The aim of this longitudinal study was to identify risk factors for posttraumatic stress disorder (PTSD) in inpatients injured in the Ludian earthquake and examine the relationship between PTSD symptoms and health-related quality of life (HRQoL) following the earthquake.Three assessments were performed during an 18-month follow-up period. In total, one-hundred forty-seven inpatients of one-hundred seventy-four inpatients  underwent all the assessments. Injured inpatients admitted to the No. 1 People’s Hospital of Zhaotong City after a severe earthquake  were enrolled in the study and assessed using the Posttraumatic Stress Disorder Checklist-Civilian Version, Clinician-Administered Posttraumatic Stress Disorder Scale, and Medical Outcomes Study Short Form-36 Scale.At the first, third and eighteenth months after the earthquake, the prevalence rates for PTSD were 23, 14, and 7%, respectively. In a regression model, bereavement, history of major diseases, and severe injury in the earthquake were associated with severe PTSD symptoms. HRQoL was negatively correlated with PTSD symptoms. Compared to that of Chinese norms, participants’ HRQoL was significantly lower in all eight HRQoL domains of the Medical Outcomes Study Short Form-36 Scale.The findings suggest that a substantial proportion of inpatients injured in the earthquake experienced severe PTSD symptoms and poor HRQoL. Therefore, early preventive programs and interventions should be implemented following disasters, to reduce PTSD and improve HRQoL in injured individuals. Natural disasters, such as earthquakes, cyclones, floods, and tsunamis, lead to not only direct economic loss, death, and physical injury but also long-term adverse psychological outcomes . A propoThe current literature suggests that approximately 10 to 40% of injured survivors will develop PTSD , 7, 8. SPTSD is independently related to a broad profile of functional impairments and diminished quality of life (QoL) following injury , 17. RedThe present study aimed to provide insight into the prevalence, course, and predictors of PTSD and elucidate the relationship between PTSD and HRQoL in inpatients injured in the Ludian earthquake, via a longitudinal follow-up study, in contrast to most previous studies based on cross-sectional analysis.On August 3, 2014, an earthquake  occurred in Yunnan Province of China, with 617 deaths, 112 missing persons, 3143 injuries, and 1,088,400 victims. The epicenter was located in Zhaotong City, a medium-sized city located southwest of China. The region has experienced serious natural disasters in recent years and was hit by the YiLang earthquake  in 2012, the Ludian earthquake  in 2014, and a flood in 2016.This longitudinal study included injured inpatients in the Ludian earthquake and treated at the No. 1 People’s Hospital of Zhaotong City. Of approximately 600 injured patients, approximately 200 were discharged from the No. 1 People’s Hospital of Zhaotong City within a week, and 125 were transferred to other hospitals because of the severity of their injuries. In total, 174 patients aged between 10 and 75 years fulfilled the following inclusion criteria: (I) suffered physical injury caused by the Ludian earthquake, (II) treatmented in the hospital for longer than 1 month, (III) had no history of alcohol dependence or addictive drug use; and (IV) had no current pregnancy or breastfeeding; however, 101 injured patients did not meet the inclusion criteria for the study  and was performed in accordance with the Declaration of Helsinki and its later amendments. All participants provided informed consent. Data were collected via face-to-face interviews conducted by four local psychiatrists and individuals who held master’s degrees in psychology from Sichuan university and were trained in group discussion and standardized data collection procedures. The four psychiatrists each held more than 5 years’ work experience and reviewed the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for PTSD and the Clinician -Administered Posttraumatic Stress Disorder Scale (CAPS) prior to the interviews.Participants’ demographic characteristics, including age, sex, ethnicity, educational level, marital status, occupation, earthquake-related disaster exposure, and experiences after the Ludian earthquake were measured via a self-report questionnaire, which included the following questions: (1) Was your house destroyed entirely in the earthquake? (2) Were you buried or did you witness the death of a family member in the earthquake? (3) Did a family member die in the earthquake? (4) Were you with your family members when the earthquake occurred? (5) Have you been diagnosed with any major disease such as hypertension, stroke, heart disease, diabetes, or tumor? (6) Did you experience any major life events, such as the death of a family member , serious injury, disability, or divorce, before the earthquake? All these questions were coded dichotomously as yes/no items (shown in Self-report Interview Questionnaire 1).The PTSD Checklist–Civilian Version (PCL-C) was used to measure self-reported trauma-related stress 1 and 3 months after the disaster. The PCL-C is a clinical self-assessment diagnostic scale consisting of 17 items that correspond to the fourth edition of criteria the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) . ResponsParticipants underwent a structured clinical interview via the CAPS, which was based on 1994 DSM-IV Diagnoses (American Psychiatric Association) , 18 montN = 174) and 3 months (N = 163) after the disaster involved the PCL-C, while those performed at 18 months (N = 147) after the disaster involved the CAPS, administered by four psychiatrists to confirm PTSD diagnosis. To evaluate investigator reliability, we selected 20 of the 147 cases at random for independent assessment by the four psychiatrists. Two of the 20 cases showed inconsistency in the diagnoses formed by the four psychiatrists. Therefore, we concluded that investigator reliability was 90%, and the diagnoses formed by the four psychiatrists showed good inter-rater reliability . It reasonable to speculate that the clinical diagnosis of patients at 18-month are more valuable. Thus, the results of 18-month were reported in detail.All assessments performed at 1 month  is widely used in HRQoL research and has been validated and tested for reliability in some studies and used extensively to evaluate functional and QoL outcomes in injured individuals . The scaP ≤ .05.All data were analyzed using SPSS for Windows (version 16.0). The results of the descriptive analyses are presented as central tendencies for continuous variables and frequencies for categorical variables. The data for scores of the PCL-C, the CAPS and the SF-36 all passed the normality test. We performed t tests for continuous data and 2-sided Fisher exact test for categorical data, to compare differences between two groups (with PTSD and without PTSD at 18 months). Single sample t-test was used to compare the difference between patients and Chinese norms on the SF- 36 scale. The prevalence rates for PTSD were described as a percentage and the 95% confidence intervals for PTSD prevalence rates were calculated using binomial the distribution of these rate. The multivariate logistic regression analysis was performed to identify the independent effects of the predictors of PTSD (dependent variables). In all tests, coefficient values, odds ratios (ORs), and 95% confidence intervals (CIs) were used to quantify correlation strength. All tests were 2-tailed, and statistical significance was set at n = 154). With respect to disaster exposure, 49 of 174 patients had experienced burial and bereavement, 24 patients were separated from their families, and 23 patients were affected by severe injury. The numbers of patients who reported a history of major diseases and life events were 27and 52, respectively.Table n = 11) did not differ significantly from that of participants who attended follow-up assessment . In addition, of the participants who attended follow up at 3 months, PCL-C scores for those who did not attend follow up (n = 16) at 18 months did not differ significantly from that of participants who attended follow-up assessment . Of the participants who dropped out, 74% (20/27) were men and 26% (7/27) were women. Of the participants who dropped out, 7% (2/27) were seriously injured and 93% (25/27) were not seriously injured.As shown in Table Moreover, to understand the reasons for dropout, we randomly selected eight of the 27 participants who had dropped out and interviewed them by telephone to ask about their recovery status and the reasons why they did not wish to participate in the assessments. Three main reasons were reported: some participants had left their settlements or homes to work in other cities; some participants lived far from the assessment of site, which was approximately 4 h’ walk away; and two participants had begun to receive financial and health support from other social organizations. Therefore, it is reasonable to speculate that there were valid reasons for attrition. Most men who dropped out had left to work in larger cities. Further, some participants lived in scattered areas and most lived high in the mountains, and it was difficult for them to attend assessments at community health centers. In addition, both follow-up interviews were conducted in autumn and winter; therefore, it was difficult for participants to attend. Moreover, the rehabilitation assessments might not have provided sufficient support to patients, and participants received more support from the government or other social organizations.The prevalence rates for PTSD assessed by PCL-C at 1 month and 3 months after the earthquake were (40/174) 23%and (22/163)14%respectively. Further, the prevalence of PTSD was (10/147) 7%at 18 months, according the criteria of PTSD . Therefore, the overall prevalence of PTSD decreased gradually following the earthquake. In addition, we checked the individuals with PTSD at 3-month and 18-month. Seventeen of twenty-two individuals who had PTSD at the 3-month assessment were screened positive-PTSD at the 1-month and eight of twenty-two individuals were still diagnosed with PTSD at the 18-month. Meanwhile, seven and eight of ten individuals who had PTSD at the18-month assessment were screened positive-PTSD at the 1-month and 3-month, respectively.n = 10) and non-PTSD (n = 137) groups 18 months after the disaster are summarized in Table P = 0.003), being bereaved 7/10 (70%) versus 39/137 (29%) (P = 0.011), a history of major diseases 7/10 (70%) versus 16/137 (12%) (P < 0.001), and sustained severe injuries 7/10 (70%) versus32/137 (23%) (P = 0.004) in the PTSD group were significantly higher than those observed in the non-PTSD group. Moreover, the proportion of participants in the PTSD group who had undergone physical rehabilitation at 18 months was significantly lower than that observed in the non-PTSD group 6/10 (60%) versus 122/137 (89%) (P = 0.048).The differences in demographic characteristics between the PTSD (P < .05) in the univariate analyses were included in the logistic regression model to identify the independent role of each predictor variable after adjustment, including bereavement, a history of major diseases, severe injury, experience of being buried and rehabilitation at 18 months. The results of the logistic regression analysis indicated that risk factors for PTSD included bereavement , a history of major diseases , and severe injury . The experience of being