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The aim of the present study was to establish a novel perioperative care system according to preoperative SII levels. A total of patients who underwent surgery for GC between January and June at the Kyoto Prefectural University of Medicine were included in the present study. The inclusion criteria were as follows: 1 patients pathologically diagnosed with gastric adenocarcinoma; 2 patients with pathological stages pStage I, II, and III; and 3 patients undergoing the curative resection of GC R0.
Patients with missing information on preoperative CBC and those with simultaneous malignancies other than GC were also excluded. Tumor staging was performed according to the 8th edition of the Tumor, Node, Metastasis staging classification by the Union for International Cancer Control [ 11 ].
In the present study, grade 2 or higher postoperative complications according to the Clavien-Dindo Classification [ 12 , 13 ] occurred in 60 patients All patients provided written informed consent before surgery. The following clinicopathological data were reviewed from the medical record database of our institution: age, sex, body mass index BMI , physical status PS , comorbidities hypertension, diabetes mellitus, heart disease, and chronic renal failure , tumor location, preoperative serum carcinoembryonic antigen CEA , cancer antigen CA , albumin, C-reactive protein CRP , preoperative CBC Neut, Lymp, Mono, and Plt , pathological T stage pT , pathological N stage pN , lymphatic invasion, venous invasion, and tumor differentiation.
After curative gastrectomy for GC, patients with pStage I generally received postoperative examinations alone without any adjuvant treatments. Most patients were postoperatively followed up for 5 years or until their death. GC recurrence was confirmed by imaging, such as CT and upper gastrointestinal endoscopy. If possible, recurrence was histologically confirmed via surgical biopsy, needle biopsy, or appropriate fluid cytology.
Peritoneal recurrence was diagnosed by imaging alone, and diagnostic laparotomy was rarely performed. Differences between the two groups for categorical and continuous variables were analyzed by the chi-squared test and Mann-Whitney U test, respectively.
The optimal cutoff value for each immune-nutritional parameter Neut, Lymp, Mono, Plt, or SII was selected according to the receiver operating characteristic ROC curve for overall survival OS with the maximal Youden index based on the sum of sensitivity and specificity [ 17 , 18 ].
The cutoff values for serum albumin and CRP were set at 3. OS and recurrence-free survival RFS were generated using the Kaplan-Meier method, and the differences between the two groups were assessed with the log-rank test. In one model model 1 , Neut, Lymp, or Plt was separately incorporated as explanatory variables.
The median range values were —15, for Neut, — for Lymp, 50— for Mono, As shown in Fig. Survival curves of patients stratified by preoperative SII. B RFS. GC recurrence was detected in 51 out of patients. Cumulative recurrence rates stratified by preoperative SII were examined according to the type of GC recurrence peritoneal, hematogenous, and lymph node recurrence Fig. Cumulative recurrence rate for each recurrence pattern stratified by preoperative SII.
A Peritoneal recurrence. B Lymph node recurrence. C Hematogenous recurrence. In the present study, we examined the clinical significance of preoperative SII to predict postoperative survival outcomes in GC. Of special note was that high SII correlated with peritoneal recurrence. These results suggested that preoperative SII may contribute to perioperative precise care and adjuvant treatments for patients with GC undergoing curative gastrectomy.
A relationship was previously suggested between obesity and chronic inflammation [ 21 ]; therefore, patients with high BMI may have a stronger inflammatory response. In cancer patients, inflammation is induced by inflammatory cytokines as cancer progresses, and, thus, patients with a high inflammatory response may lose weight [ 22 ]. In the present study, high SII correlated with low albumin levels, suggesting that cachexia had an influence on the results obtained.
Hirahara et al. In addition, several indexes calculated by combining these factors, such as neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and monocyte-to-lymphocyte ratio, have been used to predict survival outcomes of GC [ 30 — 32 ]. Accordingly, high SII, resulting from neutrophilia, lymphopenia, and thrombocytosis, may also be a useful prognostic indicator. The negative impact of postoperative complications on survival outcomes has recently been clarified [ 33 , 34 ].
Accordingly, worse OS may be attributed to a higher incidence of postoperative complications. However, in the present study, the incidence of postoperative complications of Clavien-Dindo grade II or higher in the high SII group was To do this, the country programme will strengthen the capacity of educators, trainers and institutions in the formal and non-formal education system to deliver effective, quality skill-based education that is linked to the needs of the labour market.
