Bombyx mori. It is unknown whether there are other cells or tissues that can produce PPO and release it into the hemolymph besides circulating hemocytes. In this study, we use the silkworm as a model to explore this possibility. Through tissue staining and biochemical assays, we found that wing discs contain PPO that can be released into the culture medium in vitro. An in situ assay showed that some cells in the cavity of wing discs have PPO1 and PPO2 mRNA. We conclude that the hematopoietic organ may wrongly release hemocytes into wing discs since they are connected through many tubes as repost in previous paper. In wing discs, the infiltrating hemocytes produce and release PPO probably through cell lysis and the PPO is later transported into hemolymph. Therefore, this might be another source of plasma PPO in the silkworm: some infiltrated hemocytes sourced from the hematopoietic organ release PPO via wing discs.In insects, hemocytes are considered as the only source of plasma prophenoloxidase (PPO). PPO also exists in the hemocytes of the hematopoietic organ that is connected to the wing disc of  Prophenoloxidase (PPO) is an important immune protein in insects Drosophila melanogaster, the hematopoietic organs are called lymph glands that are located along the dorsal vessel in vivo melanization, we hypothesized that wing discs may contain or produce PPO, or the plasma PPO attached to the targeted tissue after injury by heavy ion beams, to induce wing disc browning.Insect PPO is produced by hemocytes in circulation as well as in the hematopoietic organs. Many types of hemocytes have been found to contain PPO in vitro, PPO was released into the culture medium. The amount of PPO released by wing discs alone was higher than that by hematopoietic organs. Due to the physical connection of wing discs and hematopoietic organs In this study we examined whether there is PPO in wing discs. Through tissue staining and biochemical methods, we found that PPO can be transcribed by some cells in the cavity of wing discs. PPO was located in cells in the cavity as well as among cells near the surface of wing discs. When wing discs were cultured Bombyx mori became brown in vivoThe heavy ion beam targeted wing discs of Manduca sexta laccase was used to determine if there is laccase in wing disc and epidermis from larvae on V-3. The results show that only epidermis has laccase . Therefore, lysozyme is suitable as a probe to show whether there are large molecules communication between the wing discs and hemolymph. According to the Western blot assay using PPO and lysozyme antibodies separately as the primary antibody, lysozyme was detected in plasma alone but not in wing discs  were surgically operated to remove two pairs of wing discs along with hematopoietic organs after feeding for 6 h as previously described Bombyx mori was recently found to produce PPO and that this PPO was released into the hindgut content to induce the melanization of feces and reduce bacteria number in the hindgut In vivo insect PPO is activated through a proteolytic cascade terminating with a serine proteinase cleaving PPO to produce the active enzyme PO. However, in vitro PPO can also be activated by many chemicals like SDS, ethanol and propanol by a hitherto unknown mechanism Tribolium castaneum through proteomics assay, and the change of PPO transcription was also found higher in the elytra than in the hindwing Armigeres subalbatus, the adult wings became malformed In insects, PPO produced by hemocytes is released into the hemolymph via a very unclear mechanism in vitro, PPO in the wing discs was obviously released as shown by the native gel assay (When the wing discs were cultured el assay  and tissel assay . Althougel assay . These rel assay . When weel assay . TherefoBombyx mori larvae (Nistari) were reared on mulberry leaves at 25°C under a 12-h photoperiod. Larval age was reported in days as described by Kiguchi et al. Silkworm hematopoietic organ can be extirpated with wing discs without affecting larval growth and development The dissected or cultured wing discs were incubated in 10 mM dopamine containing 30% ethanol for staining at room temperature for 5 min. Dopamine is a PPO substrate and ethanol can be used to activate PPO Wing discs, hematopoietic organs, and fat bodies dissected from 4 larvae were separately cultured in 500 µl Grace medium containing 10% heated silkworm plasma in which PPO was inactivated at 60°C for 30 min after modifying the previously published method 6 formalin-killed Escherichia coli (E. coli) cells suspended in sterilized 0.85% NaCl solution or 0.85% NaCl alone for immune challenge for 12 h V-3 silkworm larvae were injected with 5×10Wing discs were dissected and fixed overnight at 4°C in Bouin’s fluid Bombyx mori PPO1 and PPO2 mRNA were detected in wing discs and hematopoietic organs by in situ hybridization following described methods in vitro transcription with T7 RNA polymerase in a reaction containing digoxigenin-UTP . The primers for cloning PPO1 and PPO2 and those for synthesizing antisense and sense RNA probes are listed in Cell lysate from wing discs was separated by native gel. One gel was used for Western blot assay (see below) to show the position of PPO. Another gel was stained by Coomassie Brilliant Blue R250 (CBB) and the band at the same position with PPO detected was excised for liquid chromatography tandem mass spectrometry (LC–MS/MS) analysis as previously described Semiquantitative RT-PCR was used to examine relative abundance of selected genes in different tissues. Total RNA of each tissue was isolated using Trizol, and the first-strand cDNA was synthesized as described above. The primers are listed in Manduca sexta laccase  Approximately 15 µg protein was loaded per lane unless otherwise mentioned, and SDS-PAGE and Western blot assay were performed as previously described Figure S1Identification of the proteins in the bands that exhibit prophenoloxidase (PPO) activity. (A) PPO in the cell lysate from wing discs was detected by western blot (lane 1) using the antibody against PPO Another lane (lane 2) was stained by Coomassie Brilliant Blue R250 (CBB) to target the band containing PPO for liquid chromatography tandem mass spectrometry (LC–MS/MS) analysis. The arrowheads indicate the position of PPO.  Peptides were identified as PPO1 (B) and PPO2 (C) as indicated. Other proteins were also identified and these results are not shown.(TIF)Click here for additional data file.Figure S2Semi-quantitative RT-PCR analysis of transcription of PPO1 and PPO2 in hematopoietic organs (HPO), hemocytes (H), wing discs (W) and fat bodies (FB). The number of PCR cycles used was 35. Ribosomal protein 3 (rps3) was used as an internal control for equal RNA loading.(TIF)Click here for additional data file.Table S1Primers for RT-PCR analysis and in situ hybridization.(XLS)Click here for additional data file.