buried  and rehabilitation at 18 months  were not risk factors for PTSD.The results of the logistic regression to identify factors that predicted PTSD were as follows Table . All sigN = 147) and the general Chinese population (N = 4251). In our study, 46 and 54% of patients was for male and female and the average age (± sd) was 46 ± 17.6 years, old, while among the 4251 respondents of the general Chinese population, male and female respondents accounted for 51% (2154) and 49% (2097) and the average age (± sd) was 41 ± 17.3 years old, ranging from 14 ~ 99 years old [P < .001; PF: 63.80 ± 31.75 versus 87.6 ± 16.8, P < .001; RP: 11.14 ± 30.19 versus 83.0 ± 20.7, P < .001; GH: 47.5 ± 15.23 versus 68.2 ± 19.4, P < .001; VT: 48.26 ± 11.49 versus 70.1 ± 16.8, P < .001; SF: 78.26 ± 19.42 versus 84.8 ± 16.6, P = .001; RE: 23.19 ± 42.15 versus 85.3 ± 17.7, P < .001; MH: 57.00 ± 8.93 versus 78.8 ± 15.4, P < .001). These data indicated that the health status of inpatients injured in the earthquake was poorer relative to that of the general Chinese population.There were differences in health status between the participants  the present results should be considered with caution. Despite these limitations, this was the first study conducted in China to examine QoL and explore PTSD via follow-up research involving inpatients following a disaster. In addition, the findings could contribute to the design of evidence-based interventions to promote QoL and reduce the prevalence of PTSD in injured inpatients.The study was subject to some limitations. First, although PCL-C scores are very strongly correlated with CAPS scores, differences between the results obtained via these diagnostic tools for PTSD remain. In the comprehensive assessment of PTSD, the CAPS is one of the gold standards for use in PTSD diagnosis. In the current study, we used the PCL-C 1 and 3 months after the earthquake and the CAPS 18 months after the earthquake, because the PCL-C involves self-assessment and saves time, while the CAPS is used by psychiatrists and takes approximately 33 ± 16 min to complete . ActuallAdditional file 1. Investigation of Earthquake Impact.


Community-based programs in rural low-and middle-income country settings are well-placed to conduct gender transformative activities that aid program sustainability and catalyse wider social change, such as reducing gender inequities that in turn improve health outcomes. The Anchal program is a drowning prevention intervention for children aged 1–5 years old in rural Bangladesh. It provides community crèche-based supervision delivered by local trained paid-female volunteers. We aimed to identify the influence of the Anchal program on gender norms and behaviours in the community context, and the effects these had on program delivery and men and women’s outcomes.Qualitative in-depth interviews, focus group discussions and observations were conducted with program beneficiaries and providers. Gender outcomes were analysed using FHI 360’s Gender Integration Framework.The Anchal program was found to be a gender accommodating program as it catered for communities’ gender-based roles and constraints but did not actively seek to change underlying beliefs, perceptions and norms that led to these. The program in some cases enhanced the independence and status of female community staff. This changed perceptions of communities towards acceptable levels of physical mobility and community involvement for women. Conversely, gender affected program delivery by reducing the ability of female supervisory staff to engage with male community leaders. The double burden of wage and household labour carried by local female staff also limited performance and progression. Gender-based constraints on staff performance, attrition and community engagement affected efficiency of program delivery and sustainability.The Anchal program both adapted to and shaped community gender norms and roles. The program has well-established relationships in the community and can be leveraged to implement gender transformative activities to improve gender-based equity. Health programs can broaden their impacts and target social determinants of health like gender equity to increase program sustainability and promote equitable health outcomes. Community-based programs in lower-middle income country contexts have a bi-lateral relationship with contextual gender norms, roles and relationshipsThe Anchal drowning reduction program in Bangladesh has affected gender-based norms relating to women’s employment and physical mobilityThe Anchal program is in turn affected by cultural norms and must cater to these, such as hiring only women in child caregiving roles and recruiting fewer female supervisory staff due to mobility and cultural constraintsCommunity-based programs such as Anchal are well-embedded in communities and have the opportunity to be gender transformative and actively seek to change harmful or limiting gender norms and rolesTo enhance uptake and sustainability of community based health programs it is important to highlight the suite of additional beneficial outcomes, such as impacts to wider social norms and other health indicators. These broader outcomes may affect acceptance and implementation of a program, and hence its sustainability –3. CommuWhile community-based programs no doubt affect cultural gender norms, gender-based roles may in turn affect program delivery and sustainability, especially in cases where local women are agents of change or program beneficiaries. Understanding the gender-related constraints local staff face may improve retention and wider community acceptability , 11. FurThe Anchal program is a community-based drowning reduction intervention in rural southern Bangladesh. It hires local women to supervise groups of children in a secured space during daytime when they are most at risk of drowning. Rural communities in Bangladesh typically follow gender-based norms and roles for men and women . Women aWe conducted a gender analysis of the Anchal program aimed at identifying and assessing the bi-lateral relationship between the program and effects on gender norms, roles and relationships. We identified program influences on gender-related context, and how gender influenced program delivery and sustainability. The detailed protocol for this study has been previously published .Qualitative methods were used to develop an in-depth understanding of relationships between the program and contextual gender norms, roles and behaviours in communities. A range of key stakeholders were engaged to ensure perspectives from both program providers and beneficiaries.A drowning mortality survey in Bangladesh found high rates of drowning at 121 per 100,000 children 1–4 years old .Maa (caregiver) and Anchal Assistant, with 20–25 children aged 1–5 years old under their care from 9 am to 1 pm, 6 days a week. The centres are most often located in the home of the Anchal Maa.The Anchal program was introduced in 2016 for the purposes of drowning prevention by a large non-governmental organisation, the Centre for Injury Prevention and Research, Bangladesh (CIPRB), based on a World Health Organization recommendation to keep children in crèches during at-risk hours . CIPRB rAnchal staff  are directly managed by Supervisors employed by the program provider. Of 14 supervisors, three are women. Each Supervisor oversees between 25 and 30 centres. Anchal Maas are also provided ongoing training and support from female Anchal Mentoring Officers (AMOs) in monthly cluster meetings. See Additional file Within each community, program implementers established a Village Injury Prevention Committee (VIPC) comprised of leaders and influential locals. The VIPCs oversee program operations, contribute to community outreach and facilitate Anchal Maa and Assistant recruitment. At the lowest government ward level, Union Injury Prevention Committees (UIPCs) engage government and community leaders bi-annually to update on program progress and gather support.See Additional file The Anchal program is implemented in a rural community setting and is impacted by its social context, including existing gender norms, roles and relationships. We sought to better understand this context using the Gender Integration Framework , which aThe framework was used to analyse how gender interacted with program delivery and affected opportunities, needs, constraints and relationships across the five key domains outlined in Table Data collection was of a qualitative nature with key informant In-Depth Interviews (IDIs), Focus Group Discussions (FGDs) and observations. While IDIs provided insights into individual perspectives, FGDs provided information on community dynamics and norms, and involved between 6 and 8 participants. Observations allowed for a deeper understanding of program settings and interactions between providers, beneficiaries and the community. These data sources were triangulated to provide a comprehensive picture of gender effects. A total of 57 IDIs, four FGDs and three observations were conducted engaging 41 men and 48 women. See Table Qualitative methodology was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ)  once initially approached. Data collection for each participant role ceased once thematic saturation was reached in Phase 2.Anchal Supervisory staff introduced data collectors to the communities, who engaged local leaders to gain appropriate permissions before approaching participants. All participants were recruited and interviewed face to face. All IDIs and FGDs were audio recorded and held in private locations that were accessible for the participant and lasted between 30 min and 1.5 h. Only data collectors and participants were present. Less than 10% of participants refused to participate . Ethical approval was also obtained from the University of New South Wales Human Research Ethics Committee (HC: 180608).All participants were informed on study objectives and freely provided verbal or written consent to participate and be audio recorded (as depending on participant’s literacy). Participant Information Statements were provided in Bangla where required.All qualitative data were transcribed in Bangla and translated into English for analysis by professional transcription and translation agencies. A fluent Bangla and English speaker completed a quality check on all documents to ensure translation and transcription was accurate. Transcripts or findings were not returned to participants due to logistical difficulties and low literacy rates in the region.Analysis of the transcribed qualitative data was assisted by NVivo 12 software . DeductiThis analysis allocated the program along the Gender Integration Continuum , which dLegal rights and status as this refers to impacts of the wider rights and status of women under law.Bi-directional effects of the Anchal program and gender were found. The program was influencing gender norms, roles and relationships in the communities, while also adapting its delivery to cater to these. The results are discussed below as per the types of gender effects along the framework domains. No findings were reported against the domain of Involvement in the program led to changes in access to resources for Anchal Maas and Anchal Assistants hired in the community. As part of the program, Anchal Maas and Assistants opened their own bank accounts to receive their salary.