Monthly Archives: March 2022

Promoting Larval Source Management in Urban and Arid Communities as a Vital Supplementary Intervention, Zambia

DOI: 10.31038/JCRM.2022513

Abstract

Objective: To show the capabilities of Larval Source Management (LSM) as a tool that can significantly contribute to malaria elimination agenda.

Methods: Reviewed both published and unpublished literature for LSM of varying periods from (1929-2019), learning lessons from the mines in Zambia, Sri Lanka, Kenya, India, Greece, Philippines, Rwanda and Tanzania.

Cluster-Randomized Control Trials undertaken in Sri-Lanka, larviciding of abandoned mines, streams, irrigation ditches and rice paddies reduced malaria incidence by three-quarters compared to control (RR 0.26, 95% CI 0.22 to 0.31,20,124 participants, two trials, moderate quality assurance evidence). In three controlled, before- and trials in urban and rural India and rural Kenya, results were inconsistent (98,233 participants, three trials, very low-quality of evidence). I none trial in urban India, the removal of domestic water containers, weekly larviciding of canals and stagnant pools reduced malaria incidence that was higher at baseline intervention areas than in controls.

One cluster-RCT from Sri Lanka, larviciding reduced parasite prevalence by almost 90% (RR 0.11, 95% CI 0.05 to 0.22, 2,963 participants, one trial, and moderate quality evidence). In five controlled, before-and after trails in Greece, India, Philippines and Tanzania, an average reduction in parasite prevalence of two-thirds (RR 0.32, 95% CI 0.19 to 0.55,8041 participants, five trials, moderate quality evidence) resulted. The interventions in these five trials included dam construction to reduce larval habitats, flushing of streams, removal of domestic water containers, and larviciding. In randomized cross-over trial in the flood plains of Gambia River, larviciding by ground teams insignificantly reduced parasite prevalence (2,039) participants, one trial). So, there is strong evidence that LSM is associated with 69% of reduction in incidence (95% CI, 58-77% (in six studies) and a 75% reduction in prevalence of parasitemia (95% CI 49-88%, six studies).

In the first half of the 20th century, Zambia in the copper mines used LSM that resulted in a 97% reduction of malaria incidence from 514/1000 in 1929/1930 to 16/1000 in 1949/50; mortality fell by 88% from 32/1000/ year to 4/1000/year.

Conclusion: LSM is another policy option for Zambia to consider, alongside the primary interventions to reduce malaria morbidity and mortality in targeted breeding sites that are few, fixed, discrete and easily identifiable.

Keywords

Targeted management, Mosquito Breeding sites, Promoting larval source management, Zambia

Background

The global malaria control strategy of the 21st century aims at protecting individuals and the general public using Long Lasting Treated bed nets (LLINs), Indoor Residual Spraying (IRS) with prompt and effective measures of clinical malaria [1,2]. Notably, malaria still remains a major public health concern in Zambia and its elimination agenda strives for universal coverage of utilizing these global vector control tools. These two vector control interventions, complement each other for universal coverage for the population, as having either full coverage of LLINs or IRS within a household (NMESP, 2017-2021).

This momentum has to be maintained for further malaria reductions, supported by supplementary vector control tools needed to be added to the present arsenal [3-8]. The suppression of the transmission could be achieved by targeting the aquatic stages by reducing vector larval habitats. Larval Source Management (LSM) must be particularly important in those areas targeted for malaria elimination where malaria foci or “hot spots” persist [9-15]. LSM has been one of the oldest tools in the fight against malaria and has been largely forgotten and more often dismissed as malaria control intervention by non-vector control professionals [16].

Importantly, Zambia has to leverage the unrealized potential of LSM, that could help as the main focus for mosquito control program through lessons learnt for decades, in the developed countries like; America and other African countries [17,18]. LSM potentially aids in combating both mosquito physiology and behavioral resistance. Because LSM is primarily a complementary intervention, its impact needs to be evaluated in terms of the additive effect and cost-effective on top of primary interventions. The concept of “species sanitation” must be applied for malaria elimination. This means that attention must be directed primarily to local anopheline mosquitoes being the principal transmitters of malaria (WHO, 1982).

However, very little or no attention on financing has been given to LSM by government in Zambia. The objective of this paper was to appraise relevant literature on the global perspective, the success stories and feasible capabilities of LSM being an important tool that would contribute to the attainment of the current malaria elimination agenda for Zambia.

Justification on What Mosquito Larval Source Management is All about

Vector control has been proven to successfully reduce or interrupt malaria transmission when coverage is sufficiently high. Indoor Residual Spraying and Long-Lasting Insecticide Treated Bed nets target host-seeking adult mosquitoes while larval source management attempts to reduce malaria transmission by decreasing the number of mosquitoes that reach adult hood. However, there has been some noted chemical resistance to the two primary interventions. The mosquito larval source management is the management of water bodies (aquatic habitats) that are known to be potentially breeding sites for mosquitoes in order to prevent the completion of immature development.

Challenges of Existing Primary Malaria Interventions (LLINs and IRS) (Derue et al. 2019)

1)            Wide Spread Chemical Resistance Observed in Vector Control

The insecticides used in vector control need monitoring and understanding of their trend. Malaria vector control currently in most parts of Africa relies on the use of insecticides through IRS and Plinth has proven to be effective in the last Plinth emergence and spread of insecticide resistance is threatening the susceptibility of this approach posing further enormous logistics challenges.

Monitoring and understanding the dynamics in relation to some environmental elements such as climate, physicochemical properties are key to addressing the challenges. Mosquito resistance to chemical insecticides has been identified as a global threat. According to the World Health Organization urgent action is required to prevent the further development of resistance and to maintain the effectiveness of existing vector control interventions.

2)            Behavioral Modification of Target Species

Indoor mosquito species adapt to the use of LLINs and IRS through spatial avoidance and by altering the timing of their aggressiveness (changing feeding periods to earlier or later in the day).

3)            Limited Outdoor Application

The dynamics of mosquito control within a confined indoor space are fundamentally different than mosquito control outdoors. Insecticide-infused nets and surface sprays have little value for controlling adult vectors that prefer outdoor spaces where disease vectors pose a significant threat to human health (beyond just malaria).

4)            Negative Impact on Non-target Organisms

Depending on the product and the application, chemical interventions might have (or might be perceived as having) a negative impact on non-target organisms such as birds, bees, fish, and people.

5)            Progress on Malaria Reduction has Slowed

According to the World Malaria Report 2018, only modest progress was made on global malaria reduction from 2015-2017.

LSM has been classified into:1) habitat modification, 2) habitat manipulation 3) biological control and 4) larviciding [19-22]. Habitat modification is a permanent change of land and water including landscaping drainage of surface water, land reclamation and filling but also coverage of large water storage containers, wetlands and other potential breeding sites. In addition, habitat manipulation is a recurrent activity, such as water-level manipulation, which includes measures like flushing, drain clearance, shading or exposing habitats to the sun depending on the ecology of the local vector.

Further, the biological control is the introduction of natural enemies (predators) into aquatic habitats; these are predatory fish or invertebrates, parasites or disease organisms. The use of larvicides has been the regular application of biological or chemical insecticides to water bodies for the control of mosquitoes. However, it has to be noted that the insecticides used for LSM have different modes of action including the: (1) surface films like mineral oils and alcohol or silicon based surface products that suffocate larvae and pupae, (2) synthetic organic chemicals such as organophosphate (e.g.) that interfere with the nervous system of immature stages, (3) microbial such Bacillus Thuringiesis Israelis is (BTI), and Bacillus Spharerians (BS) that kill larvae with toxins that are ingested and lead to lysis of the insect`s gut and (4) insect growth regulators such as pyriproxyfen, methoprene and diflubenzuron that interferes with metamorphoses of the insect and prevent adult emergence from the pupae stage.

Historically, by Garis Green (Copper acetoarsenite), an arsenical compound, was extensively used for anopheline larval control and the application of BTI, akatoreite, draining, and the introduction of fishes (Flinger and Lindslay, 2011) proved to be a success. http://www.malariajurnal.com/content).

Related Benefits of Larviciding as Part of an Integrated Vector Management (IVM) Approach

1)            Larvicides Extend the Useful Life of Chemical Adulticides

By reducing the size of the population being selected for resistance. Biological mosquito larvicides promote the effects of chemical adulticide interventions when such applications are warranted.

2)            Larvae Cannot Change Their Behavior

Unlike adult mosquitoes; larvae cannot change their behavior to avoid interventions. Once habitats have been identified and targeted interventions are highly successful because larvae are concentrated, immobile, and accessible.

3)            Larviciding Works For Indoor and Outdoor Species

Larviciding is an effective intervention against both outdoor and indoor vector species. Advancements in wide area larvicide application strategies have demonstrated that larvicides can be delivered to cryptic habitats in both urban and rural settings, providing excellent reduction data for adult mosquitoes.

4)            Bacterial Larvicides are Highly Specific in Their Activity

The activity of the larvicides Bacillus Thuringiensis spp. israelensis (BTI) and Bacillus Sphericus (BS) are based on highly specific protein toxins that only break down in the gut of mosquitoes and other select dipterans larvae. Excellent safety data exists for these products and their low impact on non-targets, such as birds, bees, fish, and people, all unaffected by these beneficial bacteria.

5)            Data clearly Shows the Positive Effects

There is increasing adoption and a growing amount of empirical data on the impact and value of bacterial larviciding as part of an IVM program in developing countries.

Materials and Methods

We reviewed both published and unpublished literature for LSM of varying periods from (1929-2019). Zambia and other countries such as Rwanda and Tanzania LSM were reviewed bearing in mind that it is an additional intervention to the current National Malaria Elimination strategies. The reviews also addressed perceived challenges to larviciding, and heralded the research and development work that has expanded the capacity of larviciding and research cites mounting evidence that clearly demonstrates the value of larviciding in a broader integrated vector management strategy. Tanzania and Rwanda point to their empirical data demonstrating the value of a change towards a new set of interventions that includes an intensified focus on larval source management rather than only focusing on adult mosquitoes.

Discussion

This paper challenges the notion that larval source management cannot successfully be used for malaria elimination in Zambian transmission settings by highlighting historical and recent successes. It discusses LSM potential in an IVM approach working towards malaria elimination and critically reviews the common arguments that have been used against the adoption of larval source management. In addition, the paper does not aim to control advantages and disadvantages for LSM with the first line critical interventions (IRS and LLINs) which could be found everywhere [23,24] but rather aims to highlight its potential benefits as a neglected vector control tool.

The literature review addresses high demand LSM prospect, its role, efficiency and the maximum impact it can offer as well as the national neglect and underutilization in Zambia for malaria elimination, despite past success stories the interventions have contributed in some countries to control and eliminate malaria. By targeting the larval stages, mosquitoes larvae are killed “whole sale” before they disperse to human habitations. Mosquito’s larvae, unlike adults cannot change their habitat to avoid control activities [7].

Eliminating aquatic habitats close to human habitations by modification and manipulation of the environment, where possible could provide long-term and cost-effective solutions [8]. The drainage of aquatic habitats can be incorporated in the “Keep Zambia Clean, Green and Healthy Campaign Concept”. The cost for this exercise can be paid outside the health sector budget. In places where habitats cannot be eliminated, larvicides can be applied. The available formulations are very effective formulations that have been developed for anopheline control [10].

These larvicides are environmentally acceptable with minimal or no effect at all on the non-target invertebrate populations, aquatic insects such as fish, birds and mammals including human beings. LSM has been found to require no substantial change in human behavior or the management of key resources such as water, land and skills for larviciding that are similar to those requirements for IRS [11]. When LSM is appropriately and effectively used can contribute to reducing the numbers of both out-door and indoor house biting mosquitoes for malaria elimination.

LSM is a useful tool to reduce mosquito population more especially in “hot spots” and can reduce on overdependence on chemicals that at times face mosquito’s resistance. The intervention needs to be tailored to local environmental conditions. LSM can be a fordable on a small scale with pilot chemicals and then building capacity and appearance. LSM requires more than the current findings and political support needed for strategic planning and long-term funding.

The local authority and small communities with few resources but with high intervention to eliminate malaria such as in places where ITNS and IRS has not been deployed can implement LSM through heavy community strengthened engagement efforts. The interested parties outside the health sector can contribute support to LSM through major projects such as roads and buildings construction including infrastructure development in large areas and private schemes and as the mines and agriculture operations can implement LSM independent of but in collaboration with NMEP activities using corporate or local resources [6].

According to Griffin and colleagues (90) recently persecuted strong evidence that out-door biting defines the limit of what is achievable with IRS and LLINS. The only available solution to this is LSM being one of the few strategies effective against outdoor biting vectors. Locally appropriate implementation systems need to be developed on an individual basis taking local structures and administration systems into account and adapted to local epidemics ……. conditions (73). For sustainability’s sake, LSM program need time for implementation staff and institutions to develop, pilot refine and stabilize locally-appropriate, effective and sustainable procedures and institution structure (77). LSM is applied at in scale depending upon the local ecology, institutional structures including financial support.

Evidence of Efficacy of Vector Control Interventions

LSM advantage is that it abates the general mosquito’s population rather than anopheline control alone. The local population must generate more support for the program and at the same time produce infrastructure and reinforcement for the control of the adult mosquitoes especially the other viruses that have the potential for public health problems. It has to be known that interventions against malaria are typically evaluated by measuring a decline in malaria morbidity and mortality.