Cultural competence training in residency is important to improve learners’ confidence in cross-cultural encounters. Recognition of cultural diversity and avoidance of cultural stereotypes are essential for health care providers.We developed a multimethod approach for cross-cultural training of Internal Medicine residents and evaluated participants’ preparedness for cultural encounters. The multimethod approach included (1) a conference series, (2) a webinar with a national expert, (3) small group sessions, (4) a multicultural social gathering, (5) a Grand Rounds presentation on cross-cultural training, and (6) an interactive, online case-based program.n=25). Following training, 89% of participants were more comfortable obtaining a social history. However, prior to the course only 27% were comfortable caring for patients who distrust the US system and 35% could identify religious beliefs and customs which impact care. Most (71%) believed that the training would help them give better care for patients from different cultures, and 63% felt more comfortable negotiating a treatment plan following the course.The program had 35 participants, 28 of whom responded to the survey. Of those, 16 were white (62%), and residents comprised 71% of respondents (Multimethod training may improve learners’ confidence and comfort with cross-cultural encounters, as well as lay the foundation for ongoing learning. Follow-up is needed to assess whether residents’ perceived comfort will translate into improved patient outcomes. Previous recommendations to teach about racial and ethnic disparities in health care highlighted the need for institutions to evaluate, teach, and adapt their curricula . NationaA variety of curricular approaches have been used to teach cultural competence. A previous study used a novel approach of nominal group techniques to demonstrate a cognitive map which defined four neighborhoods of concepts to be included in curriculum development: patient's background, provider/health care, cross-culture, and resources to manage cultural diversity . AnotherStill, it is challenging for providers to become experts of all cultures in an increasingly ethnically diverse United States. Thus, the most effective methods to teach and practice cultural competence remain elusive . As the improve comfort with cross-cultural encounters;improve the ability to have a dialogue about one's culture;increase awareness of health care disparities andcollaborate with community stakeholders.We conducted our study in a community-based, university-affiliated Internal Medicine residency program. We requested a waiver from the University of Tennessee College of Medicine, Chattanooga Institutional Review Board. This project was a descriptive, observational evaluation of cultural competence teaching concepts which began in August 2010. The educational program included multiple instructional approaches. Program objectives were to:As part of routine educational activities, residents were required to review online case-based modules (which are available in the public domain) to generate a discussion regarding barriers to care, cross-cultural communication, and racial and ethnic disparities.We developed a week-long cultural competence curriculum; Exhibit 1 outlines the week-long curriculum goals and objectives. Although, the program was duplicated 1 year later, here we report the results from 2010. The residency program dedicated existing conference time for 1 week to underscore the importance of cultural competence in residency education. All residents were encouraged to attend. However, residents who were off site, not on duty, or who had competing patient issues were excused. All residents and students who were enrolled in the medicine residency program were required to review five online modules to document learning in core competencies, including patient care, medical knowledge, professionalism, interpersonal and communication skills, and systems-based learning and practice-based learning. Developing the curriculum required 4–6 weeks of advanced planning in order to invite guest speakers and coordinate the timing of the webinar. The planning was coordinated with the Departmental Chair and the Graduate Medical Education in order to utilize existing conference times. In preparation for the program, flyers and announcements were sent out via email and posted throughout the hospital.http://www.c-comp.org). Residents were expected to complete an interactive, online case-based training, Quality Interactions® . There were five online interactive modules which incorporated live clinical encounters to demonstrate different aspects of cross-cultural communication. A panel discussion and the multicultural social activity served as springboards for discussions.Multimethod learning activities included noon conferences, a webinar with a national expert, small group discussions, and a Grand Rounds discussing the development of Cultural Competency Online for Medical Practice  or second year  residents. The respondents’ participation is noted in Cultural Competency Overview, Health Literacy and Disparities in Women Health; 39% of respondents (n=11) rated the session as strongly agree and 36% agreed (n=10) to the statement ‘improved my attitude regarding cultural competence and health disparities.’ Of the 28 respondents, many felt that the course improved their confidence in cross-cultural encounters as 33% (n=9) reported that they strongly agreed and 48% (n=13) agreed.Of 35 program participants considered as the target audience, 28 responded; data on non-responders were not available. Of those, 8 were female (31%) and 18 male (69%); 16 were white (62%), 5 African American (19%), and 5 Asian (19%). Twenty residents comprised 71% of respondents, two faculty (7%), two medical students (7%), and four others . Most participants were first year (Evaluations of domains were categorized as cultural knowledge, cultural attitudes, or cultural skills – all shown in Internal Medicine residency program participants in a cultural competence education training course felt that the structured course helped prepare them for culturally competent care. Our study supports previous literature suggesting that integration of cultural competence concepts into other clinical teaching may be effective in reinforcing that this is not an ‘add-on’ topic for study . Traininattention;retention;production; andmotivation.We opted to use multiple teaching strategies. Multimedia design principles have been shown to improve short-term retention among medical students, though further studies are needed to determine how these principles affect transfer of learning . Our resIn one study, learners were exposed to earlier versions of an oral presentation, which developed over time into more polished versions. Retention is increased by using ‘multichannel’ instruction, such as videos and open discussions . Not onlNonetheless, our program design allowed us to employ multiple educational strategies to provide education and exposure. In previous studies, very few opportunities existed for cultural competence education and mentoring, highlighting the need for more training for residents . This pr


The ‘Be the Best You Can Be’ (BtBYCB) program is a school-based intervention designed to foster positive physical, psychological, and social development via empowering young people to take ownership over their own personal development. The aim of this work is to determine the effectiveness of the BtBYCB program on (i) pupils’ well-being, self-perceptions, self-esteem, aspirations, and learning strategies; and (ii) changes in modifiable health-risk behaviors .A two-arm cluster randomized controlled trial employing a wait-list control plus qualitative and mixed-method evaluations was used. Participants were school pupils from Years 7 and 8 (aged 11–13 years). Ten schools located in southwest England were randomly allocated to receive the BtBYCB intervention  or a control condition  . Participants in the intervention condition received a program consisting of (i) a talk from an Olympian/Paralympian; (ii) 11 one-hour teacher-led PSHE classroom sessions in which pupils identified their aspirations, values, and interests and explored and acted on these via activities such as personal development planning, goal-setting, and peer-mentoring; and (iii) participated in a celebration event . Data were collected at baseline, post-intervention, and at 3-month follow-up.Focus groups (pupils and teachers) and individual interviews (headteachers) were conducted in the 5 intervention schools to (i) gain an in-depth understanding of mechanisms of change; (ii) explore ways in which the participants’ motivation and engagement could be enhanced, and (iii) elicit user-feedback pertaining to how the program, content, and appeal could be improved.A mixed-method approach was used to describe and explain the differing experiences of particular groupings within and across the intervention schools; i.e., those for whom the program was effective, those that experienced little, if any change, and those for whom the program led to an inverse effect.The findings of this work will provide insight into the effectiveness of an innovative and child-centered program. The research will inform improvements to the BtBYCB program as well as other interventions targeting child/youth health and wellness.ISRCTN99443695.The trial is registered as Current Controlled Trials  Games of the Thirtieth Olympiad to the city of London as part of the legacy aimed at inspiring the nation’s generation of children . Developed and refined by a team of educational experts, education specialists/policy makers, and university scholars, the BtBYCB program was designed to foster positive physical, psychological, and social development by encouraging pupils to take ownership over their own personal development . Such overarching aims and objectives directly align with key UK education, well-being and health policies and directives e.g.,  that may mediate changes were assessed at a mid-point data collection (week 6 of the program). The measures selected in the trial were:Eudaimonic well-being was assessed at the contextual level by the Personally Expressive Activities Questionnaire . The work is also novel by adding a qualitative and mixed-methods approach to gaining a better understanding of the intervention. That is, the use of the simultaneous mixed-methods approach builds on recent calls for such methods  and to our knowledge represents the first application of such an approach in the extant SDT-related literature. Such an approach can be readily extended and modified to other areas of study that focus on the mechanisms underpinning adaptive and sustained behavior-change.There are a number of limitations worthy of note. First, the follow-up period of 3 months is short in duration. Second, many of the measures used were self-report in nature. Thus, issues surrounding common method variance and reporting biases cannot be negated. Future work assessing the BtBYCB program would benefit from using more objective measures across all participants . Future evaluation should also include cost-effectiveness analyses to ascertain whether the intervention leads to meaningful changes within a financially sustainable model.Findings from this work will be disseminated to practice based audiences , lay summaries of findings to the general media , and within peer-review articles and conference presentations. The results from this research will be reported akin with the Consolidated Standards of Reporting Trials (CONSORT) recommendations .BMI: Body Mass Index; BtBYCB: Be the best you can be program; CRCT: Cluster randomized controlled trial; PSHE: Personal social and health education classes; SDT: Self-determination theory.The authors declare they have no competing interests.MS and SPC designed the study and obtained the research funding. FBG contributed qualitative expertise in the design. MS drafted the first draft of the manuscript. SPC and FBG provided revisions to the paper. All authors read and approved the final manuscript.This study was funded by the Economic & Social Research Council (ESRC) (UK) ref: RES-177-25-001. The views expressed in this publication are those of the authors and not necessarily those of the ESRC.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/666/prepub