“The Anchal Maas or Assistants … find it a good opportunity. Because community people, especially females, work at home. They do not have access to any income generating activities through which they can earn.” - Women in communities previously had few opportunities for formal employment due to constrained economic conditions and cultural limitations on appropriate work for women. Employment in the Anchal program provided a rare opportunity for women to earn an income.“She makes assets with her earnings, such as making gold ornaments…They also utilize the money in their family businesses.” - “I have children and I spend my money on them. I admitted my son in a better private school and their fee is costly.” - With access to income Anchal Maas and Assistants contributed to family expenses and businesses which reduced financial stress. Anchal Maas purchased fertiliser for their farms, materials for trade or invested in goats and chickens. They contributed to better education for their children with admissions into private schools and tuitions. Greater access to resources such as mobile phones, refrigerators, TVs and other electrical devices improved their overall quality of life.“Previously I would have to demand from my husband if I wanted to purchase anything and ask him several times. Now I can buy anything that I like to buy. There is no problem now.” - In addition to material changes for Anchal Maas and Assistants, access to income improved financial independence. Anchal Maas became less reliant on male family members for money and showed more discretion and efficiency when spending. For example, Anchal Maas were able to quickly purchase emergency medicine if their child was sick.“Still, there are some who don't allow their daughters and daughters-in-law to work outside the home, but as they are working inside the home, they [the Anchal Maa’s family] accept it.” - Within communities, women were considered responsible for household domestic duties and child rearing as per prevailing gender norms. The Anchal program was acceptable to communities as it catered to these gender norms by largely taking place in the women’s homes and involving the care of children.“She goes house to house now. She would not go outside of the home earlier because of criticism, as she is a wife. Now she does not think about that criticism.” - Although the Anchal program upheld norms pertaining to women’s roles, it simultaneously influenced the breakdown of constructive attitudes towards mobility. Culturally, most women in these communities did not travel beyond a few homes alone due to gender-based norms and fears for safety. Anchal Maas, however, travelled within and between communities for training, child enrolment and community meetings. Many Anchal Maas and Assistants’ families were initially concerned about this outside exposure but became accepting as Anchal staff became settled into their roles and fears around safety dispersed with experience. Anchal Maas gained more independence and access to resources as they were free to travel outside the community to places such as markets without taking permission. Anchal Maas and Assistants appeared to be self-assured in their right to independence and chose to ignore negative perceptions from their communities around their mobility.“Nobody gave me any attention before. But now I have become a President for one NGO a few days ago. I go for a meeting every Friday. We receive 20,000 taka and I have the responsibility of managing this money.” - Involvement in the program also challenged the norms preventing women from entering formal employment. Families became more accepting of women working and interacting with program implementing staff, including men. Some Anchal Maas were able to access additional employment because of the knowledge, skills and experience they gained through the Anchal program. Anchal Maas and Assistants developed their own identity as teachers and advisors in addition to their role as a mother, wife or daughter-in-law.“The people of the village think that housewives can’t do anything. But now, they realize that if we let her train a little then she would be able to do a big job.” - These changing perceptions around women’s work influenced the perceived value of educating girls. Anchal Maas also reported that community girls they interacted with felt encouraged to continue their education so they may also 1 day find employment. Lack of exposure to working women also meant that communities may have viewed women as unable to effectively engage with formal work. However, according to both program providers and community members, exposure to the Anchal program shifted community beliefs around the capability of housewives in conducting complex tasks and contributing in the wider community.“The male Supervisors are better able to connect with the decision makers. Suppose a Supervisor met a chairman at a tea shop in the evening and they sat together and had some tea and a chat. My female Supervisors can’t do it…The females get more access to connect with the local people but the males connect better with the decision makers.” - Gender attitudes affected program monitoring staff. Female Supervisors experienced initial difficulty in engaging with male community leaders due to limiting norms around interaction between genders and little community exposure to women in leadership positions. Compared to male Supervisors, female Supervisors sometimes required more time to build rapport with community leaders and gain permission for implementing the Anchal program as leaders were slower to trust and engage productively with them. However, female Supervisors were better able to access households and engage mothers at a community level than male Supervisors due to cultural barriers on interactions between members of opposite genders.“… the AMOs of Kalapara are new in the job. I am working for a long time. I was an administrator in a local NGO...It is better for me.” - Hiring women local to the area as Anchal Mentoring Officers or Supervisors mitigated some of these challenges for female program monitoring staff, as they had pre-existing relationships with the communities.“They have to make the baby’s food, take care of the father-in-law, her husband’s needs, demands of the office. She does a lot of jobs. And we have to create a suitable environment for her to do her jobs well and support her.” - Employment in the Anchal program led to limited changes in the roles of Anchal Maas and Assistants at home. Anchal Maas and Assistants’ responsibilities were still constrained by their defined domestic gender roles and their lower position in the household hierarchy. Anchal Maas and Assistants were expected to carry a double burden, being responsible for both domestic work and child rearing. Anchal Maas and Assistants worked long hours to ensure all their work was completed. Some received support from other women in their family, but often only in return for sharing their income. A major reason for Anchal Maa and Assistant drop out was difficulty in managing responsibility at home with work in the Anchal program.“If you analyse our parent meetings, VIPC meetings, any kinds of meetings that we run, the fathers are not found. The number of fathers is very low. All the mothers remain present. Because most of the people in this area are fishermen.” - Gender roles also reduced the ability of the program to engage effectively with fathers of Anchal children. Although fathers were usually the final decision makers on children’s attendance in the Anchal program, they were more likely to be away for work and rarely available for engagement due to their roles as family breadwinners. Many fathers in the region are fishermen who are absent for weeks at a time. This often slowed initial enrolment. Fathers were also less likely to be educated on the Anchal program activities and injury prevention methods through parent meetings.“If the office provided vehicular support to female staff while working in the field it would be very helpful for us. It's needed only for females, males don't need it.” - Male and female program monitoring staff reported being treated equally within the implementing organisation. However, the lack of differential support catering to gender differences meant that staff were not always able to produce the same outcomes. Female staff struggled with transport and mobility. As it was not culturally appropriate to ride their own motorbikes, female Supervisors were spending more time waiting for shared transport which impacted their productivity. They were also less able to respond to community problems or engagement opportunities that required night-time return travel due to safety concerns.parda system, where women covered their faces in public and were unable to speak directly to men. This system prevented community women from talking to male Supervisors face to face. This adversely affected quality control of Anchal activities and community engagement for male Supervisors.“The women of this area are very sheltered. If our office staff go to them, they [the women] do not want to come out. They do not want to talk. There is a village where the women there will not even come out of the fence. Our supervisor talks with them from outside of their house.” - Conversely, male Supervisors faced difficulty in engaging with Anchal Maas and mothers due to cultural constraints on contact between genders. Male Supervisors were not able to provide Anchal Maas feedback or engage with mothers as effectively as female Supervisors. This was a problem in more conservative communities which follows the “Because when a girl is married her parents don’t have any control over her. Her husband becomes everything for her. She has to do what her husband tells her to do.” - [Anchal Maa]“Some family members like fathers and mothers-in-law also don’t keep their word. They say they will provide a room for the Anchal centre and will give support to Anchal Maa, but they don’t. At that time, it becomes very difficult for the Anchal Maa to continue and then they drop out. If the family doesn’t support the wife, it becomes difficult for that Anchal Maa.” - Although the program encouraged shifts in thinking around women’s participation outside the home, their power to make autonomous decisions remained limited due to their lower place in household hierarchy and men’s roles as main decision makers. Family support was vital for Anchal Maas and Assistants to work. Anchal Supervisors spent considerable time ensuring family support before Anchal Maa and Assistant recruitment. In some instances, family members were invited to visit field offices to meet the larger team to gain their trust. Ongoing permission from Anchal Maas and Assistants’ in-laws, parents or husbands was essential for them to continue in the program. The family decision-making hierarchy where women were often at the bottom usually remained intact.“You would be able to earn a lot working in tailoring. I would get at least 5000 taka wage. If I spend 3 to 4 hours here, I do not get that money…Society considers us [Anchal Maa and Assistant] good as we do great work...I like it very much.” - Anchal Assistants had lower educational qualifications and fewer responsibilities during centre hours, but were present with the Anchal Maa four hours a day and took sole responsibility of the children when Anchal Maas attended monthly cluster meetings. As their salaries were one third of Anchal Maas’, here was a less pronounced effect on access to material resources and financial independence. Many Anchal Assistants were motivated by the social cause of the work and some were foregoing other activities that may generate more income by working in the program.