Support will go to national networks of Youth Houses and Youth Development and Career Centres and the school system to expand basic life skills, career counselling, job orientation and social entrepreneurship programmes for young people aged years to equip them for future employability. The country programme will support digital learning platforms and new e-learning opportunities to increase accessibility for young people, especially in rural areas. It will also support girls education in science, technology, engineering and mathematics.
Youth participation in local decision-making, including participation of young people with disabilities, young women and those from internally displaced communities, will be enhanced by scaling up youth advisory councils at the subnational level and by routinely engaging young people and local authorities to identify, plan and implement joint initiatives. Online platforms will supplement initiatives within the networks of Youth Houses and Youth Development and Career Centres and other structures to actively support civic engagement, involvement in local governance, gender equality, innovation and youth participation in climate change as well as research and policy strengthening.
Positioning child rights at the heart of the national development agenda By , the country programme will contribute to a multi-partner social, economic and political environment in which child rights are clearly prioritized in the national sustainable development agenda. Priorities include increasing the fiscal space for sustainable investment in child development and improving the effectiveness and efficiency of public expenditures for children.
This will involve support for socioeconomic impact analysis of the COVID pandemic, public finance management activities and tools that enhance results and performance-based budgeting. Private and public partnership in selected programme areas will be encouraged to leverage additional resources for investment. The country programme will support improved data collection to strengthen national capacity on monitoring and reporting on the Sustainable Development Goals.
The programme will also support strengthening and modernization of management information systems including real-time data collection tools and nationally representative household surveys , while analysis and relevance of data will be enhanced by introducing multidimensional poverty measurements, promoting evidence-based decision-making and strengthening capacity of government and academic partners for analysis and use of data. Public engagement and advocacy on child rights, in line with the countrys commitment to the Convention on the Rights of the Child, will be supported through engagement of various influencers.
This will be informed by compelling policy briefs and investment cases to advocate strengthened national legislation and policy, compliance with international child rights obligations and improved coordination mechanisms for children. The country programme will promote private sector partnerships focused on sustained child rights investment in business practices and policies.
Summary budget table Programme component In thousands of United States dollars Regular resources Other resources Total Investing in the very best start to every childs life 1 3 5 Investing in the second decade of life and the transition to adulthood 1 3 5 Positioning child rights at the heart of the national development agenda 1 1 3 Programme effectiveness Total 4 9 13 Programme and risk management This country programme document outlines UNICEF contributions to national results and serves as the primary unit of accountability to the Executive Board for results alignment and resources assigned to the programme at the country level.
Accountabilities of managers at the country, regional and headquarters levels with respect to country programmes are prescribed in the organizations programme and operations policies and procedures. The country programme is designed around the assumptions that Azerbaijan remains resilient to global economic volatilities, is unaffected by significant natural disasters and continues its commitment to sustainable and inclusive growth. Risks to achieving results include economic vulnerability reducing national resources to invest in child development including the possible economic impact of the COVID pandemic , limited technical capacities, limited integration of approaches by government and non-government entities and the impact of natural disasters, including earthquakes and flooding.
UNICEF will support emergency preparedness efforts to establish an effective readiness and response system to protect children in times of cr isis. The commitment of the Government to a national Sustainable Development Agenda creates an opportunity to focus on key child and youth indicators and encourages national ownership of priorities for children reflected in the country programme.
Annual workplans will be designed, approved and implemented with relevant ministries and State entities. In line with the United Nations reform process, UNICEF will seek out effective partnerships with other United Nations agencies and explore more innovative financing for development through engagement with partners including international financial institutions and the private sector emphasizing the centrality of human capital investment to long-term economic potential.
UNICEF will continue to invest in its effective governance and management systems, stewardship of financial resources and management of human resources. UNICEF will strengthen management of the harmonized approach to cash transfers to mitigate risks associated with programme implementation.
Monitoring and evaluation Results will be monitored through joint annual and midterm reviews with the Government and partners including the Cabinet of Ministers and the UNSDCF Working Groups and Steering Committee to assess progress and available resources; identify strategic, programmatic, operational and financial risks ; define appropriate mitigation measures; and assess the effectiveness of partners contributions to inform annual planning and strengthen accountability for results.
UNICEF will work with partners to increase national monitoring and evaluation capacity by institutionalizing results-based management, the use of real-time monitoring and greater use of evaluation results. Investment in a multiple indicator cluster survey will provide updated baselines against which to track key indicators.