The purpose of this study was to evaluate the effectiveness of the Tier 1 Program of the Project P.A.T.H.S.  in Hong Kong by analyzing 1,327 school-based program reports submitted by program implementers. In each report, program implementers were invited to write down five conclusions based on an integration of the subjective outcome evaluation data collected from the program participants and program implementers. Secondary data analyses were carried out by aggregating nine databases, with 14,390 meaningful units extracted from 6,618 conclusions. Results showed that most of the conclusions were positive in nature. The findings generally showed that the workers perceived the program and program implementers to be positive, and they also pointed out that the program could promote holistic development of the program participants in societal, familial, interpersonal, and personal aspects. However, difficulties encountered during program implementation (2.15%) and recommendations for improvement were also reported (16.26%). In conjunction with the evaluation findings based on other strategies, the present study suggests that the Tier 1 Program of the Project P.A.T.H.S. is beneficial to the holistic development of the program participants. Although the prevention science approach that focuses on risk and protective factors of high-risk adolescent behavior has generated much research and prevention programs in the past few decades, it has been criticized as focusing too much on adolescent problems and pathology. As such, there is an alternative approach that emphasizes the importance of positive youth development. Damon  stated tThere are many positive youth development programs in the field. In a review of existing programs on positive youth development, Catalano et al.  reviewedWith reference to the intensification of adolescent developmental problems in Hong Kong , 4, therThere are two tiers of programs (Tier 1 and Tier 2 Programs) in this project. The Tier 1 Program is a universal positive youth development program in which students in Secondary 1 to 3 participate, normally with 20 h of training in the school year at each grade. Because research findings suggest that roughly one-fifth of adolescents would need help of a deeper nature, the Tier 2 Program is generally provided for at least one-fifth of the students who have greater psychosocial needs at each grade . To date, more than 244 schools  and 223,101 students have participated in the Tier 1 Program of the project [Several evaluation strategies have been utilized to evaluate the Project P.A.T.H.S. in Hong Kong. These include objective outcome evaluation, subjective outcome evaluation, qualitative evaluation, process evaluation, and evaluation based on personal construct psychology. Among these evaluation strategies, the subjective outcome evaluation method was used to assess the perceptions of the participants as well as program implementers regarding the program, instructors, and benefits of the program , 8. It iThere are several reasons why program implementers should be engaged in the evaluation process. First, by engaging the program implementers in the evaluation process, a more complete picture of the effectiveness of the program can be constructed. In particular, by adding the perspective of the program implementers, bias due to subjectivity of the program participants can be reduced and the related data can enrich our understanding of the program effect. Second, engagement of program implementers is commonly emphasized in different evaluation models. For example, in the utilization-focused evaluation paradigm, it is argued that as different stakeholders are involved in the evaluation process, program implementers' views are legitimately covered . SimilarIn the Project P.A.T.H.S., subjective outcome evaluation is used to capture the views of the program participants and implementers. Based on these data, implementers in each school are required to submit a report documenting the effects of the program, including five conclusions that they would like to put down in the report. By utilizing and integrating the five conclusions drawn in the school-based evaluation reports prepared by the program implementers based on the views of both program participants and implementers, the present study conducted secondary data analyses to evaluate the effectiveness of the Tier 1 Program of the P.A.T.H.S. Project. According to Royse , secondaSeveral studies have been carried out to examine the five conclusions drawn in different cohorts of the Project P.A.T.H.S. –20. GeneIn each year of the Experimental and Full Implementation Phases, after completion of the Tier 1 Program, students and program implementers were invited to respond to subjective outcome evaluation forms . The program implementers then prepared a report based on the subjective outcome evaluation data to report the program effectiveness. Throughout the years, a total of 1,327 reports involving 244 schools, 223,101 students, and 9,915 program implementers were collected .There are several parts in Form A:participants' perceptions of the program, such as program objectives, design, classroom atmosphere, interaction among the students, and the respondents' participation during class (10 items),participants' perceptions of the instructors, such as the preparation, professional attitude, involvement, and interaction with the students (10 items),participants' perceptions of the effectiveness of the program, such as promotion of different psychosocial competencies, resilience, and overall personal development (16 items),the extent to which the participants would recommend the program to other people with similar needs (1 item),the extent to which the participants would join similar programs in the future (1 item),overall satisfaction with the program (1 item),things that the participants learned from the program (open-ended question),things that the participants appreciated most (open-ended question),opinion about the instructor(s) (open-ended question),areas that require improvement (open-ended question).Similar to Form A, Form B includes the evaluation of the following:program implementers' perceptions of the program, such as program objectives, design, classroom atmosphere, interaction among the students, and the students' participation during class (10 items),program implementers' perceptions of their own practice, including their understanding of the course, teaching skills, professional attitude, involvement, and interaction with the students (10 items),program implementers' perceptions of the effectiveness of the program, such as promotion of different psychosocial competencies, resilience, and overall personal development of the students (16 items),the extent to which the workers would recommend the program to other students with similar needs (1 item),the extent to which the workers would teach similar programs in the future (1 item),overall satisfaction with the program (1 item),things that the workers obtained from the program (open-ended question),things that the workers appreciated most (open-ended question),difficulties encountered (open-ended question),areas that require improvement (open-ended question).Based on the evaluation data collected in each school, program implementers in each school were required to complete a Tier 1 Program evaluation report where both quantitative and qualitative findings based on Forms A and B were summarized and described. In the last section of the report, the program implementers were requested to write down five conclusions regarding the program and its effectiveness. The involvement of the workers in writing the conclusions is consistent with the thesis that program implementers can give a more comprehensive and valid picture about the program quality and benefits to students. In addition, it is argued that they are proficient in accounting program effectiveness with reference to various aspects of the program, and providing recommendations for improving program arrangement and delivery in the real teaching context.In each cohort, the data generated from the five conclusions were analyzed using general qualitative analyses techniques  by two rIn the previous analyses, the conclusions were categorized into several areas, including programs, implementers, benefits, difficulties, and recommendations. In the present secondary data analyses, the data in the existing datasets were also aggregated and analyzed with reference to these categories.Based on the 6,618 conclusions in the 1,327 evaluation reports, 14,390 meaningful units were extracted. Utilizing the analysis framework adopted in previous studies, these raw responses were further categorized into several categories, of which 28.75% related to views on the program , 16.87% Regarding the conclusions related to the perceptions of the program, results in To safeguard the reliability of the results, both the intra- and interreliability tests were conducted every year. The consolidated findings of the reliability analyses from 2005 to 2009 on stakeholders' perceptions toward program, instructors and program effectiveness can be seen in n = 310, 2.15% of the total responses) were related to difficulties encountered. The difficulties included time constraints, difficulty in engaging the students, and inadequate school support . It is noteworthy that some suggestions for improvement were contradictory .Despite the positive feedback, a small number of responses  and schools (n = 244) were involved. Second, as there are very few published evaluation studies on positive youth development programs in different Chinese contexts, this is a pioneer addition to the literature. Third, as few subjective outcome evaluation studies are based on program implementers, the present study highlights the utility of including implementers' views in the evaluation of positive youth development programs. Utilizing secondary data analyses, this study attempted to analyze the conclusions drawn by the program implementers of the Tier 1 Program of the Project P.A.T.H.S. in a series of studies over time. There are several unique characteristics of this study. First, a large number of reports . Furthermore, program implementers are required to adopt a flexible and reflective approach in implementing the Tier 1 Program and they are expected to have much interaction with the students via structured activities, such as role play, group discussions, debates, and self-disclosure, which can arouse students' interest and motivation to learn. However, as Chinese teachers typically adopt an authoritarian rather than an egalitarian role in teaching, teachers might find it hard to play and share with the students. Finally, as Hong Kong is undergoing education reform, participation in the Project P.A.T.H.S. means intensive involvement of the workers, which may pose a challenge for the teachers and social workers. On the whole, the difficulties encountered and suggestions for improvement can serve as useful pointers to fine tune the program.Regarding the evaluation methodology, the present study utilizes evaluation reports prepared by the program implementers via secondary data analyses. The approach to analyzing the evaluation reports prepared by the program implementers is consistent with several views in the evaluation literature. According to utilization-focused evaluation, involvement of the stakeholders in evaluation is an important element of evaluation . In addiAlthough the present findings can be interpreted as evidence supporting the merits and benefits of the Project P.A.T.H.S., several alternative explanations should be noted. The first alternative explanation is that the findings are due to insufficient evaluation expertise of the program implementers. Nevertheless, this alternative explanation can be partially dismissed because professional social workers and teachers received evaluation training in this project, and evaluation is also part of the training for social workers and teachers in Hong Kong. Furthermore, there are findings showing that subjective outcome evaluation converged with objective outcome evaluation findings . The secThere are several limitations of the present integrative study based on nine databases. First, due to the nature of the secondary data analysis, it is not possible to have interaction with the program implementers. It would be helpful if some dialogues between the program implementers and researchers could be carried out in the future. Actually, the use of focus groups as an evaluation strategy has partially solved this problem. Second, because the conclusions written by the workers were not in great detail, the relevant findings failed to give us a thorough understanding of the implementation processes involved. Third, validity of the data derived from the present study relies on the assumption that program implementers can make reasonable and fair judgments about the program based on the subjective outcome evaluation findings. While this assumption might be met because teachers and social workers are trained to conduct practice evaluation in Hong Kong, inexperienced workers may have problems in integrating the subjective outcome evaluation findings and translating them into valid conclusions. Of course, it can be counterargued that systematic training before program implementation can reduce this problem to a great extent. Despite these limitations and in conjunction with the previous research findings described above, the findings in the present study provide further support for the effectiveness of the Tier 1 Program of the Project P.A.T.H.S. in Hong Kong.


There was information omitted from the Funding statement.The correct statement is: This work was funded by the Italian Ministry of Health (GR program 2010-2311017) and the Associazione Italiana per la Ricerca sul Cancro (AIRC) program MyFAG. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.