“I do the job, I get 1000 taka – but I do not tell anyone how much I earn. I tell them that I get about 2000 or 2500 taka otherwise there exists no honour for me.” For some Anchal Assistants, the low pay reduced their value in their family or community as it wasn’t considered enough for the number of hours worked. Some Anchal Assistants felt shame and lied about their earnings to others. This partially explained the higher dropout rate of Anchal Assistants compared to Anchal Maas reported by Supervisors.“There she [Anchal Maa] learns so many things, so many tips. Since we are Assistant, we have to learn from her. That’s it. In addition to this, if something more is required to learn, then there should be one training for us as well. Suppose, if there will be one training for us in each month, then shouldn’t we participate in it? Couldn’t we learn so many things?” Anchal Assistants were also provided fewer opportunities for skill development and support from the Supervisors and AMOs, who concentrated their efforts on Anchal Maas. This led to lower engagement in the program and poorer development of their capabilities, possibly reducing their ability to access other employment or opportunities compared to Anchal Maas.Based on the criteria for program allocations along the Gender Integration Continuum and the above findings, we found the Anchal program to be a gender accommodating program . As per Our findings suggest that while the Anchal program was delivered in line with gender norms in rural Bangladesh, it did not actively seek to change them. Gender transformation usually occurs once a program is well embedded in the community . At the At the time of the study, the Anchal program could not be considered a gender transformative program as it did not systematically employ strategies to change harmful or limiting gender norms and relationships that can improve program sustainability and the social position of women involved in it . One oppRetention of Anchal Maas and Assistants may be improved by assessing the impact of the double burden of work and home duties. Solutions to improve conditions for Anchal Maas and Assistants at home may be brainstormed with the community, such as through gender sensitisation workshops and discussions which have been implemented in health programs internationally , 42. In As programs are impacted by their social context, the approach the Anchal program took in adapting delivery to gender roles, such as hiring women for childcare roles and more male Supervisors for leadership and community leader engagement roles, initially supported the implementation of the drowning program at the ground level. The program appeared to have acceptability in the view of communities who were generally supportive of hiring community women as Anchal Maas and Assistants and were also ready to accept some changes in their access to resources and mobility in return for their good work. As most community health workers in rural health programs in LMICs are women, being cognisant of gender attitudes and roles ensures that these workers are supported and retained , 46, 47.Lastly, public policy structures and incentives can play a role in ensuring programs take gender transformative actions. For examples, cash incentives to parents to send girls to school have been effective in increasing girl engagement in developing countries, and similar policies can be applied to improve girl participation in physical education classes like swimming . Policy Legal rights and status. A longer study period and additional methods such as interviews with local government-level key informants may have revealed program influences on gender norms, roles and relationships mediated by women’s legal rights and status.No findings were reported on the effect of wider legal structures and context on gender as per the Gender Integration Framework domain of The Anchal program is integrated in southern Bangladeshi communities and has been able to adapt to and shape gender norms and roles. However, further opportunities exist for the program to take strategic steps towards ensuring gender equity in social and health outcomes as well as program sustainability. Identifying and implementing initiatives that empower program provider staff, community staff and the wider community to challenge harmful gender-based norms and beliefs would move the program from being gender accommodative to gender transformative. These may include hiring and supporting supervisory female staff to change norms around working women, engaging communities in discussions relating to division of household work and child rearing between genders, and engaging males in childcare work. This has implications for men and women’s equity, health and financial outcomes, as well as for program success.Additional file 1. Organisational chart of the Anchal program.Additional file 2. Logic model for the Anchal program.Additional file 3. COREQ  Checklist.Additional file 4. Codebook


Exposure to patient or user suicide (PUS) is identified as a challenging occupational hazard for mental health and social work professionals. Professionals exposed to PUS may encounter several ranges of emotional, traumatic or professional impacts in the aftermath. A high proportion of exposed professionals reports a lack of support in the aftermath of PUS. SUPPORT is a postvention program designed to provide a comprehensive, adaptative and effective support to professionals impacted by PUS. The aims of the SUPPORT-S study are to (1) improve the design of the SUPPORT program, (2) evaluate the effectiveness of the program to buffer the emotional, traumatic and professional impacts and to improve the perceived social support for professionals exposed to PUS, and (3) provide more insights into the consequences of PUS on both professionals and organizations.Differential Emotions Scale IV); (b) traumatic impact ; (c) professional impact ; and (d) perceived social support . The action research design will rely on: (a) the cycling process of implementation/evaluation/data sharing/adjustment and (b) the participatory approach through data sharing with providers and participants. Triangulation, saturation, randomization, and participatory design will also reduce the risk of biases and will improve the generalizability of conclusions.The SUPPORT-S study is a mixed method collaborative and participatory action research. The simultaneous and complementary collection and analysis of qualitative and quantitative data will offer an in-depth evaluation of the implementation and the effectiveness of the program. The qualitative evaluation includes: (a) an ethnographic observation; (b) 25 semi-directed interviews with randomized participants; (c) an activity analysis with providers of the program; and (d) collaborative sharing of the results with providers and participants. The quantitative evaluation includes pre- and post-measures in participants of: (a) emotional impact (We expect the SUPPORT-S study to evaluate and improve the design of the SUPPORT program to effectively help professionals to cope with PUS.The results of the study will allow us to disseminate an effective and adaptive postvention program for professionals and institutions encountering PUS. Exposure to patient or user suicide (PUS) has been identified as a frequent and challenging occupational hazard for mental health and social work professionals . For insPostvention refers to the activities developed in the aftermath of a suicide to prevent negative health outcomes and facilitate recovery among the bereaved . DespiteHence, research dedicated to the development and evaluation of comprehensive and adaptive programs providing support to mental health professionals and social workers exposed to PUS is needed. In line with this urgent need for social change, this article aims to describe (1) the design and implementation of a postvention program (SUPPORT) for professionals exposed to PUS and (2) the protocol of the SUPPORT-S research-action study evaluating and improving the design of the SUPPORT program to effectively help professionals to cope with PUS.The Center for Suicide Prevention (CSP) is an ambulatory care unit located in Lyon, France, that provides several types of suicide prevention activities, including brief contact interventions for people showing suicidal ideation or those who attempted suicide, outreach interventions for people showing suicidal behaviors, postvention counseling for individuals or family bereaved by suicide and information and training on suicide prevention.According to the model of support for professionals after adverse events developed by Inspired and adapted from the STTIM, SUPPORT is a 6-week program divided into four distinct stages. The three following stages are mandatory: (a) basic emotional first aid at the local level; (b) team-based 1- to 2-h supportive intervention in the institution; and (c) follow-up, late detection. A fourth optional stage including long-term support and training or workshops on suicide prevention may be provided to professionals. The objectives of the SUPPORT program are to (1) buffer the traumatic, emotional and professional impacts in professionals, (2) improve the support perceived by exposed professionals, and 3) promote the return to normal functioning in the institution exposed to PUS.The first stage of the program includes early contacts by the CSP with the head of the exposed team  to provide them with an organizational framework of structured and synchronized crisis management. According to the guidelines for postvention interventions , the objThe team-based intervention consists of a 1- to 2-h intervention in the institution where the suicide occurred, driven by two professionals  from the CSP in the month following a PUS. All of the exposed professionals are invited to participate in the intervention, during which a debriefing of the event and its impacts is performed. Exposed professionals are offered a supportive space to freely express their feelings about, emotions toward and experience of PUS. The intervention on the entire team aims to buffer the emotional, traumatic, and professional impacts, both in individuals and in the working team. In particular, the presence of the professionals who discovered the corpse or performed resuscitation techniques, those who were the closest of the deceased and those who were the most impacted is encouraged. Stage 2 thus aims to provide professional emotional aid at institutional level, through an in-depth team-based debriefing intervention.The third stage of the program seeks to perform late detection and counseling support for professionals who are strongly affected or traumatized by exposure to PUS. Those who feared attending the team-based intervention stage may notably receive individual debriefing during this stage. Stage 3 aims to promote the return to normal functioning in the institution, at both the individual and organizational levels. When stage 3 has not been effective in ensuring the recovery among professionals, a fourth stage can be added to properly support the impacted team.This optional stage is notably delivered if several suicides occurred or if the whole team is highly impacted by the suicide(s). The support of the management team and the close collaboration with the CSP are the most important components of this stage. A second debriefing intervention or a 3-hour