The Evidence Information Systems Integration system and costed evaluation plan will define priority monitoring, research and evaluation needs for programme implementation.
Analysis of evidence generated by programmes will help to determine and address bottlenecks and barriers to reaching the most vulnerable children and families. By , adolescent girls and boys, especially the most vulnerable, are benefiting from improved skills- driven formal and non-formal education systems, a strengthened protective environment from all forms of violence, exploitation and abuse, and increased opportunities for maximizing their well-being, civic engagement and participation, for a smooth transition to adulthood.
By , a multi- partner social, economic and political environment is established to prioritize child rights within the national sustainable development agenda. Proportion of sustainable development indicators produced at the national level with full disaggregation when relevant to the target, in accordance with the Fundamental Principles of Official Statistics [UNSDCF indicator] B: Programme effectiveness Total resources 4 9 13 Costed evaluation plan Azerbaijan UNICEF country programme of cooperation, The table draws from the Integrated Monitoring and Evaluation Plan to cover present evaluations planned for the duration of the programme cycle.
Il inclut une proposition de budget indicatif global dun montant de 4 dollars des tats-Unis imputer sur les ressources ordinaires, dans la limite des fonds disponibles, et de 9 dollars imputer sur les autres ressources, sous rserve de la disponibilit des contributions des fins spciales, pour la priode Aprs la priode de volatilit conomique en qui a succd une chute spectaculaire des prix du ptrole, lAzerbadjan sest lanc dans un ambitieux programme de diversification conomique ; le pays a ensuite fait tat dune croissance conomique continue, notamment dune augmentation de son produit intrieur brut PIB , qui est pass de 37,9 milliards de dollars en 47,1 milliards de dollars en Les 2,62 millions denfants5 en Azerbadjan reprsentent environ le quart de la population.
Il existe un important cart entre les sexes la naissance, la proportion des naissances tant de garons pour filles6. Les jeunes reprsentent une grande partie de la population : en effet, on compte quelque 1,6 million de jeunes gs de 15 25 ans7.
Depuis son indpendance en , lAzerbadjan a fait des progrs sagissant damliorer la sant des enfants. Le taux officiel de mortalit des moins de 5 ans tabli par lONU est pass de 38 pour 1 naissances vivantes en 22 en , le taux de mortalit infantile est pass de 32 19 pour 1 naissances vivantes et le taux de mortalit nonatale a diminu de 20 11 pour 1 naissances vivantes Selon les statistiques nationales, en , le taux de mortalit des moins de cinq ans tait de 13,1 ; le taux de mortalit infantile se situait 11,1 et le taux de mortalit nonatale, 6, Les dcs au cours de la priode nonatale reprsentent la moiti de la mortalit des enfants de moins de cinq ans, ce qui indique quil faut amliorer les soins prnatals, nonatals et infantiles.
LAzerbadjan prend plusieurs mesures importantes en vue dadopter lapproche du modle. Amid the ongoing uncertainty that the COVID pandemic has brought to every aspect of our daily lives, returning to school will not be the same as in previous years.
Countries will apply different approaches: full opening with health and hygiene measures in place,…, The report team thanks all who gave so willingly of their time, expertise…. Flagship Report. The State of the World's Children examines critical issues in maternal and newborn health, underscoring the need to establish a comprehensive continuum of care for mothers, newborns and children.
The SitAn aims to inform these planning processes by providing policy makers with a current and comprehensive overview of the needs of children and women in Kenya. Given the availability of rich data on children in Kenya conducted between and , the SitAn report used secondary analysis of recent data on children and women in Kenya, and was also complimented by key informant interviews with Government technical departments, and technical input from the Kenya Bureau of National Statistics KNBS.
The report highlights evidence on the various policies, legislation, legal frameworks and interventions adopted by the Government aimed at strengthening the realization of childrens rights, including adolescents. It also presents an overview of the most recent data and analysis relating to the status of women and children in terms of poverty; health and nutrition; HIV and AIDS; water and sanitation; education; protection; inclusion in society and in emergencies, at both national and at county levels.
As the report shows, the Government of Kenya is committed in providing an enabling legislative and policy environment for addressing women and childrens issues.