Background: Launched by the U.S. Environmental Protection Agency (EPA) in 1998, the High Production Volume (HPV) Challenge Program was developed to address the perceived gap in basic hazard information for the 2,800 chemicals produced or imported into the United States in quantities of ≥ 1 million pounds per year. Health and environmental effects data obtained from either existing information or through new vertebrate animal testing were voluntarily submitted by chemical companies (sponsors) to the U.S. EPA. Despite the potential for extensive animal testing, animal welfare guidelines were not provided until after the start of the program.Objectives: We evaluated compliance with the animal welfare principles that arose from an agreement reached between the U.S. EPA and animal protection organizations and tracked the HPV program’s use of animals for testing.Discussion: Under a worst-case scenario, the HPV program had the potential to consume 3.5 million animals in new testing. After application of animal-saving measures, approximately 127,000 were actually used. Categorization of chemicals based on similar structure–activity and application of read-across, along with use of existing test data, were the most effective means of reducing animal testing. However, animal-saving measures were inconsistently used by both sponsors and the U.S. EPA.Conclusions: Lessons learned from the HPV program can be applied to future programs to minimize animal testing and promote more human-relevant chemical risk assessment. Launched in October 1998 as part of the Chemical Right-to-Know initiative [U.S. Environmental Protection Agency (EPA) 1998b], the High Production Volume (HPV) Chemicals Challenge Program (HPV program) was developed by the U.S. EPA in concert with the Environmental Defense Fund , the American Petroleum Institute (API), and the Chemical Manufacturer’s Association [now the American Chemistry Council (ACC)]. The HPV program focused on chemicals produced in or imported into the United States in annual quantities of ≥ 1 million pounds, which in 1998 amounted to approximately 2,800 substances. The stated goals of the HPV program were to collect health and environmental effects data and provide the public with basic hazard information on these chemicals that would allow individuals to actively participate in environmental decision making (U.S. EPA 2011e).Chemical companies were encouraged to volunteer for the HPV program or face regulation under the Toxic Substances Control Act (TSCA 1976). For each chemical that was sponsored, the U.S. EPA requested all the information specified in the Organisation for Economic Co-Operation and Development (OECD) HPV Screening Information Data Set (SIDS) . The OECTo satisfy SIDS ecotoxicity and human health effects data requirements that relied on animal data (end points), a chemical sponsor could either submit existing animal test results or conduct new animal tests. Considering the 2,800 chemicals identified and the amount of test data sought, the HPV program had the potential to consume millions of animals in new testing efforts, yet there had been no participation by animal protection organizations (APOs) in its planning. Subsequent critiques of the HPV program by People for the Ethical Treatment of Animals (PETA); the Physicians Committee for Responsible Medicine; other nongovernmental organizations including the Doris Day Animal League, the American Anti-Vivisection Society, and the Medical Research Modernization Committee; and the public eventually led to an agreement with the White House and the U.S. EPA to include a number of animal protection measures in the HPV program  not perform an animal test when a validated non-animal method was reasonably and practically available; b) use existing, scientifically adequate data to the maximum extent, including information from international chemical databases; c) use in vitro genetic toxicity testing unless known chemical properties precluded its use; d) conduct a thoughtful, qualitative analysis, including consideration of a substance’s physicochemical properties; e) apply a weight-of-evidence (WoE) approach whenever possible and forgo conducting certain tests if appropriate; and f ) maximize grouping of related chemicals into categories based on structure–activity relationships (SARs). In addition, sponsors were told not to develop subchronic or reproductive toxicity data for closed system intermediates , and to consider whether any additional information obtained through new testing would be useful or relevant for substances generally recognized as safe by the Food and Drug Administration (FDA). Finally, the U.S. EPA agreed to incorporate these elements into future HPV test rules  or the in vivo  method, but they were asked to provide a rationale for proposing the animal test instead of the in vitro assay. One chemical tested for all animal test end points would require, on average, 60 fish and up to 2,480 mammals  and one for environmental effects (acute toxicity to fish) (U.S. EPA 2000).  mammals  if separAs of January 2010, sponsors had submitted 428 test plans to the U.S. EPA to address 1,420 of the original 2,800 HPV chemicals, most of which were grouped in categories containing two or more related chemicals. The plans present existing data that satisfy some or all SIDS requirements, and propose new tests to fill any perceived data gaps. Here, we review these plans and accompanying documents, focusing primarily on compliance with the principles contained in the animal welfare guidance and on the resulting impact of proposed and actual tests on animal use. We also discuss which animal-saving measures were most effective for reducing the number of animals used.We reviewed all publicly available test plans, the U.S. EPA comments on those test plans, and test plan revisions available online in “Robust Summaries and Test Plans” (U.S. EPA 2012d). Although the U.S. EPA commented on 413 of the 428 test plans submitted, sponsors subsequently revised only 330. We based our analysis on original test plans, the U.S. EPA comments, and test plan revisions available from the HPV program (U.S. EPA 2012d) as of January 2010.a) the original test plan, if no U.S. EPA comments on that test plan or subsequent revisions were posted; b) the U.S. EPA comments on the original test plan if no subsequent revisions were posted; or c) the latest revision posted in response to U.S. EPA comments.For each health and environmental effect end point potentially requiring animal test data, we determined whether new animal testing was proposed in original test plans and if not, which of the animal-saving measures listed in a) that the test was accepted as proposed; b) that the proposed test was unnecessary; or c) that the proposed test could be replaced with a different test requiring fewer or no animals. The U.S. EPA also recommended additional tests in cases where it did not accept one or more animal-saving measures proposed by sponsors to satisfy required end points. In revised test plans submitted by sponsors, we noted whether or not they agreed to make the changes recommended by the U.S. EPA. If sponsors had not responded, we counted the tests recommended in the U.S. EPA comments.After reviewing original test plans, the U.S. EPA generally provided a response for each animal test proposed by sponsors, indicating In some cases involving complex mixtures and process streams, chemical companies proposed new testing for related non-HPV substances rather than for the sponsored chemicals themselves. We included the tests used for these substances in our animal test totals, and end points for the sponsored chemicals were counted as satisfied by read-across, a process by which end point information for one chemical is used to predict the same end point for another chemical based on similarities in their chemical structure or functionality. In several cases for which sponsorship of chemicals was withdrawn due to overlap with international regulatory programs, we considered the end points addressed by existing data. In some situations the U.S. EPA accepted or rejected proposed animal-savings measures based on the sponsor meeting certain conditions, such as supplying study details in a robust summary or locating additional studies. If sponsors did not make revisions to test plans or if it was unclear as to what was actually done, we judged whether those conditions were likely to be met and how the end points were eventually satisfied.Analysis of animal use. Based on the median or standard number of animals used per test  stated thatIn Today, even the most basic toxicity testing results cannot be found in the public record for nearly 75% of the top volume chemicals in commercial use.Chemical Hazard Data Availability Study: What Do We Really Know About the Safety of High Production Volume Chemicals? (U.S. EPA 1998a). However, the Likewise, the U.S. EPA reported a paucity of data in its follow-up publication Practical considerations—mainly cases in which sponsors determined a chemical to be ineligible for testing based on its physicochemical properties—saved animals as well, avoiding testing for 9.2% of the end points . This apOwing to the highly reactive nature of this chemical when in contact with air or water, it is not feasible to perform physicochemical, environmental fate, mammalian or ecotoxicological tests.in vitro CAD test, were used sparingly, accounting for only 1.2% of end points. A chemical’s status as a CSI satisfied requirements for < 1% of end points  to evaluate reproductive and/or developmental toxicity, with or without repeated dose toxicity. The U.S. EPA’s recommendations regarding elimination of tests and replacement with less animal–intensive tests would have resulted in nearly 36,000 fewer animals used than originally proposed . Thus, almost 9,000 more animals were used in the HPV program as a result of sponsors’ failure to follow