However, a decision making frame work must be considered before embarking on the project. The Insecticide Resistance Management and Monitoring Committee (IRMMP), the Technical Advisory Committee (TAC) must assist in decision making. The Framework to would be implementers must look at the Roll Back Malaria Structure: What is LSM? Evidence of efficacy, Economics of LSM, Minimum requirements before and embarking on LSM, where to do LSM and when not to, when to start LSM and when to stop, what`s needed for implementation? What`s needed for monitoring? Role of LSM in IVM (RBM-LSM Work stream, 2012).

Urban and Peri-urban Larval Source Management Implementation

In towns and cities, larval habitats have been found largely man-made and become relatively easy to identify and treat, as seen in the Zambian cities. Cities like Lusaka, IRS is deemed not feasible in the urban malaria vector control. LSM is very similar to that of IRS where the main evidence of efficacy is also on historical accounts and where there are few high -quality trials to measure their impact (97).

Several authors have convincingly shown that the limitations of LLINs/ITNs and IRS are largely defined by mosquitoes avoiding them by feeding or resting outdoors and/or at earlier hours and developing insecticide resistance (83,85). The concerns could be reduced if LSM is combined with indoor vector control tools. However, recent research suggests that LSM does not reduce the number of adult vectors.

It has been argued by many that LSM was not feasible in African setting due to the high number of temporary and small larval habitats for Agamidae that are difficult to find and treat promptly that the delivery of larvicide to very small habitats for example cattle hoof prints has been difficult and environmental management targets primarily larger, permanent water bodies, that are not typically anopheline habitats and therefore contribute little to malaria elimination [17]. However, recent studies show that these assertions have been found to be incorrect in many areas of the sub-Saharan Africa with stable malaria transmission. Importantly, the widely feared small and temporal habitats contribute little to the overall production of larvae and adults throughout the years (112).

Utilization of state-of-the-art tools for mapping like geographical positioning systems, geographical Information Systems with a remotely sensed imaginary, combined with modern communication tools increases the operational efficiency of disease control interventions. These interventions are successfully used for mosquito vector surveillance for example in Rwanda (126).

LSM Contributing Factors for Its Success for Malaria Elimination

There is a need for community engagement, acceptance, responsiveness, involvement, empowerment and support for LSM. The LSM interventions must strive towards community engagement of the locals in the targeted areas so that larval habitats can be increased and either treated with a larvicide or modified. The community needs have to be taken into consideration when the interventions are well planned, for example the local population livelihood might depend on some of the aquatic habitats such as sugar cane, rice and irrigation channels, pits and wells.

Therefore, capacity building programs need to be implemented to the technocrats and the community to be involved in connecting LSM as in other countries like Rwanda and Tanzania [6]. For LSM activities, information is needed for effective leadership, good arrangement and clarity of objectives. The health workforce at all levels of the implementation system and must relieve the LSM as an important industry with a tough support of the community.

Management capacity development is key to a successful LSM program. Importantly, the ability to quickly guarantee, collate, report the meaningful monotone of dates in reality, inadequate framing and management of staff and the LSM activity could lead to the limitation of LSM program, strengthening the promotion of multi-sectoral collaboration. There are key partners for LSM in Zambia such as: the Government of Republic Zambia (GRZ) sectors: Ministry of Local Government, Ministry of Agriculture, Ministry of Mining and Minerals Development, the community, local community, local business community, local parastatals, the mediators and NGOs including the Faith -Based Organizations in community mobilization.

When collaboration is well coordinated with other sectors, good practice is observed in for good infrastructure development and housing (Road construction, block making or house construction) do not create or build up new habitats for the larva [6]. Building enhanced surveillance system: strengthened surveillance system is quite important through continuous entomological monitoring. This approach has been crucial to ensure that habitat or the larva is being well handled. The epidemiological enhanced surveillance has been found to be quite vital to monitor the LSM program impact. In addition, technological innovations have also been found to make larviciding strategy viable in many parts of the world [8].

Management, Cost-effectiveness and Rate of Application of Larvicides for Malaria Elimination

Again, recent analysis from three LSM programs of various sizes and ecological settings in Africa showed the cost per person protected each year ranged from u$ LLINs U$0.94 to U$2.50 [25-50]. This compares favorably with IRS (Range from various African settings U$0.88-4.94 [47] or LLINs range costing U$5 and assumed to last three years U$1.48-2.60 [51], suggesting that LSM presents a viable and cost-effective malaria control tool that can complement existing malaria control methods. With the current agenda for the movements towards malaria elimination, there has been a need to scale-up use of additional LSM cost-effective tools to reach the elimination goal.

In order to be effective, larviciding must be specifically adapted to each locality and be carried out thoroughly and selectively. The current strategy of LSM with larvicides has been to treat all available larval habitats [24]. Many people argue for more spatially targeted approach [36] to apply larvicides only at the most productive habitats [19]. In fact, to date no published evidence exists that shows that accurately, determining where malaria vectors will develop is possible [20].

However, several models have been developed recently to predict mosquito larval habitats, location and productive potential. Still, in future it might well be possible to target interventions more effectively [22]. Any benefit of targeting larval habitats at specific times of the year needs to be proven but may work well when LSM has been part of the IVM package of intervention [14].

The other concern of LSM is the application frequency. For frequency, it must be considered for the elimination agenda with or without other interventions in the communities, where the breeding sites are few, fixable and findable [41]. The application of larvicides to potential breeding sites could be cost-effective more especially in urban communities. The LSM strategy is to treat all available larval habitats [42]. In some cases, whilst some types of habitats have been more likely than others to have aquatic stages 25, this has not been sufficiently refined for spray teams to be able to identify and target only these high-risk habitats.

However, the application frequency of larvicides is another concern; where microbial larvicides are generally applied weekly to all potential sites [4]. Whilst the larvicides with greater residual activity would benefit for treating permanent habitat [49]. It is important also to note that they are not necessarily the panacea. They might appear to be, since during periods of rain new potential mosquito larval habitats can appear and larvae can develop into adults before the next round of application becomes simpler, because the people who apply the larvicide become familiar with their treatment community area and weekly cycle of activity.

Consequently, the overall targeting interventions in space and time as well as the utilization of more residual larvicides will only reduce costs if proven to be equally effective, than blanket application and if the increased management effort for decision making does not outweigh the larvicides costs [13]. Further, the substantial reductions in long term costs might be made, if larviciding is combined with environmental management. In some country studies, like the study in Tanzania-Dar-es-Salaam, indicated that simply by improving the drainage in drains would reduce larval breeding by 40% [9].

Larval Source Management Feasible Capacity for Malaria Elimination

Generally speaking, Africa has renewed interest in LSM and is often called the heartland of malaria, with LSM application as a complementary intervention to Indoor Residual Spraying and Long-lasting Insecticide Treated nets [18]. As can be expected, LSM could perform better especially where outdoor biting by malaria vectors has been problematic or where there has been resistance to the insecticides used for IRS or LLINs [18]. In certain eco-epidemiological settings, where larval habitats have been fixable, few and findable for example in Asia and Africa have shown that larviciding can reduce adult vectors density and consequently morbidity and mortality due to malaria [6].

Major Findings

There are several lessons learnt, success factors and best practices on the effects of larval source management:

Effects of Bacterial Larvicides

It has been found that at low rates, bacterial larvicides cause: a reduction in larval density, vector density, vector biting, reduction in disease transmission in most tested areas [8]. Further, according to Cochrane data base of systemic reviews [5], they also concluded 13 studies; four cluster-RCTs, eight controlled before-and-after trials, and one randomized cross-over trial. The included studies evaluated habitat modification (one study), habitat modification with larviciding (two studies), habitat manipulation (one study), habitat manipulation plus larviciding (two studies), and larviciding alone (seven studies) all together) in a wide variety of habitats and countries.

Evidence of Effects of LSM on Malaria Incidence

Another cluster-RCTs undertaken in Sri-Lanka, larviciding of abandoned mines, streams, irrigation ditches and rice paddies reduced malaria incidence by around three-quarters compared to control (RR 0.26,95% CI 0.22 to 0.31,20,124 participants, two trials, moderate quality assurance evidence). In three controlled, before- and trials in urban and rural India and rural Kenya, results were inconsistent (98,233 participants, three trials, very low-quality of evidence). In one trial in urban India, the removal of domestic water containers together with weekly larviciding of canals and stagnant pools reduced malaria incidence that was higher at baseline intervention areas than in controls.

Further, dam construction in India and larviciding of streams and swamps in Kenya reduced malaria incidence to levels similar to the control areas. In addition, randomized cross-over trials in the flood plains of the Gambia river, where larval habitats were extensive and ill-river, where by ground teams did not result in a statistically significant reduction in malaria incidence (2039 participants, one trial).

Evidence of Effects on Parasite Prevalence

A further study, in one cluster-RCT from Sri Lanka, larviciding reduced parasite prevalence by almost 90% (RR 0.11, 95% CI 0.05 to 0.22, 2,963 participants, one trial, and moderate quality evidence). In five controlled before-and after trails in Greece, India, the Philippines and Tanzania, LSM resulted in an average reduction in parasite prevalence of around two-thirds (RR 0.32, 95% CI 0.19 to 0.55,8041 participants, five trials, moderate quality evidence). The interventions in these five trials included dam construction to reduce larval habitats, flushing of streams, removal of domestic water containers, and larviciding. In randomized cross-over trial in the flood plains of the Gambia River, larviciding by ground teams did not significantly reduce parasite prevalence (2,039) participants, one trial). So, there is strong evidence that LSM is associated with 69% of reduction in incidence (95% CI, 58-77% (in six studies) and a 75% reduction in prevalence of parasitemia (95% CI 49-88%, six studies).

In the first half of the 20th century, Zambia by then had a major threat of malaria to the economic success of the copper mines. Andes can arose to implement integrated malaria vector control program primarily based on attacking the larval stages of malaria vectors by use of environmental management 39], that resulted in a 97% reduction of annual malaria incidence from 514/1000 in 1929/1930 to 16/1000 in 1949/50 similarly, overall mortality fell by 88% from 32/1000/ year to 4/1000/year.

Recent evidence under research showed that; (I) hand – applied larviciding reduced transmission by 70-90% where the majority of aquatic mosquito larval habitats were defined and aquatic surface areas not too extensive [50], that the addition of larviciding with LLINs resulted in greater gains than could be achieved by using LLINs alone. Hard drive application of larvicides was not effective in areas with very extensive water bodies such as the floods -plains of larger river systems [33].

In the meantime, the mines on the Copper belt and Zambia Sugar field efficacy trials have been conducted for various strains of larvicides to ascertain LSM effectiveness as well as its feasibility capabilities to reduce malaria vector population density. The trial results revealed that larvicides performed extremely well and provided effective anopheles control for 30 days [31]. A further 2nd field trial study conducted by the NMEP in Nigeria on mosquitocidal strains of Bacillus Thuringiesis Var Israelensis (BTI) and Bacillus Sphaerians (BS) in 1 Kene Local Government Authority of Ogun State, revealed that the biological larvicides were highly effective against all strains of anopheline culicines and aedes mosquitoes [40].

Again, another 3rd trial was conducted in Nigeria on another formulation of BTI serotype H-14 (Bactive) and Bacillus Sphaerians strain 2362 (Griseleaf). In conclusion, the effectiveness of the residual efficacy of bactivec and Griseleaf biolarvicides were proven for the control of anopheles and other species present such as the culex quinequefasciatus. The selected 1, 2 and 4 sites a stable and significant reduction was observed from the first 24hrs to the 30th day in at least 3 of the 4 treated sites within ranges of 80.3% to 100%.

Currently, there are 734 named mosquitos’ abatement districts in countries/continents like the US, all deploying LSM, which is the primary and preferred method of mosquito control in the States. In states like California and Florida, LSM has been found to provide dual benefits of not only reducing numbers of house entering mosquitoes but, importantly, also those that bite outdoors. The large scale of LSM was a highly effective tool for malaria control in the first half of the twentieth century, but was largely disbanded in favor of IRS with DDT [40].

Further, it has been noted that currently many countries in Africa lack the capacity of local entomologists [12]. The few scientists available are very well qualified but their professional decisions are usually at the peril of the financiers` negative influence on the scientific decisions made by these scientists on the LSM programs. Yet the lack of capacity can be increased as available human resource need to be improved to ensure that any improved control could be sustained [37].

There is need for skills adaptation for empowering communities. It has been observed that LSM has several aspects that are significantly more sustainable than IRS and LLINs, since highly effective tools other than larvicides can be applied by local communities with dependency of high recurrent costs. Importantly, there is need for local adaptation and skills must be seen as an important opportunity for creating self-empowerment for malaria elimination.

Clearly, larval source management must build upon local initiatives with collaboration of existing stake holders and advocates. All mosquito species must be targeted to reduce nuisance biting “pest mosquitoes” and maintain community support. Community expectations must be met based on their perceptions of the impact to which the relationship between malaria, mosquito species and habitats are usually poorly understood, by local communities that are often more motivated by mosquito biting nuisance than malaria or any other pathogens they transmit [44].

However, there is a key challenge for mosquito control programs, focusing on larvicides in urban areas is to have full regular access to all open spaces potential for accommodating aquatic habitats where mosquito proliferation takes place. This includes all fenced plots and other areas within restricted access for the public. This has been found to require substantive and open collaboration between residents and stakeholders. Community involvement in both the recruitment process of the individuals and implementation of the intervention has been found to be essential to program performance [14].

In order to achieve wide -scale community-based implementation through a decentralized vertical management structure is by utilization of the hierarchical gradient of implementation strategies and partner roles across all the necessary spatial scales. Such centralized coordination is essential to enable institutionalization of strengthened management and planning, improved community mobilization capability and the capacity to exploit national, private and business community funding systems [43].