Some of the finalized policies in key childrens rights areas include i the education curriculum reform ii early childhood and development policy iii free secondary school scheme and iv FGM policy. The Childrens Act is also being revised. The SitAn also notes that groups of children- particularly those living in the northern counties of the Arid and Semi-Arid Lands ASAL ; those living in informal settlements within growing cities; and many girls living within communities which practice harmful traditions- are being left behind in the realization of their fundamental rights and the opportunity to thrive.
The Government will address these gaps through the SDGs to ensure that no child is left behind. The report provides the much-needed evidence to design interventions for children in Kenya and as such we urge partners to use this report as a document for planning for children.
The report would not have possible without the input of a wide cross-section of organizations and individuals, who contributed to the quality of data collected. The compilation of the report was facilitated by technical support from the Kenya National Bureau of Statistics under the leadership of the Director General, Mr Zachary Mwangi, with final oversight and approval from the Principal Economic Secretary of the National Treasury and Ministry of Planning.
The technical sections of the report were produced in collaboration with the Ministry of Health; Ministry of Education, Science and Technology; Ministry of Water and Sanitation; and Ministry of Labour and Social Protection whose staff participated in key informant interviews and validated drafts of the report.
The Situation Analysis of Children and Women SitAn is based on existing published data, collated through a comprehensive desk review. The Situation Analysis was drafted in consultation with the following non-governmental organizations, who provided reference materials on the status of children in Kenya: International Mercy Corps, Save the Children and World Vision.
Although not possible to mention everybody by name, their contribution and input is well recognized. In September , Kenyas Government launched its national implementation plan for the Sustainable Development Goals, and expressed commitment that no one will be left behind in the economic and social prosperity of the country.
The report presents an overview of the Situation of Children and Women in Kenya using the results of the most significant research and analysis between and in areas related to the wellbeing of children and women.
It is the product of a desk review of key reports, studies, surveys and evaluations produced in the last three years in the area of child rights and associated issues in Kenya by the Government and its development partners, as well as a series of interviews with national and local officials and other stakeholders.
By focusing on the key knowledge gaps related to inequities and child deprivations and promoting the broad engagement of all stakeholders, the Situation Analysis is intended to contribute to implementation of Kenya Vision , to support achievement of national and child-related sustainable development goals. The Situation Analysis is divided into several sections.
The background section provides information on the geographical, political, economic and social situation in Kenya; and the Enabling Environment section looks at more specific aspects of governance for children in the country.
This is followed by six sections that focus on key issues affecting the lives of children and women in the country today: Surviving, which focuses on health and nutrition challenges Learning, primarily looking at access to and quality of education Protection from violence, abuse, exploitation and family separation Safe and clean environment, looking at water, sanitation, housing and energy Children and emergencies, covering the effects of natural disasters, security challenges, and refugee children; and Equitable chances in life, highlighting the situation of children with disabilities, challenges ensuring birth registration, the social protection system and adolescent empowerment.
Key findings4. Kenyas GDP growth has been relatively strong in recent years: reaching an estimated 5. Kenya has also experienced some progress towards meeting its development goals. However, the country faces several challenges that complicate the countrys efforts to fulfil the rights of women and children. In , progress towards achieving childrens rights was threatened by the drought declared in February in 23 of the countrys 47 counties, which worsened food and nutrition security, and led to displacement of children and disruption to social services.
Meanwhile, insecurity in areas affected by the conflict in neighbouring Somalia and instability associated with pasture in lands that have become increasingly arid as a result of the drought, have further aggravated population movement and barriers to service provision. Rapid population growth, coupled with the effects of climate change, has led to a growth in rural to urban migration and use of informal settlements. While prevalence of HIV has fallen in recent years, Kenya continues to be one of the countries most affected by the virus, and the number of new cases has been increasing recently, particularly among those aged 15 to Poverty continues to hamper the full realisation of childrens rights.
Successes included improved net enrolment rates in education, and greater promotion of gender equality and empowerment of women. However, targets were not met with regard to eradicating extreme poverty and hunger; reducing child mortality; combating HIV and AIDS, malaria and other diseases; ensuring clean water supply and sanitation; and improving maternal health. There are some striking differences between development indicators across Kenyas 47 counties.
Figures for poverty, education and healthcare, are particularly low in the arid and semi arid counties, and especially in Mandera, Wajir and Turkana Counties, which are affected both by security concerns and by ongoing drought. Groups of children in other areas of the country also face acute vulnerabilities.