the U.S. EPA’s recommendations. Of these, 6,380 could have been spared if the sponsors had used combined protocols instead of separate reproductive or developmental toxicity tests.Due to the voluntary nature of the program and stated commitments to certain product stewardship efforts, sponsors did not always comply with the U.S. EPA’s recommendations to eliminate tests or to substitute tests using fewer or no animals. Sponsors went on to conduct 12 of the 49 tests that the U.S. EPA determined were not needed, including 5 fish toxicity tests using 300 fish, 4 acute mammalian toxicity tests using about 60 rodents, and 3 combined protocol tests using 1,740 animals. Sponsors also did not perform 21 of the 62 less animal–intensive tests recommended by the U.S. EPA and, instead, conducted the tests originally proposed . In addition, the U.S. EPA issued TSCA Section 8(a) and Section 8(d) data reporting rules  in August 2006 for 243 HPV chemicals, 35 of which were subsequently removed from the list of unsponsored substances subject to reporting under TSCA Section 8 .On October 21, 2011, the U.S. EPA issued a proposal to collect data on 23 remaining HPV chemicals through a fourth and final TSCA Section 4 test rule (U.S. EPA 2011a). In the same notice, the agency also proposed to simultaneously issue a significant new use rule (SNUR) under TSCA Section 5(a)(2) for another 22 HPV chemicals. The SNUR would require manufacturers to file significant new use notifications (SNUN) with the U.S. EPA prior to any uses of the listed chemicals that would result in significant consumer or occupational exposure. This exercise of the U.S. EPA’s authority under TSCA Section 5 appears to allow the agency to effectively require new testing for HPV chemicals, including animal testing, without first finding that available data are insufficient to determine health or environmental effects, as required under TSCA Section 4. Such an approach would very likely lead to duplicative testing should the agency fail to comprehensively search for relevant data and provide opportunities for public review and comment. In addition, because companies producing the same chemical would likely cross the SNUN threshold at different times, and some may not cross it at all, the SNUR approach could lead to duplicative reporting requirements by defeating efforts to share costs and testing through formation of consortia.Outcomes and future of the HPV challenge program. Sponsors were asked by the U.S. EPA to submit SIDS data no later than 2005 (U.S. EPA 2001); however, more than a decade since the start of the program, new test plans and revisions are occasionally submitted, and the U.S. EPA has posted information on its Robust Summaries and Test Plans web site (U.S. EPA 2012d) as recently as May 2012. The High Production Volume Information System (HPVIS), a web interface for accessing the hazard data (U.S. EPA 2012e), was not launched until April 2006, and efforts to familiarize potential users of the data have been limited to one national data-users conference held in December 2006 (U.S. EPA 2010b) and two regional workshops held in 2007 (U.S. EPA 2010c). Several methods of data query are offered on the HPVIS web site, but there is considerable variability in format and presentation of the data , which limits the ability to use this information. Clearly, data formatting requirements should have been standardized early in the program.The utility of the HPV data set for risk assessment is limited, acknowledged even by EDF, the organization that strongly advocated for the formation of the HPV Program, as “…provid[ing] little if any reliable, comprehensive information about the use of and exposure to HPV chemicals” . The U.Shttp://dx.doi.org/10.1289/ehp.1104666)]. Although it is appropriate to tailor data acquisition to meet regulatory needs, information also should be obtained in an organized, efficient manner.The voluntary nature of the HPV program and the limited data acquisition authority of the U.S. EPA under TSCA have led to a lengthy and fragmented data-gathering process, and attempts to update TSCA to address this problem have, thus far, been unsuccessful [see Supplemental Material , and the recent announcement of the Endocrine Disruptor Screening Program for the 21st Century .In the 14 years since the HPV program began, numerous new methods, initiatives, and programs have been launched that promise to set priorities, reduce animal testing, and provide better regulation in the long run. Driven in part by the realization that animal testing is inefficient and that the information it provides is often difficult to use for regulatory purposes, the National Academy of Sciences published a seminal report, Strategy , which dStrategy . These sConsidering the length of time it has been in existence and the increased number of chemicals that now meet the HPV definition, the HPV program as administered by the U.S. EPA has clearly been unable to keep pace with changes in the chemical industry. An industry-led initiative, Extended HPV (EHPV), was announced in 2005 e.g.,  to expanCompared with the threshold of 1 million pounds for the HPV program, REACh is decidedly more ambitious: Its goal is to comprehensively assess the safety of all chemicals produced or imported in Europe in quantities of ≥ 1 metric ton  . REACh pin vitro methods—eye irritation, skin irritation, and genotoxicity—were submitted. This is likely to change as non-animal assessment tools, such as the (Q)SAR models collected in the OECD Toolbox . As in the HPV program, actual efficiencies and reductions in animal use will depend on the degree to which these animal-saving measures are implemented. A recent preliminary assessment of the use of animal alternatives in the first phase of REACh (ECHA 2011a) indicated that formation of consortia by chemical companies greatly reduced duplicative animal testing and, as we observed for the HPV program, the use of existing data and read-across satisfied the largest number of end points requiring vertebrate animal testing. Not surprisingly, considering the current scarcity of universally accepted non-animal tests, data from only three  Toolbox , continuin vitro tests and computer simulation, had comparatively little impact on mitigating animal use, satisfying only about 1% of the end points potentially requiring animal test data.The U.S. HPV Program had the potential to consume > 3 million animals in health and environmental effects testing, but after involvement by APOs, a variety of animal-saving measures were introduced that reduced the number of animals actually used to approximately 127,000—still a considerable amount. Grouping related chemicals and applying read-across to estimate the toxicity of untested chemicals had the greatest impact on reducing animal use. Discovery of existing data by both APOs and chemical sponsors also substantially decreased testing on animals, a significant finding considering that the HPV program was founded on the premise that little hazard assessment data existed for HPV chemicals. Non-animal methods, such as Of the animal tests that were conducted, combined protocols that could assess multiple end points in a single test significantly reduced animal use. Sponsors proposed these much more often than separate tests, and the U.S. EPA, in its test plan reviews, went on to recommend them in place of nearly all the separate tests proposed.Because participation in the HPV program was voluntary and HPV sponsors may have had other reasons for conducting tests, the U.S. EPA’s recommendations to eliminate tests or conduct tests involving fewer or no animals were not always followed, thus resulting in almost 9,000 more animals being used. On the other hand, the voluntary nature of the HPV program saved animals by allowing sponsors to decline to do additional testing recommended by the U.S. EPA, although this testing may still be required through regulatory means at some point in the future. Ultimately, the impact of the HPV program on animals could have been far greater if APOs and other members of the public had not succeeded in advancing basic animal welfare principles shortly after it began.The HPV program’s primary goal of making chemical hazard information available to the public seemingly has been met by the posting of raw data on the U.S. EPA’s web site (U.S. EPA 2012f). However, the U.S. EPA significantly underestimated the amount of time necessary to complete the program, and its own use of the data to assess the hazards of HPV chemicals has, for the most part, not progressed beyond the screening level stage. Although the data can be retrieved digitally, albeit through a somewhat cumbersome web interface, the extent to which the public is using it to participate in environmental decision making is unknown. Also, the HPV program did not systematically address information requirements by standardizing data reporting.Both the HPV and REACh programs showcase the need for applying a different approach to prioritize chemicals for further evaluation and articulating targeted data requirements to increase the efficiency of chemical risk assessment. The science of toxicology is evolving rapidly, and although only some of the tools being developed as part of the Tox21 collaboration have been adequately evaluated for use in risk assessment, they can and are being used for prioritization and screening purposes. Building on the means by which animal testing was reduced in the HPV program, along with the development of new technologies, will likely increase the efficiency and efficacy of chemical hazard and risk assessment and continue to decrease the use of animals in chemical safety testing. However, decision makers must ensure incorporation of animal welfare principles and evolving chemical assessment strategies into current and future regulatory efforts in order for this to occur.(20 KB) PDFClick here for additional data file.


