohort, mdr rates among e. coli were lower, proportion of cr isolates was much higher. testing to more antimicrobial classes, including co-trimoxazole and nitrofurantoin21, may have contributed to this discrepancy. in addition, we excluded 643 e coli isolates from mdr analysis, as they underwent testing for fewer than three antimicrobials. however, our data encompasses a larger sample; and results did not change upon subanalysis of urine isolates (n=1201): 13.4% were multidrug resistant, relying on gentamicin, quinolone, beta-lactams and, since 2016, carbapenem testing. kao et al22 report findings closely resembling our study: in 104 isolates from ncmch in 2013, 18% of e. coli isolates were esbl producers, mediated by tem1 and associated with fluoroquinolone resistance. our data shows rising rates the following year, identifying 27% of e. coli inpatientand 19% of outpatient isolates as esbl producers. the diagnostics available at ncmch may influence esbl rates, underlining the need for rapid introduction of esbl confirmatory testing, not only to ensure accurate surveillance but also to avoid unnecessary use of carbapenems. given that esbl rates in our cohort doubled between 2014 and 2017 from 27% to 60%, the difference between the two studies may reflect the true increase in esbl rates over time. in summary, the here presented data is in keeping with studies reporting susceptibilities that included the confirmation of esbl. as no significant changes to the diagnostic work up occurred during the study period it has to be assumed that the significant increase in multidrug resistance, esbl production and carbapenem resistance may well reflect an approximation of the true development of amr, which was mainly driven by inpatient isolates. this information may represent a chance to effectively impact spread of mdr and esbl positive gnos in mongolia by intensifying infection control in health care facilities. proportion of esbl phenotype and carbapenem resistance was extraordinarily high among nosocomially acquired klebsiella bsis on nicu, steeply rising since 2016. cr affected one third of klebsiella isolates on nicus by 2017. in keeping with reports from icus globally, carbapenemase-positive klebsiella has been included in the who global priority pathogen list23. given the level of concern due to these results, a detailed assessment of clinical and infection control practices on nicus was performed. nicu staff were aware of the high prevalence of klebsiella, and despite empiric treatment of neonatal bsis with imipenem, neonatal demise due to klebsiella bsis whilst on imipenem therapy was reportedly common, though no mortality data was available. neonatal picc lines were not routinely used, and staff did not feel competent in sterile line insertion. nursing staff were unfamiliar with line care, hub sterilization before flushing and connecting, fixation of lines etc. newborns requiring antibiotic treatment or total parenteral nutrition underwent frequent peripheral re-cannulations, performed routinely every three days. in the interim, guidelines addressing infection control procedures, central venous access insertion and line care have been provided to staff. sterile line insertion was supervised and training provided. the introduction of medium-term, silver or heparin coated long lines for neonates has been discussed24. ongoing data collection on central line access related bsis on nicu including associated morbidity and mortality following these interventions will inform future clinical practice. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu our study emphasizes the preeminent role bsis have played in the overall increase of mdr at ncmch, especially affecting intensive care units. with a use of icu beds in mongolia equivalent to that of western european or north american countries at 11.7 per 1.000.000 inhabitants25, the intensive care environment appears to be a major contributor to the emergence of amr. cr and mdr in icus is well recognized to be a pressing issue in other countries in central asia, such as kazakhstan26. the largest published record of clinical gnos in mongolia to date emphasizes the importance of consequent surveillance and raises attention to multidrug-resistance in central asia, and highlights the intensive care environment as important source of amr emergence27. the data presented here will form part of the national action plans including surveillance systems nested under the multi-sectoral framework and the one health approach of the who for mongolia28,29. international collaboration, financial reprioritization and educational support for health care professionals will be required in order to assist measures combating the spread of amr in mongolia. references 1. zhang z, chen m, yu y, pan s, liu y. antimicrobial susceptibility among grampositive and gram-negative blood-borne pathogens collected between 2012-2016 as part of the tigecycline evaluation and surveillance trial. antimicrob resist infect control. 2018 dec 13;7:152. doi: 10.1186/s13756-018-0441y. ecollection 2018 2. bhatia r. universal health coverage framework to combat antimicrobial resistance. indian j med res 2018;147:228-32 3. versporten a, zarb p, caniaux i, gros mf, drapier n, miller m, global-pps network. antimicrobial consumption and resistance in adult hospital inpatients in 53 countries: results of an internet-based global point prevalence survey. lancet glob health. 2018 jun;6(6):e619-e629 4. zhang j, zhao c, chen h, li h, wang q, zhang f et al. a multicenter epidemiology study on the risk factors and clinical outcomes of nosocomial intra-abdominal infections in china: results from the chinese antimicrobial resistance surveillance of nosocomial infections (cares) 2007-2016.infect drug resist. 2018 nov 15;11:2311-2319. 5. singh p. one health approach to tackle antimicrobial resistance in south east asia. bmj 2017;358:j3625 6. central asian and eastern european surveillance of antimicrobial resistance. annual report 2018. http://www.euro.who.int/__data/assets/pdf_file /0007/386161/52238-who-caesar-ar2018_low_v9_web.pdf?ua=1 7. antimicrobial resistance: global report on surveillance. geneva: world health organization; 2014. http://apps.who.int/iris/bitstream/10665/11264 2/1/9789241564748_eng.pdf 8. logan lk, weinstein ra. the epidemiology of carbapenem-resistant enterobacteriaceae: the impact and evolution of a global menace. j infect dis. 2017; 15(215):s28-s36. doi 10.1093/infdis/jiw282. 9. park s, park jy, song y, how sh, jung ks, respiratory infections assembly of the apsr. emerging respiratory infections threatening public health in the asia-pacific region: a position paoer of the asian pacific society of respirology. respirology. 2019; 15. doi: 10.1111/resp.13558 [epub ahead of print] 10. lee y, wakabayashi m. key informant interview on antimicrobial resistance (amr) in some countries in the western pacific region. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu global health. 2013 jul 26;9:34. doi: 10.1186/1744-8603-9-34. 11. wpro. antibiotic awareness week campaign 2017. https://sites.wpro.who.int/antibiotic_awareness /?page_id=1346 12. national statistics office of mongolia. social and economic situation of mongolia (as of october 2018). http://www.en.nso.mn/content/293 13. unicef multiple indicative cluster surveys, mongolia. http://mics.unicef.org/surveys 14. ayukekbong ja, ntemgwa m, atabe an.the threat of antimicrobial resistance in developing countries: causes and control strategies. antimicrob resist infect control. 2017 may 15;6:47. doi: 10.1186/s13756-017-0208-x. ecollection 2017. 15. gendenjamts’s national center for maternal and child’s health, dr. enkhtur shonkhuuz, md, phd, clinical director. annual surveillance and health provision data ncmch, 2017. 16. clsi performance standards for antimicrobial susceptibility testing. 26th ed. clsi supplement m100s. wayne pa. clinical and laboratory standards institute, 2016. 17. clsi. performance standards for antimicrobial susceptibility testing; twentythird informational supplement. clsi document m100-s23. wayne, pa: clinical and laboratory standards institute; 2013. 18. clsi. analysis and presentation of cumulative antimicrobial susceptibility test data; approved guideline—fourth edition. clsi document m39-a4. wayne, pa: clinical and laboratory standards institute; 2014. 19. exner m, bhattacharya s, christiansen b, gebel j, goroncy-bermes p, hartemann p, et al. antibiotic resistance: what is so special about multidrug-resistant gram-negative bacteria? consensus statement. gms hyg infect control. 2017 apr 10;12:doc05. doi: 10.3205/dgkh000290. ecollection 2017. 20. lob sh, biedenbach dj, badal re, kazmierczak km, sahm df. discrepancy between genotypic and phenotypic extendedspectrum β-lactamase rates in escherichia coli from intra-abdominal infections in the usa. j med microbiol. 2016 sep;65(9):905-9 21. munkhdelger y, gunregjav n, dorjpurev a, juniichiro n, sarantuya j. detection of virulence genes, phylogenetic group and antibiotic resistance of uropathogenic escherichia coli in mongolia. j infect dev ctries. 2017 jan 30;11(1):51-57 22. kao cy, udval u, wu hm, bolormaa e, yan jj, khosbayar t et al. first characterization of fluoroquinolone resistance mechanisms in ctx-m-producing escherichia coli from mongolia. infect genet evol. 2016 mar;38:7981 23. rello j, kalwaje eshwara v, lagunes l, alves j, wunderink rg, conway-morris a, et al. a global priority list of the top ten resistant microorganisms (totem) study at intensive care: a prioritization exercise based on multicriteria decision analysis. eur j clin microbiol infect dis. 2018 nov 13. doi: 10.1007/s10096018-3428-y. [epub ahead of print] 24. balain m, oddie sj, mcguire w.antimicrobial-impregnated central venous catheters for prevention of catheter-related bloodstream infection in newborn infants. cochrane database syst rev. 2015 sep 27;(9):cd011078. 25. mendsaikhan n, begzjav t, lundeg g, brunauer a, dünser mw. a nationwide census of icu capacity and admissions in mongolia. plos one. 2016; aug 17;11(8):e0160921 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx felsenstein this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.371|http://cajgh.pitt.edu 26. viderman d, brotfain e, khamzina y, kapanova g, zhumadilov a, poddighe d et al. bacterial resistance in the intensive care unit of developing countries: report from a tertiary hospital in kazakhstan. j glob antimicrob resist. 2018 nov 15. pii: s22137165(18)30226-1.[epub ahead of print] 27. seale ac, gordon nc, islam j, peacock sj, scott jag. amr surveillance in low and middle-income settings a roadmap for participation in the global antimicrobial surveillance system (glass). wellcome open res. 2017 sep 26;2:92. doi: 10.12688/wellcomeopenres.12527.1. ecollection 2017. 28. global antimicrobial resistance surveillance system (glass) report. early implementation 2016-2017. world health organization. jan. 2018. isbn: 978-92-4-151344-9 29. worldwide country situation analysis response to antimicrobial resistance. who. http://apps.who.int/iris/bitstream/handle/10665/ 163468/9789241564946_eng.pdf?sequence=1 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. prevalence of overweight, obesity, and associated risk factors in healthy female adolescents in tehran, iran behnaz abiri1, parvin sarbakhsh2, mohammadreza vafa3,4* 1department of nutrition, faculty of paramedicine, ahvaz jundishapur university of medical sciences, ahvaz, iran; 2department of statistics and epidemiology, school of public health, tabriz university of medical sciences, tabriz, iran; 3department of nutrition, school of public health, iran university of medical sciences, tehran, iran 4pediatric growth and development research center, institute of endocrinology and metabolism, iran university of medical sciences, tehran, iran *corresponding author. email: vafa.m@iums.ac.ir vol. 8, no. 1 (2019) | issn 2166-7403 (online) doi 10.5195/cajgh.2019.413 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ abiri this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu abstract introduction: obesity is an important health concern worldwide and is a growing problem in iran. adolescent obesity has a major role in development of adulthood obesity and its complications. the present study was conducted to evaluate the prevalence of overweight, obesity, and associated risk factors in female adolescents living in tehran, iran. methods: this cross-sectional study was carried out among 2,132 female adolescents aged 14-17 years in tehran recruited between 2017 and 2018. weight and height were measured and body mass index (bmi) was calculated. underweight, overweight, and obesity were considered as < 5th, ≥ 85th, and ≥ 95th percentile, respectively, of cdc bmi-for age and sex criteria. adolescents and their mothers filled in the questionnaires on physical activity, computer use, duration of breastfeeding, total sleep time, and family socioeconomic status. statistical analysis was performed using spss version 22.0 software. p < 0.05 was considered statistically significant. results: the overall prevalence rates of overweight and obesity were 24.1% and 6.5%, respectively. the prevalences of overweight and obesity were highest in the south district (28.9% and 7.7%, respectively) and were lowest in the north district (19.1% and 5.2%, respectively). there were significant differences in physical activity level (p < 0.001), total sleep time (p < 0.001), duration of breastfeeding (p < 0.01), and daily computer use (p < 0.001) among the four groups (underweight, normal, overweight, and obese). regarding the socioeconomic status, parental education level and economic status were significantly higher in those who had normal weight compared to other weight groups (in both, p < 0.001). conclusion: this study showed that overweight and obesity among female adolescents in tehranhave become a major public health concern. level of physical activity, computer use, sleep duration, breastfeeding duration, levels of parental education, and economic status were associated with overweight and obesity prevalence. keywords: overweight; obesity; body mass index; female adolescents; tehran prevalence of overweight, obesity, and associated risk factors in healthy female adolescents in tehran, iran behnaz abiri1, parvin sarbakhsh2, mohammadreza vafa3,4 1department of nutrition, faculty of paramedicine, ahvaz jundishapur university of medical sciences, ahvaz, iran; 2department of statistics and epidemiology, school of public health, tabriz university of medical sciences, tabriz, iran; 3department of nutrition, school of public health, iran university of medical sciences, tehran, iran 4pediatric growth and development research center, institute of endocrinology and metabolism, iran university of medical sciences, tehran, iran research introduction the epidemic of overweight is a growing worldwide public health concern.1 it is well established that obesity elevates the risk of cardiovascular diseases, diabetes, hyperlipidemia, and musculoskeletal disorders in adults.2 recent studies have indicated that obesity in adolescence is a strong risk factor for obesity and associated morbidity in adulthood, with 50% to 80% of obese adolescents becoming obese adults.3 on the other hand, in many developing countries undergoing epidemiologic transition, the double burden of malnutrition and overweight co-occur.4 although, the contribution of heredity factors may account for about 30-70% of obesity,5 the intake of high calorie food and decreased expenditure of energy, http://www.library.pitt.edu/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu changing lifestyle and behaviors, also contribute to the overweight and obesity epidemic. breastfeeding is one of the earliest initial prevention measures that can be implemented to decrease the rates of childhood obesity. previously published studies show a 26% reduction in the risk of being overweight or obese in later life of children who were breastfed compared to those were formula fed.6,7 in addition, prior studies indicate that sleep insufficiency elevates the risk of overweight and obesity. while the mechanisms are not well understood, sleep insufficiency may lead to hormonal alterations, less physical activity, and to unhealthy eating patterns including elevated consumption of foods with a high glycemic index.8 socioeconomic factors also have a notable effect on adolescent weight, since it has been demonstrated that populations with low economic level have a higher prevalence of childhood obesity, due to diet, which is mainly based on a high intake of carbohydrates that were established to be the most easily obtainable foods for their environment.8 to our knowledge, studies evaluating the trends of overweight and obesity among adolescents in tehran are scarce. hence, the present study was designed to investigate the prevalence rates of overweight, obesity, and associated risk factors in female adolescents aged 1417 years in tehran, iran. methods study design, subjects, and sampling this crosssectional study was conducted among female adolescents, aged 14-17 years, enrolled in high schools in tehran, the capital city of iran, in 20172018. the sample of 2,132 female adolescents were enrolled based on sample size calculation with presumption of 6% obesity prevalence.9 we classified the study location as north, east, central, west, and south, according to 19 educational districts of tehran city. a random sample of 2,132 female adolescents was selected in a multistage sampling technique from the governmental supported public high schools. female adolescents, healthy (not suffering from any chronic and acute disease), and aged 14-17 years were eligible for the study. adolescents who were taking laxative or hormonal medications, who did not give signed informed consent by parents or by themselves, refused to participate, and those with physical disabilities were not investigated. mothers were invited to schools by an invitation letter. the aims and methodology of the research were explained to them by the members of the research team, and written consents was obtained from