suicide prevention training may be provided to the whole team. Workshops on the means and actions seeking to improve the prevention of suicidal behaviors or the support of professionals in the exposed setting are encouraged and organized, to involve impacted professionals in proactive and meaningful actions related to PUS. Stage 4 can last from one to three months and aims to provide in-depth long-term support for teams and institutions that have been strongly impacted by PUS.The primary objective of the SUPPORT-S study is to improve the design of the SUPPORT program through the participatory involvement of professionals who deliver the intervention and those who receive it.The SUPPORT-S study aims to evaluate the effectiveness of the SUPPORT program to buffer the emotional, traumatic and professional impacts and to improve the perceived social support for professionals exposed to PUS. The SUPPORT-S study also seeks to provide more insights into the consequence of PUS on both professionals and the organization and to identify markers that may help in implementing programs adapted to different professional settings.The SUPPORT-S study will take place in Rhône, France, which is the geographical area of intervention for the CSP. The SUPPORT program is designed to be implemented in the following institutions: psychiatric hospitals, general hospitals, nursing homes and social work institutions. The study will start in February 2020 and last 18 months. Every psychiatric and general hospitals, nursing homes and social work institutions of the geographical area will receive in February 2020 detailed information on the SUPPORT-S study. A mail and an email will be sent to all executive managers.Every professional working in the institution in which PUS occurred are eligible for participation in the SUPPORT-S study, without any exclusion criteria. Only professionals who do not agree to participate will not be included in the study but they will receive the postvention intervention if they wish to. The eligible professionals will be informed of the concepts, design and running of the study through an information sheet and oral explanations at inclusion.SUPPORT-S is a mixed method collaborative and participatory action research study, including a total of five SUPPORT interventions over a total of 15 months . SUPPORTin situ between researchers and participants to develop a process through knowledge building and social change  will be allowed to express their feelings about and experience with the SUPPORT program to propose adjustments for the program. The discussion, revision and validation of the results by the participants ensure their social relevance for the modification of practices in the institution and the implementation of new professional postures in professionals. This approach thus has a transformative role in the pluri-professional collective workforce rather than only focusing on individuals by involving them as active actors and not only participants of the research  implementation, (b) qualitative and quantitative evaluation, (c) collaborative sharing of the results, and (d) adjustment of the program according to the restitution and evaluation  and after (T1) the SUPPORT program among professionals exposed to a PUS. Sociodemographic data and information on the therapeutic relationship with the deceased will be collected at T0. A pre/post measure of emotional, traumatic and professional impacts and perceived social support will be performed at T0 and T1.The following sociodemographic characteristics of participants will be collected at T0: age, gender, profession, and years spent working in the organization.The following information on the relationship between the professional and the event or the patient or user who died by suicide will be collected at T0: connection with the deceased, discovery of the corpse, resuscitation techniques used, being at work or not the day of the event, and therapeutic alliance with the deceased.Impact of Event Scale-Revised  and modifications in practice. The participants will be asked through close-ended questions about the self-perception of their effectiveness at work, the perception of modification in their professional practice and the type of modification that they perceive. Regarding the self-reported modifications in professional practice, a fear and avoidance of suicidal patients, an increased tendency to hospitalize patients, a fear of granting passes for patients and a prolonged duration of hospitalization are considered negative professional impacts. A better assessment of suicidal ideation in patients, an increased tendency to ask advice to colleagues, a better trackability of information in patients’ files and an interest in suicide prevention are considered positive professional impacts. Regarding self-efficacy, the perceived loss of self-confidence or self-control and perceived difficulties in problem solving or decision-making will be considered as negative professional impacts. The presence of at least three items indicating a negative impact on professional practice or self-efficacy will be considered as a negative professional impact.Perceived Social Support Scale for Professionals  to collect in-depth observational data on the implementation of the program. The observation will notably focus on the reaction of the professionals exposed to PUS, and how they manage and experience the implementation of the SUPPORT program. The interactional processes between professionals delivering the program will also be examined.An individual semistructured interview at the end of the program. The semistructured interviews will last between 30 and 60 min and will be performed by one or two social researchers  in the workplace of participants. The participants will be interviewed regarding their individual experience of the SUPPORT program, including: how they perceived the program for themselves and for their team, which mechanisms led to its effectiveness and how the program could be improved. The content of the interview will be recorded and anonymized.For each intervention, five exposed professionals will be randomly selected to participate in an activity analysis will be performed with the providers of the intervention. An activity analysis is an effective means to analyze complex processes occurring in professional practices   . We wills, etc.) . Regardis, etc.) . To perfThe inclusion of 150 exposed professionals is expected for the collection of quantitative data. Considering the five local implementations of the SUPPORT program throughout the SUPPORT-S study, the inclusion of 150 exposed professional is needed to observe a 30% decrease in the mean IES-R score between T0 and T1 with a 90% statistical power.Of them, a total of 25 professionals will participate in the semistructured interviews. According to previous qualitative studies on professionals’ experiences of adverse events in which similar  or lowerThe quantitative and qualitative data collected in the study will be separately analyzed through independent statistical and qualitative analyses.t-test or non-parametric sum rank test for matched samples, depending on the distribution of the variables. Then, the proportion of subjects above the cut-off scores will be compared between T0 and T1 using the McNemar test. For the main outcome criteria analysis (IES-R score) a multivariate analysis will be conducted using a multivariate linear mixed model to adjust for main confounders: age, gender, profession, relationship with the decease. All tests will be two-tailed and the statistical significance threshold will be set at 5%.Data manipulation and analyses will be performed using R software (R 3.4.1). Qualitative variables will be summarized using numbers and percentages, and quantitative variables will be described using either means and standard deviations or medians and interquartiles. Quantitative variables will be analyzed with the appropriate test, depending on the application conditions. The evolution between T0 and T1 of the following four dependent variables will be measured: (1) PTSD reaction (IES-R > 24), (2) high emotional impact (DES-IV > 108), (3) negative professional impact , and 4) low perceived social support (P3SP < 12). For each variable, the total scores will be compared between T0 and T1 using paired Student’s Based on the narratives of the semidirective interviews, a content analysis will be performed, with several chronological phases  . AccordiFinally, the results issued from the two methods will be grouped and organized through a coding scheme.The SUPPORT-S study is funded by the Scientific Research Committee from the Centre Hospitalier le Vinatier and University Lyon 2. The study received ethical approval from the Ethical Review Board Sud-Est IV of Clermont-Ferrand (registration number 2019/CE67).Although the impact of PUS on mental health professionals and social workers has been well described, the SUPPORT-S study will be the first to evaluate the effectiveness of a postvention program for professionals exposed to PUS. The mixed method and action research design will allow us to collect both in-depth qualitative and quantitative data on the effectiveness of the implementation of the SUPPORT program. The multidisciplinary approach through the collaboration of researchers and clinicians from different disciplines and theoretical backgrounds is another strength of the study, as it will improve the strength and generalizability of our conclusions. While previous studies have relied on retrospective data collection through large surveys or qualitative interviews , the longitudinal design of the current study will offer new insights and perspectives on PUS and its impact on professionals and institutions.Triangulation refers to the use of multiple methods or data sources in qualitative research to develop a comprehensive understanding of phenomena , and (d) data saturation . The saturation used in the SUPPORT-S study will focus on the data saturation and the inductive thematic saturation. The participatory approach is an effective means to limit the misinterpretation of the collected data by the researchers. The involvement of participants in the restitution process promotes the ability to adjust the program as well as the conclusions issued from the research through their direct comments of the results.Our study protocol has several limitations. First, the non-controlled design prevents us from making definitive inferences on the effectiveness of the program. The use of a research-action approach may also limit the representativeness of the sample, induce selection biases and limit the ability to avoid misinterpretation in the researchers’ conclusions. Second, the SUPPORT-S study is a monocentric study performed in the French context. This setting may impede the generalizability of our conclusions and results, due to the particularities of the French health system and social policies. Finally, the small number of local implementations (5) may limit the power of our results and conclusions. However, the following four main bias limitations will be used in the SUPPORT-S study: (a) triangulation, (b) randomization, (c) saturation, and (d) participatory approach. henomena . Denzin analysis . AccordiHealth and social work professionals are frequently exposed to PUS and may encounter several ranges of emotional, traumatic or professional impacts in the aftermath. The lack of support in the aftermath of PUS has been reported by a high proportion of