Increasing numbers of children are residing in rapidly growing informal settlements around the countrys major cities, often in poor living conditions, with limited access to services, and heightened risk of violence and abuse. The high prevalence of HIV and large numbers of orphaned children in the southwest of Kenya particularly Homa Bay, Siaya, Kisumu and Migori Counties has contributed to specific violations of rights, and access to services for children living on islands on Lake Victoria is problematic.
Enabling environment 7. The national legislative and policy framework in Kenya is generally favourable for children. Revision of the Children Act is currently in progress. Childrens rights and their implementation are also enshrined in the Constitution and in Kenya Vision , the national long-term development blueprint.
In , significant powers were devolved to 47 county-level governments. This was intended to enhance local participation and service delivery to the most deprived populations. With devolution, county governments have become highly strategic entities, controlling more than 4.
Following devolution, in some cases counties have struggled with insufficient resources to meet competing sector demands; weak systems; and challenges attracting and retaining competent or trained staff for planning, budgeting and participatory processes. Experience from the last three years appears to indicate that where county governments are committed to improving the situation of the population in their area, and have been provided with support to develop and implement strong county integrated development plans, significant improvements have been made to several key indicators in administrative data for health, nutrition and sanitation for example.
However, other counties appear to have struggled to spend their new annual budgets, partly because of delays to transfers from national Government, and have not seen similar rises in indicators.
The Government is committed to investing in improving quality of and access to free healthcare and education as well as the social safety net to reduce burdens on households and complement sustainable long-term growth and development. Including spending at county level, almost 40 per cent of government expenditure was on social sectors in , of which education accounted for more than half. However, efforts are still needed to allocate resources in sectors such as water, sanitation, nutrition and child protection, and planning for and monitoring child rights is constrained by a lack of disaggregated data.
The Government is working to improve the capacity of Ministries to generate sectoral statistics. In , Kenya officially moved from a low income to a lower-middle income country. In this context, official development assistance has fallen and is expected to further reduce in upcoming years.
The country is increasingly exploring how the private sector can be engaged in meeting development goals, through investment on social sectors, innovation, and sponsorship.
However, care should be taken to ensure that the private sector is adequately regulated to prevent violations of childrens rights. Surviving and thriving According to the Kenya Demographic and Health Survey, the maternal mortality ratio in Kenya has improved from per , live births in to per , in The main drivers of declines in maternal mortality are a reduction in maternal HIV and reduced mortality from giving birth, ranging from complications associated with abortion, haemorrhage, and obstructed labour.
The United Nations estimates that one in 42 women will die of a maternity related cause, and that 8, women die every year in Kenya of maternity related conditions, the seventh highest figure in the world. Recent county figures for total maternal mortality are not available, but Mandera County had the highest figure at the time of the census. Ministry of Health administrative data suggest that significant improvements have been made in skilled birth attendance since devolution, with the figure rising from This is largely a result of making maternity services free of charge, and improved access to comprehensive obstetric maternal and newborn services.
In some counties, the improvements are linked to stipends given to mothers for antenatal care visits and delivery at health facilities. The process has also been facilitated by the engagement of Community Health Volunteers, who continuous follow-up with mothers during pregnancy, and linkage with health facilities increasing the use of health services at the community level. However, in addition to being understaffed, dispensaries in the counties often lack basic equipment, facilities and access to water.
In pastoral communities, distance to facilities also continues to lead to more deliveries at home. Neonatal, infant and child mortality have also been steadily falling in recent years, though not enough to meet the MDG targets. However, for neonatal mortality the reduction is slower.
Factors behind the downward trend in childhood mortality include high impact interventions, such as increased use of mosquito nets among children, immunization programmes and improvements in the health system, including community-based systems. Under-five mortality is generally higher in arid, semi-arid and rural areas, but Kenya Demographic and Health Survey data suggest that Nairobi also has high levels of under-five mortality.
Full immunization coverage fell from This was as a result of underfunding for outreach for underserved populations, stock out of injection devices and vaccines, and frequent labour disputes in the health sector that led to closure of healthcare facilities. These problems arose from challenges linked to devolution of health services and reduced communication between healthcare facilities and communities to address demand side constraints.
However, some counties that have been able to develop strong action plans such as Turkana have reversed this trend. Then I decided to give him porridge frequently and not be hesitant. These cultural ideas relating to the insufficiency of breastfeeding alone were often reinforced by the idea mixed feeding soothed babies and breastfeeding alone was the reason infants cried so much [ 17 , 18 , 41 ].