adolescents and their parents. this study was approved by the ethics committee of iran university of medical sciences (tehran, iran). anthropometric measurements and data collection weights and heights of the participants were measured by the trained nutritionists using the same standard tools. height was measured to the nearest 0.1 cm, in standing position and without shoes, using a fixed tape meter. weight was measured using a portable beurer scale (beurer, germany) with minimum clothing and without shoes to the nearest 0.1 kg. body mass index (bmi) was computed by using the formula. based on cdc criteria, female adolescents with bmi-for-age and sex at or above the 95th percentile, between 85th and 95th percentile and less than 5th percentile were considered as being obese, overweight, and underweight, respectively.10 designed questionnaires were used to collect demographic and lifestyle data, age, physical activity level, total sleep time, daily computer use, and duration of breastfeeding from students, while socioeconomic status of participants were obtained from their mothers. physical activity level was investigated by the persian and the international physical activity questionnaire (ipaq) short form and expressed as met-min/week.11 http://www.library.pitt.edu/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx abiri this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu variable value min max age (years)a 15.50 ± 1.06 14.00 17.00 height (cm)a 160.38 ± 6.39 140.00 185.00 weight (kg)a 59.66 ± 13.00 21.30 104.70 bmi (kg/m2)a 23.14 ± 4.61 15.00 40.10 physical activity (met-min/week)b 730.00 (644.50) 234.00 2023 sleep duration (hours)b 7.00 (3.00) 3.00 9.00 computer using time (minute)a 90.49 ± 37.43 30.00 240.00 breastfeeding duration (month)b 6.00 (7.00) 0.00 24.00 a values are described as mean±sd b values are described as median (interquartile) table 1. characteristics of the participants the socioeconomic status (ses) of the adolescents was obtained from their mothers, using an economic indicator on the presence or absence of private bedroom, personal computer, automobile and travelling on holidays. according to this scale, three economic groups were idetified: low, medium, and high. educational levels of parents were investigated as a social factor (primary, secondary, or university). this socioeconomic frame has been commonly used in iran.12 total sleep time (in hours), daily computer use (in minutes), and duration of breastfeeding (in months) were assessed by the questionnaire. statistical analysis statistical analysis was performed by using spss version 22.0 (spss, inc, chicago, illinois) software. all continuous variables had normal distribution except for physical activity, duration of breastfeeding, and total sleep time. data were shown as mean±sd, unless expressed otherwise. categorical variables are reported as frequencies and percentages. chi-square test was used to evaluate the differences between categorical variables. analysis of variance (anova) was used to identify differences between the four groups (underweight, normal, overweight, and obese) for continuous variables. comparison of nonnormally distributed data was performed using kruskalwallis test. in addition, we applied ordinal logistic regression analysis to estimate the determinatives of overweight and obesity. p < 0.05 was considered statistically significant. results this report is based on data from 2,132 female adolescents aged 14-17 years in tehran, iran, enrolled between 2017 and 2018. the characteristics of the study participants who were recruited in this study are shown in table 1. the prevalence rates of underweight, overweight and obesity are demonstrated in table 2. the overall prevalence of underweight, normal, overweight, and obesity were 14.3, 55.2, 24.1, and 6.5%, respectively. the proportions of overweight and obesity were highest in the south district (28.9 and 7.7%, respectively) and were lowest in the north district (19.1 and 5.2%, respectively). the proportion of underweight was highest http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abiri this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu normal underweight overweight obese total district, n (%) north east central west south 110 (63.6) 365 (58.6) 147 (55.5) 289 (59.5) 265 (45.3) 21 (12.1) 86 (13.8) 36 (13.6) 55 (11.3) 106 (18.1) 33 (19.1) 135 (21.7) 65 (24.5) 112 (23.0) 169 (28.9) 9 (5.2) 37 (5.9) 17 (6.4) 30 (6.2) 45 (7.7) 173 623 265 486 585 total, n (%) 1176 (55.2) 304 (14.3) 514 (24.1) 138 (6.5) 2132 table 2. prevalence of overweight and obesity in female adolescents in the south district (18.1%) and was lowest in the west district (11.3%). no significant differences were seen between the four groups (underweight, normal, overweight, and obese) in age and height in each district and overall in the city (p ≥ 0.05). there were significant differences in regards to physical activity level (p < 0.001), total sleep time (p < 0.001), duration of breastfeeding (p < 0.01), and daily computer use (p < 0.001), among the four groups in each district and overall city. there were significant differences in economic status among the four groups (underweight, normal, overweight, and obese) (p < 0.001). the percentage of low economic status was highest in obese group (44.2%), and both percentages of medium (68.5%) and high (22.4%) economic states were highest in normal group (table 3). significant differences were observed in both mothers’ and fathers’ educational level, between the four groups (underweight, normal, overweight, and obese) (p < 0.001) (table 3). the proportion of mother’s primary educational level as the maximum education achieved was highest in underweight group (36.0%), and both proportion of mother’s secondary and university education level (67.5 and 21.5%, respectively) were highest in normal group (table 3). regarding the father’s education level, the proportion of primary education level was highest in underweight group (33.9%), and the highest proportions of secondary and university education levels were seen in overweight (59.5%) and normal (34.9%) groups, respectively (table 3). ordinal logistic regression analysis, physical activity, daily computer use, total sleep time, duration of breastfeeding, economic status, and mothers’ and fathers’ educational level were significant predictors of weight status in female adolescents (p < 0.001). discussion the findings of the present study indicate that the overall prevalence rates of underweight, normal, overweight, and obesity in 14-17 years old female adolescents in tehran are 14.3, 55.2, 24.1, and 6.5%, respectively, with the highest prevalence of overweight and obesity in the lowest socioeconomic district (south). the results of the current study are different from the findings reported from other geographical areas of iran. in a study among the female adolescents aged 15-18 years in najafabad highschools (najafabad, iran) in 2011, the overall prevalence rates of underweight, overweight, and obesity were 10.6, 20.5, and 6%, respectively.9 the higher rates of overweight http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abiri this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu variable normal (n=1,176) underweight (n=304) overweight (n=514) obese (n=138) p* economic status low, n (%) middle, n (%) high, n (%) 107 (9.1) 805 (68.5) 264 (22.4) 88 (28.9) 184 (60.5) 32 (10.5) 164 (31.9) 309 (60.1) 41 (8.0) 61 (44.2) 68 (49.3) 9 (6.5) < 0.001 maternal education level primary, n (%) secondary, n (%) university, n (%) 129 (11.0) 793 (67.5) 252 (21.5) 109 (36.0) 157 (51.8) 37 (12.2) 89 (17.3) 346 (67.3) 77 (15.0) 43 (31.2) 71 (51.4) 24 (17.4) < 0.001 paternal education level primary, n (%) secondary, n (%) university, n (%) 67 (5.7) 698 (59.4) 411 (34.9) 103 (33.9) 166 (54.6) 35 (11.5) 122 (23.7) 306 (59.5) 86 (16.7) 36 (26.1) 66 (47.8) 36 (26.1) < 0.001 *chi-square test. table 3. comparison of the socioeconomic variables in the participants in bmi groups and obesity in our study may be attributed to the differences in sample size, socioeconomic status, physical activity level, or eating habits. in another study between 2,900 students (1,200 males and 1,700 females) aged 11-17 years in tehran (2004-2005), prevalence of overweight and obesity were 17.9 and 7.1%, respectively.13 in another investigation, among a sample of 398 students (199 girls and 199 boys) aged 10-15 years in tehran (2000-2001), overall prevalence of overweight and obesity were 16 and 10%, respectively.14 in the investigation the prevalence of overweight in girls (19%) was higher than that in boys (14%), but the prevalence rate of obesity among boys (13%) was two times as many as girls (6.5%).14 similar to the increasing trend in adults, the proportions of overweight and obesity have elevated notably since 1980 among children and adolescents worldwide.1,15 but the prevalence of overweight and obesity among adolescents in other parts of the world differs based on the geographical region. available data demonstrated that roughly 33.8% of adolescent girls aged 12-19 years were overweight and obese and 20.7% were obese in 2011-2012, based on cdc criteria, in the united states.16 in china, the china health and nutrition survey findings indicated that 8.0% of adolescent girls aged 1518 years were overweight/obese in 2011.17 obesity definition, the age of participants, and the time when the participants were evaluated vary in http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu studies describing the prevalence of obesity, making it difficult to compare the rate of overweight and obesity among existing studied populations. hence, according to the findings of our investigation and similar studies,9,13,18-20 overweight and obesity should be considered as serious public health challenges at the national level in iran.20 there was a significant difference in physical activity level between the four groups (underweight, normal, overweight, and obese), with the highest level among normal weight and the lowest in obese groups. in addition, a significant difference was observed between the four groups in term of the times spent on computer, with the highest duration among underweight and the lowest in overweight adolescents. similar to our results, another study with the aim of determining the prevalence of overweight/obesity in relation to lifestyle among 7-17 years old children and adolescents in lithuania, reported that time spent on the computer or tv during the week was not related to being overweight/obesity.2 we hypothesize that absence of the direct association between the overweight/obesity and computer use does not reflect the other side of overweight/obese adolescent inactivity: these adolescents might have inactive hobbies (music, art, etc) contrary to normal weight and underweight counterparts who could be took part in more active hobbies including tennis, swimming, etc. previously demonstrated that overweight/obese children are more active and report more screen duration than normal weight ones.21 this notion is in line with earlier report of nitzan kaluski et al, who did not show any association between time spent at the computer, watching tv or videos, or listening to music on physical inactivity and obesity.22 another justification could be a direct kind of the question in the questionnaire (computer use), which does not encompass other gadgets use (tablets, smart phones, consoles, etc.). as proposed by some researchers, a negative impact of computer/tv use may be related to an elevated intake of sweets and snacks, both because of an effect on altering eating behavior and of higher exposure to advertisements of food high in sugar and fat.23,24 in addition, physical inactivity seems to be both a cause and a consequence of obesity.25 we found a significant difference in duration of breastfeeding between the four groups (underweight, normal, overweight, and obese), with the highest duration in normal weight. prior studies have investigated the association between infant feeding and overweight and obesity, with different results.26-31 the studies that indicated no relationship had comparatively smaller sample sizes, were frequently not populationbased, and limited to young aged groups ranging from 6-8 month old infants. in contrast, some other investigations indicated a strong and reverse association based on larger sample sizes.32-34 in a study conducted by fallahzadeh et al, among 800 school children aged 11-13 years, a reverse association between the duration of breastfeeding and overweight was reported.35 karmer et al. demonstrated a strong protective relationship of breastfeeding on obesity in two samples (clinic and schools) of more than 600 adolescents of 12-18 years old.32 both behavioral and metabolic explanations for the observed relationship between breastfeeding and obesity have been suggested. breast milk composition alters during feeding and makes satiety signals for the infant to stop suckling.36 while in bottle-fed infants, the amount consumed is controlled mainly by volume, which may lead to overfeeding. moreover, breastfed infants may obtain more control throughout their feeding behavior than bottle-fed ones.37 bottle-fed infants indicate significant higher plasma levels of insulin and a prolonged insulin response.38 this is in turn may prompt cell glucose uptake and suppress biolysis, hence leading to differences in deposition of subcutaneous adipose http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abiri this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu tissue.39 odeley et al. have demonstrated that fasting insulin is positively related to weight gain and alter in triceps skin fold in a cohort of 5to 9year old pima indian children followed during 9 years, a finding confirmed in young adults aged 18-30 years.40 the weight and fat gain stimulating impacts of insulin in young populations could therefore underlie the observed relationship of breastfeeding and overweight and obesity. moreover, ravelli et al. have reported that individuals aged 48-53 years who were exclusively breast fed over the first 10 days of life exhibit significantly lower fasting levels of insulin and glucose than those who were bottle fed.41 they also have higher bmi, waist circumference and waist-to-hip ratio, which however, were not statistically significant.37 in another study conducted by mirzaeian et al. among female adolescents aged 15-18 years, it was reported that breastfeeding (without considering its duration) was significantly related to a decreased risk of overweight and obesity.9 while, no statistically significant relationship was reported between duration of breastfeeding with overweight and obesity in the participants.9 hence, our study showed that the duration of breastfeeding is reversely associated with the prevalence of overweight and obesity in female adolescents. in the present study, there was a significant difference in total sleep time (during 24 hours) between the four groups (underweight, normal, overweight, and obese), with the highest sleep duration (6.98 ± 1.22) in normal weight group. this result is similar to the findings of the longitudinal study by kim et al. among adolescents to evaluate the associations of sleep patterns, health outcomes, and health risk behaviors.42 it was indicated that shorter sleep duration was related to obesity.42 these results are corroborated by the reports indicating that shorter sleep time has contributed to the obesity epidemic.43-47 wheaton et al. indicated that short sleep duration was associated with unhealthy weightcontrol behaviors that can result to being obese.47 our results propose that shorter sleep duration may be related to overweight or obesity. several mechanisms that might connect inadequate sleep to higher bmi values have been suggested. it has been well established that inadequate sleep is related to lower levels of anorexigenic hormones, such as leptin, in contrast with increased serum concentrations of orexigenic hormones such as ghrelin.48,49 serum levels of cortisol also increased toward the evening in states of total and partial sleep insufficiency.50 cortisol has a lipogenic influence, which may lead to weight gain in chronic sleep insufficiency.50 in addition, lower physical activity has been indicated as other mechanism that might lead to weight gain in those with insufficient sleep.51 the results of another study propose that the relationship between sleep insufficiency and obesity may in part be the result of alterations in neuronal activity when exposed to food stimuli. these alterations apparently influence brain parts known to be connected to motivation and desire and may demonstrate an elevated tendency to eat food in those who are not getting sufficient sleep.52 in our study, there was a significant difference in economic status between the four groups (underweight, normal, overweight, and obese). low economic status was more prevalent in obese group. while both, middle and high economic states were more frequent in normal weight group. moreover, level of maternal and paternal education was higher in normal weight group. family socioeconomic status has been indicated to be inversely associated with the prevalence of overweight and obesity,53 with the highest prevalence of overweight being in the lowest socioeconomic groups.23,54 previous investigations indicated that higher levels of maternal or paternal education were related to the lower risk of being overweight in children. finnish late study reported that paternal education had inverse relationship, mediated by parent’s bmi, with overweight in older boys. however, maternal education indicated indirect relationship.55 level of parental education is a strong socioeconomic determinant associated with eating behaviors and screen time.2 children of less educated http://www.library.pitt.edu/ http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu parents with low income reported to consume nutrientpoor but calorie-dense beverages more frequently instead of nutrient-dense beverages.56,57 it is well known that the impact of ses on overweight and obesity differs in differently developed regions.58,59 the strengths of our study include the populationbased approach, and a large sample size. the study was conducted by the same trained research team by using the same standard tools. this study also has few limitations. first, the cross-sectional design, which can result in uncertainties regarding the temporality of cause and effect of the observed relationships, and selfreported responses, which are suspected to error and underor over reporting. second, we did not evaluate dietary intake of the adolescents, as well as their parent’s bmi. these factors may contribute to overweight and obesity. parental history of obesity is one of the most important known risk factors for obesity in the offspring, more than doubling the risk.60 third, data on breastfeeding duration were collected based on mother’s recall, which may be subjected to recall and/or reporting bias. collecting data many years later may lead to misclassified exposures and subsequently incorrect conclusions. forth, we evaluated only bmi as the measure of adiposity, but it does not differentiate fat and lean body mass. in conclusion, the results of this study demonstrate that overweight and obesity among female adolescents in tehran, iran, is now a major public health challange. with respect to the findings, several factors such as level of physical activity, times spent on computer, sleep duration, breastfeeding duration, levels of parental education and economic status have important effects on weight gain. hence, public health strategies are needed to combat with elevated rates of overweight, obesity, and subsequent complications in adolescents. more research on the risk factors is needed before preventive public health strategies can be developed and put into practice. acknowledgements we thank the students and their parents for their cooperation and participation in this study. this work was financially supported by the vice chancellor of research, iran university of medical sciences. references 1. ng m, fleming t, robinson m, et al. global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the global burden of disease study 2013. lancet. 