This paper presents an evaluation of Avahan, a large scale HIV prevention program that was implemented using peer-mediated strategies, condom distribution and sexually transmitted infection (STI) clinical services among high-risk men who have sex with men (HR-MSM) and male to female transgender persons (TGs) in six high-prevalence state of Tamil Nadu, in southern India.Two rounds of large scale cross-sectional bio-behavioural surveys among HR-MSM and TGs and routine program monitoring data were used to assess changes in program coverage, condom use and prevalence of STIs (including HIV) and their association to program exposure.The Avahan program for HR-MSM and TGs in Tamil Nadu was significantly scaled up and contacts by peer educators reached 77 percent of the estimated denominator by the end of the program’s fourth year. Exposure to the program increased between the two rounds of surveys for both HR-MSM  and TGs . There was an increase in consistent condom use by HR-MSM with their regular male partners . Last time condom use with paying male partners  also showed an increase. Among TGs, the increase in condom use with casual male partners  was not significant, and last time condom use declined significantly with paying male partners . Syphilis declined significantly among both HR-MSM  and TGs , while change in HIV prevalence was not found to be significant for HR-MSM (9.7 percent to 10.9 percent) and TGs (12 percent to 9.8 percent). For both groups, change in condom use with commercial and non-commercial partners was found to be strongly linked with exposure to the Avahan program.The Avahan program for HR-MSM and TGs in Tamil Nadu achieved a high coverage, resulting in improved condom use by HR-MSM with their regular and commercial male partners. Declining STI prevalence and stable HIV prevalence reflect the positive effects of the prevention strategy. Outcomes from the program logic model indiacte the effectiveness of the program for HR-MSM and TGs in Tamil Nadu. Men who have sex with men (MSM) and transgender persons (TG) are among the most vulnerable core-risk groups affected by HIV. Five to 10 percent of the global HIV prevalence is reportedly attributed to sexual transmission involving MSM , the maiIndia is recognized as having multiple concentrated HIV epidemics , hence iaravani in Tamil Nadu). The initiative’s key strategies for reaching its goals were to saturate HIV-prevention program coverage among HR-MSM and TGs (target of 80 percent) and deliver a proven package of services [NACO has implemented targeted HIV prevention interventions among FSWs, MSM and TG since 1992 . In 2003services ,18 to adOne of Avahan’s six focus states was the southern state of Tamil Nadu, where the program covered FSW, HR-MSM, and TG populations across 14 of the state’s 32 districts between October 2004–March 2009. Key elements of the Avahan program for HR-MSM and TGs in Tamil Nadu included peer-based outreach and education for behavior change, promotion and distribution of condoms, STI treatment services, and community mobilization .A comprehensive adequacy and plausibility evaluation was designed to assess the Avahan program’s scale, coverage, outcomes and impact sequentially over time and described elsewhere . With thData for the present analysis came from three main sources:(i) Routine program monitoring data on outreach and clinic services ,22 from (ii) Two rounds of cross-sectional integrated behavioral and biological assessment (IBBA) surveys were conducted separately for HR-MSM and TGs in 2006 (Round 1) and 2009 (Round 2). The surveys collected socio-demographic and behavioral data in face-to-face interviews and took blood and urine samples to test for STIs and HIV. The operational definition of the HR-MSM surveyed by IBBA was same as the Avahan program — male, aged 18 years or older, visible in cruising sites or sex venues and who had had anal sex with another man in the last one month in exchange for cash or kind. In both rounds of IBBA, HR-MSM were sampled in four districts  using time location cluster sampling, a probability-based sampling method. TGs were sampled in five districts  and operationally defined as any individual who self-identified as aravani, aged 18 years or above, who had any type of sex , paid or unpaid, with another male in the last one month. Since HR-MSM and TGs are highly mobile and sex venues/cruising sites keep changing, mapping exercises were carried out separately for each group in both rounds of surveys to develop a comprehensive sampling frame. Two-stage sampling protocol was used: in the first stage, primary sampling units (PSU) were selected using probability proportion to size (PPS) from the sampling frame; this was followed by the second stage, where a random selection of respondents was done based on listing at selected clusters. Time location cluster sampling was used to sample HR-MSM and TGs from street-based sites such as markets and bus stops; conventional cluster sampling was used for TGs when respondents were from fixed sites such as homes. Further details of IBBA survey protocol and the methodology have been published elsewhere .(iii) Another set of data came from condom distribution by Avahan program and sales from Avahan-supported and other social marketing efforts ,24.The current analysis was conducted using data from the 14 Avahan implementation districts in the state of Tamil Nadu, for the period of January 2005–March 2009. The analytical framework is similar to Avahan’s evaluation design . The fraCoverage indicators  from monMeasures of program intensity included: ratio of the program staff (peers and outreach workers) to target group (against a target of 1:50 HR-MSM and TGs) and the frequency of exposure to Avahan program services. The number of free condoms provide by the program and sold through program-supported social marketing efforts  were useIBBA data on self-reported exposure  to Avahan services was analyzed and used for comparing and validating the program monitoring data.IBBA collected self-reported condom use data to examine changes in condom use patterns. Consistent condom use was defined as reported condom use during every act of anal intercourse in the past with any male sexual partner, including regular male partners, paid male partners (when buying sex) and other casual male partners; last time condom used captured information on condom use with paying male partners (when selling sex).Treponema pallidum hemagglutination assay (TPHA). Positive RPR confirmation by TPHA was used to define reactive syphilis or lifetime syphilis. RPR titres of ≥1:8 with a confirmatory TPHA were defined as active or high-titre syphilis. Urine was tested using nucleic acid amplification (Gen-Probe APTIMA COMBO 2) to assess chlamydial and gonococcal urethral infection [Blood samples were tested for syphilis using rapid plasma reagin (RPR) and a confirmatory nfection . Rectal Blood samples were also tested for HIV infection with a two-test algorithm using an enzyme immunoassay  . HIV preData from the two rounds of IBBA surveys was used to study the link between exposure to Avahan services and the presence of any STIs  and the practice of consistent condom use with commercial and non-commercial partners. A composite indicator of exposure — ever been exposed to any of the three core program services  — was used for this analysis . SPSS 14.0®  was used to analyze the data. District level data were merged to get state data set from each round. Pooled IBBA Round 1 and 2 dataset was used to analyse the association between condom use and exposure. Appropriate district- or state-level weights were calculated and used for analysis .The Wald Chi-square test was used to assess significant changes in profile characteristics of HR-MSM and TGs between the two IBBA rounds, including age, literacy, marital status, income source, age at first sex, residency, sex work outside the place of residence and sexual self-identity.Separate multivariate logistic regression was conducted to assess: a) significant changes over time in exposure; b) condom use outcomes with each partner type; c) changes in prevalence of STIs and HIV between the two rounds; and d) the link between exposure to Avahan services and intermediate outcomes. The key profile variables associated with outcomes — self-identity, age, literacy, occupation, residency, age at first sex for HR-MSM; and self-identification as aqua (non-castrated) or nirvana (castrated) aravani, district, age, literacy, occupation, age at first sex and residency for TGs — were controlled for confounding in logistic regression models. Adjusted odds ratios (AORs) and 95 percent confidence intervals (95% CI) were generated. Chi-square test was used to examine the association between condom use and duration of Avahan exposure using pooled IBBA data. The association was considered significant for p-values lower than 0.05.Protection of Human Subjects Committee of FHI 360 and the ethics committee of National Institute of Epidemiology (NIE), Indian Council of Medical Research (ICMR), approved the study.The Avahan program for HR-MSM and TGs in Tamil Nadu was initially rolled out in 14 districts. By April 2007, it was stabilized in 11 districts through 24 non-governmental organizations (NGOs) working in these districts. During 2007–2008, one implementation district was transferred from Avahan to NACO and another district from NACO to Avahan, based on the state plan for implementing phase III of India’s National AIDS Control Plan [HR-MSM and TGs ever contacted by Avahan peer educators increased to 82 percent 12,412) of the estimated HR-MSM and TG population by September 2006, while those who had ever visited program STI clinics increased to 81 percent  by March 2008. By March 2009, these percentages had increased to 147 percent and 113 percent, respectively  and 807 TGs (404 in Round 1 and 403 in Round 2) were sampled. Significant differences were seen in the profile characteristics of HR-MSM between Round 1 and Round 2, including in age, literacy, occupation, residency in the district, age at first sex, occupation, and self-identity . HR-MSM who reported ever visiting Avahan program’s STI clinics increased significantly from 67 percent to 82 percent . A significantly higher proportion of TGs reported that they were contacted by a peer educator from the Avahan program in Round 2 compared to Round 1 . However, the proportion of TGs attending STI clinic reduced significantly in Round 2 compared to Round 1 .The proportion of HR-MSM who reported during IBBA surveys that they were contacted by peer educators in the last month increased significantly from 64 percent in Round 1 to 90 percent in Round 2 . The reported frequency of contact by peers increased between the two IBBA rounds — the percentage contacted 1–2 times increased from 46 percent in Round 1 to 57 percent in Round 2, and those contacted 3–4 times increased from 28 percent in Round 1 to 38 percent in Round 2 (p < 0.001). The proportion of TGs who reported being contacted by a peer educator in the last month reduced in Round 2 compared to Round 1, but was not statistically significant .Avahan’s condom distribution initiative for all target groups  in Tamil Nadu saw a sharp increase, from about 800,000 in 2004 to 6.1 million in 2008. Similarly, the volume of condoms distributed through social marketing outlets in Avahan districts increased from more than 400,000 in 2004 to about 3 million in 2008. The monthly ratio of condoms distributed by the program directly to HR-MSM and TGs and through social marketing efforts increased from 6 per HR-MSM and TGs in 2005 to 26 per HR-MSM in 2008. The estimated number of monthly commercial sex acts per MSM, based on Round 2 IBBA data, was 15 in 2009. IBBA data also showed that a significantly higher proportion of HR-MSM in Round 2 (87 