exposed professionals, indicating the urgent need to implement and evaluate innovative programs dedicated to facilitating recovery and preventing negative health outcomes after a PUS. The SUPPORT program is a postvention program designed to provide comprehensive, adaptative and effective support to professionals impacted by a PUS. The SUPPORT-S study is a mixed method collaborative and participatory action research project aiming to (1) improve the design of the SUPPORT program, (2) evaluate the effectiveness of the SUPPORT program to buffer the emotional, traumatic and professional impacts and to improve the perceived social support for professionals exposed to PUS and (3) provide more insights into the consequences of PUS on both professionals and organizations. The simultaneous and complementary collection and analysis of qualitative and quantitative data will offer an in-depth evaluation of the program’s implementation and effectiveness. The action research design will also improve the limitation of biases and improve the generalizability of the conclusions. The results of the study will allow us to disseminate an effective postvention program for professionals and institutions encountering PUS.The studies involving human participants were reviewed and approved by Comité de Protection des Personnes Sud-Est VI. The patients/participants provided their written informed consent to participate in this study.EL, MP-T, NC, BCh, and EP contributed to the conception and design of the SUPPORT program. EL, BCu, MV, NC, A-FP, JH, and CD-B contributed to the conception and design of the study. EL wrote the first draft of the manuscript. BCu, AF, JH, and CD-B wrote the sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Ganoderma biomass, ergosterol concentration, BSR disease progress and to validate the efficiency of microwave assisted extraction (MAE) method for extraction of ergosterol compound. In addition, testing on the sensitivity of thin layer chromatography (TLC) analysis for detection of ergosterol was also the aim of this study. The optimised procedure involved extracting a small amount of Ganoderma-infected oil palm root tissues suspended in low volumes of solvent followed by irradiation in a conventional microwave oven at 70°C and medium high power for 30 s, resulting in simultaneous extraction and saponification. Based on the results obtained, MAE method may be effective in extracting low to high yields of ergosterol from infected oil palm roots demonstrating disease scale 2, 3 and 4. Positive relationship was observed between ergosterol content and inoculation period starting day 3 in the inoculated oil palm seedlings and hour 6 in germinated seeds. TLC analysis demonstrated a good correlation with high performance liquid chromatography (HPLC) quantification. Therefore, a semi-quantitative TLC analysis may be applied for handling a large amount of samples during onset field survey.Basal stem rot (BSR) is a devastating disease to Malaysian oil palm. Current techniques employed for BSR disease detection on oil palm are laborious, time consuming, costly, and subjected to accuracy limitations. An ergosterol detection method was developed, whereby it correlated well with the degree of infection in oil palm. This current study was designed to study the relationship between  Ergosterol was detected as early as six hours and three days after inoculation with oil palm’s germinated seeds and seedlings respectively.The concentration of ergosterol increased with the inoculation period and disease severity.For infected field palm, ergosterol was detected from all sample categorised in scale 2, scale 3 and scale 4 and absent in scale 1 palms.Elaeis guineensis) is a monocotyledon in the family Arecaceae  within the subfamily Cocosoideae , vascular wilt, spear rot-bud rot, sudden wither and red ring . However disease . An earl disease  as well anoderma . For insanoderma  and ELISanoderma . Hence, Ergosterol is part of cell wall component of a fungus which is exclusively found in higher fungi and absent in other organisms . ErgosteFirst data published on the use of ergosterol analysis as a diagnostic method to detect BSR supports the view that ergosterol exhibits the effectiveness for detection of BSR in oil palm   analysis for detection of ergosterol in artificially inoculated germinated seeds, artificially inoculated oil palm seedlings and infected oil palm field tissues was another objective.Hence, the present study was undertaken to establish relationship between G. boninense was isolated from a basidiomata of an infected oil palm trunk in Felda Gua Musang, Malaysia using Ganoderma selective medium (GSM) (A pure culture of um (GSM) .Ganoderma culture. DNA was extracted using the modified CTAB method of Ganoderma specific primers (Gan 1: 5’ TTG ACT GGG TTG TAG CTG 3’ and Gan 2: 5’ GCG TTA CAT CGC AAT ACA 3’) (Molecular identification was conducted to confirm the  ACA 3’)  and 9.5 Extraction of ergosterol from roots tissue were carried out using MAE method based on the procedure by Rf value was calculated using this formula:TLC was carried out to detect the presence of ergosterol from the extracted root tissues. TLC detection was undertaken based on An Agilent 1100 series HPLC equipped with a Diode Array Detector (G1315B), a pump (G1311A), and an auto sampler (G1313A) was used for quantification of ergosterol using an Ascentis express 2.7 μ C18 reverse-phase column . Operating conditions was based on Germinated seeds (Dura × Pisifera) used were supplied by Sime Darby Research Centre, Banting, Selangor. They were maintained in sterilised sand containing Hoagland solution for two weeks to allow rooting.G. boninense (T1) and inoculated with G. boninense (T2). The germinated seeds were uprooted carefully and rinsed with distilled water. Germinated seeds for treatments (T2) were placed into 45-culture jar containing MAE slant culture of G. boninense (isolated from Gua Musang Felda) with three roots per culture jar. Non-inoculated germinated seeds (culture jar containing only MEA) were used as negative control. Random samplings of the experimental materials were done over a period of 6, 12, 24, 48, 72, 96, 120, 144 and 168 hours after inoculation with five culture jars per sampling time. All the roots were pooled and subjected to detection and quantification of ergosterol and further confirmed with PCR using modified method by The experimental design for this experiment was complete randomised design (CRD) consists of two experimental treatments: Non-inoculated with The experiment was repeated using six month old oil palm seedling (Dura × Pisifera) supplied by Sime Darby Research Centre, Banting, Selangor. The seedlings were maintained in polybags in the glasshouse until five to six leaf stages. The seedlings were watered daily and fertilised with NPK fertiliser (10 g per polybag) at monthly interval.G. boninense colonised rubber wood block (RWB) (T1) and inoculated with G. boninense colonised RWB (T2). The seedlings were uprooted carefully and transplanted into polybags (size 12 cm × 15 cm) containing 3 kg soil mixture (3:2:1 v/v/v topsoil: peat: sand). Treatment (T2) was inoculated with a G. boninense mycelium colonised RWBs placed in contact with the roots  for internal and external symptoms of roots tissues and foliar symptoms was calculated based on formula derived from A visual assessment of BSR infection was determined by examining the roots and foliar symptoms of the seedlings. The seedlings were also split longitudinally to observe root and bole decay and to visually assess the severity of the symptoms based on the proportion of number of lesion (rotting) roots. The estimation was based on the scale modified from 2 in a mortar and a pestle into fine powder. Samples were subjected to MAE extraction, TLC and HPLC analysis.Oil palm tissue samples were collected from high BSR disease incidence plot at Serting Felda Plantation Berhad, Negeri Sembilan. Mature palms aged 13 years old were randomly chosen based on the appearances of external symptoms of BSR disease and were categorised into scale 1, scale 2, scale 3 and scale 4 with 15 palms for each category . Tissue P ≤ 0.05). Correlation analysis was performed using Microsoft Excel 2007.The data were analysed using SAS Release 6 (SAS Institute Inc. 1990). Triplicate determinations of ergosterol concentrations from each sample were analysed using ANOVA and means were compared by Least Significant Difference (LSD) . These concentrations apply for all the sampling periods determined from hour 6 to hour 168 after inoculation. Ergosterol was detected by visual evaluation image of TLC plates under UV-light in all inoculated seedlings .Rf values of all samples were similar with that ergosterol standard spot with the value of 0.68. However, the ergosterol spot intensity under UV-light was faint and no detectable differences in inoculated seedlings at 6, 12, 24, 48, 72, and 96 hours after inoculation. However, the spot intensity increased gradually at hours 120, 144 and 168 after inoculation. High performance liquid chromatography analysis showed that ergosterol concentration increased with the increase of inoculation period   .Ganoderma specific primer Gan1 and Gan2 were analysed with 1.5% agarose followed by ethidium bromide staining showed visible band for the inoculated germinated seeds on the expected region at 150–200 bp, while no visible band was observed for the un-inoculated germinated seed  amplification with ted seed . Gene baGanoderma sp. detected on the root   .f values of all samples were similar to that ergosterol standard spot with the value of 0.68cm. However, the ergosterol spot intensity under UVlight was faint and no detectable differences was found in inoculated seedlings at day 3, 7, 14, and week 4. Nonetheless, the spot intensity increased steadily from week 8 to week 28.Ergosterol was detected in different concentrations in all inoculated oil palm seedling roots from the samplings of day 3 to week 28. Ergosterol was also detected via images of TLC plates under UV-light in all inoculated seedlings . The Rf High performance liquid chromatography analysis showed ergosterol concentration increased parallel with the in internal and external disease severity from week 4 to week 28 .