2014;384(9945):766–781. 2. smetanina n, albaviciute e, babinska v, karinauskiene l, albertsson-wikland k, petrauskiene a, verkauskiene r. prevalence of overweight/obesity in relation to dietary habits and lifestyle among 7-17 years old children and adolescents in lithuania. bmc public health. 2015 oct 1;15:1001. 3. berenson gs, srinivasan sr, bao w, newman 3rd wp, tracy re, wattigney wa. association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. the bogalusa heart study. n engl j med. 1998;338(23):1650–6. 4. rachmi cn, li m, alison baur l. overweight and obesity in indonesia: prevalence and risk factors-a literature review. public health. 2017 jun;147:20-29. 5. eckel rh, krauss rm. american heart association call to action: obesity as a major risk factor for coronary heart disease. circulation 1998; 97: 2099–2100. 6. styne dm, arslanian sa, connor el, farooqi is, murad mh, silverstein jh, et al. pediatric obesityassessment, treatment, and prevention: an endocrine http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abiri this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu society clinical practice guideline. j clin endocrinol metab. 2017 mar 1;102(3):709-757. 7. weber m, grote v, closa-monasterolo r et al. lower protein content in infant formula reduces bmi and obesity risk at school age: follow-up of a randomized trial. am j clinnutr. 2014; 99(5):1041-51. 8. morales camacho wj, molina díaz jm, plata ortiz s, plata ortiz je, morales camacho ma, calderón bp. childhood obesity: aetiology, comorbidities, and treatment. diabetes metab res rev. 2019 jul 12:e3203. 9. mirzaeian s, fakhari m, hosseini r, hassanzadeh a, esmaillzadeh a. association between duration of breastfeeding and subsequent overweight and obesity in female adolescents . iranian journal of nutrition sciences & food technology. 2011; 6 (2). 10. cdc growth charts: united states percentile data files with lms values [on line]; available from: url: http://www.cdc.gov/nchs/about/major/nhanes/growthch arts/datafiles.htm. accessed on december 19, 2019. 11. craig cl, marshall al, sjostrom m, bauman ae, booth ml, ainsworth be, pratt m, ekelund ul, yngve a, sallis jf, oja p. international physical activity questionnaire: 12-country reliability and validity. medicine & science in sports & exercise. 2003 aug 1;35(8):1381-95. 12. abiri b, vafa m, sarbakhsh p, saleck l, mousavi e, amiri f, amiri z. the association of intelligence quotient with obesity and some related factors in children girls. progr nutr [internet]. 2018dec.11 [cited 2019aug.16];20(2-s):218-24. 13. moayeri h, bidad k, aghamohammadi a, rabbani a, anari s, nazemi l, gholami n, zadhoush s, hatmi zn. overweight and obesity and their associated factors in adolescents in tehran, iran, 2004-2005. eur j pediatr. 2006 jul;165(7):489-93. 14. amini, m., omidvar, n., & kimiagar, m. (2007). prevalence of overweight and obesity among junior high school students in a district of tehran. journal of research in medical sciences, 12(6), 315-319. 15. wabitsch m, moss a, kromeyer-hauschild k. unexpected plateauing of childhood obesity rates in developed countries. bmc med. 2014;12(1):17. 16. ogden cl, carroll md, kit bk, flegal km. prevalence of childhood and adult obesity in the united states, 2011–2012. jama. 2014;311(8):806–814. 17. jaacks lm, slining mm, popkin bm. recent trends in the prevalence of underand overweight among adolescent girls in lowand middle-income countries. pediatr obes. 2015;10(6):428–435. 18. ghassemi h, harison g, mohammad k (2002) an accelerated nutrition transition. public health nutr 5:149–155. 19. mohammadpour-ahranjani b, rashidi a, karandish m, eshraghian mr, kalantari n (2003) prevalence of overweight and obesity in adolescent tehrani students, 2000–2001: an epidemic health problem. public health nutr 7:645–648. 20. rashidi a, mohammadpour-ahranjani b, vafa mr, karandish m (2005) national prevalence of obesityprevalence of obesity in iran. obes rev 6:191–192. 21. herman km, sabiston cm, mathieu me, tremblay a, paradis g. sedentary behavior in a cohort of 8to 10year-old children at elevated risk of obesity. prev med. 2014;60:115–20. 22. nitzan kaluski d, demem mazengia g, shimony t, goldsmith r, berry em. prevalence and determinants of physical activity and lifestyle in relation to obesity among schoolchildren in israel. public health nutr. 2009;12(6):774–82. 23. groholt ek, stigum h, nordhagen r. overweight and obesity among adolescents in norway: cultural and socio-economic differences. j public health (oxf). 2008;30(3):258–65. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/datafiles.htm http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/datafiles.htm http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/datafiles.htm http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/datafiles.htm central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu 24. lissner l, lanfer a, gwozdz w, olafsdottir s, eiben g, moreno la, et al. television habits in relation to overweight, diet and taste preferences in european children: the idefics study. eur j epidemiol. 2012;27(9):705–15. 25. stubbs co, lee aj (2004) the obesity epidemic: both energy intake and physical activity contribute. med j aust 181:489–491. 26. zive mm, mckay h, frank-spohrer gc, broyles sl, nelson ja, nader pr. infant-feeding practices and adiposity in 4-y-old angloand mexican-americans. am j clin nutr 1992;55:1104-1108. 27. bergmann ke, bergmann rl, von kries r, böhm o, richter r, dudenhausen jw, et al. early determinants of childhood overweight and adiposity in a birth cohort study: role of breast-feeding. int j obes relat metab disord 2003;27:162-172. 28. elliott kg, kjolhede cl, gournis e, rasmussen km. duration of breastfeeding associated with obesity during adolescence. obes res 1997;5:538-541. 29. grummer-strawn lm, mei z. does breastfeeding protect against pediatric overweight? analysis of longitudinal data from the centers for disease control and prevention pediatric nutrition surveillance system. pediatrics 2004;113:e81-86. 30. ariza aj, chen eh, binns hj, christoffel kk. risk factors for overweight in fi veto six-year-old hispanic american children: a pilot study. j urban health 2004;81:150-161. 31. wadsworth m, marshall s, hardy r, paul a. breast feeding and obesity. relation may be accounted for by social factors. bmj 1999;319:1576. 32. kramer ms. do breast-feeding and delayed introduction of solid foods protect against subsequent obesity? j pediatr 1981;98:883-887. 33. von kries r, koletzko b, sauerwald t, von mutius e, barnert d, grunert v, et al. breast feeding and obesity: cross sectional study. bmj 1999;319:147-150. 34. strbak v, skultetyova m, hromadova m, randuskova a, macho l. late effects of breast-feeding and early weaning: seven-year prospective study in children. endocr regul 1991;25:53-57. 35. fallahzadeh h, golestan m, rezvanian t, ghasemian z. breast-feeding history and overweight in 11 to 13year-old children in iran. world j pediatr. 2009 feb;5(1):36-41. 36. hall b. changing composition of human milk and early development of an appetite control. lancet 1975;1:779-781. 37. liese ad, hirsch t, von mutius e, keil u, leupold w, weiland sk. inverse association of overweight and breast feeding in 9 to 10-y-old children in germany. int j obes relat metab disord 2001;25:1644-1650. 38. lucas a, sarson dl, blackburn am, adrian te, aynsleygreen a, bloom sr. breast vs. bottle: endocrine responses are different with formula feeding. lancet 1980;1:1267-1269. 39. oakley jr. differences in subcutaneous fat in breast and formula-fed infants. arch dis child 1977;52:79-80. 40. odeley oe, de courten m, pettitt dj, ravussin e. fasting hyperinsulinemia is a predictor of increased body weight gain and obesity in pima indian children. diabetes 1997;46:1341-1345. 41. ravelli ac, van der meulen jh, osmond c, barker dj, bleker op. infant feeding and adult glucose tolerance, lipid profi le, blood pressure, and obesity. arch dis child 2000;82:248-252. 42. kim j, noh jw, kim a, kwon yd. relationships between sleep patterns, health risk behaviors, and health outcomes among school-based population of adolescents: a panel analysis of the korean children http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abiri this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu and youth panel survey. int j environ res public health. 2019 jun 27;16(13). 43. martinez, s.m.; tschann, j.m.; butte, n.f.; gregorich, s.e.; penilla, c.; flores, e.; greenspan, l.c.; pasch, l.a.; deardor_, j. short sleep duration is associated with eating more carbohydrates and less dietary fat in mexican american children. sleep 2017, 40, 1–7. 44. nixon, g.m.; thompson, j.m.d.; han, d.y.; becroft, d.m.; clark, p.m.; robinson, e.; waldie, k.e.; wild, c.j.; black, p.n.; mitchell, e.a. short sleep duration in middle childhood risk factors and consequences. sleep 2011, 31, 71–78. 45. o’brien, e.m.; mindell, j.a. sleep and risk-taking behavior in adolescents. behav. sleep med. 2005, 3, 113–133. 46. sung, v.; beebe, d.w.; vandyke, r.; fenchel, m.c.; crimmins, n.a.; kirk, s.; hiscock, h.; amin, r.; wake, m. does sleep duration predict metabolic risk in obese adolescents attending tertiary services? a cross-sectional study. sleep 2011, 34, 891–898. 47. wheaton, a.g.; chapman, d.p.; croft, j.b. selfreported sleep duration and weight-control strategies among us high school students. sleep 2013, 36, 1139– 1145. 48. taheri s, lin l, austin d, young t, mignot e. short sleep duration is associated with reduced leptin, elevated ghrelin, and increased body mass index. plos med 2004;1:e62. 49. spiegel k, tasali e, penev p, van cauter e. brief communication: sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. ann intern med 2004;141:846–50. 50. spiegel k, leproult r, van cauter e. impact of sleep debt on metabolic and endocrine function. lancet 1999;354:1435-9. 51. z shi, m mcevoy, j luu and j attia. dietary fat and sleep duration in chinese men and women. international journal of obesity (2008) 32, 1835–1840. 52. marie-pierre st-onge, andrew mcreynolds, zalak b trivedi, amy l roberts, melissa sy, and joy hirsch. sleep restriction leads to increased activation of brain regions sensitive to food stimuli. am j clin nutr 2012;95:818–24. 53. valdes pizarro j, royo-bordonada ma. prevalence of childhood obesity in spain: national health survey 2006–2007. nutr hosp. 2012;27(1):154–60. 54. o'dea ja, amy nk. perceived and desired weight, weight related eating and exercising behaviours, and advice received from parents among thin, overweight, obese or normal weight australian children and adolescents. int j behav nutr phys act. 2011;8:68. 55. parikka s, maki p, levalahti e, lehtinen-jacks s, martelin t, laatikainen t. associations between parental bmi, socioeconomic factors, family structure and overweight in finnish children: a path model approach. bmc public health. 2015;15:271. 56. pinard ca, davy bm, estabrooks pa. beverage intake in low-income parent– child dyads. eat behav. 2011;12(4):313–6. 57. brug j, van stralen mm, te velde sj, chinapaw mj, de bourdeaudhuij i, lien n, et al. differences in weight status and energy-balance related behaviors among schoolchildren across europe: the energy-project. plos one. 2012;7(4), e34742. 58. sánchez-vaznaugh ev, kawachi i, subramanian sv, sanchez bn, acevedo-garcia d. do socioeconomic gradients in body mass index vary by race/ethnicity, gender, and birthplace? am j epidemiol. 2009;169(9): 1102–1112. 59. monteiro ca, moura ec, conde wl, popkin bm. socioeconomic status and obesity in adult populations of developing countries: a review. bull world health organ. 2004;82(12):940–946. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 8, no. 1 (2019) | issn 2166-7403 (online) | doi 10.5195/cajgh.2019.413|http://cajgh.pitt.edu 60. whitaker rc, wright ja, pepe ms, seidel kd, dietz wh. predicting obesity in young adulthood from childhood and parental obesity. n engl j med 1997;337:869-873. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abstract abstract keywords: overweight; obesity; body mass index; female adolescents; tehran keywords: overweight; obesity; body mass index; female adolescents; tehran research research research microsoft word erratum toa systematic review of the effects of aromatherapy with lavender essential oil on depression.docx new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. erratum to: a systematic review of the effects of aromatherapy with lavender essential oil on depression the editors of the central asian journal of global health regretfully published the article “a systematic review of the effects of aromatherapy with lavender essential oil on depression” with a misspelled word in the title. this mistake has been corrected. the original article has been updated to reflect this change. jafar-koulaee a, elyasi f, taraghi z, ilali es, moosazadeh m. a systematic review of the effects of aromatherapy with lavender essential oil on depression. cent asian j glob health. 2020;9(1). doi:10.5195/cajgh.2020.442. vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.546 | http://cajgh.pitt.edu microsoft word padilla-raygoza.docx new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. clinical data, comorbidities, and mortality of covid-19 in the state of guanajuato, mexico until may 20, 2020 nicolás padilla-raygoza1*, efraín navarro-olivos2, maría de jesús gallardo-luna2, francisco j. magos-vázquez2, daniel alberto díaz-martínez2, cuauhtémoc sandoval-salazar3, luis antonio díaz-becerril1 1school of medicine, university of celaya, celaya mexico; 2institute of public health from guanajuato state, guanajuato, mexico; 3department of nursing and obstetrics, division of health sciences and engineering, university of guanajuato, celaya, mexico *corresponding author vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.527 | http://cajgh.pitt.edu padilla-raygoza this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.527 | http://cajgh.pitt.edu abstract introduction: in december 2019, cases of pneumonia of unknown cause arose in wuhan, china. the causative agent was subsequently identified as 2019-ncov and later called sars-cov-2. in mexico, since january 2020 when the first cases were reported, the spread of the infection has occurred throughout the country. the state of guanajuato, which is located in the center of the country, has taken isolation measures and closed public places in march 2020. the objective of this study was to analyze the evolution, symptoms, co-morbidities and deaths due to confirmed cases of covid-19. methods: an ecological study was designed from the database of confirmed cases of covid-19 in the state of guanajuato. odds ratios and 95% confidence intervals were calculated for symptoms and co-morbidities in deaths of confirmed cases. logistic regression models were generated adjusting for age group and gender. results: among the 838 confirmed cases in the state, cases with dyspnea and cyanosis showed more significant effect on death. age group and gender had little involvement as confounders. for practically all comorbidities (including diabetes, hypertension, cardiovascular disease, chronic kidney disease, and immunosuppression), there was a significant effect (odds ratio greater than 2) on mortality from covid-19. age group showed a confounding effect on comorbidities and death, but not gender. conclusion: the confirmed cases had more than twice the possibility of having comorbidities, compared with those who did not die. keywords: sars-cov-2; covid-19; population; deaths; clinical data; comorbidities clinical data, comorbidities, and mortality of covid-19 in the state of guanajuato, mexico, until may 20, 2020 nicolás padilla-raygoza1, efraín navarro-olivos2, maría de jesús gallardo-luna2, francisco j. magosvázquez2, daniel alberto díazmartínez2, cuauhtémoc sandovalsalazar3, luis antonio díaz-becerril1 1school of medicine, university of celaya, celaya mexico; 2institute of