Table 5 demonstrated a refined CMO theory for the mechanism of prioritisation, highlighting that prioritisation of counselling advice for EBF is more likely to occur when a mother has good knowledge of PMTCT implications and a trusting relationship with HCPs who challenge the cultural misconceptions she may have.
There was strong evidence to support the role of support and empowerment in encouraging EBF. Male partners of HIV-positive women play a highly influential role in the determination of infant feeding choice, whether that be individually or jointly with the mother [ 9 , 14 , 31 , 39 ].
They are also one of the greatest supports in maintaining infant feeding choice [ 40 ]. EBF was found to be associated with marital status; this was certainly true of stable marital relationships where there was disclosure of HIV status [ 9 ]. Partners were found to defend the mixed feeding pressure from extended family, many who were not be aware of infant feeding guidelines for EBF [ 16 , 33 ]. This support also mitigated stigma that came from EBF choices [ 16 , 33 ]. She used to drink that porridge and breastfeed the child.
Partner support was important in defending against the pressure to mix feed that often came from mothers-in-law and extended family [ 9 ]. This was more evident when the mothers-in-law lived in the same house as the HIV-positive woman. Grandmothers in particular had a lot of power when it came to make infant feeding decisions, especially in contexts where women were young, inexperienced, unmarried or with no partner support.
Particularly in situations of non-disclosure to family members, or when partner disclosure had produced negative outcomes. They provided strength and support to women, reinforcing the infant decision they had made [ 32 ].
The objective of this realist review was to evaluate key mechanisms theorised to be involved in resulting in EBF adherence in HIV positive women from sub Saharan-Africa. The findings of this review highlight how EBF best occurs when an HIV-positive woman has a desire for motherhood, understands EBF and feels equipped to do it, is not affected by stigma, prioritizes infant feeding counselling advice over cultural feeding norms, and finally, when she feels supported in her infant feeding decision to EBF.
These theories have been tested to better understand for whom and in what circumstances EBF adherence occurs. This realist review identified the role of a desire for motherhood and motivation for child survival in EBF adherence.
This mechanism had a lesser effect on EBF adherence when mothers were young and transferred the parenting role to their own mothers. This highlights the need for expansion of PMTCT services, which are currently targeted at mothers, to target grandmothers as well who are often a crucial support in infant feeding.
Furthermore, healthcare providers who counselled mothers based on their own personal beliefs, discouraging EBF, often led mothers to make feeding decisions based on fear of HIV transmission, instead of the promotion of child survival. Frequently changing guidelines, and the provision of free infant formula have led to mixed messages in counselling [ 13 , 28 — 30 , 37 , 39 , 42 ].
The subsequent maternal confusion and distrust of counselling advice has resulted in a decrease in EBF. Furthermore, little emphasis has been placed on high quality, in-depth counselling with practical tools to equip mothers for EBF.
The evidence shows that EBF can best occur when a mother learns and understands the role of EBF through regular, in-depth and practical counselling, and where there is clarity around feeding expectations and trust of HCPs.
This increased clarity was seen in regions that did not provide free government funded formula. In these regions, there was less mixed feeding and participants were better able to maintain exclusive feeding [ 16 , 42 ].
From initial scoping of the literature, it was expected that stigma around formula feeding would be protective for EBF, which it was. However, other mechanisms were also at play due to EBF being seen as a deviation away from cultural norms of mixed feeding, and consequently being identified as an activity for HIV positive women.
For instance, when women perceived the physical effects of breastfeeding to mimic those seen in AIDS, they were less likely to adhere to EBF due to the increased stigma. During the process of testing our hypothesized mechanisms, a theory gap was found when trying to explain the mechanism that led to EBF in the context of strongly held cultural beliefs.
Evidence was found that some women were able to EBF, even in times when cultural beliefs were still strongly held. It was theorized that for women to EBF when faced with cultural feeding norms of mixed feeding, they would need to be able to prioritize the information received during feeding counselling over any cultural ideas.
There were contexts where prioritisation of EBF over cultural norms was difficult. In these cases, it was suggested that fear and insecurity around going against cultural norms was the mechanism inhibiting EBF prioritisation. EBF adherence could be improved if HCPs regularly challenged the mixed feeding cultural beliefs held by women through infant feeding counselling; however, it was noted that even HCPs had little confidence that overcoming cultural barriers to EBF would be possible for mothers [ 13 ].