Data Utilization for Larval Source Management

Equally important has been the management of a successful larviciding program that requires a scientific approach with knowledge and data capture and analysis on: mosquito physiology [mosquito feeding strategy, age of larvae, and density of larvae] Temperature [Humidity, water depth and water turbidity], water organic content [Presence of vegetation, location of habitats, access to habitats]. Data shows that these skills and competencies can be managed effectively by a team, and that knowledge base created by this process offers additional benefits with positive impacts, on other areas of the program including such fundamental objectives as reduced vector densities, reduction in vector biting and reduction in disease transmission [43].

All things considered, effective mechanisms for communication and feedback to the community of monitoring data within days, weeks or months, rather than years are essential for LSM of mosquitoes that can develop from egg to an adult within a day and weeks. This calls for continuous and thorough monitoring because success and failure occur on the remarkable fine spatial (<1 KM2) and temporal scales (<1 Week) that match to the retreatment cycles and geographical division of responsibility to individual staff [43].

There is need for intensified surveillance for larvae mosquito populations in order to assess the effectiveness of the larvicide application, and the performance of individual personnel. This approach is essential for internal monitoring functions and external quality assurance of the activities, as well as monitoring and evaluation of impact on adult mosquitoes. However, malaria risk should be separately conducted by institutionally independent partners by reporting directly to program management to avoid conflicts of interest that inevitably arise from self-assessment [38].

In other words, proven systems for rigorous and timely monitoring of LSM remain to be fully developed, and take many years to slowly evolve to address the high standards required to ensure rapid identification of implementation failures at sufficiently fine spatial and temporal scales. LSM programs must therefore start small, through a manageable pilot scales and then progressively build and institutionalize implementers capacity and experience. Training and development cost must therefore be included in the budgets. These must be strategically planned and consistently supported over the long term so that locally-adapted LSM program and their supporting institutions have sufficient time to learn, consolidate and stabilize [44].

Ultimately, the effectiveness of LSM program relies upon monitoring and managing at very fine spatial and temporal scales. There must be the ability to collate, synthesize and report simple but reliable monitoring of data in the shortest time possible is essential. Furthermore, maintenance and management of a stable funding base, as well as an effective collaboration between the partner institutions responsible for the diverse and distinct functions of an LSM program that is paramount to the long-term success. Capacity to manage logistics, human resources, institutional partnerships and funding support are most limiting, far more so at this juncture than the technical entomology skills [38].

Conclusion

The pace of urbanization poses a number of public health problems including increases in malaria morbidity and mortality. Urban malaria control has to heavily rely upon larviciding and strengthened community implemented environmental management such as drainage and habitat filling. This provides vital LSM effectiveness, affordability and sustainable vector control for malaria elimination. In addition, participatory planning is equally essential to enhance local capacities and ensures community ownership. To achieve the required results, there is need for central coordination role of urban LSM by the local authorities, enabled institutionalization of strengthened management and planning, improved community mobilization capability and capacity to exploit planning for improved communities. In Zambia, LSM is another policy option to consider, alongside LLINs and IRS in order to reduce malaria morbidity and mortality in both urban and rural areas, where sufficient proportions of larval habitats can be targeted and where malaria breeding sites are fixed, discrete and easily identifiable. Therefore, in some settings LSM may complement other methods of vector control in malaria elimination programs. In such communities, there is need for high degree of LSM program ownership by the city councils, coupled with catalytic generated funding and technical support from the expertise from MOH for the establishment of a sustainable LSM program.

Acknowledgement

Part of the contents of this publication is based on the several results of the meetings of the Technical Working Groups (TWGs), Technical Advisory Committees (TACs) and Open Forum discussion on LSM over several years. I would like to thank all those who gave me time to discuss with over LSM prospects and arrived at crafting this article to spearhead the implementation of LSM as a critical supplementary Vector Control Intervention to LLINs & IRS.

References

  1. Becker N, et al (2003) Mosquitoes and their Control. New York.
  2. Blair J, et al (2008) Integrated Vector Management for malaria control.
  3. Carlson B (2006) Source reduction in Florida`s salt marshes: Management to reduce pesticide use and enhance the resource. J Am Mosq Control Assoc 22: 534-537. [crossref]
  4. Castro MC, Tsurutu A, Kanamoris S, Kamadu K, Mkude S Community-Based Environmental Management for malaria control: Evidence from a small -scale intervention in Dar-es- Salaam, Tanzania.
  5. Cochrane Data Base of Systematic Reviews (2013). cochranelibrary.com
  6. Cochrane Reviews (2012) WHO Documents, Country documents, private sector documents, LSM pilots and case studies.
  7. Cohen JM, Mooned B, Snow RW, Smith DL (2010) How absolute is Zero? An evaluation of historical and current definitions of malaria elimination.
  8. Derue, et al. (2019) Challenges of existing primary malaria interventions (LLINs and IRS).
  9. Dongus S, P Feither C, MettaE, Mbuyita S, Obrist B (2010) Building multi–layered resilience in a malaria control program in Dar -es-Salam, Tanzania.
  10. Elsen L, Eisen RJ (2011) Using Geographical Information Systems (GIS) and decision support systems for the prediction, prevention and control of vector borne diseases. Annu Rev Entomol 56: 41-61. [crossref]
  11. Ernst KC, Adoka SO, Kowuor DO, Wilson ML, John CC (2006) Malaria hotspot areas in a high land Kenya Sites are consistent in epidemic and non-epidemic years and are associated with ecological factors. Malar J 5: 78. [crossref]
  12. Ferguson HM, Dorn haust A, Beeche A, Borgemeister C, Gottlieb M, et al. (2007) Ecology: a prerequisite for malaria elimination and eradication. Plos Med 7: e1000303. [crossref]
  13. Flinger U, Lindslay SW (2011) Larval Source Management for malaria control in Africa: myths and reality. Malar J 10: 353. [crossref]
  14. Flinger U, Ndenga B, Githeko A, Lindslay SW (2009) Integrated Malaria Vector Control with microbial larvicides and Insecticide Treatednets in Western Kenya: a controlled trial. Bull World Health Organ 87: 655-665. [crossref]
  15. Flinger U, Sombroek H, Megampere S, Van Loon E, Takken W, et al. (2009) Identifying the most productive breeding sites for malaria mosquitoes. Malar J 8: 62. [crossref]
  16. Floore TG (2006) Mosquito Larval Control Practices: Past and Present. J Am Mosq Control Assoc 22: 527-533. [crossref]
  17. Gadawski R (1989) Annual Report on mosquito surveillance and control in Godowsky control Branch, Parks & Recreation Dept.
  18. Griffin JT, et al. (2010) Reducing Plasmodium Falciparum malaria transmission in Africa: a model -based evaluation of intervention strategies.
  19. Gu W, Novak R (2005) Habitat -Based Modelling of impacts of mosquito larval interventions on entomological inoculation rates, incidence and prevalence of malaria.
  20. Killen GF, Tanner M, Mukabana WR, Kalongolela MS, Kannady K, et al. (2006) Habitat targeting for controlling aquatic stages of malaria vectors in Africa. Am J Trop Med Hyg 74: 517-518. [crossref]
  21. Lee County Mosquito Control district website. http://www.Icmd.org/I
  22. LI L, Bian L, Yakob L, Zhou G, Yan G (2011) Analysing the generality of spatially predictive mosquito habitats models. Acta Trop 119: 30-37. [crossref]
  23. National Malaria Elimination Strategic Plan (2017-2021)
  24. Majambere S, Pinder M, Fillinger U, Ameh D, Conway DJ, et al. (2010) Is the mosquito larval source management appropriate for reducing malaria in areas of extensive flood in the Gambia? A cross-over intervention trial. Am J Trop Med Hyg 82: 176-184. [crossref]
  25. Malaria Vector Control in Africa (2001) Strategies and Challenges; Report from a symposium held at the American Association for the advancement of science annual meeting.
  26. Minakawa N, Sonye G, Yan G (2005) Relations between the occurrence of Anopheles Gambiae S.L (Diptera, Culicidae) and size and stability of larval habitats. J Med Entomol 42: 295-300. [crossref]
  27. NajeraJ A, Zaim M (2002) Malaria Vector Control-Decision making criteria and procedures for judicious use of insecticides. WHO Pesticide Evaluation Scheme (WHOPES).
  28. National Malaria Control Strategic Plan (2012-17)
  29. Pluess B, Tauser FC, Lengeler Sharp B (2010) Indoor Residual Spraying for Preventing Malaria (Review). Cochrane Review 2010: CD006657. [crossref]
  30. RBM: Global Malaria Action Plan. Roll Back Malaria Partnership (2008)
  31. Rezendaal JA (1997) Vector Control: Methods for use by individuals and communities. WHO.
  32. Riehle M, Guelbeogo WM, Gneme A, Eiglmeier K, Holm I, et al. (2011) A cryptic subgroup of Anopheles Gambiae is highly susceptible to human malaria parasites. Science 331: 596-598. [crossref]
  33. Roll Back Malaria -Larval Source Management (2012).
  34. Russell TL, Govella NJ, AZIZIS, Drakeley C, Kachurs P, Killen GF (2011) Increased proportion of outdoor feeding a mong residual malaria vector populations following increased use of ITNs in rural Tanzania.
  35. Smith D, Dushoff J, Snow RW, Hay SI, et al. (2005) The Entomological Inoculation Rate (EIR) and Plasmodium Falciparum infection in African children. Nature 438: 492-495. [crossref]
  36. Smith McKenzie FE, Snow RW, Hays (2007) Revisiting the basic reproductive number for malaria and its implications for malaria control. Plos Biol 5: e42. [crossref]
  37. Townson H, Nathan MB, ZAIM M, Gullet P, Manga L, et al (2005) Exploiting the potential of vector control for disease prevention. Bull World Health Organ 83: 942-947. [crossref]
  38. TustingL S, Thwing J, Sinclair D, Fillinger U, Gimnig J, et al. (2013) Mosquito Larval Source Management for controlling malaria (Review). Cochrane Database Syst Rev 2013: CD008923. [crossref]
  39. Utizinger J TozamY, Singer BH (2001) Efficacy and cost effectiveness of environmental management for malaria control. Trop Med Int Health 6: 677-687. [crossref]
  40. Walker K, Lynch M (2007) Contributions of Anopheles Larval Control to malaria suppression in Tropical Africa: Review of achievements and potential. Med Vet Entomol 21: 2-21. [crossref]
  41. WHO (2007).Malaria Elimination; Afield Manual for low and moderate endemic countries.
  42. WHO (2010). Hand book on integrated Vector Management (IVM) Geneva.
  43. WHO (2012). Related benefits of larviciding as part IVM Approach
  44. WHO (2013).A supplementary measure for malaria vector control. An Operational Manual.
  45. WHO Expert Committee on malaria Geneva: World Health Organization
  46. Wool House M, Dye C, Etard JF, Smith T, Charlwood JD, et al. (1997) Heterogeneities in the Transmission of Infectious agents: Implications for the design of control programs. Proc Natl Acad Sci USA. 94: 338-342. [crossref]
  47. E, Conor, Thomson M (2008) Improving the cost-effectiveness of IRS with climate informed health surveillance systems. Malar J 7: 263. [crossref]
  48. World Health Organization (1982) WHO Expert Committee on malaria, Geneva
  49. World Malaria Report (2018).
  50. Worrall E, Fillinger U (2011) Large scale use of mosquito larval source management for malaria control in Africa: A cost analysis. Malar J 10: 338. [crossref]
  51. Yelich Jedis Flagler C (2007) Operations, costs and cost-effectiveness of five insecticide-treated nets programs (treated) and two Indoor Residual Mozambique. Spraying Programs (Kwa Zulu Natal).

The Role and Impact of Female Health Workers on the Well-Being of Global South Communities: A Call for Gender-Transformative Action

DOI: 10.31038/AWHC.2022521

Abstract

One of the cornerstones of a sustainable health system is the presence of a strong primary health care sector; it is important to recognize the central role that universal health coverage has in achieving the Sustainable Development Goals. The 2030 Agenda for Sustainable Development has set its vision to ‘leave no one behind’. In particular, Sustainable Development Goal No. 3 and its targets (intended to ensure healthy lives and promote well-being for all people of all ages) will advance through substantial strategic investments in the global health workforce. There is, therefore, a need to address issues related to both the shortage and maldistribution of the health workforce and performance challenges in order to promote universal health care and improve all health-related goals. Many countries have adopted the concept of ‘task-shifting’, through the involvement of lay and community health workers as a rational strategy for addressing the shortage in human resources, impeding the roll-out of primary care programs in these countries. Anchored on the models of task-shifting and task-sharing, this paper explores the role and impact of female Community Health Workers (CHWs) to the well-being of communities in the ‘Global South’ (a term generally used to identify regions of Latin America, Asia, Africa, and Oceania. Findings revealed the well-known gaps that affect gender-transformative action for women, including occupational segregation, harassment, the gender pay-gap and leadership challenges in the health and social workforce, yet programmatic focus on maternal and newborn health and wellness in Global South communities are the most highly impacted by female CHWs.

Keywords

Women, Health workers, Developing countries

Introduction

In 1969, progressive social activist, Carl Oglesby, coined the term ‘Global South’, a broad term often referring to poor and/or socio-economically marginalized parts of the world and is generally understood to mean developing countries, underdeveloped countries, low-income economies or, the least-favored term, Third-World countries. It would include formerly colonized countries in Africa and Latin America, as well as the in the Middle East, Brazil, India, and parts of Asia.