public health from guanajuato state, guanajuato, mexico; 3department of nursing and obstetrics, division of health sciences and engineering, university of guanajuato, celaya, mexico research at the end of 2019, the world health organization (who) office in wuhan, hubei province, china, received the report of a case of pneumonia of unknown cause1 that was related to other cases of pneumonia in people who worked or lived near the local hunan seafood market2-5. the infection spread throughout the city and to other countries and was declared an international public health emergency by the who6. the causative agent was determined to be a new coronavirus, called 2019-ncov and later sars-cov-2 by who7. it was reported that the cause of covid-19 shares 79.5% of the sars-cov sequence and uses the same cell entry receptor, angiotensin-converting enzyme2, as sars-cov8. zhu et al.9 reported the cytopathic effects and morphology of the virus and that it is a member of a family of coronaviruses that infect humans. this virus grew more in human airway epithelial cells than tissue culture cells, suggesting the potential for increased infectivity. central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.527 | http://cajgh.pitt.edu covid-19 patients who present with a comorbid condition may have an increased risk of deterioration and should therefore be admitted to a designated unit for close monitoring in accordance with the who guidelines for screening and triage10. in a series of 41 patients infected with sars-cov-2, 32% had some underlying pathology, 20% had diabetes, 15% had hypertension, 15% had cardiovascular disease, and 2% had chronic obstructive pulmonary disease (copd)11. in mexico, the first detected case started with symptoms on january 8, 2020, and the first two deaths were reported on march 18, 202012. in the state of guanajuato, before the arrival of the pandemic, the local authorities began measures of social isolation. the closure of educational institutions at all levels began on march 20, 2020, and later, there was the closure of restaurants, gyms, and public parks. meetings with more than 10 people were also cancelled. the state of guanajuato is located in the center of the mexican republic (longitude # 102° 5'49.2” w # 99° 40'16.68" w, latitude 19° 54'46.08" n 21° 50'21.84" n13). as of the 2010 mexican census, guanajuato had 5,486,372 inhabitants, accounting for 4.88% of the national population14. the state is a relay center for transportation to the four cardinal points of mexico. in the state of guanajuato, the first confirmed case of covid-19 was reported with the onset of symptoms on march 10, 2020, and the first two deaths were reported on april 5, 202015. the number of confirmed cases of covid-19 in guanajuato state remained low through april, but given the significant dates in may for the mexican population, people began to break social isolation, and the number of confirmed cases increased markedly. the aim of this study was to analyze the effect of clinical data and comorbidities on deaths from covid-19 in guanajuato state, mexico. this is important because few studies are published from mexico and even less so from guanajuato state. methods an analytical ecological study was designed with the data reported in the database15 of the secretary of health of the state of guanajuato, with confirmed cases and deaths from covid-19 until may 20, 2020. a suspected case is one that manifests fever, cough, dyspnea, and has had a trip abroad to a country with a high frequency of covid-19 cases or have had contact with a confirmed case. a confirmed case is one that, in addition to the previous criteria, also tested positive for the virus using reverse transcriptase-polymerase chain reaction (rt-pcr). sociodemographic variables in the database were age and gender. among the study variables, the date of onset of symptoms was collected, as well as the clinical data recorded: fever, cough, dyspnea, odynophagia, diarrhea, vomiting, headache, chest pain, cyanosis, abdominal pain, myalgia, arthralgia, and rhinorrhea. all were measured as absent or present. other variables were comorbidities in the confirmed patient: diabetes, chronic obstructive pulmonary disease (copd), asthma, immunosuppression, hypertension, cardiovascular disease, chronic kidney disease, obesity, and smoking. the result variable was death and its date. all included registries had a positive rt-pcr test for sars-cov-2. for statistical analysis, descriptive statistics were used to show the variables. odds ratios (or) and corresponding 95% confidence intervals (95% ci) were used for clinical data, comorbidities, and covid-19 death. logistic regression models were generated between comorbidities and death by covid-19, using age categories and gender as potential confounding variables. statistical analyses were performed using stata 13.0 ® (stata corp., college station, tx, usa). padilla-raygoza this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.527 | http://cajgh.pitt.edu results the sample consisted of 838 confirmed cases distributed throughout the state, with the municipality of león predominating. the distribution by gender was 378 (45.11%) women and 460 (54.89%) men. ages ranged from 0 to 93 years, with an average of 45.03 ± 17.76 years. figure 1 shows the municipalities of the state of guanajuato with a report of at least 20 cases; the rest of the municipalities had at least one case reported. figure 1. map of guanajuato state, with municipalities with 20 or more confirmed cases of covid-19 figure 2 shows the distribution of confirmed cases of covid-19 per day. the first detected case in guanajuato state started with symptoms on march 10, 2020 and the curve remained low, possibly due to the measures of social isolation and closure of public places that began to be applied in the state as of march 17. throughout april, however, the curve for cases increased. the few confirmed cases in mid-may may be an artifact due to delayed delivery of rt-pcr test results for sars-cov-2. figure 3 shows the distribution of deaths due to covid-19 per day. the specific mortality rate (smr=9.55%) for guanajuato until may 20, 2020 is 80 deaths among 838 cases. central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.527 | http://cajgh.pitt.edu source: sinave/dge15 figure 2. distribution of confirmed cases of covid-19 by day in guanajuato state, mexico (n-848) source: sinave/dge15 figure 3. distribution of deaths for covid-19 by day in guanajuato state, mexico (n=80) 0 1 2 3 4 5 6 7 05 -ap r 09 -ap r 14 -ap r 17 -ap r 22 -ap r 24 -ap r 26 -ap r 30 -ap r 02 -m ay 04 -m ay 06 -m ay 08 -m ay 10 -m ay 12 -m ay 14 -m ay 16 -m ay 18 -m ay de at hs date 0 5 10 15 20 25 30 35 40 45 50 10 -m ar 15 -m ar 18 -m ar 21 -m ar 24 -m ar 27 -m ar 31 -m ar 3ap r 6ap r 9ap r 12 -a pr 15 -a pr 18 -a pr 21 -a pr 24 -a pr 27 -a pr 30 -a pr 03 -m ay 06 -m ay 09 -m ay 12 -m ay 15 -m ay ca se s date padilla-raygoza this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.527 | http://cajgh.pitt.edu table 1 shows the distribution by age and gender of confirmed cases for covid-19 by death (n=838). men accounted for 62.50% of the deaths by covid-19, though among the non-deceased, accounted for a similar but lower percentage of 54.09%. the or for gender indicates that being a woman was a protective factor for dying by decreasing the risk by 29%, an effect that is nullified when reviewing the 95% ci. for age group, those aged 60 years or older predominated among the deceased (57.50%). presence of dyspnea and cyanosis had the greatest increased risk of death from covid-19 compared to those who were not deceased. the deceased had more than ten times the odds of having presented dyspnea or cyanosis than those not deceased. fever and chest pain only had an effect on death four times greater. diarrhea, cough, vomiting, headache, myalgia, arthralgia, and rhinorrhea had no statistically significant effect on mortality. sore throat had a protective effect against death. age group had a confounding effect for dyspnea, chest pain, and cyanosis, but maintained the strong effect of these clinical data on death (table 2). asthma showed a non-significant protective effect. diabetes, hypertension, copd, cardiovascular disease, and chronic kidney disease show a strong effect on mortality from covid-19 with ors greater than 3. for each of these comorbidities, age group acted as a confounder, decreasing the ors, but they remained significant. for obesity and smoking, an or effect was found higher than 2, though age group also acted as a confounder. gender in no one comorbidities acted as a confounder (table 3). variable confirmed cases deaths (n=80) n % non-deaths (n=758) n % or (95% ci) gender female male 30 50 37.50 62.50 348 410 45.91 54.09 0.71 (0.44 to 1.14) age group (years) 0–5 6–11 12–19 20–49 50–59 60 or higher 0 0 0 12 22 46 0 0 0 15.00 27.50 57.50 14 10 24 444 145 121 1.85 1.32 3.17 58.58 19.13 15.96 3.59 (2.66 to 4.85) source: sinave/dge15 table 1. distribution of gender and age group by death for covid-19 in guanajuato, mexico padilla-raygoza this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.527 | http://cajgh.pitt.edu clinical data confirmed cases (n=838) logistic regression or (95% ci) deaths n % non-deaths n % unadjusted age-adjusted gender-adjusted fever* yes no 74 92.50 6 7.50 566 74.77 191 25.23 4.17 (1.78 to 9.72) 4.19 (1.75 to 10.05) 4.02 (1.72 to 9.41) cough yes no 72 90.00 8 10.00 668 88.13 90 11.87 1.21 (0.57 to 2.60) 1.18 (0.53 to 2.65) 1.23 (0.57 to 2.65) sore throat yes no 30 37.50 50 62.50 466 61.48 292 38.52 0.37 (0.23 to 0.60) 0.48 (0.29 to 0.79) 0.38 (0.24 to 0.61) dyspnea yes no 66 82.50 14 17.50 152 20.05 606 79.95 18.80 (10.28 to 34.37) 11.01 (5.88 to 20.60) 18.73 (10.23 to 34.36) diarrhea yes no 19 23.75 61 76.25 96 12.66 662 87.34 2.15 (1.23 to 3.75) 1.84 (1.01 to 3.37) 2.08 (1.19 to 3.64) vomiting yes no 6 7.50 74 92.50 47 6.20 711 93.80 1.23 (0.51 to 2.97) 1.54 (0.60 to 3.98) 1.22 (0.50 to 2.95) headache yes no 65 81.25 15 18.75 651 85.88 107 14.12 0.71 (0.39 to 1.29) 0.75 (0.39 to 1.44) 0.72 (0.39 to 1.30) chest pain* yes no 40 50.00 40 50.00 157 20.74 600 79.26 3.82 (2.38 to 6.13) 2.61 (1.58 to 4.31) 3.96 (2.46 to 6.38) abdominal pain yes no 9 11.25 71 88.75 67 8.84 691 91.16 1.31 (0.63 to 2.73) 1.04 (0.48 to 2.28) 1.32 (0.63 to 2.76) myalgias* yes no 57 71.25 23 28.75 521 68.82 236 31.18 1.12 (0.68 to 1.87) 1.29 (0.75 to 2.22) 1.09 (0.66 to 1.82) arthralgias yes no 53 66.25 27 33.75 441 58.18 317 41.82 1.41 (0.87 to 2.29) 1.23 (0.74 to 2.07) 1.40 (0.86 to 2.27) rhinorrhea yes no 28 35.00 52 65.00 304 40.11 454 59.89 0.80 (0.50 to 1.30) 1.00 (0.60 to 1.68) 0.82 (0.51 to 1.33) cyanosis** yes no 16 20.00 64 80.00 14 1.85 742 98.15 13.25 (6.19 to 28.37) 7.66 (3.34 to 17.53) 13.81 (6.40 to 29.78) *one case removed for missing information **two cases removed for missing information source: sinave/dge15 table 2. distribution of clinical data by death from covid-19 in guanajuato, mexico padilla-raygoza this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.527 | http://cajgh.pitt.edu confirmed cases (n=838) logistic regression or (95% ci) comorbidity deaths n % non-deaths n % unadjusted age-adjusted gender-adjusted diabetes yes no 25 31.25 66 68.75 97 12.80 661 87.20 3.10 (1.84 to 5.22) 1.29 (0.73 to 2.28) 3.17 (1.88 to 5.34) hypertension yes no 39 48.75 41 51.25 104 13.72 654 86.28 5.98 (3.68 to 9.71) 2.57 (1.50 to 4.40) 6.01 (3.70 to 9.78) copd yes no 9 11.25 71 88.75 19 2.51 739 97.49 4.93 (2.15 to 11.30) 1.54 (0.64 to 3.69) 5.06 (2.20 to 11.66) asthma yes no 1 1.25 79 98.75 11 1.45 747 98.55 0.86 (0.11 to 6.75) 0.72 (0.08 to 6.33) 0.85 (0.11 to 6.68) cardiovascular disease* yes no 6 7.50 74 92.50 15 1.98 742 98.02 4.01 (1.51 to 10.65) 1.57 (0.56 to 4.45) 4.07 (1.53 to 10.85 immunosuppression yes no 0 0.00 80 100.00 9 1.19 749 98.81 n/a n/a n/a chronic kidney disease yes no 3 3.75 77 96.25 7 0.92 751 99.08 4.18 (1.06 to 16.49) 3.19 (0.71 to 14.28 4.13(1.04 to 16.37) obesity yes no 24 30.00 56 70.00 116 15.30 642 84.70 2.37 (1.41 to 3.98) 2.19 (1.25 to 3.84) 2.44 (1.45 to 4.11) smoking yes no 13 6.25 67 83.75 56 7.39 702 92.61 2.43 (1.27 to 4.67) 1.76 (0.86 to 3.59) 2.37 (1.23 to 4.56) *one case removed for missing information source: sinave/dge15 table 3. distribution among comorbidities by deaths from covid-19 in guanajuato, mexico discussion the sample of 838 infected with sars-cov-2 who developed covid-19 registered in the state of guanajuato shows a very slow spread during the month of march, but in april and may, the number of cases increased markedly (figure 2). this slow spread is possibly due to the initial measures taken by the government of the state for social isolation and closure of public places, as well as the avoidance of massive events. as the quarantine and social isolation continued, the population may have gone out to cover basic needs and obtain food supplies, and in places of supply possibly being infected, infection may have spread. this could explain the increase in cases in the months of april and may despite social isolation. it should not be forgotten that the rt-pcr test only applies to symptomatic patients, so asymptomatic carriers are not detected and may avoid their isolation. it was reported that after social distancing, 20% of new cases and many hospitalizations could be avoided, but upon completion of isolation, new cases would rebound16 and, reinforced by li et al.17, that the central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.527 | http://cajgh.pitt.edu imposition of social controls impacts the number of new cases. the smr of 9.55% in the state of guanajuato is slightly lower than that of mexico, which was 10.59% as of may 15, 202018, but is higher than the global smr of 6.34% reported by the who19. the most reported symptoms among the guanajuato cases were fever, cough, dyspnea, and sore throat, but the symptoms that showed the greatest effect in terms of mortality were cyanosis, dyspnea, and chest pain (table 2). in a series of 926 symptomatic sarscov-2 infected cases, there was fever reported in 42.2% of cases, cough in 67.2%, dyspnea in 15.0%, arthralgia in 14.4%, headache in 13.4%, sore throat in 14.0%, diarrhea in 3.3%, and vomiting in 4.6%20. the figures reported in patients from guanajuato, mexico differ from these reported by guan et al.20, but the predominant symptoms were still fever, cough, and dyspnea. liu et al.21, in a series of 44 symptomatic patients with covid-19, reported fever in 97.7%, cough in 56.8%, dyspnea in 9.1%, and arthralgia in 52.3%. in a series of nine pregnant women, fever was reported in 77.8%, cough in 44.4%, dyspnea in 11.1%, arthralgia in 33.3%, headache in 33.3%, and sore throat in 33.3%22. the comorbidities with the greatest effect on mortality in patients from the state of guanajuato are similar (table 3) to those described in all of mexico18. in a series of 41 patients infected with sasr-cov-2 in wuhan, china, 32% had some underlying pathology, 20% had diabetes, 15% had hypertension, 15% had cardiovascular disease, and 2% had copd23. the spread of sars-cov-2 infection has been constantly increasing since january 2020. in the state of guanajuato, since mid-march, the government authorities decided to close educational institutions, mass events, and public places, which resulted in the curve for new confirmed cases remaining low; with community transmission, cases increased dramatically during april and may. the clinical data of the confirmed cases in the state of guanajuato are similar to those already reported, with cough, fever, and dyspnea as the main symptoms. mortality in the presence of comorbidities such as diabetes, hypertension, copd, and cardiovascular disease in the state of guanajuato are similar to what is reported throughout mexico. it is important to continue the follow-up of the epidemiology of sars-cov-2 in guanajuato state because it is possible that the number of confirmed cases may rise with the breaking of quarantine. references 1. world health organization. rolling updates on coronavirus disease (covid-19). world health organization. https://www.who.int/emergencies/diseases/novelcoronavirus-2019/events-as-they-happen . updated 7 may 2020. accessed: june 21, 2020. 2. lu h, stratton cw, tang yw. outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle. j med virol. 2020; 92(4):401402. doi: https://doi.org/10.1002/jmv.25678 3. hui ds, azhar ei, madani ta, ntoumi f, kock r, dar o, et al. the continuing 2019-ncov epidemic threat of novel coronaviruses to global health – the latest 2019 novel coronavirus outbreak in wuhan, china. int j infect dis. 2020; 91: 264-66 doi: https://doi.org/10.1016/j.ijid.2020.01.009 4. huang c, wang y, li x, ren l, zhao j, hu y, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. the lancet. 2020; 395(10223):497-506 doi: https://doi.org/10.1016/s0140-6736(20)30183-5 5. chen n, zhou m, dong x, qu j, gong f, han y, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. the lancet.2020; 395(10223): 507-513 https://doi.org/10.1016/s01406736(20)30211-7 6. yoo jh, hong st. the outbreak cases with the novel coronavirus suggest upgraded quarantine and isolation in korea. j korean med sci. 2020;35(5): e62 doi: https://doi.org/10.3346/jkms.2020.35.e62 padilla-raygoza this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.527 | http://cajgh.pitt.edu 7. carlos wg, de la cruz c, cao b, pasnick s, jamil s. novel wuhan (2019-cov) coronavirus. am j respi crit care med. 2020; 201(4): 7-8 doi: https://doi.org/10.1164/rccm.2014p7 8. zhou p, yang xl, wang xg, hu b, zhang l, zhang w, et al. a pneumonia outbreak associated with a new coronavirus of probable bat origin. nature. 2020; 579: 270-273. https://doi.org/10.1038/s41586-020-2012-7 9. zhu n, zhang d, wang w, li x. yang b, song j, et al. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med. 2020; 382: 727:737. doi: https://doi.org/10.1056/nejmoa2001017 10. world health organization. clinical management of severe acute respiratory infection (sari) when covid19 disease is suspected. interim guidance. world health organization. 