percent), compared to Round 1 (55 percent), reported receiving condoms on the last occasion from peers educators or NGOs (p < 0.001); this increase was also reported by the TG population (82 percent in Round 2 vs. 74 percent in Round 1).Condom use with regular male partners improved considerably over the two rounds of IBBA . TGs reported an increase in consistent condom use with casual male partners, up from 18 percent in Round 1 to 51.5 percent in Round 2, but this increase was not statistically significant . Table Syphilis prevalence declined significantly from 14.3 percent in Round 1 to 6.8 percent in Round 2 . Prevalence of urethral gonorrhoea and Chlamydia, less than 1 percent in both Round 1 and Round 2, did not change significantly between the two rounds . No TGs tested positive for chlamydia or gonorrhoea in either of the two IBBA rounds.Using logistic regression, we found a significant and positive association between exposure to program services and condom use with different partners . Similarly, TGs exposed to the intervention were significantly more likely to report consistent condom use with other male partners than those not exposed to the intervention .This paper presents one of the first systematic evaluations of a large-scale prevention program for HR-MSM and TGs in Tamil Nadu. An adequacy and plausibility evaluation design  was usedAccording to program monitoring data, the percentage of HR-MSM and TGs who were ever contacted by a peer educator or had ever visited a clinic increased over time to over 100 percent, by March 2009. Unique monthly contacts (against the estimated denominator) by Avahan peer educators increased to 77 percent by March 2009, close to the program’s saturated coverage target of 80 percent. IBBA data from a subset of districts showed that by 2009, 90 percent of HR-MSM and TGs had been contacted in the previous month. These IBBA findings validate the monitoring data and bolster confidence in monitoring data for the districts that were not covered in IBBA.A plausible explanation for the increase beyond 100 percent for those who were ever contacted and had ever visited a clinic is the turnover in the HR-MSM and TG population, that is, some target population who had accessed the services had moved out and were not counted as part of the denominator in March 2009. MSM and TG populations are known to be mobile, so it is likely that some who had received the services moved out of Avahan coverage areas over time.Examination of scale-up and intensity measures showed that the targets established for program infrastructure (peers and outreach workers) were in place by June 2007. The observed reduction in the number of active peers in March 2007 and June 2008 was likely due to revised program strategies  and the Increasing frequency of HR-MSM who reported being contacted by peer’s points to the increasing uptake of program services. Continuous quality monitoring assessments of Avahan STI clinics  have also shown consistent improvement in the quality of STI clinical management, operations and performance ,29.Analysis of condom availability data indicates that the program distributed a large number of condoms; this was validated by the IBBA data. The analysis also indicated that the minimum number of condoms required to cover the estimated commercial sex acts by HR-MSM had been made available by March 2008. Other studies also provide evidence that a sufficient number of condoms were made available through social marketing; more than 80 percent hot spots in Avahan districts were found to have a greater number of condom distribution outlets , and conkothi  [IBBA data on HR-MSM profile characteristics showed considerable change over the two rounds of IBBA, with a substantial increase in the proportion of HR-MSM who reported their self-identity as a nal sex) . This chSignificant increases were seen in condom use with the regular male partner, paying male partners (when selling sex) and casual male partners. Evaluation of HR-MSM programs with a similar package of services in other Asian countries has shown increasing condom use with commercial and non-commercial partners after program implementation . A meta-Although consistent condom use increased between the two rounds, many high-risk sexual practices with both commercial and non-commercial partners were still being reported. In addition, reported consistent condom use with paid partners did not increase, suggesting the need for greater programmatic effort. Additional studies and analyses are required to better understand the factors affecting condom use patterns among MSM with multiple/different partners, so as to inform programs in developing more effective behavior change communication. The finding that condom use outcomes were linked to Avahan program exposure is strongly suggestive of the program’s effectiveness. However, causality could not be determined with the current analysis, given the lack of a proper control group and the limitations of cross-sectional data.Our evaluation showed that the prevalence of HIV stabilized (9.7 percent to 10.9 percent) and the prevalence of syphilis declined (14.3 percent to 6.3 percent) in the HR-MSM in IBBA districts. Data prior to Avahan is available only from small studies in select locations. For example, in Chennai, a study of 774 men reported HIV prevalence of 6.5 percent and prevalence of any laboratory-diagnosed STI at 22 percent among HR-MSM . AnotherIncreased HIV prevalence in HR-MSM of ages 18–20 years, though not statistically significant, is still an issue of concern and requires in-depth examination. In some IBBA districts, such as Chennai and Coimbatore, increase in HIV prevalence despite increased program exposure is a cause of concern. The program in Chennai was transitioned to the Tamil Nadu state in 2008, but Coimbatore continued to be an Avahan intervention district throughout the study period. Given that consistent condom use in general remained low in HR-MSM, inconsistent condom use could likely have been a major contributor to HIV transmission, resulting in our finding that overall HIV prevalence did not change between the two rounds of IBBA.Male-to-female TGs formed an important part of our interventions. Interestingly, we found similar HIV prevalence in TGs and other MSM. These findings are in contrast with findings from other parts of the country. Indeed, studies from Mumbai and Pune (in western India) consistently reported HIV prevalence in TGs to be significantly higher than MSM ,34,35. SThis assessment is among the first to show evidence of declining STI prevalence in MSM in Tamil Nadu after the implementation of a large-scale prevention program. Although the finding is encouraging, one of its limitations is that only urethral STIs were examined in this assessment. Given the difficulties in field implementation, it was not possible to collect samples for assessing rectal STIs, which other studies have shown to be high among HR-MSM . There wWhile the sentinel surveillance data has limitations of a small sample size and potential bias due to non-representative recruitment methods, data from two sites (250 sample from each) in Tamil Nadu notably indicated HIV prevalence at 6.8 percent in 2004, which increased to 7.6 percent in 2007 and then declined to 3.6 percent in 2008 ,38. HoweThe major limitations of cross-sectional studies apply to the current analysis as well. While the sampled population was representative of the HR-MSM and TG populations in each round of IBBA, changes in the universe of these populations must be accepted. Further, the denominators used to assess coverage also have limitations. Estimates of HR-MSM and TG denominators were based on formal mapping exercises by Avahan NGOs. However, size estimates varied in terms of rigor and frequency of updation, with size estimation information in some areas being updated only once every one or two years.One key limitation of the current evaluation is the lack of proper baseline data and control groups. Round 1 of IBBA was conducted in 2006, about 14 months after the Avahan program was implemented in the state. Due to ethical considerations, control groups were not included in evaluation design. Therefore, it is impossible to definitively attribute outcomes to the program. Although some other programs have ongoing HR-MSM and TG interventions in other districts of Tamil Nadu, data from these programs is not available for comparison. Since Avahan was the sole intervention in the IBBA districts (except Chennai) and high levels of coverage was achieved (based on program size estimates), sub-analysis of IBBA data from HR-MSM and TGs who were not exposed to Avahan program had limited power because of small numbers.Notably, in a majority of Avahan districts (except Chennai) Avahan’s was the first and only intervention for HR-MSM and TGs. Given this, our findings have provided early evidence of the effectiveness of Avahan program for HR-MSM in Tamil Nadu. However, further analysis and studies are required to better understand the factors that affect the condom use patterns of HR-MSM and TGs with their different partners. Understanding these factors would help HIV prevention programs develop more effective behavior change communication strategies.The practical considerations discussed earlier, the mobile nature of HR-MSM and TGs, diffusion effect of the intervention, and the program’s intent to rapidly scale-up and transition to existing government programs made it difficult to have any control groups  for the The current evaluation study provides evidence of the successful implementation of the Avahan program for HR-MSM in Tamil Nadu. Using the program logic model, the study shows consistent scale up of the program and high levels of service uptake by HR-MSM and TGs; this was validated by independent IBBA survey data. The HIV prevalence rate did not change much, but syphilis prevalence in HR-MSM and TGs showed a decline. Although further gains in condom use are urgently required, exposure to Avahan program services was linked with condom use, which is a strong indication of the program’s effectiveness.The authors declare that they have no competing interest.TS and LR contributed to the conception, design, writing and finalization of the manuscript. SA, SR and EC helped with acquisition and interpretation of data and finalization of the manuscript. GP and BK contributed through concept development, data analysis and final editing of the manuscript. GCP’s contribution lay in acquisition of biological data, interpretation of data and editing of the manuscript. MS and IV also contributed to data analysis and interpretation of data. AR and PR contributed in concept development and finalization of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/857/prepub