This mechanism was well documented in the literature, with both males and HCPs playing key supportive roles for women. Male involvement, for women in stable marriages who had disclosed their HIV status, facilitated EBF through the support provided in making and adhering to feeding choices, in the face of feeding pressure from extended family.
HCPs provided support by empowering women to be assertive about their feeding choices, particularly in cases of non-disclosure to other family members. These situations highlight the supportive role that extended family could play in encouraging EBF adherence, as strong influencers of feeding habits. This re-iterates the role for increased family involvement in PMTCT, targeting not only mothers but also fathers and grandmothers [ 16 ].
The strengths of this review of infant feeding counselling for EBF lie in the chosen review methodology. Taking a realist approach meant this review considered that interventions work in different ways to produce different outcomes in different contexts [ 23 ]. This allowed for a more in-depth analysis of various successes and failures of the interventions. There are however limitations to this review, some of which are inherent to the realist approach and others which due to the research topic itself.
It is important to note that mechanisms are all interconnected, with multiple mechanisms operating in contexts. As such CMO configurations do not act independently and two mechanisms can work concurrently to produce an outcome [ 43 ]. There were occasions when the methodology of the review, similarly to Rycroft-Malone et al. This was not done due to the time constraints of the review. An important limitation to the review was that it focussed on women in sub-Saharan Africa engaged with PMTCT services and received infant feeding counselling.
The reality is that many women do not have access to these interventions. Further research on this topic could look into mechanisms that result in a woman attending and engaging with PMTCT services. This review has identified the basis for future research studies that use an intervention approach to encourage mothers to exclusively breastfeed their infant. Another study of value would be to follow these infants prospectively to evaluate how many become and remain HIV positive and develop disease over time.
Such research would take immense commitment and support but would be of great value to understanding the role of breastfeeding in HIV prevention and management. The aim of this review was to create a model showing how and in what contexts infant feeding counselling best worked to fire mechanisms in HIV positive women to result in EBF. It was found that EBF occurred when a woman desired or had motivation for motherhood, correct learning and understanding about infant feeding practices obtained through good quality and practical counselling, the resolve to prioritize EBF advice over cultural beliefs and stigma, no fear of breastfeeding or the impact of opposing feeding related cultural beliefs, and the support from partners and HCPs to be assertive about the feeding choices when faced with pressure to mix-feed.
The primary audience for this review are researchers and health care workers in PMTCT in low and middle-income countries, particularly sub-Saharan Africa, who may benefit from the work that has been done to identify contexts for the success and failures of EBF. Title: Search Outcomes Conducted September Title: Characteristics of citations included in review. Description: summary table of all 27 items included in the review.
Data on predictors not collected quarterly were carried forward. Predictors of persistence on PrEP and retention in the program will be published separately. We examined the association between adherence and SMS survey responses at the participant-week level, with adherence defined over the week before the completed SMS survey. We again used logistic generalized estimated regression models to assess participants' weekly adherence with yes versus no responses to each survey question as predictor variables.
Models included fixed effects at the individual level. All participants provided written informed consent. The only significant difference in those participants not retained versus retained in the study was the baseline VOICE risk score, which was slightly higher in the former mean 6.
Four women acquired HIV in the Kisumu site incidence 0. We analyzed total person-years of follow-up. PrEP adherence over time. Each column indicates the number of participants picking up PrEP at each study visit ie, pharmacy refill adherence from months 0 through Electronically monitored adherence over the period covered by each pharmacy refill is shown as the average number of doses per week.
Most discordance was because of lower TFV-DP levels compared with electronically monitored adherence levels. A total of participant visits were considered for analysis. Notable trends toward high adherence were seen with more sexual relationship power moderate aOR 1.
All measures were updated over time unless noted as baseline values. Similarly, we saw no significant difference in adherence between weeks in which participants reported perceived HIV risk or perceived protection from HIV because of PrEP.
Surveys were sent to all participants weekly from Month 6—24 of the study 72 total weeks. In this two-year study of young women offered PrEP in Kenya, we found high interest in PrEP, but steadily declining adherence according to multiple measures. These findings replicate those of other studies among young women in sub-Saharan Africa.
The inconsistent associations between multiple measures of HIV risk and PrEP adherence reveal the complexity in understanding risk behavior and perception. Lower baseline HIV risk according to the VOICE risk score was associated with higher adherence, which potentially indicates some degree of concordance between control over HIV exposure and ability to take a daily preventive medication.