2020. https://www.who.int/publicationsdetail/clinical-management-ofsevere-acute-respiratoryinfection-when-novel-coronavirus-(ncov)-infection-issuspected . accessed june 21, 2020. 11. huang c, wuang y, li x, ren l, zhao j, hu y, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. the lancet. 2020; 395(10223): 497-506 doi: https://doi.org/10.1016/s0140-6736(20)30183-5 12. secretaría de salud. datos-abiertos bases históricas. 6 mayo 2020. available in: https://www.gob.mx/salud/documentos/datos-abiertosbases-historicas-direccion-general-de-epidemiologia accessed may 20, 2020 13. inegi. mexico en cifras. guanajuato. inegi. https://www.inegi.org.mx/app/areasgeograficas/?ag=11, accessed june 21, 2020 14. inegi-población. inegi. https://www.inegi.org.mx/temas/estructura/. accessed: june 21, 2020 15. departamento de epidemiología de la dirección de servicios de salud. sistema nacional de vigilancia epidemiológica, dirección general de epidemiología, secretaría de salud. available in: http://www.sinave.gob.mx/ . 2020. accessed may 21, 2020. 16. matrajt l, leung t. evaluating the effectiveness of social distancing interventions to delay or flatten the epidemic curve of coronavirus disease. emerg. infect. dis. 2020; 26(8). doi: http://doi.org/10.3201/eid2608.201093 17. li l, yang z, dang z, meng c, huang j, meng h, et al. propagation analysis and prediction of the covid-19. infectious disease modelling. 2020; 3: 282292. doi: http://doi.org/10.1016/j.idm.2020.03.002 18. padilla-raygoza n, sandoval-salazar c, díazbecerril la, beltran-campos v, díaz-martínez da, navarro-olivos e, et al. update of the evolution of sars-cov-2 infection, covid-19, and mortality in mexico until may 15, 2020: an ecological study. international journal of tropical disease & health, 2020; 41(5): 36-45. doi: https://doi.org/10.9734/ijtdh/2020/v41i/530277 . 19. world health organization. coronavirus disease 2019 (covid-19). situation report – 85, april 14, 2020. available in: https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200414-sitrep85-covid-19.pdf?sfvrsn=7b8629bb_4 accessed: june 21, 2020. 20. guan wj, ni zy, hu y, laing wh, ou cq, he jx, et al. clinical characteristics of coronavirus disease 2019 in china. n engl j med. 2020; 382:1708-1720. doi: https://doi.org/10.1056/nejmoa2002032 21. liu j, liu y, xiang p, pu l, xiong h, li c, et al. neutrophil-to-lymphocyte ratio predicts severe illness patients with 2019 novel coronavirus in the early stage. medrxiv. 2020. doi: https://doi.org/10.1101/2020.02.10.20021584 22. chen h, gua j, wang c, lua f, yu x, zhang w, et al. clinical characteristics and intrauterine vertical transmission potential of covid-19 infection in nine pregnant women: a retrospective review of medical records. the lancet. 2020; 395 (10226): 809-815. doi: https://doi.org/10.1016/s0140-6736(20)30360-3 23. huang c, wuang y, li x, ren l, zhao j, hu y, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. the lancet. 2020;395(10223): 497-506 doi: https://doi.org/10.1016/s0140-6736(20)30183-5 microsoft word pagdhune.docx new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. poisoning cases reported to poison information centre, ahmedabad, india: a three year observational study avinash pagdhune1, kundan kunal1, kanubhai amrutlal patel1, aswin bhailalbhai patel1, sukhdev mishra2, rajendra palkhade3, jaseer muhamed1,4,* 1poison information centre, icmr-national institute of occupational health, ahmedabad, gujarat, india; 2biostatistics and data management, icmrnational institute of occupational health, ahmedabad, gujarat, india; 3animal facility, icmr-national institute of occupational health, ahmedabad, gujarat, india; 4biochemistry, icmr regional occupational health centre (southern), karnataka, india *corresponding author email: jaseermuhamed@gmail.com vol. 9, no. 1 (2020) | issn 2166-7403 (online) doi 10.5195/cajgh.2020.471 | http://cajgh.pitt.edu pagdhune this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.471 | http://cajgh.pitt.edu abstract introduction: morbidity and mortality associated with pesticide poisoning is a major public health issue, especially in lower and middle income countries, including india. timely understanding of poisoning trends is required for improved prevention. the objective of the present study was to analyze the trend of poisoning cases in ahmedabad, india in the period of 2015-2017. methods: detailed history, including demographic data, risk factors, poisoning history, agents involved, and occupational influence were collected for poisoning cases reported to the poison information centre in ahmedabad. cholinesterase activity and hptlc method for detection of sanguinarine in urine were used to investigate the agents of poisoning. non-parametric tests, such as chi-square test and mann-whitney u test were applied to test statistical significance between the groups. all statistical analysis was carried out using ibm spss statistics for windows, version 26.0. armonk, ny: ibm corp. results: a total 1373 poisoning cases were investigated. the incidence and fatality rate was found to be higher in males compared to females (m/f ratio 1.89:1). about 91.62% of the poisoning were through the oral route. erythrocyte cholinesterase activity assay results indicated that 41.29% of the cases were due to organophosphorus/carbamate poisoning. insecticides were found to be the agent of poisoning in 26.29% cases, and 11.07% of all the cases were agricultural workers. poisoning with medications, household pesticides and chemicals were also reported. few cases of food poisoning with sanguinarine were detected. conclusion: the data presented here suggest that pesticides used for agriculture are the major source of poisonings. implementation of usage guidelines, educating farmers and vulnerable population, and finding novel alternatives for highly toxic chemicals may be helpful in decreasing the number of poisoning cases. keywords: trend of poisoning; pesticide poisoning; organophosphorous; suicide poisoning cases reported to poison information centre, ahmedabad, india: a three year observational study avinash pagdhune1, kundan kunal1, kanubhai amrutlal patel1, aswin bhailalbhai patel1, sukhdev mishra2, rajendra palkhade3, jaseer muhamed1,4,* 1poison information centre, icmr-national institute of occupational health, ahmedabad, gujarat, india; 2biostatistics and data management, icmrnational institute of occupational health, ahmedabad, gujarat, india; 3animal facility, icmr-national institute of occupational health, ahmedabad, gujarat, india; 4biochemistry, icmr regional occupational health centre (southern), karnataka, india *corresponding author email: jaseermuhamed@gmail.com research morbidity and mortality due to pesticide poisoning is a major public health issue, especially in lower and middle income countries.1 according to the national crime records bureau of india, the official estimate of suicides resulted from insecticide poisoning was 10.4% of the total suicide cases in 2014.2 this estimate is more likely to be lower than the actual number because of under-reporting of suicide cases and exclusion of poisoning cases associated with rodenticides, fungicides and herbicides.1 an estimate of 11.3% of total suicide cases due to insecticide poisoning was also reported in lower and middle income countries of the south-east asia region.1 in 2010, there was reports of incidence of 38.8% of suicide by pesticide ingestion in india.3 among the indian states, gujarat state accounts for 5.4% of the suicide cases, and this is above the national average of the country.4 central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.471 | http://cajgh.pitt.edu to date, considerable efforts have been taken by the world health organization (who) and different countries to reduce the incidence of poisoning cases. one such initiative is an ipcs intox program by who in 1988, which promoted chemical safety by establishing poison information centers, which is a global endeavor to promote chemical safety by the introduction and support of poison information centers. the program aimed to harmonize the collection of poisoning data, training and sharing of information related to poisoning within member countries.5 in accordance with this program, india currently has six poison information centers. the central insecticides board & registration committee, under the department of agriculture and co-operation, government of india, is engaged with registration of pesticides used in agriculture in the country. its activities involve banning the pesticides and chemicals that are hazardous to health and the environment, establishing guidelines for registration of new pesticides, establishing minimum infrastructure requirements for pesticide manufacturing, and setting guidelines for the export and import of pesticides.6 still, morbidity and mortality from poisoning continue to be a major public health concern in the country. the incidence of poisoning depends on several factors including socioeconomic status, culture and religion, educational status, agricultural practices and knowledge of pesticides and other poisonous substances, extent of industrialization, and geographical conditions.7 consequently, the epidemiology of poisoning cases may vary depending on geographic location, while understanding of the pattern and trend of poisoning in a particular area is necessary for efficient design and implementation of sustainable prevention and control strategies. previous study conducted in delhi, india, identified that household chemicals followed by drugs, agricultural pesticides, and industrial chemicals were the major agents of poisoning.8 the objective of this study was to understand the trend of the poisoning cases arising from human exposure to different poisons, including pesticides, during 2015-2017 to inform preventive measures that may help to reduce future incidence of poisoning cases. the article describes the trend of poisoning cases reported to a poison information center at ahmedabad, gujarat between 2015 and 2017. methods fatality rate due to poisoning in order to understand the annual mortality trend due to poisoning, the rate of fatality due to poisoning was obtained. it was calculated from the number of fatalities due to poisoning and the total number of poisoning cases reported. collection of epidemiological data a detailed history of poisoning cases was taken for each of the poisoning cases reported to the poison information center from january 1, 2015 to december 31, 2017. the ethical committee approval was obtained from institutional ethics committee at the national institute of occupational health, ahmedabad, gujarat, india. informed oral consent was obtained from each patient and/or their guardians for the use of their data in this research. the proforma for patient history included patients’ personal data such as age, sex, marital status, education and geographical area of residence. occupation of the patient was noted to identify any occupational exposures. the poison severity score (none, minor, moderate or severe) as per persson et al., 19989 was documented at the time of admission to the hospital and was obtained for this study. efforts were taken to document information on the chemical involved in the poison. other information like chronicity of poisoning, route of poisoning, such as oral, inhalation, dermal exposure, etc. were obtained from the attending physician. information such as the consciousness of the patient at the time of admission, as well as requirement of ventilator support, were also documented for each patient. pagdhune this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.471 | http://cajgh.pitt.edu estimation of cholinesterase activity cholinesterase activity was used as the diagnostic tool for acute organophosphorus poisoning. plasma and/or rbc cholinesterase activity was measured using modified ellman’s spectrophotometric method.10 briefly, plasma was added and mixed with 5,5’-dithiobis(2-nitrobenzoic acid) reagent (sigma) and acetyl thiocholine substrate (sigma) was added to the mixture. the yellow color developed was measured at 410nm using a spectrophotometer (cary 100 bio, varian), and cholinesterase activity was expressed in units per liter of plasma. the value of cholinesterase activity was then compared with biological reference range generated inhouse. detection of sanguinarine sanguinarine in urine samples of poisoning cases were detected by hptlc method according to methodology published by shenolikar et al.11 briefly, sanguinarine in urine samples was extracted with 1% acetic acid in chloroform and spotted onto tlc plates (sigma) along with standard and developed with butanolacetic acid-water in the ratio 63:10:27 by volume. the plates were then observed under ultraviolet light and the golden-yellow fluorescent band in line with standard sanguinarine spot was identified and evaluated as sanguinarine in the sample. statistical analysis non-parametric tests such as chi-square test and mann-whitney u test were applied to test statistical significance between the groups. all statistical tests were carried out at 5% level of significance. all statistical analyses were carried out using ibm spss statistics for windows, version 26.0. armonk, ny: ibm corp. results a total of 1373 poisoning cases was reported to the poison information center, with the highest number in the year 2016 (480 cases). although the fatality rate due to poisoning in ahmedabad showed an increasing trend annually (table 1), it was not statistically significant. the male to female ratio was 1.4, 1.8 and 2.7 in the years 2015, 2016 and 2017, respectively, indicating the increasing trend of incidence of poisoning in males. also, the fatality rate was significantly high in males compared to females. the distribution of poisoning cases with respect to the age of patients12 represented as young (age ≤35 years), middle age (36-55 years) and older (age ≥56) are shown in figure 1a. 2015 2016 2017 total number of cases 447 480 446 1373 males 262 310 326 898 females 185 169 120 474 third gender 0 1 0 1 male to female ratio 1.42 1.83 2.72 1.89 number of fatalities 27 42 43 112 number of fatalities (male) 19 30 36 85* number of fatalities (female) 8 12 6 26 percentage of fatal rate 6.04% 8.75% 9.64% 8.15% *significant at p-value 0.10 table 1. data on poisoning cases reported to poison information center pagdhune this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.471 | http://cajgh.pitt.edu the highest level of incidence was observed in the younger age group. figure 1b shows the education status of the patients. the educational status of 136 patients was not known. the trend was similar in all the three years of the study. the poison severity score at the time of admission to the hospitals revealed that 338 cases were severe (24.61%), while 51.42% cases were of moderate severity. figure 2a shows the three-year trend of severity at admission, indicating similar trends in these three years. during the course of treatment, 289 (21.04%) poisoning cases required ventilator support. a total of 47 patients suffered from limb paralysis due to poisoning during this time period. the route of exposure was oral in the majority of the cases with 89.5%, 91.6% and 93.7% cases reported in the years 2015, 2016 and 2017, respectively. a total of 23 poisoning cases were reported due to poisoning through inhalation of toxic agent. four cases of poisoning through dermal exposure were also documented. figure 2b illustrates the trend of various chemical agents used for poisoning. the trend was similar in all three years, except the occurrence of seven edema cases due to contaminated edible oil in the year 2015, followed by one case in 2016. there were no edema cases reported in the year 2017. the chemical nature of the poison was not known to the investigators in 52.5% of the cases. agricultural insecticides were found in 26.29% cases, followed by household chemicals like phenyl, rodenticides, mosquito repellents and bleaching powder, together comprising about 12.31% of the poisoning cases. the trend in relation to circumstances of poisoning cases reported is shown in figure 3a. most of the cases were suicidal in nature (73.4%, 75.2% and 88.8% in the years 2015, 2016 and 2017, respectively) with intentional oral intake of poison at home. agricultural chemicals stored in home were found to be the poisoning agent in 28.18% of the suicide cases. figure 1. the pie chart shows the number of poisoning incidences in young, middle and older aged subjects (a) and educational status of the patients (b) between 2015 and 2017. pagdhune this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.471 | http://cajgh.pitt.edu figure 2. the annual trend of poisoning cases in relation to the severity of cases at the time of admission to hospital (a) and the agents involved in poisoning (b) between 2015 and 2017. chemical agents included acephate, phorate, adrin, carbofuran, celphos, chlorophos, chorpyriphos, cypermethrin, ddt, gamexin, dimethoate, imidochloprid, malathion and monocrotophos. the list also includes some insecticides with local trade names whose chemical composition was not clear. analysis of cholinesterase activity in these patients revealed 571 (52.57%) cases with reduced plasma cholinesterase activity and 428 (39.41%) cases with reduced rbc cholinesterase activity, indicating the widespread use of organophosphorus chemicals for intentional poisoning. plasma/serum cholinesterase activity and rbc cholinesterase activity reduced in 49.67% and 41.29% of all the cases. the cholinesterase values of poisoning cases due to agricultural pesticides were significantly lower than that of poisoning due to causes other than agricultural pesticides (p value <0.05) as shown in figure 3b. thirteen cases were homicidal in nature (1, 10 and 2 cases in the year 2015, 2016 and 2017, respectively). six of them had reduced rbc cholinesterase activity with normal level of plasma cholinesterase activity, and another 2 cases had very low level of plasma cholinesterase activity. about 55 cases of food poisoning and 35 cases of accidental poisoning were recorded in the study period. the number