The 2030 Agenda for Sustainable Development has set its vision to ‘leave no one behind’. In particular, Sustainable Development Goal No. 3 and its targets (intended to ensure healthy lives and promote well-being for all people of all ages) will be advanced through substantial strategic investments in the global health workforce. To ensure a diverse mix of sustainable skillsets, interprofessional primary care teams of health workers would be trained and deployed as part of greater efforts to strengthen primary health care, supported by strong health systems that enable and empower the health workforce to deliver safe and high-quality care for all [1]. The WHO’s General Director, Tedros Adhanom Ghebreyesus, emphasizes the “triple billion” targets of the new five-year strategic plan, which include: one billion more people benefiting from universal health coverage; one billion more people better protected from health emergencies; and one billion more people enjoying better health and well-being [2].

Strengthening Primary Health in Universal Health Care

A strong primary health care sector is one of the cornerstones of a sustainable health system; it is important to recognize the vital role of universal health coverage as part of achieving the Sustainable Development Goals. The 2008 Alma-Ata Declaration on Primary Health Care (PHC) had eight essential components, including (a) health education, focusing on the prevailing health problems and methods of preventing and controlling them; (b) nutritional promotion, including food supply; (c) supplying adequate safe water and sanitation; (d) maternal and child health care; (e) immunization against major infectious diseases; (f) prevention and control of locally endemic diseases; (g) appropriate treatment for common diseases and injuries; and (h) provision of essential drugs [3]. Community Health Workers (CHWs) in primary care settings are integral to building strong, resilient, and safe primary health care systems that contribute to the achievement of the interrelated Sustainable Development Goals and targets that include: nutrition (SDG 2), health (SDG 3), education (SDG 4), gender equality (SDG 5), employment (SDG 8), and reducing inequalities (SDG 10) [4].

There is, therefore, a need to address issues related to the shortage and maldistribution of the health workforce and performance challenges in order to promote universal health care and improve all health-related goals. The Global Strategy on Human Resources for Health: Workforce 2030 passed a resolution (WHA69.19) in 2016 identifying the opportunity to boost the performance, quality, and impact of CHWs for the achievement of universal health coverage and sustainable development goals [5]. Furthermore, many countries have adopted the concept of ‘task-shifting’, through the involvement of lay and community health workers as a rational strategy for addressing the shortage in human resources, impeding the roll-out of primary care programs in these countries [6]. Task-shifting makes use of already available human resources by delegating tasks requiring high skills to health workers with lower qualifications.

During the UN General Assembly in September 2015, the four pillars of the Decent Work Agenda – employment creation, social protection, rights at work, and social dialogue – became integral elements of the new 2030 Agenda for Sustainable Development [7,8]. The United Nations High-Level Commission on Health Employment and Economic Growth recognized the potential of the health sector to create opportunities for qualified employment, through job creation, that contributes to the economic development agenda [9]. This was reaffirmed in 2017 by the resolution on human resources for health (WHA70.6), which called to “stimulate investments in creating decent health and social jobs with the right skills, in the right numbers and in the right places, particularly in countries facing the greatest challenges in attaining universal health coverage.” In 2018, the World Health Organization adopted the evidence-based Guideline on health policy and system support to optimize community health worker programs [10]. In 2019, the World Health Assembly passed a landmark resolution on CHWs (WHA72.3), highlighting their role “to assure that universal health coverage and comprehensive health services reach difficult-to-access areas and vulnerable populations” and their role in “advancing equitable access to safe, comprehensive health services [11].

Community Health Worker Programmes

By the year 2030, it is projected that there will be a global shortage of almost 18 million health workers [2]. Demographic changes and rising health care demands are expected to drive the creation of 40 million new jobs by 2030 in the global health and social sectors [7]. The key to reversing this trend and promoting health efforts is to invest in female CHWs through education, training, and employment [12]. However, before investing public resources in activities such as curriculum development and certification, documentation of the effectiveness of these workers making an impact on important health concerns is required [13,14]. CHWs are comprised of various community health aides who are not trained health professionals, albeit trusted and respected, and able to provide a link between people’s homes and formal government Primary Health Care (PHC) clinics, thereby engaging in task-shifting and task-sharing [15,16]. These CHWs are usually trained to deliver basic health-related interventions and services within their own community; it is difficult to generalize one universal title for all CHWs, as their specific job responsibilities within their local cultures and health systems vary (e.g., traditional birth attendant, lay health advisor, community care coordinator, community health volunteer, lactation consultant, family service worker, barangay [village] health worker, village doctors, health advocates, promotor de salud [health promoter], consejera/animadora [counselor/organizer], maternal/infant health outreach specialist, patient navigator, peer educator, public health aide, neighborhood health advisor, shasthya shebika, etc.) [17-19]. The efficacy of CHWs in reducing the burden of care in under-staffed and under-resourced health systems remains a point of dialogue, with varying perceptions regarding their value.

National CHW programs comprise the foundational component for achieving universal access to primary healthcare [6]. In 2014, a group of experts produced a guide for developing and strengthening CHW programs, at scale, that drew heavily on previous experiences with CHW programs [20]. In 2017, this same group of experts produced 13 case studies of national CHW programs [21]. The compendium Health for the People: National Community Health Worker Programs from Afghanistan to Zimbabwe updated and broadened the 2017 case studies of national CHW programs to include the following 29 countries: Afghanistan, Bangladesh, Brazil, Ethiopia, Ghana, Guatemala, India, Indonesia, Iran, Kenya, Liberia, Madagascar, Malawi, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Rwanda, Sierra Leone, South Africa, Tanzania, Thailand, Uganda, Zambia, and Zimbabwe. Each case study has at least one author who has personal in-country experience with the program being described [22].

This expanding list of countries, with large-scale and stable CHW programs, provides growing evidence of the effectiveness of CHWs in achieving specific health outcomes and a renewed global confidence in CHWs [23-25]. A number of significant international consensus statements have recommended that CHW programs be integrated into health systems, increasingly linking these to the concept of Universal Health Coverage (UHC) [26-28].

CHWs and CHW programs encompass a broad concept and umbrella of practices that are driven by different imperatives to deliver a diverse array of programmatic priorities, roles, and forms of community involvement in health and healthcare delivery. CHW initiatives have taken a variety of regional- and country-specific forms. Some, such as the Brazilian Programa Saúde da Famiília [6,25,29], Ethiopia’s health extension workers [16,30] and the Behvarzs of Iran [31], the BRAC’s Shasthya Shebika Program of Bangladesh [16,19,32], the Lady Health Workers of Pakistan [33,34] and the Community Health Assistants of Liberia [20,22] have been part of broader social, political, and health sector changes, established in response to the public health challenge of high maternal, neonatal, and under-five mortality. The overwhelming care and social needs in southern African countries afflicted with HIV engendered home-based care and support that emerged organically through local community and non-governmental organizations. In other African countries, Global Health Initiatives and partnerships focused on malaria and childhood diseases.

There are several models for governance in CHW programmes, which may be either 1) integrated, 2) networked, or 3) detached from the formal health systems; each has its implications on how programmes obtain funding, select and train CHWs, support and supervise CHWs, pay CHWs, and how the programs involve communities.

The Brazil Programa Saúde da Família [PSF] and the Health Extension Worker [HEW] programmes in Ethiopia are integrated with the formal health system and obtain support from within the system. India’s Accredited Social Health Activists [ASHA] CHW program and the Building Resources Across Communities (BRAC) CHW program in Bangladesh do not belong to any formal facility-based health system, however, they have networked structures that link to the system. Non-governmental organizations (NGOs) run the CHW programs in South Africa and are centrally driven within established parameters at the national level but are run through separate structures.

Female CHW at the Forefront in the Global South

The ‘Shasthya Shebika’ Program of Bangladesh

Bangladesh traces a long history of productive collaboration between the government and NGOs on CHW programs, and a strong community engagement in development programs. The Building Resources Across Communities (BRAC) CHW program, of national scope, consists of two cadres of female CHWs (Shasthya Shebikas [SSs] and Shasthya Kormis [SKs]) that complement the government’s three CHW cadres, i.e., the Family Welfare Assistants, the Health Assistants, and the Community Health Care Providers.

The BRAC’s Shasthya Shebika Program has been an integral part of the country’s healthcare system for more than three decades and is widely seen as having made key contributions to Bangladesh’s remarkable achievements in reducing maternal and child mortality and controlling tuberculosis [19]. During monthly household visits, SSs provide health promotion sessions, educating families on safe delivery, family planning, immunizations, hygiene, and water and sanitation. A referral system to government facilities or BRAC clinics has been established for patients with illnesses that the CHW cannot manage. Over 110 million people in Bangladesh have benefited from BRAC community-based integrated programs.

Bangladesh’s experience is exemplary because of its record two-thirds decline between 1990 and 2015 in the mortality of children younger than five years of age. It has achieved a significantly high contraceptive prevalence rate of 62% and a fertility rate of only 2.1 births per woman, to which female CHWs have made major contributions. Home visits by female CHWs have, likewise, improved the distribution of Micronutrient Powder (MNP) within communities [32].

The Brazil Programa Saúde da Família

Officially launched in 1994, the Brazil Programa Saúde da Família (Family Health Program, now called the Family Health Strategy and abbreviated as PSF), builds upon several decades of experience in rural underserved areas with Community Health Agents (CHAs). CHAs are full-time government employees who engage in monthly home visits for health promotion, surveillance, and linkage to the facility-based health system. CHAs form Family Health Teams together with other CHAs, nurses, and a physician based at a nearby health center [22]. By 2002, CHAs were officially recognized as professionals by Law No. 10.507 [29].

Brazil’s health status is one of the best in the world, and it is one of the few countries in the world that has eliminated socioeconomic disparities in the nutritional status of children that result in childhood stunting. Expanded access to services has also resulted in marked reductions in maternal, infant, and child mortality [22]. The country’s CHAs are seen as critical to this achievement through their promotion of maternal and child health by educating families on appropriate household behaviors (including good nutrition) and linking families to needed health services [6].

The Community Health Extension Program of Ethiopia

Ethiopia began its current CHW program (HEP) in 2003, although the country’s experimentation with CHW models dates back to the 1950s. Its dual cadre CHW program consists of professionalized Health Extension Workers (HEWs) and the Women’s Health Development Army (HDA) volunteers. HEWs undergo twelve-month training before they are deployed as salaried government employees, with benefits, and serve a catchment of approximately 2,500 people. The HDA volunteers, on the other hand, each serve five to ten households and form health development teams (HDTs) that comprise up to thirty households residing in the same neighborhood. More than 42,000 government-salaried female HEWs are deployed in the country to provide key health services through outreach activities. They are expected to spend 25% of their working time conducting home visits and outreach activities, and the remaining 25% at health posts providing basic curative, promotive, and preventive services [22].

Ethiopia’s advances in reproductive, maternal, and child health have been outstanding since the implementation of the HEP. Ethiopia’s CHWs have been the foundation for these advances, leading to a rapid rise in the contraceptive prevalence rate from only 5% (when the HEWs were first introduced) to 40% at present. Ethiopia’s CHWs impacted a two-thirds decline in the mortality of children younger than five years of age between 1990 and 2015. Ethiopia is also remarkable for the role of HEWs and HDA volunteers in the control of HIV/AIDS, malaria, and tuberculosis, all of which have improved remarkably since the introduction of HEWs [30].

The ASHA Programme in India

India’s Accredited Social Health Activist (ASHA) programme was launched by the National Health Mission (NHM) in 2005 [formerly known as the National Rural Health Mission (NRHM)], in line with its policy of community engagement to ensure people’s participation in health, especially among the marginalized communities. Women between 25 and 45 years are preferentially recruited as ASHAs, based on leadership and communication skills. Each ASHA functions as a ‘health care facilitator, service provider, and health activist’ and is deployed and expected to conduct health promotion activities for at least 1,000 people in a village [35].

ASHAs’ activities in Reproductive, Maternal, Neonatal, and Child Health (RMNCH) include maintaining pregnancy registration records, holding village-level health meetings, motivating and escorting women to access Antenatal Care (ANC) and facility-based delivery, providing post-natal care, promoting and facilitating the use of birth spacing methods, immunizations, and counseling about pregnancy-related issues, including anemia management, and distributing iron tablets, sanitary napkins, contraceptives, and pregnancy kits. The ASHAs’ efforts were strongly correlated with the utilization of maternity services, specifically with the improved utilization of at least one antenatal care visit, skilled birth attendance, and giving birth in a health facility [36].

The Female CHW of Afghanistan

The Village Health Council (VHC), or Health Shu’ara, nominates the Community Health Workers (CHWs) in Afghanistan as part of the country’s national health care system. They make up the majority of the health workforce in the remote areas of this country and are often the first point of contact for most of the basic health needs of the communities. The Basic Package of Health Services for the Afghanistan (BPHS) initiative only requires the CHWs to undergo highly targeted, multi-phase training for a minimum period of eight weeks to learn about the management of basic illnesses [37]. Because of limited female mobility in Afghanistan, due to cultural and religious norms, the BPHS initiative employs CHW couples/partner groups, whereby female CHWs are often accompanied by a Mahram – usually their husband, brother, or father who acts as a male religious guardian, in order to ensure that health services are delivered efficiently [38].

The Lady Health Workers of Pakistan

The Pakistan Lady Health Worker (LHW) programme (The Pakistan National Program for Family Planning and Primary Health Care), was started in 1994 with a staff of nearly 30,000 women. Over the years, it has expanded to more than 125,000 employees, deployed in all districts of the country. Patriarchal normative proscriptions of seclusion forbid women’s access to health care facilities, hence the LHWs need to provide door-step reproductive health services in a context where socio-cultural factors such as gendered norms and extended family relationships and biradari/caste-based hierarchies impact rural women’s mobility patterns and LHWs’ home-visit rates. Lady Health Workers have, likewise, successfully provided cognitive-behavioral interventions for postpartum depression. Approximately 60-70% of rural areas and urban slum populations are benefited by the programme [33,34].