Postpartum depression is a significant public health problem affecting approximately 13% of women. There is strong evidence supporting Cognitive Behavioral Therapy (CBT) for successful psychosocial treatment. This treatment model combines cognitive and behavioral strategies to address pessimism, attributions for failure, low self-esteem, low engagement in pleasant activities, social withdrawal, anxiety, and low social support. Encouraging results have been reported for using Web-based CBT interventions for mental health domains, including the treatment of panic disorder, post-traumatic stress disorder, and complicated grief and depression. To date, however, Web-based interventions have not been used and evaluated specifically for the treatment of postpartum depression.We describe the formative work that contributed to the development of our Web-based intervention for helping to ameliorate symptoms of postpartum depression, and the design and key components of the program.A total of 17 focus group participants and 22 usability testers, who shared key characteristics with the participants of our planned feasibility study, took part.The proposed structure and ingredients of the program and mock-ups of selected webpages were presented to focus group participants. At various points, participants were asked a series of thought questions designed to elicit opinions and set the occasion for group discussion. At the end of the session, participants were asked to describe their overall reaction to the proposed features of the program emphasizing candid opinions about what they did not like and features they thought were missing and should be added.think-aloud technique. They were then asked to consider all that they had learned about the program and complete the System Usability Scale that we adapted slightly to be appropriate for evaluating the proposed website.Usability testers were asked to interact with a series of seven different Web-based interactions planned for the program while receiving minimal direction. Each tester was asked to describe her thoughts using a Transcripts from the focus groups and usability tests were reviewed by research team members for overarching themes with particular emphasis on suggested changes. A list emerged, and iterative and incremental adjustments were made as a result.The qualitative and quantitative data gathered in the focus groups and usability sessions reported here suggest that the new mothers involved had largely positive reactions to the major features of the program and that those program features performed well in terms of usability.MomMoodBooster program is provided including innovative features supplementing 6 core CBT sessions, which include a partner’s website, a library, and individual feedback by a personal coach.An overview of the eventual design, architecture, and key program ingredients of the  Postpartum depression (PPD) is a significant public health problem affecting many women with incidence estimates ranging from 5% to more than 13% of new mothers -6.Stuart, O’Hara, and Gorman  have claLewinsohn’s Coping With Depression (CWD) course ,16 is a Milgrom, Martin, and Negri  adapted It is becoming evident that even when postnatal depression is detected, use of clinic-based treatment for postnatal depression is poor, with only around 30-40% of women taking up treatment services -32. MateAlthough early attempts to use Web-delivered interventions to reduce depressive symptomatology yielded equivocal results ,36, subsWeb-based interventions offer unique advantages that should increase engagement and improve impact ,49:Web-based treatment programs can reach a larger percentage of women in need than clinic-based programs. This public health impact is especially important for women in rural settings with limited transportation, childcare resources, and access to mental health professionals ,51.Program content can be tailored to participant characteristics and interests. While there are not yet clear data as to which factors may have the greatest impact on outcomes, there is broad consensus that tailoring of materials to individual participant characteristics enhances program credibility  and is lThe program can monitor which intervention materials each user has accessed in order to encourage participant engagement by presenting fresh, non-redundant content.Information from past sessions can be used more efficiently than in a face-to-face setting to reinforce gains made, to shape the subsequent program content, and to provide ongoing feedback ,56.Users can set their own pace and can access information at any time. This “on demand” capability is of particular importance with postpartum women, for whom flexible access to program content is a requirement given their childcare commitments and general lack of time.Web forums can provide helpful advice and support within an anonymous environment ,54.There is low post-development cost to deliver the program to each participant.Guided human support (ranging from a technician-level coach to a more highly skilled therapist) has been shown to increase adherence to online mental health treatments ,58 and aMomMoodBooster program (USA) and MumMoodBooster program  are Web-based interventions, supplemented with a series of calls with a personal coach, based on an adaptation of Milgrom’s group CBT treatment for postpartum depression. The program was developed by a multinational team composed of researchers based in three organizations: Oregon Research Institute (ORI), Parent-Infant Research Institute (PIRI) in Melbourne, Australia, and the Iowa Depression and Clinical Research Center (IDCRC). This report delineates the formative research procedures used to develop the program content and provides an overview of the eventual design, architecture, and key program ingredients of the MomMoodBooster program.The MomMoodBooster program involved focus groups and usability testing. We followed an iterative and incremental process in which early feedback was used to accomplish rapid changes  very easy program, it doesn’t have a lot of—you know how sometimes you get on web pages and there’s so much to see, and it seems like every time you go to the spot you need to go to, you always need to go back four pages. It doesn’t seem to have any of that sort of stuff.”“I do like the partner part…I think that coming to see the psychologist, I think my partner missed out, and he would have liked to have known—he was so scared of what was being said.”“A lot of reading here. He would not read this much.”“It was good, actually, because it sounds like it’s a really useful tool for mothers.”“Chunks of writing [are] too much; needs colors to stand out more.”MomMoodBooster program. For example, we added language and tone gleaned from comments shared in focus group and usability testing sessions to enhance the relevance of our content and increase the credibility of our program. Portions of some of the stories shared in the focus group were used as the basis of stories presented in our online video vignettes. The eventual protocol we used for coordinating calls between personal coaches and program participants took into consideration the opinions mothers shared with us in focus group sessions regarding the fact that the Personal Coaches should initiate the calls, but mothers have an online method to share scheduling messages with their Coach.Feedback in terms of tester comments and the observations of the research staff who facilitated the formative sessions led to myriad important refinements to the eventual design of the MomMoodBooster program.Usability feedback about challenges with our initial online tracking tools led us to further simplify their interface and add more context-sensitive user instructions. Based on comments we received, the Practice Change (homework) activities in the program became key components that encouraged home practice of the recommended behavioral skills. Because participants emphasized the importance that their Practice Change activities along with their other progress in the program should be available to Personal Coaches to enhance the relevance of their shared calls, a sophisticated administration website was created that provided Personal Coaches with a digital dashboard showing details of participant progress in using the MomMoodBooster program combines a tailored, interactive Web-based postpartum depression intervention for individual mothers who also receive a series of Personal Coach calls. The overall program also includes two additional websites: a Partner Support website and an Administrative website that includes a dashboard for Personal Coaches  the formative work that contributed to the development of our Web-based intervention for helping to relieve symptoms of postpartum depression, and (2) the design and key components of the program.Postpartum depression represents an important public health problem especially because many new mothers are unable or reluctant to seek help. Poor treatment uptake results in many mothers not accessing services or receiving support to ameliorate their depression. This can have substantial consequences for themselves, their partners, and their infants. Web-based depression interventions represent a rapidly emerging approach for extending the reach of efficacious treatments ,88. The MomMoodBooster program and that those program features performed well in terms of usability. Specifically, the formative results supported our use of sequential sessions, involvement of the Personal Coach having certain characteristics, the availability of a separate support website for the partner, etc. In addition, we found that using the ATLAS.ti qualitative analysis tool helped to identify useful themes from our focus group session transcripts.The qualitative and quantitative data gathered in the focus groups and usability sessions reported here suggest that the new mothers involved had largely positive reactions to the major features of the Limitations of the current formative research are largely related to the fact that our focus group and usability testing samples were not representative of all mothers nor did all participants provide us with a complete data set. Although participants in the formative research satisfied eligibility criteria similar to those we intended to use for participants in our planned feasibility study, this group of women is best considered a convenience sample that may not generalize to all postpartum mothers. For example, the Australian sample was somewhat older  than the median age of mothers in Australia  but more consistent with Australian women ages 30-34 years who have the highest fertility rate of all age groups in that country . The AusMomMoodBooster program continued to be developed [MomMoodBooster program.It is also important to acknowledge that the usability test results described in this report were obtained in a preliminary usability phase. Our usability testing efforts did not end at this initial step in the process. Instead, usability feedback continued to occur in an iterative and incremental manner as the eveloped . In addiIn terms of lessons learned, we concluded that there were many more similarities than differences between our Australian and American samples of postpartum mothers. There were differences in language in terms of spelling and in terms of common usage. We concluded that these differences were critically important features that need to be localized in the final Web-based program. But some differences in language and accent did not preclude the use of Australian videos and audios with an American audience and vice versa. As more than one participant indicated, they felt less isolated knowing that mothers from the other cultures shared similar challenges with postpartum depression. Finally, the technological sophistication of our two participant samples was quite equivalent. These similarities provide support for expanded US/Australia collaborative research on Web-based interventions.MomMoodBooster program is currently being tested in a feasibility trial that involves 50 depressed postpartum mothers—25 in Australia using the MumMoodBooster program and 25 additional mothers in Iowa using the MomMoodBooster program. While the content of the two programs is identical in meaning, each version uses country-specific language, and each has its own set of host videos for every session. The two programs use Personal Coaches and they also share video vignettes of mothers describing their implementation of some of the strategies using a mixture of American and Australian actors. It remains for the results of our feasibility trial and a subsequent fully powered RCT to establish the efficacy/effectiveness of the MomMoodBooster program. Results from our formative research have been highly encouraging and were instrumental in developing a program acceptable to mothers with PPD.The