of food poisoning cases showed a decreasing trend with 38, 16 and 1 cases in the year 2015, 2016 and 2017, respectively. paralysis of both limbs of the patients were present in 18 food poisoning cases reported in 2015. among these, eight were suspected cases of argemonium oil consumption, and hptlc analysis of urine sample of the patients revealed the presence of sanguinarine in three cases. about 38.18% of the food poisoning cases showed reduction in the plasma cholinesterase activity, and 65.45% showed reduced rbc cholinesterase activity. pagdhune this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.471 | http://cajgh.pitt.edu figure 3. the trend of poisoning 2015-2017 in relation to the circumstances of poisoning (a), the box plot showing plasma cholinesterase activity in victims of poisoning due to agricultural pesticides in comparison to other known causes (b), and the occupation of patients (c). pagdhune this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.471 | http://cajgh.pitt.edu fourteen cases were associated with the abuse of toxic substances. four of them were with bhang, a locally available cannabinoid substance, and one case with locally made alcohol. three of these patients showed reduced plasma/rbc cholinesterase activity indicating the possibility of organophosphorus poisoning. twenty-eight cases were reported with poisoning related to occupational exposures. all of these were acute poisoning cases, out of which 16 cases were from inhalation of toxicant, and 11 cases were oral poisoning cases. at least 21 of them had reduced plasma cholinesterase activity, and 15 cases had reduced rbc cholinesterase activity, indicative of organophosphorus poisoning in occupational settings. figure 3c shows the trend of poisoning with respect to the occupation of patients. in all three years, housemakers constituted the highest number of poisoning cases (21.2%), followed by laborers (11.2%), agricultural workers (11.0%) and industrial workers (7.7%). the number of industrial workers exposed to poison at workplace was 19, 29 and 56 in the years 2015, 2016 and 2017, respectively. discussion this study presents the trend of poisoning cases reported to poison information center, ahmedabad from 2015 through 2017. the fatality rate due to poisoning was found to be similar from 2015 to 2017, underlining the importance of poisoning as a public health concern. this rate may be an underestimate because of under-reporting of deaths due to poisoning. the incidence and fatality due to poisoning was higher in males. a similar study conducted in a tertiary hospital in karnataka state, india also reported higher incidence (75.4%) of poisoning among males compared to females.13 however, there are studies that reported higher incidence in females14 , as well as comparable incidence in males and females.15 this might be attributed to the difference in the cultural, lifestyle, occupational and socioeconomic nature of the population studied. in the present study, 11.07% of the population comprised of agricultural workers, and in 26.29% of the reported cases, the poisoning was associated with insecticides used in the agriculture sector. this is a matter of concern, especially in the context of recent reports of fatal occupational poisoning of 45 agricultural workers in the bt-cotton plantations of maharashtra state.16 a similar method of cotton cultivation is being practiced in gujarat too.17 though bt-cotton plants are supposed to be resistant to insect cotton ballworms, new reports are suggestive of development of resistance in ballworms.18 this leads to heavy insecticide use in bt-cotton plantations and results in occupational poisoning in agricultural workers, as well as higher incidence of suicide. a notable study among 127 acute poisoning cases in maharashtra reported 48.8% cases in agriculture workers.19 the cause of higher incidence of poisoning cases among farmers of vidarbha region of maharashtra was identified as a complex interplay of social, political and environmental factors. relief packages, as well as implementation of mental health programs at the regional level to offer support and counselling to vulnerable population, may prevent the incidence of poisoning cases in future.20 similarly, the use of personal protective equipment and safety guidelines in the use of pesticides may also aid in reducing the occupational poisoning, especially in workers who spray the insecticide solution. proper training in integrated pest management has been proven as an effective strategy in reducing the number of poisoning cases in farm workers of south india.21 organophosphorus pesticides are the most common cause of poisoning in agricultural workers and other unskilled workers.22 currently, cholinesterase activity in serum/plasma/rbc is used as most reliable tests for organophosphorus poisoning.23 this study revealed reduced cholinesterase activity in plasma of victims exposed to agricultural pesticides compared to cases due to other means of poisoning, emphasizing the central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.471 | http://cajgh.pitt.edu prevalence of poisoning with pesticides such as organophosphorus chemicals/carbamates in the community. this observation warrants the need for replacing highly poisonous organophosphorus chemicals with less toxic chemicals. we would also like to emphasize the need to regulate the supply of toxic chemicals, implementation of usage guidelines, and banning of highly toxic pesticides. poisoning with alcohol is relatively low in gujarat.24 in this study, we came across 11 alcohol poisoning cases, which comprised only 0.80% of total poisoning cases reported. this could be the result of bombay prohibition bill passed in 1949 and subsequent amendments by the state government, according to which liquor is prohibited by law in gujarat state.25 however, previous studies on the drunkenness at ahmedabad civil hospital have reported some episodes of alcohol poisoning, and the alcohol prohibition by law did not necessarily change the behavior of people towards the usage of alcohol.24 eight cases of poisoning through contaminated edible oil was reported. out of this, the presence of sanguinarine, a toxic alkaloid present in argemone mexicana seeds was detected in the urine of three patients, suggestive of edema (epidemic dropsy), in the year 2015. edema usually occurs in the form of an epidemic affecting a population that consume edible oil adulterated with argemone mexicana oil.26 in the year 2012, thirteen cases of edema were reported from panchmahal district of gujarat.27 hence, even though a small incidence of the disease was reported to the poison information center in the year 2015, the data points towards the need of active toxicovigilance and anti-food adulteration activities. moreover, the toxicology laboratories have to be strengthened for timely detection and diagnosis of edema in future. household chemicals like insecticides, rodenticides, phenyl, bleaching powder and mosquito repellents constituted 12.31% of the poisoning cases. previous studies also reported a higher incidence (44%) of poisoning due to such household chemicals.8 this difference in the trend of poisoning might be attributed to the differences in the culture, education status and availability of other toxicants for suicide purpose. the probability of poisoning is inversely proportional to the education level.28 the education status of patients in this study also showed that the poisoning incidence is high among the uneducated or less educated population (figure 1b). therefore, increasing the awareness on poisonous substances may be effective in reducing the number of poisoning cases in future. according to who, pesticide poisoning accounts for the most of the global suicides, and the majority of them occur in lower and middle income countries.29 the present study also shows that agriculture pesticides are the major means of poisoning and related fatality. a multifaceted approach with legislation to ban highly toxic pesticides, improvements in medical management of poisoning cases, awareness and storage guidelines may help to reduce the incidence of poisoning, as found effective in srilanka.30 more effective toxicovigilance by the regulatory agencies also can contribute to bring down the poisoning cases to minimum level.31 the limitation of this study is that it is possible that not all poisoning cases have been reported to the center. the availability and nature of particular antidotes were also not documented in this study. these are very important for assessment of health resources required to deal with poisoning cases in a particular region. therefore, strengthening the reporting procedures of poisoning cases to the poison information center and special attention to availability of antidotes is an important aspect of future work in this important area. poisonings with toxic chemicals continue to be a major health concern in gujarat, and poison information centers play a crucial role in reducing the rate of poisoning. the data presented in this paper suggest that pesticides used in agriculture were a major source of poisoning between 2015 and 2017. highly toxic pagdhune this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.471 | http://cajgh.pitt.edu chemicals used in agriculture should be either banned or given to farmers with strict usage guidelines and documentation explaining the risks involved. most of the poisoning cases reported here were suicidal in nature, indicating the need for effective measures to prevent the suicidal tendency and improve psychological health in the community. the epidemiological trend of poisoning cases presented in this paper may be helpful in reducing the incidence of poisoning cases in future. references 1. mew ej, padmanathan p, konradsen f, et al. the global burden of fatal self-poisoning with pesticides 2006-15: systematic review. j affect disord. 2017;219(supplement c):93-104. 2. national crime records bureau: accidental deaths and suicides in india in: affairs moh, ed. new dehi: govt. of india; 2014. 3. patel v, ramasundarahettige c, vijayakumar l, et al. suicide mortality in india: a nationally representative survey. lancet. 2012;379(9834):2343-2351. 4. national crime records bureau: accidental deaths and suicides in india in: affairs moh, ed. new dehi: govt. of india; 2015. 5. who. the ipcs intox programme: international programme on chemical safety. world health organization. http://www.who.int/ipcs/poisons/intox/en/. accessed september 2020. 6. central insecticide board & registration committee. department of agriculture and cooperation. http://ppqs.gov.in/divisions/cib-rc/aboutcibrc. accessed september 2020. 7. pate rs, rojekar mv, hire rc. trends of poisoning cases in tertiary care teaching hospitals in western indian population. international journal of medical toxicology and forensic medicine. 2017;7(3). 8. srivastava a, peshin ss, kaleekal t, gupta sk. an epidemiological study of poisoning cases reported to the national poisons information centre, all india institute of medical sciences, new delhi. hum exp toxicol. 2005;24(6):279-285. 9. persson he, sjoberg gk, haines ja, pronczuk de garbino j. poisoning severity score. grading of acute poisoning. j toxicol clin toxicol. 1998;36(3):205-213. 10. ellman gl, courtney kd, andres v, featherstone rm. a new and rapid colorimetric determination of acetylcholinesterase activity. biochem pharmacol. 1961;7(2):88-95. 11. shenolikar is, rukmini c, krisnamachari kavr, satayanarayana k. sanguinarine in the blood and urine of cases of epidemic dropsy. food cosmet toxicol. 1974;12(5):699-702. 12. petry nm. a comparison of young, middle-aged, and older adult treatment-seeking pathological gamblers. gerontologist. 2002;42(1):92-99. 13. ramesha kn, rao kbh, kumar gs. pattern and outcome of acute poisoning cases in a tertiary care hospital in karnataka, india. indian j crit care med. 2009;13(3):152-155. 14. adinew gm, woredekal at, devos el, birru em, abdulwahib mb. poisoning cases and their management in emergency centres of government hospitals in northwest ethiopia. afr j emerg med. 2017;7(2):74-78. 15. patil a, peddawad r, chandra v, verma s, gandhi h. profile of acute poisoning cases treated in a tertiary care hospital: a study in navi mumbai. asia pacific journal of medical toxicology. 2014;3(1):3640. 16. maitra p. 46 dead in vidarbha pesticide poisoning, 12 godowns raided. hindustan times. 11-10-2017, 2017. 17. gandhi vp, jain d. cotton cultivation in gujarat. in: gandhi vp, jain d, eds. introduction of biotechnology in india’s agriculture: impact, performance and economics. singapore: springer singapore; 2016:131-149. 18. wan p, xu d, cong s, et al. hybridizing transgenic bt cotton with non-bt cotton counters resistance in pink bollworm. proc natl acad sci u s a. 2017;114(21):5413-5418. central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by the university library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 9, no. 1 (2020) | issn 2166-7403 (online) | doi 10.5195/cajgh.2020.471 | http://cajgh.pitt.edu 19. ranjit t, sandeep k, vl d, dilip w. study of acute poisoning cases at rural tertiary care hospital in ahmednagar, maharashtra. medico-legal update. 2016;16(2). 20. dongre ar, deshmukh pr. farmers’ suicides in the vidarbha region of maharashtra, india: a qualitative exploration of their causes. journal of injury and violence research. 2012;4(1):2-6. 21. mancini f, jiggins jl, o'malley m. reducing the incidence of acute pesticide poisoning by educating farmers on integrated pest management in south india. int j occup environ health. 2009;15(2):143-151. 22. raddi d, anikethana gv. clinical profile of organophosphorus poisoning in a tertiary care hospital. indian journal of basic and applied medical research. 2014;4:14-22. 23. strelitz j, engel ls, keifer mc. blood acetylcholinesterase and butyrylcholinesterase as biomarkers of cholinesterase depression among pesticide handlers. occup environ med. 2014;71(12):842-847. 24. jigesh s, gaurang p, dharmesh p, divyesh g, rajesh j, sanjay j. study of drunkenness at civil hospital, sola, ahmedabad. journal of indian academy of forensic medicine. 2013;35(3):255-258. 25. bombay prohibition bill. http://www.prohibitionexcise.gujarat.gov.in/pne/cms.aspx?content_id=152. published 2016. updated 01/01/2016. accessed september 2020. 26. lakshmi pvm, sharma a, bhatia d, tikoo k, kumar r. dropsy outbreak in a single family in punjab, india. am j trop med hyg. 2014;91(4):786789. 27. patel a, kausadikar s, nakum r, baxi r, patel j. outbreak investigation of epidemic dropsy in panchmahal district of gujarat, 2012. int j med sci public health. 2013;2(4):1006-1010. 28. hossain f, pray ce, lu y, huang j, fan c, hu r. genetically modified cotton and farmers' health in china. int j occup environ health. 2004;10(3):296303. 29. who. preventing suicide. in: a global imperative. in. geneva: world health organization; 2014. 30. knipe dw, gunnell d, eddleston m. preventing deaths from pesticide self-poisoning&#x2014;learning from sri lanka's success. the lancet global health. 2017;5(7):e651-e652. 31. sharma s, dewan a, singh g. toxico-vigilance – an inevitable prerequisite to keep a watch on toxins around you. j forensic leg med. 2017;45(supplement c):32-35. cajgh_template new articles in this journal are licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. discovery of actinomycetes from extreme environments with potential to produce novel antibiotics lyudmila trenozhnikova1, azliyati azizan2 1institute of microbiology and virology, almaty, kazakhstan; 2nazarbayev university school of medicine, astana, kazakhstan vol. 7, no. 1 (2018) | issn 2166-7403 (online) doi 10.5195/cajgh.2018.337 | http://cajgh.pitt.edu http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx http://creativecommons.org/licenses/by/3.0/us/ trenozhnikova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu abstract introduction: antimicrobial-resistant pathogens pose serious challenges to healthcare institutions and health of the public. thus, there is an urgent need for the discovery of new and effective antimicrobial agents. microorganisms that exist in extreme environments such as those with high salinity or alkalinity, are known as extremophiles, and include various species of actinomycetes. the goal of this study is to discover novel antibiotics from extremophiles found in kazakhstan that are effective against drug resistant pathogens. methods: soil from extreme environments of kazakhstan was collected, and pure cultures of actinomycetes were isolated and cultured in modified bennett’s broth with either high concentrations of salt or high ph to mimic extreme environments. extracts obtained from selected actinomycetes strains were used to test for antimicrobial activity against staphylococcus aureus, escherichia coli and aspergillus niger. results: a total of 5936 strains of extremophile actinomycetes were isolated; from these, 2019 strains were further isolated into pure cultures. of these, 415 actinomycetes strains that demonstrated antagonistic antibacterial activities were selected. these actinomycetes were further classified into groups and subgroups based on their responses to different culture conditions. antimicrobial antagonism activity for some of the actinomycetes strains was dependent on culture conditions and development of aerial mycelia under extreme conditions. conclusion: we identified several interesting candidate extracts with putative antimicrobial activities against several strains of drug resistant pathogens. our research of the actinomycetes’ ability to produce antibiotics in the near-natural conditions provides a great opportunity to assess their biodiversity and distribution in the central asian region and to develop new methodological approaches to the screening of new antimicrobial agents. keywords: extremophiles, actinomycetes, antibiotics, natural products, pathogens, antibiotic resistance discovery of actinomycetes from extreme environments with potential to produce novel antibiotics lyudmila trenozhnikova1, azliyati azizan2 1institute of microbiology