Female Community Health Volunteers of Nepal

Some 53,000 female community health volunteer workers (FCHV), serving 125 households, comprise the Female Community Health Volunteers of Nepal since the commencement of the programme in 1988. The foci of their tasks are safe motherhood, child health, family planning and immunization. Their basic training course usually lasts for 18 days. After completion of training, FCHVs are provided a certificate from the Ministry of Health, and a medicine kit that includes oral rehydration solution packets and oral supplements such as vitamin A and iron. They are provided an identity card and a register with 30 to 40 indicators to be recorded, including maternal, infant, and child deaths, and details of vertical programmes in their areas [7,39].

The Community Health Workers in South Africa

In 2011, the South African (SA) National Department of Health (NDOH) launched ‘The Re-engineering of Primary Health Care’ policy, which relies heavily on CHWs, to reduce maternal and child mortality and improve access to health care [39,40]. Local communities and Non-Governmental Organizations (NGOs) responded to overwhelming care and social needs in the HIV-affected countries of southern Africa and provided home-based care and support that emerged organically. Global Health Initiatives and partnerships in other African countries, focused on malaria and the promotion of integrated Community Case Management (iCCM) of childhood illness. CHWs and CHW programmes in South Africa are, thus, a broad umbrella concept and practice under which a diverse array of programmatic priorities, roles, and forms of community involvement in health and health care delivery exist. The Philani Plus (+) Intervention Program builds upon the original Philani CHW home-visiting intervention program for maternal and child nutrition by integrating content and activities to address HIV, alcohol, and mental health [41].

The Barangay Health Workers in the Philippines

The Philippines was an early adopter of the CHW model for the delivery of PHC, launching the Barangay (village) Health Worker (BHW) programme in the early 1980s. Operating at the level of barangays or villages, the smallest unit of governance in the Philippines, volunteer Barangay Health Workers (BHWs) has evolved to become an essential component of the nation’s healthcare workforce. In 1995, the Philippine Congress passed Republic Act 7883 (The BHWs’ Benefits and Incentives Act) aimed to empower BHWs to self-organize, strengthen, and systematize their services to communities, and create a forum for sharing experiences and recommending policies and guidelines. In most areas of the country, BHWs are often exclusively female. This points to yet another symbolic factor that impacts and limits wider participation in the BHW programme, i.e., the persistent effect of cultural patriarchy on women’s labor force participation in the Philippines. Despite the country’s world-leading performance on several key indicators of gender equality, the most recent figures for 2019 indicate that just under half of all Filipinas above 15 years of age are actively employed, placing the Philippines in the bottom third of over 180 nations [18].

The Impact of Women in the Health Care Workforce

Women comprise a large part of the community healthcare workforce, with approximately 67% of the health workforce in 104 countries being female. Gender distribution by occupation across all regions exhibits systematic professional differences, with males comprising the majority of physicians, dentists, and pharmacists, while females comprise the majority in the nursing and midwifery workforce [42]. This is confirmed by the report “Delivered by women, led by men: A gender and equity analysis of the global health and social workforce,” that female health workers are relegated to a lower status, with lower pay or, often, into unpaid roles, while facing harsh realities of gender bias and harassment [7].

For World Patient Safety Day, 17 September 2021, the WHO urged all stakeholders to “act now for safe and respectful childbirth!” with the theme “Safe maternal and newborn care” [43]. Approximately 810 women die every day from preventable causes related to pregnancy and childbirth. Aligned with this thrust are the programmatic foci on maternal and newborn health and wellness in communities that are the most highly impacted by female CHWs [1,44]. These include birth preparedness and distribution of misoprostol to prevent postpartum hemorrhage among mothers who deliver at home [45], postnatal home visiting, umbilical cord care, thermal care, promotion of exclusive breastfeeding, and prevention of neonatal sepsis through prompt treatment of neonatal infection [46-69] and support to mothers and infants for the prevention of mother to child transmission of HIV [50,51]. Promotion of child health, including uptake of immunization [52] nutrition, including breastfeeding, micronutrient supplementation and supplemental feeding [53], community management of malnutrition [54], and early childhood development [55]. The Integrated Community Case Management (iCCM) of childhood illness combines the diagnosis and treatment of malaria with Artemisinin Combination Therapy (ACT), pneumonia with oral antibiotics, and diarrhea with zinc and Oral Rehydration Salts (ORS) [56].

Gender-transformative Action for Female CHWs

There is no doubt about the role and significance of women in society. On the 8th of March, every year, the United Nations celebrates Women’s Day around the world to honor the achievements of women in all areas of life-social, economic, and cultural. The main purpose of the day is to honor the accomplishments of women while also raising awareness about gender bias. Recognized gaps that affect gender-transformative action for women include occupational segregation, harassment, the gender pay gap, and leadership challenges in the health and social workforce.

Systemic issues in the health workforce workplace include: gender biases, discrimination, and inequities leading to occupational segregation by gender [7,42]. In many organizations, female health workers are not allowed maternity leave, because they expect women to fit into systems designed for male life patterns and gender roles. Many countries still lack legal and social protection for women on issues that underpin gender equality at work, such as gender discrimination, sexual harassment, and equal pay [12]. The theme for the 2022 United Nations International Women’s Day is: “’Break the Bias’ – #BreakTheBias”-calling for ‘gender equality today for a sustainable tomorrow’.

The stigma and fear of retaliation inhibit female health workers from reporting workplace violence and sexual harassment. Violence and harassment – often from male colleagues, male patients, and even random members of the community – harm women physically and psychologically, cause attrition, low morale, and their ill-health impacts their ability to deliver the quality of care necessary for caring for others [38].

Occupational segregation drives a gender pay gap that is larger than in many other economic sectors, thus robbing women of decent work [8]. Women in the health care sector earn, on average, 28% less than men, with occupational segregation alone driving a 10% pay gap. When multiplied over a lifetime, this pay gap translates into poverty for many women during their older years. It is estimated that women in the health care workforce contribute 5% to the global Gross Domestic Product (GDP) – approximating US$ 3 trillion – annually, out of which almost 50% is unrecognized and unpaid. It is an unsettling fact that health systems are currently subsidized by the unpaid work done by women CHWs delivering care to families and others in their communities.

Occupational segregation by gender also means that health systems fail to take advantage of female talent and perspectives in particular specializations and in leadership. A significant challenge to gender-transformative change in the health workforce is women’s relative absence from decision-making and leadership positions. Representation of women in decision-making positions in global health organizations remains low, with only 25% having gender parity at senior management levels and 20% of organizations having gender parity in their governing bodies [57,58]. Health systems are stronger when the women who deliver healthcare have an equal say in the design and delivery of the systems they know best. Investments in the health workforce lead to the economic empowerment of women with a projected 9:1 return on investments [5]. Highlighting the impact that girls and women, worldwide, have in their roles as healthcare workers, caregivers, innovators, and community organizers during the COVID-19 pandemic, the 2021 United Nations theme for International Women’s Day was “Women in leadership: Achieving an equal future in a COVID-19 world” [59]. According to the International Labor Organization, or ILO’s Decent Work Agenda, the four pillars of decent work are: promoting jobs and enterprise, guaranteeing rights at work, extending social protection and promoting social dialogue. Indeed, much still needs to be done to advocate for gender equity in the health workforce and advance the cause for Decent Work among female community health workers in the Global South.

References

  1. Campbell J, Admasu K, Soucat A, Tlou S (2015) Maximizing the impact of community-based practitioners in the quest for universal health coverage. Bull World Health Organ 93: 590A. [crossref]
  2. Ghebreyesus TA (2019) Female Health Workers Drive Global Health. World Heal Organ [Internet] 1.
  3. Somocurcio Vílchez JG (2013) Alma-Ata Declaration on Primary Health Care. Vol. 30, Revista Peruana de Medicina Experimental y Salud Publica 171-172.
  4. Sacks E, Schleiff M, Were M, Chowdhury AM, Perry HB (2020) Communities, universal health coverage and primary health care. Bull World Health Organ 98: 773-780. [crossref]
  5. World Organization Health (2016) Global strategy on human resources for health: Workforce 2030. Who [Internet] 64.
  6. Schneider H, Okello D, Lehmann U (2016) The global pendulum swing towards community health workers in low- and middle-income countries: A scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014. Hum Resour Health [Internet] 14: 1-12. [crossref]
  7. World Health Organization (2019) Delivered by women, led by men: a gender and equity analysis of the global health and social workforce [Internet]. Human Resources for Health Observer 60.
  8. Aye B, Goss J, Lappin K, Whaites M, Barria S, Montufar V. Decent work for Community Health Workers in South Asia: A Path to Gender Equality and Sustainable Development.
  9. Shamian J, Tulenko K, MacDonald-Rencz S (2017) The UN High-Level Commission on Health Employment and Economic Growth: The Opportunity for Communities and their Primary Health Systems. World Health Popul 17: 11-17. [crossref]
  10. Cometto G, Ford N, Pfaffman-Zambruni J, Akl EA, Lehmann U, et al. (2018) Health policy and system support to optimise community health worker programmes: an abridged WHO guideline. Lancet Glob Heal [Internet] 6: e1397-404. [crossref]
  11. WHO (2019) Community health workers delivering primary health care: opportunities and challenges. World Heal Assem 114th Sess [Internet] 2018: EB144.R4.
  12. Betron M, Bourgeault I, Manzoor M, Paulino E, Steege R, et al. (2019) Time for gender-transformative change in the health workforce. Lancet [Internet] 393: e25-26. [crossref]
  13. Swider SM (2002) Outcome Effectiveness of community health workers 19: 11-20. [crossref]
  14. Perry HB (2017) Engaging Communities for Improving Mothers’ and Children’s Health; Reviewing the Evidence in Resouce-Constrained Settings 223.
  15. Guilbert JJ (2006) The World Health Report 2006: Working together for health [1]. Educ Heal Chang Learn Pract 19: 385-387. [crossref]
  16. Schleiff MJ, Aitken I, Alam MA, Damtew ZA, Perry HB (2021) Community health workers at the dawn of a new era: 6. Recruitment, training, and continuing education. Heal Res Policy Syst [Internet] 19: 1-29. [crossref]
  17. Olaniran A, Smith H, Unkels R, Bar-Zeev S, van den Broek N (2017) Who is a community health worker? – A systematic review of definitions. Glob Health Action 10: 1272223. [crossref]
  18. Mallari E, Lasco G, Sayman DJ, Amit AML, Balabanova D, et al. (2020) Connecting communities to primary care: A qualitative study on the roles, motivations and lived experiences of community health workers in the Philippines. BMC Health Serv Res 20: 1-10. [crossref]
  19. Javadi D, Gergen J (2014) The BRAC Shasthya Shebika Community Health Worker in Bangladesh. CHW Cent [Internet] 1-10.
  20. Perry H (2013) Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide for Program Managers and Policy Makers. Usaid 1-386.
  21. Aitken I (2017) Case Studies of Large-Scale Community Health Worker Programs.
  22. KaShelleytharine, Frumence G, Amalberga K (2020) Health for the People: National Community Health Worker Programs from Afghanistan to Zimbabwe 381-394.
  23. Lipp A (2011) Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases: A review synopsis. Vol. 28, Public Health Nursing 243-245.
  24. Mutamba BB, Van Ginneken N, Smith Paintain L, Wandiembe S, Schellenberg D (2013) Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: A systematic review. BMC Health Serv Res 13: 412. [crossref]
  25. Perry HB, Zulliger R, Rogers MM (2014) Community health workers in low-, middle-, and high-income countries: An overview of their history, recent evolution, and current effectiveness Annual Review of Public Health 35: 399-421. [crossref]
  26. Afzal MM, Pariyo GW, Lassi ZS, Perry HB (2021) Community health workers at the dawn of a new era: 2. Planning, coordination, and partnerships. Heal Res Policy Syst [Internet] 19: 1-18. [crossref]
  27. Tulenko K, Møgedal S, Afzal MM, Frymus D, Oshin A, et al. (2013) Community health workers for universal health-care coverage: from fragmenta…: Bull World Heal Organ [Internet] 91: 847-852. [crossref]
  28. Kluge H, Kelley E, Swaminathan S, Yamamoto N, Fisseha S, et al. (2018) After Astana: building the economic case for increased investment in primary health care The Lancet 392: 2147-2152. [crossref]
  29. Jurberg C, Humphreys G (2010) Brazil’s march towards universal coverage. Bull World Health Organ 88: 646-647. [crossref]
  30. Assefa Y, Gelaw YA, Hill PS, Taye BW, Van Damme W (2019) Community health extension program of Ethiopia, 2003-2018: Successes and challenges toward universal coverage for primary healthcare services. Global Health 15: 1-11. [crossref]
  31. Madadi Z, Pishgar F, Ghasemi E, Khajavi A, Moghaddam S, et al. (2021) Human resources for health density and its associations with child and maternal mortality in the Islamic Republic of Iran. East Mediterr Heal J [Internet] 27: 16-20. [crossref]
  32. Sarma H, Mbuya MNN, Tariqujjaman M, Rahman M, Askari S, et al. (2021) Role of home visits by volunteer community health workers: To improve the coverage of micronutrient powders in rural Bangladesh Public Health Nutrition 24: S48-58. [crossref]
  33. Ahmed KA, Grundy J, Shah MA, Banskota HK. An analysis of the Gender and Social Determinants of Health in Urban Poor Areas of the Most Populated Cities of Pakistan 1-11.
  34. Mumtaz Z, Salway S, Nykiforuk C, Bhatti A, Ataullahjan A, et al. (2013) The role of social geography on Lady Health Workers’ mobility and effectiveness in Pakistan. Soc Sci Med [Internet] 91: 48-57. [crossref]
  35. Agarwal S, Curtis SL, Angeles G, Speizer IS, Singh K, Thomas JC (2019) The impact of India’s accredited social health activist (ASHA) program on the utilization of maternity services: A nationally representative longitudinal modelling study. Hum Resour Health 17: 1-13.
  36. Sarin E, Lunsford SS (2017) How female community health workers navigate work challenges and why there are still gaps in their performance: A look at female community health workers in maternal and child health in two Indian districts through a reciprocal determinism framework. Hum Resour Health 15: 1-10. [crossref]
  37. MOPH Afghanistan (2010) A Basic Package of Health Services for Afghanistan – 2010/1389. Heal San Fr [Internet] 1-90.
  38. Parray AA, Dash S, Ullah MIK, Inam ZM, Kaufman S (2021) Female Community Health Workers and Health System Navigation in a Conflict Zone: The Case of Afghanistan. Front Public Heal 9: 1-7. [crossref]
  39. Le Roux KW, Almirol E, Rezvan PH, Le Roux IM, Mbewu N, et al. (2020) Community health workers impact on maternal and child health outcomes in rural South Africa – a non-randomized two-group comparison study. BMC Public Health 20: 1-14.
  40. Schneider H (2020) Ward-Based Primary Health Care Outreach Teams in South Africa Health for the People : National Community Health Worker Programs from Afghanistan to Zimbabwe.
  41. Rahman A, Malik A, Sikander S, Roberts C, Creed F (2008) Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. The Lancet 372: 902-909. [crossref]
  42. Boniol M, McIsaac M, Xu L, Wuliji T, Diallo K, et al. (2019) Gender equity in the health workforce: Analysis of 104 countries. World Heal Organ [Internet] 1-8.
  43. Balsarkar G (2021) World Patient Safety Day 2021: “Safe Maternal and New Born Care.” J Obstet Gynecol India [Internet] 71: 465-467.
  44. Gilmore B, McAuliffe E (2013) Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: A systematic review. BMC Public Health 13: 847. [crossref]
  45. Morrison J, Tumbahangphe KM, Budhathoki B, Neupane R, Sen A, et al. (2011) Community mobilisation and health management committee strengthening to increase birth attendance by trained health workers in rural Makwanpur, Nepal: Study protocol for a cluster randomised controlled trial. Trials 12: 128. [crossref]
  46. Wilford A, Phakathi S, Haskins L, Jama NA, Mntambo N, Horwood C (2018) Exploring the care provided to mothers and children by community health workers in South Africa: Missed opportunities to provide comprehensive care. BMC Public Health 18: 1-10.
  47. Rotheram-Borus MJ, Roux IM le, Tomlinson M, Mbewu N, Comulada WS, et al. (2011) Philani Plus (+): A Mentor Mother Community Health Worker Home Visiting Program to Improve Maternal and Infants’ Outcomes. Prev Sci [Internet] 12: 372-388. [crossref]
  48. Rotheram-Borus MJ, Tomlinson M, Le Roux IM, Harwood JM, Comulada S, O’Connor MJ, et al. (2014) A cluster randomised controlled effectiveness trial evaluating perinatal home visiting among South African mothers/infants PLoS ONE 9: e105934. [crossref]
  49. Waiswa P, Peterson SS, Namazzi G, Ekirapa EK, Naikoba S, et al. (2012) The Uganda Newborn Study (UNEST): An effectiveness study on improving newborn health and survival in rural Uganda through a community-based intervention linked to health facilities – study protocol for a cluster randomized controlled trial. Trials 13: 1-16.
  50. Barron P, Pillay Y, Doherty T, Sherman G, Jackson D, Bhardwaj S, et al. (2013) Cómo eliminar la transmisión del VIH de la madre al niño en Sudáfrica. Bull World Health Organ 91: 70-74. [Crossref]
  51. Kim MH, Ahmed S, Preidis GA, Abrams EJ, Hosseinipour MC, et al. (2013) Low Rates of Mother-to-Child HIV Transmission in a Routine Programmatic Setting in Lilongwe, Malawi. PLoS One 8.
  52. Glenton C, Scheel IB, Lewin S, Swingler GH (2011) Can lay health workers increase the uptake of childhood immunisation? Systematic review and typology. Trop Med Int Heal 16: 1044-1053. [crossref]
  53. Jilcott SB, Ickes SB, Ammerman AS, Myhre JA (2010) Iterative Design, Implementation and Evaluation of a Supplemental Feeding Program for Underweight Children Ages 6-59 Months in Western Uganda. Matern Child Health J 14: 299-306. [crossref]
  54. Kimani-Murage EW, Kyobutungi C, Ezeh AC, Wekesah F, Wanjohi M, et al. (2013) Effectiveness of personalised, home-based nutritional counselling on infant feeding practices, morbidity and nutritional outcomes among infants in Nairobi slums: Study protocol for a cluster randomised controlled trial. Trials 14: 1-11. [crossref]
  55. Rahman A, Iqbal Z, Roberts C, Husain N (2009) Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 35: 56-62. [crossref]
  56. Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta ZA (2014) Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: A cluster-randomised factorial effectiveness trial. Lancet 384: 1282-1293.
  57. Zeinali Z, Muraya K, Molyneux S, Morgan R (2021) The Use of Intersectional Analysis in Assessing Women’s Leadership Progress in the Health Workforce in LMICs: A Review. Int J Heal Policy Manag 1-12. [crossref]
  58. Vong S, Ros B, Morgan R, Theobald S (2019) Why are fewer women rising to the top? A life history gender analysis of Cambodia’s health workforce. BMC Health Serv Res 19: 1-9. [crossref]
  59. Awori M, Lukyamuzi S, Acan WJ (2021) “Being a Community Development Promoter ( Cdp ) Has Made Me a Role Model and Reference Point for Any Production, Markets, Nutrition and Health Information Needs By Fellow Farmers”.
fig 2 new