−1 on week 28 with 100% external and internal disease severity where most of the palms were already dead while the lowest ergosterol concentration was 1.04 μg g−1 on day 3 with no observation of external and internal disease severity. A parallel correlation was observed between the internal disease severity with the ergosterol concentration (R2 = 0.95) and external disease severity with the ergosterol concentration (R2 = 0.85)   and S5 rG. boninense showed the presence of mycelium on the surface of the roots causing lesion and rotting to the roots, and the damages were observed increasing from day 3 to week 28 after inoculation  which is similar to Rf value of the ergosterol standard spot. The intensity of the spot increased in samples from scale 4, where the disease symptoms appeared as the appearance of foliar symptoms and presence of basidiomata at base of trunk.Ergosterol was detected from all sample categorised in scale 2, 3 and 4 and absent from the scale 1 palms when analysed via visual evaluation of images with RP-18 Silica coated TLC plates (Merck) in UV-light based on the ergosterol standard spot. . The Rf −1, respectively  5.95–14.4 μg g−1, and  17.11–39.33 μg g−1.In the HPLC analysis, ergosterol was identified by comparison of the retention time of ergosterol standard in all field palm samples. The ergosterol peak was well resolved and eluted at average of 7 min and the UV absorbance spectrum of ergosterol was clearly detected at 282 nm. The average concentration of ergosterol for scale 2, 3 and 4 were 6.31, 9.27 and 22.65 μg gectively . The ergG. boninense ergosterol concentration in artificially inoculated oil palm seedlings increased directly with the increase of inoculation period from day 3 to week 28. This finding was supported by et al. (2011). This research also carried out an experiment on oil palm germinated seeds to study the relationship between inoculation time and ergosterol concentration and also to observe the earliest ergosterol detected prior inoculation with Ganoderma. From the results, ergosterol was detected as early as six hours after inoculation which means that ergosterol can be detected once the fungus start to colonise the root; thus, indicates that G. boninense mycelial mass colonising the oil palm roots increases in abundant as a sign of disease progression following the period of inoculation. Diaporthe phaseolorum, causal agent of Phomop sis seed decay, and Cercospora kikuchii, causal agent of leaf blight and purple seed stain and biomass of these pathogens on the host plant. The findings of the present study was also inline with G. boninense’s ergosterol concentration and oil palm disease severity was recorded both internally and externally in artificially inoculated oil palm seedlings. The current findings were supported by a study conducted by −1 on week 28 with 100% root infection, while the lowest ergosterol concentration was 1.04 μg g−1 on day 3 after inoculation with no visible root infection. Detection of ergosterol as early as day 3 after inoculation indicated rapid disease establishment by G. boninense in the root tissues. In support to this finding, Ganoderma infection on artificialy infected oil palm seedling roots were visible via SEM,Transmission Electron Microscopy (TEM) and plant defense response against Ganoderma attack via plant metabolites were also identified after 24 hours of inculation period. In contrary, G. boninense inoculated oil palm roots after 3 weeks. This result was in contrast with the present study, and this could be due to the sample preparation before extraction. Whereby in the present study, roots were not washed or surface sterilised prior to ergosterol extraction, which enabled ergosterol detection on the colonised root surface tissues. Ergosterol was found in high concentrations as a fungal cell wall component : Lane 5–13.Figure S2PCR amplification of inoculated and non-inoculated germinated seeds. L1, non-inoculated germinated seed; L2–L10, inoculated germinated seeds ; M: 100bp Marker.Figure S3Ergosterol detection from uninoculated and inoculated oil palm seedlings by TLC. Ergosterol standard: Lane 1; Uninoculated seedlings: Lane 3–6; Inoculated seedlings : Lane 7–16.Figure S4G. boninense.Relationship between ergosterol concentrations detected via HPLC and internal disease severity of oil palm seedling from Figure S5G. boninense.Relationship between ergosterol concentrations quantified via HPLC and external disease severity of oil palm seedling from Figure S6Comparison between healthy root and damage root: (A) Healthy root; (B) Arrow shows root with the presence of white mycelium 3 days after inoculation; (C) Arrow shows rotting root; (D) Arrow shows lesion of root 16 weeks after inoculation.Figure S7Comparison between healthy palm (left) and infected palm (right) at 16 weeks after inoculation. Infected palms show stunted growth.Figure S8Comparison between (A) healthy bole and (B) infected bole 20 weeks after inoculation.


The Great East Japan Earthquake devasted the old community in coastal areas characterized by primary industry. The number of unemployed people increased from 150,000 to 190,000 after the earthquake. All of the adult residents of Shichigahama (18 years old or older), located in the coastal area of the Miyagi prefecture, whose houses were totally or majorly damaged, were recruited for a survey conducted in October 2011. All of the residents who responded with written informed consent were included in this study. Among 904 individuals who had a job before the Great East Japan Earthquake, 19% became unemployed. Concerning gender and age, 9% of young men, 34% of elderly men, 21% of young women, and 49% of elderly women became unemployed. Concerning the type of industry, 38%, 15%, and 16% of people who had belonged to the primary, secondary, and tertiary industries, respectively, before the disaster became unemployed. Those who became unemployed exhibited a significantly higher risk of insomnia compared to those who maintained jobs. The study pointed out the severe impact of the Great East Japan Earthquake on populations who had belonged to the primary industry, especially among elderly women, and its effect on sleep conditions. The Great East Japan Earthquake that occurred in 2011 caused massive damage to the coastal area of northeastern Japan, killing more than 15,000 people. The disaster impacted the social environment, including the employment status and economic conditions of communities [It has been reported that disasters greatly affect employment status and economic conditions  and thatThe relationships among disasters, employment status, economic conditions, and mental health conditions have been evaluated in communities affected by disasters. A study one year after the 2001 terrorist attacks on the United States suggested that unemployment and exposure to adverse work conditions, particularly high levels of perceived work stress, could be important determinants of the persistence of posttraumatic stress after a disaster . AnotherWhile there might be common relationships among employment status, economic conditions, and mental health conditions in communities affected by a disaster regardless of its type, there might also be relationships among employment status, economic conditions, and mental health conditions unique to the type of disaster. It is necessary to evaluate the relationships among employment status, economic conditions, and mental health conditions in each disaster. The impact of the Great East Japan Earthquake on employment status and the relationships among employment status, mental health conditions, and sleep status in communities affected by the Great East Japan Earthquake have not been fully evaluated. It is important to collect this information, including data about the mental health conditions of residents, to proceed with the recovery of the affected communities. The impact of disaster and recovery processes can be influenced by structural industry characteristics  of the affected community. As a specific issue concerning coastal areas severely damaged by the Great East Japan Earthquake, the primary industries of these communities were fisheries and agriculture, and many people who were older than 65 years old were engaged in these industries , therefoThe aims of this study were to profile the impact of the Great East Japan Earthquake on employment status and to investigate the associations between employment status and mental health conditions considering the structural industry characteristics of the affected coastal area. The total subjects were classified into three groups: (1) people who had not worked before the earthquake; (2) people who became unemployed after the earthquake; and (3) people who continued to work after the earthquake; differences in sleep conditions, psychological distress, and posttraumatic stress reactions among these three groups were evaluated to test the hypothesis that mental health conditions of people who became unemployed after the earthquake might be worse than those of people who had not worked before the earthquake or people who continued to work after the earthquake.An explanation of the survey, an informed consent form, and questionnaires were distributed to all of the adult residents of Shichigahama (18 years old or older), located in the coastal area of the Miyagi prefecture at the onset of the Great East Japan Earthquake, whose houses were totally destroyed or severely damaged by the disaster based on the publicly standardized assessment by the local government for damage certificates. The survey was conducted in October 2011 as part of an annual survey conducted as a collaborative health survey between Shichigahama and Tohoku University. All of the residents who responded with written informed consent were included in this study.The survey consisted of self-administered questionnaires to grasp the health and life conditions of the affected residents. Of the 2456 residents who satisfied the above criteria, 1550 (63.1%) completed the survey with written informed consent. Among them, 1494 subjects (710 men and 784 women) completed the questionnaire about employment status before the earthquake, which was subjected to analysis.The average age of the subjects was 55.3 years old (SD = 18.2). Considering the characteristics of the coastal communities inundated by the tsunami, the employment status of people aged 65 years old and older was considered because a considerable number of residents worked in the fishery or agriculture industry, and this population tended to work even after turning 65 years old, while the majority of employed persons retire at 65 years old at the latest in Japan. Of the total residents, the number of elderly people aged 65 years old or older was 841. Among them, 566 (67.3%) responded to the survey with written informed consent. Among them, 526 (229 men and 297 women) completed the questionnaire for employment status before the disaster.Changes in the employment status of the subjects before and after the earthquake were profiled for each subpopulation classified by age, gender, and job type. The subjects were asked to select “yes” or “no” for a question about employment status: “did you have a job before the earthquake”? If they answered “yes”, they were asked to select one or more from the occupational categories “agriculture”, “fishery”, “mining”, “construction”, “manufacturing”, “electricity, gas, water supply”, “information or communication”, “transportation or postal”, “wholesale or retail”, “financial or insurance”, “service industries ”, “education, medical, welfare, or public affairs”, and “other.” The subjects were then asked to select either “altered” or “no change” regarding changes in employment status caused by the earthquake: “was your employment status changed by the earthquake?” If they selected “altered”, they were asked to select one or more from the following options: “started a new job (including job change)”, “unemployed”, “stayed employed with increased earnings”, “stayed employed with decreased earnings”, and “other” for the question “how did it change”? People who answered that their employment status was altered by the earthquake and they became unemployed were regarded as having unemployed status due to the earthquake. Among the occupations, “agriculture” and “fishery” were classified as the primary industries; the “mining”, “construction”, and “manufacturing” industries were classified as the secondary industries; and the “electricity, gas, water supply”, “information or communication”, “transportation or postal”, “wholesale or retail”, “financial or insurance”, “service industries ” industries, and “education, medical care, welfare, or public affairs” industries were classified as tertiary