and virology, almaty, kazakhstan; 2nazarbayev university school of medicine, astana, kazakhstan research introduction although antibiotics have saved millions of lives over the past 70 years, their indiscriminate use has led to the emergence of antibiotic-resistant organisms. this concerns many medical experts who caution that we may soon return to the pre-antibiotic era1,2. actinomycetes, which occur in both terrestrial and aquatic habitats, are among the most common groups of gram-positive microorganisms in nature. actinomycetes decompose organic matter and display antagonism against other bacteria and fungi, with which they compete for nutrients. actinomycetes have incredible abilities to survive under extreme conditions in their natural environment and have long been the focus http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu of scholarly attention and have been harnessed as valuable sources of natural compounds, such as antibiotics, enzymes, and vitamins. more than 90 percent of chemotherapeutic antibiotics have been isolated from actinomycetes3-5. the large-scale screening of antagonistic actinomycetes under neutral conditions (with a ph of 7.0 and no addition of salt [nacl, na2co3] to the growth media) has led to the discovery of virtually all modern medical antibiotics1,2. during screening, the strains of actinomycetes that did not show activity in neutral environments were likely disregarded. microorganisms that produce antimicrobials under extreme growth conditions may have gone undetected while being screened under neutral growth conditions, preventing the discovery of potentially valuable novel compounds from these strains. advances in pcr technology have revealed that actinomycetes do not always exhibit antagonistic properties when cultivated in vitro despite the presence of genes that are involved in antibiotic synthesis in the genome of the strain. this suggested that dormant genes may be present but not expressed. certain natural conditions may exist under which these genes are expressed, and identification of these conditions is important when screening for the new natural antibiotic substances. modern screening programs should take into account the relevant characteristics of the actinomycetes and should also include alternative conditions for antibiotic isolation. to that end, we undertook a study utilizing an alternative method of screening to enhance the chances of discovering unique bacterial strains from the environment that are potentially producing novel antibiotics for therapeutic use. this study focuses on actinomycetes strains isolated from the extreme habitats of kazakhstan. we investigated the characteristics of actinomycetes in the three most commonly occurring natural habitats/conditions (which are neutral, saline, and alkaline). we believe that this approach, which is different than the conventional screening methodology, enhances the chance of identifying actinomycetes strains from extreme environments that harbor the potential to produce novel antimicrobial agents. kazakhstan possesses unique natural resources that can be sources of promising and novel biologically-active substances with antibiotic properties. soil and water resources of the republic of kazakhstan provide a great variety of natural habitats for extremophilic microorganisms (such as solonchaks, solonetzes, and saline takyrs). these habitats differ both in morphological features and salinization (chloride, sulfate, soda, and mixed). the water resources of kazakhstan present a wide variety of habitats for extremophiles; this includes the caspian sea, the aral sea, balkhash lake, and numerous saline lakes in which water salinity can reach up to 335 g/l. the area of saline soils in kazakhstan (including solonetzes, alkaline soils and combinations with other soils) is 111.55 million hectares (0.4307 million square miles), or 41% of the entire territory of the country (1.052 million square miles)6. most of these areas are marked by natural mineralization due to the presence of marine sediments. overall, research on extremophilic microorganisms in kazakhstan has been limited. the goal of this publication is to describe the process of screening for antagonistic activity against drug-resistant pathogens and characterize actinomycetes strains which are the potential producers of novel antibiotics. materials and methods sampling sites and collection of soils natural substrate samples (soils, muds, and rhizosphere) were collected from the extreme habitats of northern (kostanay region, auliekol and mendykara district) and southern (almaty region, balkhash district) kazakhstan during several field trips in summer 20102011 (fig. 1a). the soil samples collected were of the solonchaks, solonetz and takyr types. solonchaks are strongly saline soils, which are usually light colored and http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx trenozhnikova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu are typically developed in poorly drained arid or semiarid areas vegetated mostly by halophytes7. solonetz are soils with a high content of exchangeable sodium and/or magnesium ions8. takyr is usually formed in a shallow, depressed area with a heavy clay soil which is submerged by water after seasonal rains; after the water evaporates, a dried crust with fissures forms on the surface9. the soil samples were collected at the depth of 10 cm (~4 inches). the samples were packed in sterile plastic containers, transported to the laboratory, and refrigerated at 4°c (39°f) until ready for analysis. natural substrate samples (soils, muds, and rhizosphere) were collected from the extreme habitats of northern and southern kazakhstan during several field trips in the summer of 2010-2011. figure 1a. map of field trips collecting soil samples we chose the most common factors in nature, which are sodium chloride and ph, and grew the same actinomycetes in different growth media to mimic the natural environment of extremophiles. the conditions these organisms were originally isolated from are neutral, saline, and alkaline environments. strains of actinomycetes from extreme environments of kazakhstan were cultured in neutral and alternative (saline and alkaline) conditions and their antimicrobial and morphogenetic properties were studied. saline and alkaline conditions were created by using inorganic salts (nacl, na2co3) and рн modulation. isolation and maintenance of actinomycetes soil samples were plated following the standard microbiological dilution plating method. actinomycetes samples were isolated on two variants of modified bennett’s agar: glucose (0.2%), peptone (0.2%), yeast extract (0.1%), and agar (2.0%) with 5% nacl, рн 7,2 (variant #1) or with 0.5% na2co3, рн 9.0 (variant #2). the medium was adjusted with naoh to ph 9.0 after sterilization. the plates prepared with variants of modified bennett’s agar were incubated at 28°c and examined for growth after 1-2 weeks of incubation. the colonies with different cultural-morphological characteristics were inoculated from the variants of modified bennett’s agar (variant #1 and variant #2) into slants with the same variants of the medium. the purity of isolated strains was confirmed by standard microbiological methodologies whereby strains were isolated in pure cultures from http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu separately growing colonies obtained from plates seeded with soil samples. each colony was further tested by screening on specific agar growth media as described. purified isolates were maintained on the variants of modified bennett’s agar slants at 4°c for further antagonism tests and morphogenesis investigation. the percent of the total number of strains isolated in the relevant region was determined. in vitro antimicrobial assay actinomycetes isolates were tested for their antagonistic activity against the selected microorganisms by the disc diffusion agar method10. the first stage of screening: the isolates were cultured on the variants of modified bennett’s agar (#1 or # 2) for 10 days at 28°c. agar discs (7 mm) were cut by a cork borer and transferred to the surface of agar plates, previously inoculated with bacterial test organisms (hospital strain mrsa # 3316). the petri dishes were kept in a refrigerator for 3 hours before incubation to permit the diffusion of antimicrobial substances. the diameters of the inhibition zones were measured after incubation for 24 hours at 37°c. the second stage of screening: the isolates with antagonistic properties, selected based on the results of the first screening stage, were cultured on three variants of modified bennett’s agar (#1-3) for 10 days at 28°c. variant # 3 of modified bennett’s agar corresponded to a neutral habitat: glucose (0.2%), peptone (0.2%), yeast extract (0.1%), and agar (2.0%) at рн 7.2. agar discs (7 mm) were cut off by a cork borer and transferred to the surface of agar plates, previously inoculated with the test organism (mrsa # 3316, escherichia coli pmg223, and aspergillus niger). the petri dishes were kept in a refrigerator for 3 hours before incubation to permit the diffusion of antimicrobial substances. the diameters of inhibition zones were measured after incubation for 24 hours at 37°c for bacteria and for 72 hours at 28°c for fungi. each test was repeated three times and the activity was expressed as the mean diameter of the inhibition zones (mm). study of morphogenesis the degree of aerial mycelium development in isolates of actinomycetes was studied visually on three variants of modified bennett’s agar (#1-3). bacterial and fungal pathogens the following bacterial strains were used in this study as testers for the antimicrobial activity of the isolated actinomycetes strains: hospital strain mrsa # 3316, escherichia coli (pmg223) and aspergillus niger (wildtype isolate). results in northern kazakhstan (kustanai region), samples were collected from the soils of the steppe and forest zones, sor solonchaks (non-perennial salt lakes in the area of aman-karagai forest), solods, solonets (steppe and meadow), rhizospheres of plants from halophytic meadows, and muds from the salt lakes (fig. 1b). in southern kazakhstan (almaty region), samples were collected from the soils of the arid zone, typical meadows and sor solonchaks, salinized takyrs, takyr-like salinized soils, and rhizospheres of the arid zone plants (fig 1c). we collected 36 samples of natural substrates from extreme ecosystems in northern kazakhstan and 50 samples from extreme ecosystems in southern kazakhstan. we identified a link between the ability of actinomycetes to grow under conditions reflective of three habitats, the ability to antagonize in each of these conditions, and the ability to form aerial mycelia. in the course of our research, we focused on three main types of ecological niches: neutral habitats (рн 7.0), saline habitats (рн 7.0), and alkaline habitats (рн 9.0). a total number of 5936 actinomycetes strains were isolated on the two variants of modified bennett’s http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx trenozhnikova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu figure 1b. the unusual ecosystem of northern kazakhstan. in northern kazakhstan (kustanai region), samples were collected from the soils of the steppe and forest zones, sor solonchaks (non-perennial salts lakes in the area of aman-karagai forest), solods, solonets soils (steppe and meadow), rhizospheres of plants from halophytic meadows, and muds from the salt lakes. figure 1c. the unusual ecosystem of southern kazakhstan. in southern kazakhstan (almaty region), samples were collected from the soils of the arid zone, typical meadows and sor solonchaks, salinized takyrs, takyr-like salinized soils, and rhizospheres of the arid zone plants. agar; from these, 2019 strains of extremophile actinomycetes grew in media #1 and #2 and differed in cultural-morphological characteristics. these strains were further isolated in pure cultures (756 strains from northern kazakhstan and 1263 strains from southern kazakhstan). the actinomycetes from the extreme environments of kazakhstan were analyzed based on their ability to show antagonism against mrsa in saline or alkaline conditions. a total 415 strains with antagonistic properties were selected: 127 strains from northern kazakhstan and 288 strains from southern kazakhstan. these strains showed antagonistic properties against bacterial pathogens when grown under extreme conditions in media # 1 and #2. 100 percent of these 415 strains showed antagonism against clinical mrsa # 3316, 21.6 percent against e. coli (pmg223), and 28.4 percent against a. niger. the correlation of the changes in growth, morphogenesis, and antagonism of 415 strains of extremophile actinomycetes was determined under three conditions, modeling the most common natural habitats: neutral, saline, and alkaline. the actinomycetes were further classified into groups, subgroups, and variants (table 1) based on their ability to antagonize (exhibiting antimicrobial activities of test organisms mrsa, e. coli and a. niger) in all three habitats (subgroup ia), only two habitats (subgroup ib), or only one habitat (subgroup ic). subgroups iia showed growth in neutral and saline conditions, iib showed growth in neutral and alkaline conditions, and iiс showed growth in saline and alkaline conditions. in each group, we established the following subgroups. three subgroups were identified in group i: iа, ib, and ic (fig. 2). the subgroups of i are as follows; iа subgroup – actinomycetes that show antagonism in three conditions (neutral, saline and alkaline): ib subgroup – actinomycetes that show antagonism in two http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu conditions: iba – antagonism in neutral and saline conditions: ibb – antagonism in neutral and alkaline conditions: ibс – antagonism in saline and alkaline conditions: ic subgroup – actinomycetes that show antagonism in one medium: ica antagonism in neutral conditions: icb – antagonism in saline conditions, and icс – antagonism in alkaline conditions. two subgroups were identified in group ii: iia and iib. the subgroups of group ii are as follows; iia subgroup – actinomycetes that show antagonism in two media: iiaа – antagonism in neutral and saline conditions: iiab – antagonism in neutral and alkaline conditions, and iiaс – antagonism in saline and alkaline conditions: iib subgroup – actinomycetes that show antagonism in one medium: iiba – antagonism in neutral conditions, iibв – antagonism in saline conditions, iibс – antagonism in alkaline conditions. in summary, the groups of actinomycetes differ from one another in their ability to grow in different habitats, which are neutral, saline and alkaline. we define subgroups by the ability to produce antibiotics, or they may lose this ability to produce antibiotics in these specific habitats (neutral, saline or alkaline). the magnitude of the inhibition zone was determined by us, but for this study, only the presence or total absence of antibiotic production was important for the classification of actinomycetes that we identified in this study. since it was important to determine the conditions under which antibiotic production is possible for each of the producer organisms, the strains were classified into these specific groups, subgroups and variants. table 2 summarizes the data on the quantitative content of actinomycetes-antagonists of different group i subgroups in conditions mirroring those of southern and northern kazakhstan. the data on the actinomycetes of subgroup ii is not discussed here, as the group did not have a sufficient size to be represented accurately. we observed differences in the occurrence of group i antagonists in the natural substrates of the southern and northern kazakhstan. the antagonism against gram-positive bacteria in both researched regions is characterized by the predominance of subgroup ia (55.4 – 72.3%); subgroup ib was less common (21.0 – 34.0%), while subgroup ic had the smallest amount of antibacterial activity against gram-positive bacteria (6.7 10.6%). the antagonism against gram-negative bacteria and mycelial fungi also varied by region. in southern kazakhstan, the subgroup ia prevailed (41.2 – 41.4%), while the subgroups ib and ic occurred less commonly. in northern kazakhstan, the antagonism against gramnegative bacteria was characterized by the predominance of the subgroups ia (41.7%) and ic (38.9%). the antagonism against mycelial fungi in the researched substrates of northern kazakhstan is characterized by the predominance of the subgroup ib (40.7%), while in southern kazakhstan, subgroup ia predominates (41.4%). our studies of the dependence of antagonism on the degree of development of the aerial mycelium of actinomycetes under extreme conditions show that actinomycetes can be represented by the two main variants, which we designated as f and q (table 3) whereby “f” represents the “fighters” and “q” represents the “quitters” which we describe further below. the variant q is represented by the actinomycetes whose antagonism is associated with good growth and abundant development of the aerial mycelium. reduction of sporulation leads to a decrease in the production of antibiotics, and absence of aerial mycelium to the loss of this ability. the variant f is represented by the actinomycetes that exhibit antagonistic properties only in the conditions when the formation of aerial mycelium is inhibited, and its absence is associated with the maximum formation of antibiotics. the actinomycetes from the extreme environments of kazakhstan were analyzed based on http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx trenozhnikova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu table 1. classification of actinomycetes based on their ability to grow under different conditions group of actinomycetes growth in neutral habitat growth in saline habitat growth in alkaline habitat i (all habitats) + + + ii (two habitats) iia + + iib + + iic + + + means growth; means no growth table 2. the quantitative content of group i antagonists in the extreme ecosystems of kazakhstan subgroups of actinomycetes quantitative content of antagonists, %1 antibacterial activity (gram-positive bacteria, s. aureus) antibacterial activity (gram-negative bacteria, е. coli) antifungal activity (a. niger) 2southern kazakhstan n = a n = b n = c subgroup ia 55.4 41.2 41.4 subgroup iв 34 37.3 29.3 subgroup iс 10.6 21.5 29.3 3northern kazakhstan n’ = x n’ = y n’ = z subgroup ia 72.3 41.7 29.6 subgroup iв 21 19.4 40.7 subgroup iс 6.7 38.9 25.9 1note – total activity for the three subgroups ia, ib, and ic add up to 100%, for each kind of antibacterial or antifungal activity tested. 