COVID-19 “MN” Virus (Multiple Nucleons Virus) Energy Immunodeficiency’s Virus Hyper Intelligent-Hypo Detectable Virus

DOI: 10.31038/PSYJ.2022421

Introduction

The “MN” (Multiple Nucleons) or (COVID-19) bulbs cause the atmospheric molecules to expand and the protective radioactive ions to explode, which causes viral contamination. In order to carry out close health control, always remember that the virus primarily role is to affect the blood and massively destroy the cells while intoxicating them; “MN” (Multiple Nucleons) or (COVID-19) is activated from a negative atmospheric energy, its interference with the organism accentuates the operational deficiency of the cellular rhythm in normal state and procreates a second law of the body gravity compared to the atmospheric deficiency which plays a primordial role in the Organ failure or Severe Gravity Syndrome by causing Immune failure at the level of: Muscular System, Blood System, Auditory and Ocular System, Lymphatic System and Brain. It is an atmospheric-air born virus, shaped as atmospheric gas bulbs that cause an expansion of the molecules composing the tissues of the ozone layer and a bursting of the protective radioactive ions against the ultraviolet rays of the sun, which causes a very dense and contaminated gas at the level of the earth atmosphere layer which is held by the electric current of the force of the waters and the force of attraction of the earth collects by the orbit speed of the planet Jupiter/side East/and the massive ejection of the planet Mars by pressure on the western ozone layer. Currently very low resistance of the ozone layer: (0.0174691 CL O2) [1].

“MN” (Multiple Nucleons) or (COVID-19) Theory

“It is an atmospheric virus cell of approximately 1 million 224,000 < normal cell detected by infrared ray = 128 billion 236, 000, 0000 < electromagnetic ray. The ionic components of this cell are made on a very regular field and absorb the substantial energy of the organism based on the agent Iron which is formed from bulbs in the form of resistant gas in the walls of the blood vessels, the oxygenation of the organism is activated: The bulbs of “MN” (Multiple Nucleons) or (COVID-19) cause an expansion at the level of the atmospheric molecules and an explosion of the protective radioactive ions that causes viral contamination. It is the virus of the century which affects the atmosphere, as a result: the bulbs of gas cause an expansion of the molecules composing the tissues of the ozone layer and a bursting of the protective radioactive ions against the ultraviolet rays of the sun, which causes a very dense and contaminated moisture at the level of the atmospheric layer which is held from the electric current of the force of the waters and the force of attraction of the earth collects by the speed of orbit of the planet Jupiter/East side/and the massive ejection of the planet Mars by pressure on the West ozone layer. Currently very low resistance of the ozone layer: (0.0174691 CL O2)”.

Mechanism of the Organism’s Immunity

The body encompasses three (3) energies well divided and balanced in the organism; this system creates the Immunity which is sourced from the Central immune neuron.

Energy → Cognition

It is a substantial energy; it acts on the level of the blood circulation by allowing it to renew itself. The component cells circulate at a steady rate at the heart rate and react according to the intensity of the body’s magnetic energy. It is the level crossing of the blood system, it deteriorates the infectious level of blood while proceeding to the multiplication of red and white blood cells, the functional ion of this energy are located at the level of the central axis of the liver. This explains that the rejection of toxins at the level of the lymph acts on the protection of the body of any destructive energy. The atmospheric energetic molecular mass reacts directly on the blood system with the interference of the electromagnetic field of the interplanetary resistance related to the enigmatic network of Saturn and Jupiter at the bottom of the simple chemical equation composed of two essential agents which are oxygen and carbon. Oxygen plays the role of versatility between the cells constituting the neurons and traces itself on a trajectory symmetrical to the field of homogeneous mixing of hydrogen molecules in the atmosphere. A homogeneous and simple set to replace the body energy formula whatever its intensity. The human body encompasses 1 billion 69,000 nerves. The nerves are enveloped by a very fine texture while varying the temperature of the blood by stabilizing it and protecting the blood against the radiation and toxins.

Energy B → Body

It is a functional energy of the body, the rejection of toxins at the level of the lymph acts on the protection of the body from all destructive energy at the moment when the radioactive rays act directly on the vision of the producing cells. The atmospheric energetic molecular mass reacts directly on the lymphatic circuit which is of a very high functional competence. The reaction of the energies at the level of the organism depends on the lymphatic resistance which is the crossing field of any foreign agent at the level of the body connected to the lymphatic circuit which serves as a stream comprising the elements necessary for the organism and the toxins rejected by the blood.

Energy C → Brain

It is an impulsive energy that allows the elimination of any toxic body accessing the envelopment of neurons that are made of a very thin but very strong connective and protective tissue acting on the lymph. Its texture is formed from chromosomes very rich in proteins and iron, it mainly participates in the constitution of embryonic cells, this element projects rays that act directly on the gray matter fighting in this way any radioactive or viral agent. The Atmospheric energetic molecular mass reacts directly on gray matter. The bulbs of this agent tend towards a gaseous mixture integrity that qualifies as sulfuric. At the bottom of the proportional equation, the phenomenon reacts on the cellular intersection and goes as far as the growth of the milky condensation of the spinal fluid. Gray matter is the only essence of the bone mechanism. This liquid contains 1 billion 175,000 active cells, each cell contains a neuron, each neuron contains all of an oxygen atom + an iron atom + a magnesium atom, each atom is enveloped by a thin wall containing a charge electricity of 127.566 KW/mill micron, this load represents the life of the organism.

Relativity

The three (3) energies’ relativity creates the central neuron field shaped as a triangle providing an intensive force which is an electrical intensity that expands the circuits feeding the gray matter; this pressure causes a force on the cells composing the tissues and proceeds to the electric charge of the chromosomes, which creates the Body Gravity: The functional energy which defines the relativity in the body energy circuit and manipulate any offensive viral attack to the body, called immunity. The three angles are shaped as follow: The Substantial energy has some cellular fragments of the lymph and it is at this level that the nerve of the senses is located which is the motor of the brain. The root is located at the spine L5/S1 which is the most important region because it is the center of gravity and is the source of any organic failure. The gray matter is the only essence of the bone mechanism. This liquid contains 1 billion 175,000 active cells, each cell contains a neuron, each neuron comprises the set of: an atom of oxygen + an atom of iron + a volume of magnesium ,each atom is enveloped by a thin wall containing an electric charge this charge represents the life of the body. The Impulsive energy propagates very powerful and undetectable rays that act on the gray matter and cause heat that is distributed at the body level and expands as a function of the body’s magnetic field, these rays are propagated by solar energy. It acts on the circulatory rotation of the neurons, which accentuates the operational deficiency of the cellular rhythm in a normal state; the calcium reacts on the bone circuit and indirectly on the cardiac rhythm thing which controls the law of the gravity of the organism compared to atmospheric deficiency. The Virus “MN”’s (Multiple Nucleons) or (COVID-19) Impact (Figures 1 and 2):

fig 1 new

Figure 1: Interplanetary solar system

fig 2 new

Figure 2: Body energetic circuit

The Shape

The shape of the”MN” (Multiple Nucleons) or (COVID-19) is rounded and carries 1 rectangular cavity at the ends which have the function of absorbing the element oxygen which allows it to multiply at a speed equal to 278 minutes in 21 other balls things which determines the speed of its expansion. The center of is active from the electric charge of 1 billion 165,000 particles surrounding the nucleus.