Yet, no difference in adherence was seen across degrees of underlying risk tolerance, nor by SMS-reported sexual activity, condom use, sex with some who may be living with HIV, or perceived HIV risk. Assessments of risk perception and prediction tools have had mixed results and warrant further research. Interestingly, the overall HIV incidence of 0. This finding could be explained through well-aligned use of PrEP during periods of exposure that we were unable to measure.
Alternatively, the VOICE risk score may not be an appropriate measure for all populations of young women. Important differences are likely present in socio-cultural factors and behaviors, and HIV prevalence and incidence, in various settings. Nonetheless, the statistically significant association between the VOICE risk score and PrEP adherence suggests it has some relevance in this population.
Although participants indicated sexual activity and incomplete condom use throughout the study, we do not know the HIV risk behaviors among their sexual partners. The relatively high relationship power reported by MPYA participants consistent with another study in Kenya 30 suggests considerable agency, and a trend toward high adherence was seen with more sexual relationship power.
Counseling may have been empowering and an important factor in achieving overall low HIV incidence. Qualitative assessment of these factors will be published separately.
The detailed adherence data in this study have important implications for PrEP research and clinical delivery. First, the low electronically monitored adherence compared with pharmacy refill raises questions about the accuracy of PrEP adherence measurement reported in other studies relying solely on the latter 5 , 7 , 8 ; true adherence may have been even lower. Other objective measures are therefore needed to assess PrEP use in routine care.
Research on the validity of this measurement approach is ongoing. However, most adherence values were limited to the lowest categories; a broader range of adherence is needed to fully compare the measures and account for potential bias eg, more device manipulation or pharmacokinetic variability at higher adherence levels.
Notably, we did not see high TFV-DP levels concurrent with low electronically monitored adherence, suggesting that participants were not taking PrEP from alternative containers. Unpublished Master Yu, K. Tomita, Y. Chen H. Chulalongkorn University, Thailand. She University, an M. Aerial portraits of Taiwan. His received a Master in Urban Architectural and a Ph. Tran, H. In the past 50 years, Hanoi was filled up Company. Reclaiming Waterscapes. Currently, she currently ization and Food and Agricultural Organiza- lished design proposal.
She is an Olmsted Fellow Wilson, E. New York: United Nations. The Geo-Body of a Nation. Report no. New Haven: Yale University Press. Thomas Jr. He has also held positions scape Architecture at Peking University. As such, he has been working — Department of Architecture, Urbanism and Wageningen.
Van Beeck, S. Laura Rijsbosch studied architecture at the Kongjian Yu received his D. Through his research Van den Berghe, G. Mellon University, the Berlage Institute and cal infrastructure across scales, particularly in L. Sloos ed. Boeken met krijgshistorie: Fall —Spring in collaboration University of Leuven. She is presently teach- water associated landscapes in China, and op verkenning in het oudste boekbezit van Wyatt, D.
He is currently teaching Academie, 1— Gudio Geenen the University of Leuven. Nielsen ; below M. Kleppe ; left K. Kleppe ; RUA ; top to bottom: M. Kleppe ; L. Kleppe ; A. Pousi ; A. Ahi ; left top K. Shan- under: Vrooman, D. Map of the city and entire suburbs of Canton, cartographic material, De Meulder ; right middle B. De Meulder ; K. Shannon ; both B. Kleppe , , K. Shannon ; above K.
Nagels ; below left I. McGrath from Y. Takaya, ;below adapted from B. McGrath from R. Hubbard and J. Hafner, ; 54 T. Tachakitkachorn et al. English , Fig. Bonine , Fig.
Girot ; left P. Hafner, ; , Fig. Girot ; , English , Fig. Zhuang et al. Vingboons circa. Shannon; middle left He, P. Taipei: National Central Library, p.
Shan- load: 26 January , image assembled by B. Maurer, ; 65 Wikipedia Commons; 66 above, left T. Ishida , modification of Association. Tsai ; H. Sendai City Museum collection; below Watanabke, K. Hooyer, J. Residentie Bali en Lombok. Royal Tropical Institute List No. Derden, ; 74, 75 all G. Lansing ; above J. Lansing ; below J.
Watson ; J. Bennett; both J. Park; Ujang Zaelani; middle A. Pham Le; right M. Park and G. Foley ; J. Rijsbosch J. Pouyanne 22; 97 Collection of K. Shannon; S.
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