2note-total number (n) of actinomycetes strains from southern kazakhstan tested was 1,263. 3note-total number (n) of actinomycetes strains from northern kazakhstan tested was 756. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu table 3. the quantitative content of variants of actinomycetes in the extreme ecosystems of kazakhstan type of soil variants of actinomycetes variant f1 variant q2 solonchaks 67.2 32.8 takyr-like salinized soils 56.7 43.3 salinized takyrs 51.8 48.2 solonets soils 50.4 49.6 solods 75.0 25.0 total 60.2 39.8 1f (“fighters”) – antagonism in the absence of aerial growth (i.e., when they are fighting to survive); 2q (“quitters”) – antagonism associated with good aerial growth (i.e., quit producing antibiotics when growth is poor) figure 2. the classification of actinomycetes from extreme ecosystems into groups and subgroups group ia antagonism in three habitats (neutral, saline and alkaline) subgroup ibа antagonism in neutral and saline habitats http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx trenozhnikova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu subgroup ibb antagonism in neutral and alkaline habitats subgroup ibс antagonism in saline and alkaline habitats subgroup icb antagonism in saline habitat http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu subgroup icc antagonism in alkaline habitat their ability to show antagonism against mrsa in saline or alkaline conditions. the isolates with antagonistic properties, selected based on the results of the first screening stage, were cultured on three variants of modified bennett’s agar (#1-3) for 10 days at 28°c. variant #1 mimics a saline habitat, while variant # 2 mimics an alkaline habitat and variant # 3 mimic neutral habitats. agar discs (7 mm) were cut by a cork borer and transferred to the surface of agar plates, previously inoculated with the test organism (mrsa # 3316, escherichia coli pmg223, and aspergillus niger). the diameter of inhibition zones was measured after incubation for 24 hours at 37°c. each test was repeated three times and the activity was expressed as the mean of diameter of the inhibition zones (mm). the actinomycetes were classified into these groups; i (growth in all three habitats) and ii (growth in two habitats). the actinomycetes group i, showing the ability to grow in all researched habitats, had a greater variability of antagonistic properties. these actinomycetes groups were further classified into subgroups based on their ability to antagonize in the saline, alkaline and neutral habitats. group ia antagonism in three habitats (neutral, saline and alkaline). subgroup ibа antagonism in neutral and saline habitats. subgroup ibb antagonism in neutral and alkaline habitats. subgroup ibс antagonism in saline and alkaline habitats. subgroup icb antagonism in saline habitat. subgroup icc antagonism in alkaline habitat. discussion we have identified 415 strains of actinomycetes that demonstrate varying degrees of antifungal and antibacterial activities in saline and alkaline habitats. some of these strains may be producing previously unknown antibiotics. traditionally, researchers have studied the diversity of actinomycetes using neutral growth media. similarly, isolation, research of their properties, and production of natural, biologically active substances have been associated with strains grown in neutral media and conditions. these neutral conditions served as the basis of the discovery of contemporary natural antibiotics. however, the prevalence of drug resistance to known antibiotic substances necessitates the expansion of the boundaries of screening and changes in screening methods in order to identify new and promising antimicrobials11,12. thus, unusual natural substrates and extreme ecosystems have currently become the most popular targets of research as they are the most likely to yield new microorganisms with unique properties. marine environments, as well as soils with high levels of salinity and alkalinity, are being actively studied as sources of new secondary metabolites13 with their unique http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx trenozhnikova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu metabolic pathway formed in special environments, microorganisms from extreme environments produce many special bioactive substances, such as enzymes and antibiotics14-17. the molecules formed by extremophilic microorganisms have unique properties that offer ample opportunities for a variety of applications18-22. there are several limitations in this study. when investigating antagonism under changing conditions, we did not conduct studies in an acidic environment. in addition, in nature there may be other growth conditions that are not represented by the three media that we used to grow actinomycetes in the laboratory, therefore we may have missed the detection of other potential antibiotics produced by actinomycetes. the screening does not take into account the possibility of re-discovery of known antibiotics from certain strains, therefore we plan to develop approaches to rule out this possibility in future studies. the strains studied were not identified at the level of genus and species; however, in future studies we plan to perform these studies using traditional microbiology methods as well as molecular (pcr) methodologies. it is important to determine how actinomycetes interact with their changing environment and with other microorganisms in relation to their ability to consume nutrients and produce antibiotics. the main characteristics of interest of actinomycetes from extreme environments of kazakhstan are their growth, ability to form aerial mycelia, and their ability to antagonize bacteria and fungi. we have determined that the most widespread antibiotic-producing organisms were the actinomycetes belonging to group i; they grew in each of the selected habitats – neutral, saline, and alkaline. this important characteristic accounts for the wide distribution of the actinomycetes in soils and water. these actinomycetes also constituted the majority of those isolated in our research. actinomycetes of group ii were very rare. when tested for growth in three different conditions (neutral, saline or alkaline), all strains grew in at the least two or three conditions. we did not find any isolate that grew only in one condition. their absence may be a result of the isolation method used. however, their absence also indicates that despite their isolation from extreme habitats, actinomycetes are highly adaptable to different environmental conditions, including the neutral media. thus, screening from any extreme natural substrates, including the less explored marine sources, will enable the isolation of actinomycetes that belong to the subgroups ia, iba, ibb, which grow and secrete antimicrobials in neutral conditions and, perhaps also, secrete already known antibiotic compounds. our proposed classification allows researchers to concentrate their efforts on studying antibiotic-producing actinomycetes that belong to the specific groups ibс, icb, icс, iiac, iibb, and iibс, which do not show antagonism under neutral conditions but do show antagonism under saline and/or alkaline conditions; these actinomycetes have the greatest potential for yielding new and unexplored antibiotic compounds. actinomycetes are an unusual group of grampositive bacteria that have differentiated mycelia, both substrate and aerial. information on the relationship of morphogenesis and antibiotic formation in actinomycetes is often contradictory. some studies have correlated initial stages of antibiotic production with inhibition of aerial mycelium formation, while others indicate that the formation of antibiotics is linked to its abundant formation23-28. we found two variants of actinomycetes whose antagonism is inversely related to their morphogenesis. in the actinomycetes of the variant q "quitters" (which constituted 39.8% of total actinomycetes isolated), antagonism was correlated to good growth and formation of aerial mycelium. the reduction of sporulation resulted in a decrease of antibiotic production, and its absence resulted in the loss of this ability. actinomycetes of the variant f "fighters" (60.2% of total actinomycetes) exhibited antagonistic properties only when growth was poor and the production of aerial mycelium was inhibited, and its absence was associated with the highest level of antagonism. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu accordingly, in each previously selected subgroup based on the type of antagonism exhibition, the actinomycetes may be represented by these variants. actinomycetes of the variant q are more attached to certain habitats that ensure their comfortable existence, while the actinomycetes of variant f are capable of freer movement in a variety of habitats and colonization of new environments. we can conclude that in any natural environment members of both groups can be present simultaneously and can engage in certain relationships that ensure the survival of the actinomycetes community as a whole. the research of the actinomycetes’ ability to produce antibiotics in near-natural conditions provides a great opportunity to assess their biodiversity and distribution in the various regions of the world and to develop new methodological approaches to the screening of new antibiotics. those groups of actinomycetes that produce antibiotics only under extreme conditions, even if these are neutrophile strains of the variant f, may be the most promising for modern screening. once their growth is inhibited, the neutrophiles of the variant f may produce previously unknown antibiotics in saline and alkaline habitats. we consider the following subgroups to hold the greatest potential for screening: ibс, icb, icс, iiac, iibb, and iibс. in future studies, we hope to further characterize the nature of these unknown antibiotics and to test them against known fungal and bacterial pathogens, particularly those strains that may be resistant to antibiotics currently available in the market. additionally, one of our long-term goals of this work is to identify known strains of actinomycetes that exhibit interesting characteristics to the species level (which would be relevant to this study particularly for strains that produce potentially novel antibiotics), and/or to potentially identify novel actinomycetes strains. an organism’s environment may vary greatly, and a neutral habitat may gradually become saline, alkaline or acidic. accordingly, actinomycetes ability to survive is largely determined by their adaptability. the study of the behavior of actinomycetes, which use antibiotics for their survival in changing habitats may allow for the development of new approaches to the identification of pharmaceutically valuable drugs. this study has a significant global health implication. the search for new antibiotic-producing strains will require collaborations of many countries and will significantly enhance global health if new antibiotic agents become available. the actinomycetes classification we propose here is neither complete nor indisputable, and it can be changed and supplemented with new data and hypotheses that make it possible to significantly expand it. acknowledgements we thank dr. nancy touchette and dr. ranjan gupta from niaid/nih for their review and helpful suggestions on this manuscript, following up from the niaid scientific writing workshop held in tbilisi, georgia in may 2017. this research was partly supported by an nihistc grant no. k-2239. references 1. singer rs, finch r, wegener hc, bywater r, walters j, lipsitch m. antibiotic resistance--the interplay between antibiotic use in animals and human beings. the lancet infectious diseases. 2003;3(1):47-51. 2. talbot gh, bradley j, edwards je, jr., gilbert d, scheld m, bartlett jg. bad bugs need drugs: an update on the development pipeline from the antimicrobial availability task force of the infectious diseases society of america. clinical infectious diseases : an official publication of the infectious diseases society of america. 2006;42(5):657-668. 3. newman dj, cragg gm. natural products as sources of new drugs over the last 25 years. journal of natural products. 2007;70(3):461-477. 4. tobias kieser mjb, mark j. buttner, keith f. chater, david a. hopwood. practical streptomyces http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx trenozhnikova this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu genetics. https://www.jic.ac.uk/science/molmicro/strepmanu al/manual.htm. accessed 11 jul, 2018. 5. demain al. pharmaceutically active secondary metabolites of microorganisms. applied microbiology and biotechnology. 1999;52(4):455463. 6. vm b. formation of saline soils and halogeochemical provinces of kazakhstan. almaata, science (nauka). 1982. 7. merriam-webster. solonchak definition. https://www.merriamwebster.com/dictionary/solonchak. accessed nov 10, 2018. 8. paul driessen wau, international institute for aerospace survey and earth sciences (itc), jozef deckers, catholic university of leuven otto spaargaren, international soil reference and information centre freddy nachtergaele, fao. mineral soils conditioned by a (semi-)arid climate. http://www.fao.org/docrep/003/y1899e/y1899e09. htm. accessed nov 10, 2018. 9. wikipedia. takyr definition. https://en.wikipedia.org/wiki/takir_(soil). accessed nov 10, 2018. 10. egorov njmm. fundamentals of theory of antibiotics. 2004. 11. basilio a, gonzalez i, vicente mf, et al. patterns of antimicrobial activities from soil actinomycetes isolated under different conditions of ph and salinity. journal of applied microbiology. 2003;95(4):814-823. 12. natural products. humana press; 2005. 13. paul ea. soil microbiology, ecology and biochemistry. academic press; 2014. 14. ningthoujam ds, kshetri p, sanasam s, nimaichand s. screening, identification of best producers and optimization of extracellular proteases from moderately halophilic alkalithermotolerant indigenous actinomycetes. world appl sci j. 2009;7(7):907-916. 15. suthindhiran k, kannabiran k. cytotoxic and antimicrobial potential of actinomycete species saccharopolyspora salina vitsdk4 isolated from the bay of bengal coast of india. am j infect dis. 2009;5(2):90-98. 16. vasavada s, thumar j, singh sjcs. secretion of a potent antibiotic by salt-tolerant and alkaliphilic actinomycete streptomyces sannanensis strain rjt1. 2006:1393-1397. 17. dietera a, hamm a, fiedler hp, et al. pyrocoll, an antibiotic, antiparasitic and antitumor compound produced by a novel alkaliphilic streptomyces strain. j antibiot (tokyo). 2003;56(7):639-646. 18. kokare c, mahadik k, kadam s, chopade bjcs. isolation, characterization and antimicrobial activity of marine halophilic actinopolyspora species ah1 from the west coast of india. 2004:593-597. 19. manam rr, teisan s, white dj, et al. lajollamycin, a nitro-tetraene spiro-beta-lactone-gamma-lactam antibiotic from the marine actinomycete streptomyces nodosus. journal of natural products. 2005;68(2):240-243. 20. fiedler hp, bruntner c, bull at, et al. marine actinomycetes as a source of novel secondary metabolites. antonie van leeuwenhoek. 2005;87(1):37-42. 21. jensen pr, williams pg, oh d-c, zeigler l, fenical w. species-specific secondary metabolite production in marine actinomycetes of the genus salinispora. applied and environmental microbiology. 2007;73(4):1146-1152. 22. phoebe ch, jr., combie j, albert fg, et al. extremophilic orgainisms as and unexplored source fo antifungal compounds. the journal of antibiotics. 2001;54(1):56-65. 23. demain al. microbial secondary metabolism: a new theoretical frontier for academia, a new opportunity for industry. ciba foundation symposium. 1992;171:3-16; discussion 16-23. 24. wc champness kc. regulation and integration of antibiotic production and morphological differentiation in streptomyces. regulation of bacterial development. 1994. 25. demain a. why do microorganisms produce antimicrobials? paper presented at: symposiasociety for general microbiology1995. 26. demain al, fang a. emerging concepts of secondary metabolism in actinomycetes. actinomycetologica. 1995;9(2):98-117. 27. bibb mj. regulation of secondary metabolism in streptomycetes. current opinion in microbiology. 2005;8(2):208-215. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx https://www.jic.ac.uk/science/molmicro/strepmanual/manual.htm https://www.jic.ac.uk/science/molmicro/strepmanual/manual.htm https://www.merriam-webster.com/dictionary/solonchak https://www.merriam-webster.com/dictionary/solonchak http://www.fao.org/docrep/003/y1899e/y1899e09.htm http://www.fao.org/docrep/003/y1899e/y1899e09.htm https://en.wikipedia.org/wiki/takir_(soil central asian journal of global health this work is licensed under a creative commons attribution 4.0 united states license. this journal is published by theuniversity library system of the university of pittsburgh as part of its d-scribe digital publishing program and is cosponsored by the university of pittsburgh press. central asian journal of global health volume 7, no. 1 (2018) | issn 2166-7403 (online) | doi 10.5195/cajgh.2018.337|http://cajgh.pitt.edu 28. size afja. structure of the population of streptomyces hygroscopicus and characteristics of its variants. 1993;4(part 3):65-71. http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://www.upress.pitt.edu/upressindex.aspx abstract keywords: extremophiles, actinomycetes, antibiotics, natural products, pathogens, antibiotic resistance research 