Impact

The ions of the “MN” (Multiple Nucleons) or (COVID-19) viral cell are made on a very regular field and absorbing the organism’s energy, based on the agent iron which is formed from bulbs in the form of gas residing in the walls of the blood vessels; Iron agent activates the oxygenation of the organism. In a parallel position, viral radioactivity is shown to reveal itself at the level of the bone system and destroys the resistance of cells while causing dilation at the level of the atoms forming bone tissue. The virus shows itself to leak at the bone level and destroy the resistance of the cells while causing dilation at the level of the atoms forming the bone tissues. The radioactive activity of the virus is very resistant at the level of the cardiac system, although the rhythm seems very little variable, the energy activating the arterial cells is compensated at the blood level. The blood feeds from the organic cell wall which projects a viscous substance that feeds on food substances in the lymphatic circuit which serves as a stream containing the elements necessary for the body and the toxins released by the blood. The excess of carbon is attributed to immune weakness in the antibodies and subsequently in the nervous system which becomes compressed by the continuous surge of blood pressure = muscle failure. The radioactive intensity will only be operational if the radioactive ion only becomes operational if it feeds on oxygen, which will only be possible with the intersection of the hydrogen molecule. Bulbs of the virus cause the O2 molecules to expand and the protective atmospheric radioactive ions to explode which causes viral contamination. The radioactive activity of the virus affects the gray matter and the blood causing multiple inflammations in the body. It is very resistant at the level of the cardiac system, although the rhythm seems very little variable, the energy activating the arterial cells at the blood level is blocked by a failure of the potassium agent which appears in the form of energetic sparks in the blood form of compression and decompression of the body. The Impact acts on the organism’s energy and the organism’s cell. The organism’s energy is slackened as soon as toxins coil up with carbon, the agent that weakens the activity of the O2 agent, and deflects the body into iron deficiency. The “MN” (Multiple Nucleons) or (COVID-19) viral cell is shown to leak at the bone level and destroy the resistance of the cells while causing dilation at the level of the atoms forming the bone tissue. The radioactive activity of the “MN” (Multiple Nucleons) or (COVID-19) viral cell is very resistant at the level of the cardiac system, although the rhythm seems very little variable, the energy activating the arterial cells is compensated for in the blood and blocked by a failure of the potassium agent which presents itself In the form of energetic sparks in the form of a compressing and decompressing body it is the energy B which is the essence of the cardiac mechanism. This failure causes relaxation of vital tissues at the level of the blood speed which becomes greater than the magnetic pressure of the arterial pump of the blood circuit. When oxygenation to this nerve is blocked, it causes dysfunction in the blood, which causes failure in the respiratory system. The organism’s cell multiplication is well organized and takes place constantly as long as the body energies are operational correctly. The “MN” (Multiple Nucleons) or (COVID-19) viral cell interference, a failure occurs laterally with increasing blood velocity with each uncontrolled pulse. The organs’ failure at the starting point of the “MN” (Multiple Nucleons) or (COVID-19) viral cell is located in the respiratory organs. . In a parallel position, it attacks the bone system and destroys the resistance of the cells while causing dilation at the level of the atoms forming the bone tissues. The blood feeds from this wall which projects a viscous substance feeding on food substances of the lymphatic circuit which serves as a stream containing the elements necessary for the body and the toxins released by the blood. The excess of carbon is attributed to immune weakness in the antibodies and subsequently in the nervous system which becomes compressed by the continuous surge of blood pressure and affects the muscle system. The deficiency takes place as does the total shutdown of certain organs. An energy deficit causes a counterbalance and goes as far as destroying the bone balance by eliminating the magnetic energy of the human body. “MN” (Multiple Nucleons) or (COVID-19) viral cell is rich in the atmospheric radioactive agent which when combined with the agent Sulfur becomes infectious in the blood.

The Effects

Its active effect at the level of the organism will not allow any shock of the defensive cells at the level of the organism that is why the viral radioactive load reacts directly on the gray matter and its detection will not be positive that if the organism is really depleted in Iron, the agent Iron acts on the heart and cell rhythm and goes as far as the radiation of neurons. This failure causes relaxation of vital tissues at the level of the blood speed which becomes greater than the magnetic pressure of the arterial pump of the blood circuit. The ions of the viral cell are produced on a very regular field and absorb the body’s energy. Organic failure takes place as well as the total shutdown of some organs. An energy deficit causes a counterweight and goes as far as destroying the bone balance by eliminating the magnetic energy of the human body. The virus is rich in Mercury, with its combination with the agent Carbon, becomes infectious in the blood. The body’s energy fails as soon as the toxins accumulate carbon, which weakens the activity of the oxygen agent, which leads to an imbalance in the level of iron in the body. Methane is shown to leak at the bone level and destroy the resistance of the cells while causing dilation at the level of the atoms forming the bone tissue. The excess of carbon attributes to an immune weakness at the level of the antibodies and subsequently at the level of the nervous system which becomes compressed by the continuous surge of blood pressure provoking a muscle failure.

The Symptoms

The symptoms listed below are concluded from the effects of the components of the virus. The toxicity of the virus dissolves in plasma, blood and hemoglobin. Lowers the level of oxygen in the blood; rapid breathing and pulse, slight muscle in coordination; Emotional disturbances, abnormal exhaustion, difficulty breathing; Nausea, vomiting, loss of motor skills, collapse and possible loss of consciousness; Convulsions, shortness of breath, pulmonary collapse; Damage likely to affect all organs and the central nervous system and the brain; Tissue damage Methemoglobinemia which in turn produces oxidation of ferrous iron to ferric iron. In normal hemoglobin, the nucleus will bind a ferrous iron (Fe2+) which will bind oxygen. In the case of methemoglobinemia, the nucleus will bind a ferric iron (3+) which is unable to bind oxygen; Discoloration of the skin and mucous membranes, headache, dizziness, Irritations; Irritation of the eyes, throat, painful cough, shortness of breath, and effusion of fluid in the lungs; Fatigue, loss of appetite, headache, memory loss and dizziness, loss of smell; Irritation of the respiratory system; Paralysis of the diaphragm from the first inhalation, rapid asphyxiation; Rapid loss of consciousness, cessation of breathing and death.

Conclusion

The Mechanism of viral transmission starts with an atmospheric Stage: Crash of the virus of the atmosphere in the aquatic energy network while enveloping itself in walls which allow it to resist the aquatic environment and to make its crossing in the aquatic energy to the EST which is point the start-up of the viral Path crash point. Followed by an aquatic stage: the virus sneaks into the depths thanks to its energetic molecular composition rich in Hydrogen, the low temperature favors its survival, the necessary time to capture its adopted nest of a marine animal Candidate that has a favorable morphology and environment and finally the Land stage: this stage includes an expansion segment: The Pandemic occurs by transfer of the virus from the atmospheric path to the Land path through the aquatic path. This theory shows relativity in the pandemic trajectory made it and still making it continuous and progressive in its expansion.

Keywords

COVID-19, Pandemic, Solar system, Gravity

References

  1. Gravity Syndrome https://www.morebooks.de/store/gb/book/gravity-syndrome/isbn/978-613-8-80089-7.
  2. The Theory of Relativity and Other Essays, Secaucus, N.J.: Carol Pub. Group, 1996,©1950, 75 Pages (Einstein, Albert, 1879-1955)
  3. Web: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5313a2.htm
  4. Article : Influenza Activity — United States, 2003–04 Season
  5. CDC/https://www.cdc.gov/NASA https://cneos.jpl.nasa.gov/news/news146.html
  6. Article: Near-Earth Asteroid 2004 MN4 Reaches Highest Score To Date On Hazard Scale.
  7. Wikipedia : https://fr.wikipedia.org/wiki/(99942)_Apophis
  8. Article: (99942) Apophis
  9. Gravity Syndrome https://www.morebooks.de/store/gb/book/gravity-syndrome/isbn/978-613-8-80089-7

Ivermectin and Zuranolone: A Double Standard in the Literature

DOI: 10.31038/JNNC.2022511

 

Three recent publications illustrate the ongoing double standard concerning the effectiveness of ivermectin for treatment of early outpatient cases of COVID-19 infection. It seems to be true that ivermectin has no beneficial effect for seriously ill hospitalized patients – its potential utility is for reducing the frequency of transition from early mild outpatient cases to severely ill hospitalized cases. Lack of effectiveness inside hospitals does not prove a lack of effectiveness in outpatient populations.

Zuranolone: A New Antidepressant

A recent report by the manufacturers of zuranolone [1] concluded that, “Study supports the potential of zuranolone, when combined with standard of care, to accelerate the benefit of depression treatment compared to treatment with [antidepressants] alone.” This conclusion was affirmed by an article in the American Psychiatric Association’s Psychiatric Times [2]. The study involved 215 participants who received standard care with antidepressants and 210 for whom zuranolone was added to their standard care. Initial scores on the 17-item Hamilton Rating Scale for Depression (HAM-D) were 26.8 (SD 2.5) for the zuranolone group and 26.2 (SD 2.6) for the standard care group. The score range for the HAM-D is 0-50 (8 items are scored 0-4 and 9 are scored 0-2), and scores above 22 are regarded as indicating severe depression.

HAM-D score reductions at different time points in the 15-day study were:

Zuranolone Group

Standard Care Group

p value

Day 3

-8.9

-7.0

.0004

Day 8

-11.3

-9.2

.0012

Day 12

-12.8

-11.4

.0381

Day 15

-13.7

-12.9

.2477

At all points in the study the difference between the two groups on the HAM-D was less than 4%. This is a clinically meaningless difference, even though it was statistically significant at days 3, 8 and 12. By day 15, the difference was no longer statistically significant. Nevertheless, the drug likely will be prescribed by many psychiatrists: the Psychiatric Times article stated that, “Study examining zuranolone treatment in patients with major depressive disorder (MDD) demonstrated a rapid and statistically significant reduction in depressive symptoms at day 3 and over the 2-week treatment period” [2]. The Psychiatric Times article skimmed over the fact that there was no difference between the groups at the end of the study. This is how things work in psychiatry: tiny effects of medications are hailed as advances in the field because they are statistically significant. Pharmaceutical companies sell many billions of dollars of psychiatric drugs per year, whereas ivermectin is a cheap generic medication.

A Negative Study of Ivermectin

When it comes to ivermectin, the situation is reversed. Highly clinically significant benefits are cited as evidence that ivermectin does not work for COVID-19 because the results were not statistically significant. In a recent study [3], ivermectin was added to standard care for 241 participants while standard care was provided to 249 participants. The authors concluded that, “The study findings do not support the use of ivermectin for patients with COVID-19.” What were the results of the study? Mechanical ventilation was required in 1.7% of the ivermectin cases and 4.0% of the standard care cases (relative risk 0.41); ICU admissions were required in 2.4% of ivermectin cases and 3.2% of standard care cases (relative risk 0.78); and 28-day in-hospital deaths occurred in 1.2% of ivermectin cases and 4.0% of standard care cases (relative risk 0.31). Ivermectin reduced the frequency of 28-day in-hospitals deaths by 69%. The results of this study indicate that if ivermectin had been prescribed routinely to outpatients early in their course of infection, throughout the pandemic, hundreds of thousands of lives could have been saved worldwide.

Concluding Thoughts

Unscientific hostility toward ivermectin [4] as an outpatient treatment for COVID-19 continues in 2022. Physicians who recommend ivermectin are attacked, ostracized, fired from their jobs, canceled from social media, and threatened with board sanctions. Physicians who hail zuranolone as a significant step forward in the treatment of depression, on the other hand, get a round of applause from drug companies and their colleagues. They do not get accused of being anti-scientific, of being conspiracy theorists, or of spreading disinformation. It is unclear what financial or professional forces could ever change this pattern.

References

  1. Sage Therapeutics and Biogen announce the phase 3 CORAL Study met its primary and key secondary endpoints. BioSpace. News release. February 16, 2022. https://www.biospace.com/article/sage-therapeutics-and-biogen-announce-the-phase-3-coral-study-met-its-primary-and-key-secondary-endpoints/.
  2. Kuntz L (2022) Improving depression symptoms: study meets endpoints. Psychiatric Times, February 16. https://www.psychiatrictimes.com/view/improving-depression-symptoms-study-meets-endpoints.
  3. Lim SC, Hor CP, Tay KH, Jelani AM, Tan WH, et al. (2022) Efficacy of ivermectin treatment on disease progression among adults with mild to moderate Covid-19 and comorbidities. The I-TECH randomized clinical trial. JAMA Internal Medicine doi:1001/jamainternmed.2022.0189.
  4. Ross CA (2021) Thoughts on the Politics of COVID-19. Journal of Neurology and Neurocritical Care 4: 1-3.
fig 2

Recent Approaches in the Treatment of Polycystic Ovary Syndrome: An Update

DOI: 10.31038/AWHC.2022514

Abstract

Polycystic Ovary Syndrome (PCOS) is a dominant and complex endocrine disorder present in women worldwide. The characteristic features include anovulation, polycystic ovaries, insulin resistance, menstrual irregularities, and hyperandrogenism-related difficulties. Medical treatment of PCOS focus on symptoms, and several drugs, natural products, and herbal plants are applicable to reduce PCOS-associated symptoms. This review discussed the treatment options for PCOS women, including lifestyle changes, bariatric surgery, and therapy for anovulation, insulin resistance, menstrual dysfunction, and hyperandrogenism-related symptoms. Furthermore, it provides the chemical structure of drugs and natural products exhibiting effectiveness in PCOS treatment.

We anticipate that the information provided in this review is beneficial to scientists globally associated with the discovery and development of PCOS treatment in the pharmaceutical industry and academia.