industries, according to the Japan Standard Industrial Classification .This survey’s questionnaire also included inquiries about perceived economic conditions; habits of eating, smoking, and drinking alcohol; physical conditions, sleep conditions evaluated by the Athens insomnia scale (AIS) ,18; psycThe AIS is a self-reported questionnaire to evaluate sleep difficulty and is scored with a four-point scale. The first five items assess sleep induction, awakenings during the night, final awakening, total sleep duration, and sleep quality. The next three items assess well-being, functional capacity, and sleepiness during the day . The JapThe K-6 has been widely used for epidemiological surveys detecting problems in mood and anxiety. The participants were asked whether during the past 30 days they had felt “nervous”, “hopeless”, “restless or fidgety”, “so depressed that nothing could cheer you up”, “that everything was an effort”, or “worthless.” Each question was rated on a five-point Likert scale from zero (none of the time) to four , with higher scores signifying worse mental health conditions . The JapThe IES-R is a 22-item self-rating scale to evaluate traumatic stress symptoms developed by Weiss . The scaThe total subjects were classified into three groups: (1) people who had not worked before the earthquake; (2) people who became unemployed after the earthquake; and (3) people who continued to work after the earthquake; differences in the AIS, K-6, and IES-R among these three groups were evaluated by one-way analysis of variance using JMP statistical analysis software   to test The study was conducted following the protocol approved by the Tohoku University Ethics Committee .n = 1494), 904 (60.5%) worked before the earthquake. Regarding the proportion of people who worked before the earthquake by gender and age, 84.4% of young men and 67.4% of young women (both younger than 65 years old) worked, while 42.8% of elderly men and 24.2% of elderly women (both 65 years old or older) worked before the earthquake  became unemployed after the earthquake. The proportion of people who became unemployed after the earthquake by gender and age was 9.1% young men, 20.7% young women, 33.7% elderly men, and 48.6% elderly women. The impact of the earthquake on employment status prevailed in each group, particularly in the female and elderly subpopulations .p < 0.01). The proportions of people who became unemployed after the disaster among elderly men (39.1%) and young women (51.5%) were prominent in the primary industry. In the secondary industry, the number of elderly men who became unemployed after the disaster (43.8%) was prominent. In the tertiary industry, the unemployment proportion among elderly women (55.2%) was prominent  reported increased income, while 185 (27.1%) reported decreased income. Nearly one-fifth (18.4%) of young men who remained engaged in the secondary industry reported increased income after the earthquake, while the proportions were only 6.9% of young men who remained engaged in the primary industry and 5.4% of young men who remained engaged in the tertiary industry. In contrast, 62.1% of young men who remained engaged in the primary industry, 14.9% of young men who remained engaged in the secondary industry, and 25.5% of young men who remained engaged in the tertiary industry reported decreased income. Similarly, 43.8% of elderly men, 70.0% of young women, and 50.0% of elderly women who were engaged in the primary industry reported decreased income after the earthquake .p < 0.01). Tukey–Kramer’s HSD tests showed a significant difference between those who became unemployed after the earthquake and those who continued to work since the earthquake (p < 0.01). A significant difference was also shown between the group who had not worked before the earthquake and the group who became unemployed after the earthquake (p < 0.01). As there was a significant difference in the age of subjects that made up each group (p = 0.02), analysis of covariance was applied to the data using age as a confounding factor. The analyses indicated that there was no significant interaction between age and employment status (p = 0.37), while the difference in AIS among the groups remained statistically significant (p < 0.01).The average AIS score, an indicator of insomnia, for the group that had not worked before the earthquake was 4.76; for the group that became unemployed after the earthquake, it was 6.11; and for the group that continued to work after the earthquake, it was 4.57 . There was a significant difference among the three groups (p = 0.08).The relationship between employment status and mental health conditions in the 2011 survey data was evaluated using a one-way analysis of variance. The average score of K-6, an indicator of psychological distress, for the group that had not worked before the earthquake was 5.26; for the group that became unemployed after the earthquake, it was 5.90; and for the group that continued to work after the earthquake, it was 4.97 . There was no significant difference among the three groups (p < 0.01). Tukey–Kramer’s HSD tests showed a significant difference between those who were unemployed after the earthquake and those who continued to work (p < 0.01). A significant difference was also indicated between the group that had not worked before the earthquake and the group that continued to work after the earthquake (p = 0.01). As there was a significant difference in the age of subjects of each group (p < 0.01), analysis of covariance was applied to the data using age as a confounding factor, showing that there was no significant difference in the IES-R among the three groups . There was a significant difference among the three groups . For the proportions of becoming unemployed after the earthquake for each type of industry regardless of age, 15.2% in the secondary industry group and 16.1% in the tertiary industry group became unemployed, while a much larger proportion (37.9%) in the primary industry became unemployed. The data highlighted the severe impact of the disaster on affected residents who worked in the primary industry, leading to a large unemployed proportion of elderly populations. The data also indicated that the unemployment proportion of women was much larger than that of men, especially among elderly populations.Among those who continued to work in the same workplace, nearly half of the primary industry workers reported decreased income after the disaster, showing a greater impact of the disaster on those who worked in the primary industry compared with those who worked in the secondary and tertiary industries. It was also remarkable that the majority of elderly people reported declined income regardless of the type of industry. Considered together, the data highlighted the severe impact of the disaster on both the employment and economic statuses of elderly people, reflecting that a considerable proportion of elderly people was engaged in self-employed fisheries and agriculture with no retirement system before the Great East Japan Earthquake in typical communities affected by the disaster.According to a government report in 2012, the percentages of employed elderly men and women (65 years old or older) in Japan were 27.8% and 13.1%, respectively . MoreoveSecond, this study aimed to investigate the association between employment status and mental health conditions considering the structural industry characteristics of the affected coastal area. There was no significant difference in psychological distress measured by the K-6 in the three subgroups regarding employment status. Analysis of covariance using age as a confounding factor also indicated that there was no significant difference in posttraumatic stress reactions measured by the IES-R in the three subgroups. These results did not endorse previous findings that unemployment was associated with posttraumatic stress symptoms or poor mental health outcomes.In contrast, this study indicated that symptoms of sleep disturbance scored by the AIS were significantly different in the subgroups regarding employment status. One-way ANOVA, followed by Tukey–Kramer’s HSD tests, indicated that the level of insomnia of the subgroup that became unemployed after the disaster (AIS score = 6.11) was significantly higher than that of the subgroup that continued to work after the disaster (AIS score = 4.57), as well as that of the subgroup that had not worked before the disaster (AIS score = 4.76). As elderly subjects were significantly dominant in the subgroup that became unemployed, and elderly people are generally likely to have insomnia ,26, analPrevious research has indicated significant associations between factors such as unemployment or poor socioeconomic conditions and the symptoms of posttraumatic stress disorder ,13,14, wAfter disasters, the impact of the event on employment and economic conditions might need to be evaluated, considering the regional characteristics of the affected communities. This study suggests that, when disasters occur in coastal and mountainous areas where elderly men and women tend to be engaged in primary industries, elderly people, especially elderly women, might inevitably lose their jobs. In designing support systems for recovery after a disaster, the characteristics of the pre-disaster industrial structure of the affected communities must be considered. Employment support might be needed for subpopulations of affected communities that have vulnerable employment status. For the majority of seaside communities in the Tohoku region devastated by the Great East Japan Earthquake, elderly people who were engaged in the primary industries had a vulnerable employment status. Especially after a disaster, employment is important for maintaining good mental health conditions, not only from the aspect of earning income to reconstruct the foundations of life but also concerning increasing opportunities to interact with others. It is desirable to integrate support for employment and for mental health conditions, including guidance for maintaining good sleep. Integrative care for employment and sleep conditions might be needed for the elderly, especially elderly women in the area affected by the disaster.There were several limitations to this study. First, the primary purpose of this study was to understand the changes in employment status before and after the Great East Japan Earthquake by gender, age, and type of industry. While this study included preliminary analyses of the relationship between changes in employment status and mental health conditions, the considered factors were limited. Factors including experiences of disasters and physical-health conditions ,28, the Second, although we examined employment status before and after the earthquake, we did not investigate the reasons for these changes. It is uncertain whether the reason for becoming unemployed was the direct impact of the earthquake. Third, this study was a cross-sectional analysis of the results of a survey conducted in 2011. It is necessary to conduct longitudinal analyses of the results of surveys conducted in consecutive years to estimate the causal relationship between employment status and mental health conditions.This study pointed out the severe impact of the Great East Japan Earthquake on the employment and economic status of populations who had belonged to the primary industry, the elderly, and women. Becoming unemployed after the disaster was significantly associated with sleep disturbances.