Keywords

Polycystic ovary syndrome (PCOS), Anovulation, Insulin resistance, Menstrual dysfunction, Acne, Alopecia

Introduction

Polycystic Ovary Syndrome (PCOS) is a common endocrine condition of hormonal imbalance in women, and it is affecting at least 5% to 10% of women of reproductive age [1]. Stein and Leventhal first described PCOS in 1953. It is a complicated ovarian disorder characterized by the clinical and biochemical manifestation of hyperandrogenism, ovulatory dysfunction (menstrual disturbances), and polycystic ovaries and one of the most common endocrinopathies in reproductive-age women of the developed world [2]. The main characters of PCOS include excess production of male hormone androgen by the ovaries resulting in anovulatory infertility. Fundamentally, this happens because of the unbalanced release of Luteinizing Hormone (LH) and Follicle-Stimulating Hormone (FSH) from the pituitary gland. The FSH is accountable for follicular development, and increasing the level of the female hormone estrogen and therefore diminution of its level in the bloodstream results in the undeveloped follicles. Several immature follicles dissolve, and the rest of them remain as fluid-filled sac known as cysts, and the name PCOS is derived from these developed cysts in one or both ovaries (Figure 1).

fig 1

Figure 1: Polycystic Ovary Syndrome (PCOS) in women with cysts in the ovary

Furthermore, not all PCOS patients develop a cyst, and cyst formation might occur in women with no PCOS condition. PCOS patients mainly build insulin resistance resulting in an increased insulin level, and it is one of the significant symptoms and underlying physiopathological causes of PCOS [3]. High insulin and LH levels result in hyperandrogenemia, which involves excess production of the male hormone androgen in females. It is one of the main reasons for PCOS’s clinical complications, including anovulation, abnormal menstrual cycle, and infertility. Furthermore, hyperandrogenism can initiate hirsutism, acne, androgenic alopecia, and metabolic abnormalities such as obesity, insulin resistance, hyperinsulinemia, and dyslipidemia. In many PCOS women, lipid abnormalities, exceptionally high triglyceride, low high-density lipoprotein cholesterol levels, and impaired fibrinolysis have been observed.

PCOS and associated complications physically affect the female body, and the complicated connection between genetics, environment, and hormones instigates mental health problems [4]. Reports suggest that PCOS patients are three times presumably suffer from depression, stress, anxiety, and Obsessive-Compulsive Disorder (OCD), bipolar illness, and eating problems. In PCOS women, the depression could be biological or because of distress associated with infertility, abnormal menstrual cycles, acne, body shape, and appearance or external pressure, including demands related to marriage, children, societal attitudes, standards, and culture. In certain cultures, irregular menstrual cycles link to a reduced sense of feminine identity, and therefore women develop feelings of being incomplete. PCOS-related ovulatory dysfunction is responsible for 75 percent of all female infertility cases and severely impacts psychological well-being, including depression in infertile women. Nevertheless, depression scores were still higher in PCOS patients in trials that included only infertile women or omitted all infertile women.

Polycystic ovary syndrome is a metabolic, hormonal, and psychosocial disorder with distinct biopsychosocial aspects and causing severe impacts on the life of PCOS patients. Women must take PCOS symptoms seriously and consult a medical professional or a counselor about any distress they are experiencing, as well as any misconceptions they may have regarding PCOS. The medical practitioner and gynecologist can facilitate the diagnosis and offer proper treatment and advice to manage PCOS. It is advisable to take good care of one’s physiological and physical health during PCOS treatment. In this respect, the advice from mental health professionals and psychologists and the lifestyle change are beneficial. Comprehensive treatment of PCOS patients in the early stages will help them overcome emotional stress; a significant complication mostly overlooked in PCOS patients. Early diagnosis and long-term management of PCOS will reduce its associated long-term complications, including metabolic syndrome and cardiovascular diseases, and allow PCOS women to live healthy and happy, active lives [5]. This review article is within the context of our ongoing drug design and discovery research work [6-14]. Here we have compiled the inclusive information related to PCOS, including its symptoms, management, and treatment, focusing on approved drugs. This article is valuable to PCOS patients and doctors, scientists involved in PCOS-related treatment and research, and anyone interested in acquiring more information on PCOS.

Common Symptoms of PCOS

PCOS symptoms are present in different ways in women with variations in severity and can change at various stages of women’s life. Some women can have only a few symptoms, mild symptoms, or many symptoms with seriousness. In PCOS women, menstrual cycles mostly last more than 35 days, as opposed to the usual 25- to 35-day menstrual cycle duration, and many women have fewer than six periods per year [15]. The women’s irregular menstrual cycle leads to the disruption of the ovulation schedule because of the hormonal imbalance. The eggs located in the follicles do not mature and ovulate, resulting in cysts in the ovaries and periods or irregular periods.

Furthermore, because of the inconsistent ovulation or inability to ovulate, the female may have trouble getting pregnant. The bodily mechanisms of normal females are different from PCOS females [16]. The hormone insulin, mainly responsible for converting sugars and starches into energy, is not utilized adequately, resulting in high insulin concentration and insulin resistance in PCOS women. Higher insulin level causes more release of male hormone androgen (hyperandrogenism) that induces weight gain. Hyperandrogenism can result in hirsutism, androgenic alopecia, or female pattern hair loss, specifically from the top of the scalp and forehead. Androgen hormones also induce the sebaceous glands to expand and produce more sebum resulting in acne on the face and body. In addition, acanthosis nigricans is witness as one of the symptoms of PCOS. It is an unsightly harmless skin condition that involves the development of patches of dark or dense skin on particular parts of your body, particularly on the pelvic area, beneath the breasts, armpits, and nape (i.e., back of the neck) is witnesses as one of the symptoms of PCOS. Skin tags are one of the less frequent signs of PCOS, although they do happen. Tiny, flexible lumps or flaps of skin are known as skin tags. PCOS-related skin tags usually develop in the same places as dark skin patches. The long-term effects of PCOS in later life include type 2 diabetes, cardiovascular diseases, and sleep apnoea, a sleeping disorder where breathing is interrupted. For several years, if a woman didn’t have periods or had highly irregular periods of less than four periods in a year, they have a greater than usual chance of getting womb lining cancer (endometrial cancer). However, the risk of developing endometrial cancer is still low and reduced by taking period-controlling medications such as the contraceptive pill or an intrauterine system (IUS). The PCOS symptoms also impair women’s confidence and self-esteem, and they might experience sadness and mood fluctuation [17].

Treatment Options for PCOS Women

As such, there is no specific treatment for PCOS. However, its therapy involves symptoms suppression. PCOS treatment is symptom-based (Figure 2) and focused on the primary leading illness. Therefore, treatment plan varies from person to person based on the symptoms. Here in this section, we will discuss in detail the various approaches utilized in PCOS treatment.

fig 2

Figure 2: Most common PCOS-associated clinical symptoms

Lifestyle Changes

The primary treatment approaches for women with polycystic ovary syndrome include diet, weight loss, and exercise. Obesity is one of the major issues not only in women but in our society as well. It is responsible for abnormalities in the reproductive system and metabolism, particularly in PCOS women [18]. Around 40-80% of PCOS patients suffer from obesity-associated anovulation, miscarriage, and late pregnancy complications. Some reports suggest that hyperandrogenism in PCOS women can cause obesity with a high waist/hip ratio independent of the Body Mass Index (BMI) [19]. Weight loss is a first-line treatment in obese PCOS patients with infertility issues. However, it is only recommended in overweight PCOS patients with a BMI of 25-27 kg/m2. In obese PCOS women, it is observed that weight loss can improves the endocrine profile and circulating androgen and glucose level and increases the ovulation and pregnancy rates.

Additionally, in obese PCOS patients, it is recommended to follow a hypocaloric diet with low carbohydrate intake that can be easily tolerated and maintained [20]. A low-fat diet reduces hyperinsulinemia and improves metabolism. Integration of low glycemic index food in the diet has exhibited improved insulin sensitivity and ovarian function. PCOS women mainly have a higher level of inflammation; therefore, an anti-inflammatory diet is recommended for PCOS women. Regular exercise and a nutritious diet can help maintain the bodyweight of PCOS patients and, therefore, can decrease the risk of severe health conditions, particularly high blood pressure, stroke, sleep apnea, etc. [21]. In addition, exercise mainly improves glucose metabolism and regulates insulin level, lowering testosterone level and helping to battle testosterone-related symptoms such as acne, hair loss, and unusual hair growth on the face. Undoubtedly, exercise is essential for PCOS patients. Still, the exercise program must be designed with the best activity of adequate duration and frequency, based on the patient’s degree of obesity and baseline fitness.

Bariatric Surgery

Recently, bariatric surgery emerged as an alternative approach for weight loss in obese PCOS patients who cannot reduce weight with diet and exercise [22]. However, the perfect bariatric procedure for PCOS is unidentified; the most common approaches include restrictive and combined restrictive, malabsorptive practices, adjustable gastric banding, and the Roux-en-Y gastric bypass. Reports suggest that bariatric surgery in some PCOS women effectively improves ovulation, insulin resistance, hyperandrogenism, and hirsutism. In several obese PCOS patients, a regular menstrual cycle is restored after bariatric surgery [23]. Undoubtedly, bariatric surgery leads to weight loss and therefore results in resumed ovulation and pregnancy. However, they are at higher risk of nutritional deficiency affecting the fetus’s nutrition and pregnancy. Reports suggest that women who conceive after bariatric surgery are at more risk for mall-for-gestational-age babies and shorter pregnancies. Although bariatric surgery has its own short and long-term risks, considering its potential benefits, it can be included as part of the treatment in PCOS women.

Therapy for Anovulation (Infertility) in PCOS Women

Ovulation is a vigorous process that involves highly coordinated endocrine changes with the hypothalamus, pituitary, and ovaries. Anovulation is the lack of ovulation and the most common cause of infertility that affects around 30% of infertile women. PCOS condition is one of the most commonly encountered reasons for anovulation [24]. In PCOS women, anovulation is described by the better response of some follicles to FSH and LH, multiple follicle development, and the arrest of antral follicles related to the suppression of serum FSH. High levels of LH, androgens, and insulin play a significant part in the anovulation process, enhancing steroidogenesis and stopping follicular growth. Several fertility drugs and medications can normalize ovulation, and we have discussed them in this section.

Selective Estrogen Receptor Modulators

Selective Estrogen Receptor Modulators (SERMs) are antiestrogens having selectivity to stimulate or inhibit the estrogen receptor of different target tissues and show variation in the ratio of the estrogenic and antiestrogenic at other tissues [25]. Clomiphene (Figure 3) (brand name Clomid and Serophene) is a triphenylethylene-derived non-steroidal selective estrogen receptor modulator used as an ovulation-inducing drug for the last 40 years. It is the first-line treatment in an ovulating woman, including PCOS patients. Clomiphene functions by affecting the hypothalamus and pituitary gland and subsequently increasing GnRH, FSH, and LH secretion that leads to follicle (egg) development and ovulation [26]. The pregnancy rate with clomiphene is 30-40% despite a reasonable ovulation rate of 70-80%, credited to the anti-estrogenic effect of clomiphene on endometrium and cervix. The multiple pregnancy rates after conception with clomiphene is 7.8%, with most twins and triplet or less than 0.9%. With Clomiphene treatment, mainly pregnancy is observed within the first six ovulatory cycles, and the live birth rate ranges from 20 to 40%.

fig 3

Figure 3: Chemical structure of drugs for the treatment of anovulation in PCOS women

Starting dose for clomiphene is 50mg/day for five days and then increased to 50mg/day and a maximum of 150mg/day in subsequent cycles if the patient remains anovulatory. However, clomiphene usage is associated with side effects including bloating, stomach or pelvic pain, ovarian enlargement, dizziness or headaches, hot flashes, abnormal uterine bleeding, yellow eyes or skin, nervousness, and change in vision or loss in vision possibly because of anti-estrogenic effect in the hypothalamus [27].

Tamoxifen (Figure 3) is another non-steroidal selective estrogen receptor modulator with a triarylethylene skeleton, which is used as an oral ovulatory agent because of its antiestrogenic activity clomiphene. Tamoxifen pregnancy rate (30-50%) and ovulation rate (50-90%) is better than tamoxifen [28]. Tamoxifen without the involvement of hypothalamic-releasing factors stimulates the ovary and promotes folliculogenesis. Tamoxifen exhibits a minimal anti-estrogenic effect on the cervix and endometrium and enhanced functioning of the corpus luteum; therefore considered an appropriate alternative to Clomiphene in PCOS patients who fail to ovulate with clomiphene or show clomiphene resistance [29]. The side effects of tamoxifen treatment include bone pain, hot flashes, nausea, fatigue, mood swings, depression, headache, and hair thinning.

Aromatase Inhibitors

Aromatase inhibitors are competitive inhibitors of enzyme aromatase that play a crucial role in the final step of the estrogen biosynthetic pathway. Anastrozole and letrozole (Figure 3) are non-steroidal aromatase inhibitors with encouraging ovulation-inducing properties [30]. Anastrozole and letrozole are selective, reversible, and highly potent aromatase inhibitors with a half-life of around 45 hours, much better than clomiphene (half-life 5-7 days). Compared to anastrozole, letrozole is studied comprehensively and considered first-line therapy in PCOS women for ovulation induction. Letrozole functions by inhibiting estrogen production in the hypothalamus-pituitary axis leading to an upsurge in Gonadotropin-Releasing Hormone (GnRH) and FSH level and subsequently results in enhancing the mature follicle quantity, optimizing ovulation, and increasing the pregnancy rate in PCOS women. The letrozole offers several advantages as an ovulation-inducing agent, including oral administration, shorter half-life, minimal peripheral antiestrogenic effect on the endometrium, higher implantation rate, and stimulating mono follicular growth ovulation, therefore, reducing the rate of multiple pregnancies [31]. Compared to clomiphene, letrozole has exhibited a 50-60% live birth rate, lower multiple pregnancy rate, higher per cycle and cumulative ovulation rate, and better quality ovulation. Letrozole can effectively induce ovulation in women with the estrogen-sensitive disease, particularly breast cancer, and long-term letrozole treatment is safe and effective in postmenopausal women with early breast cancer. Letrozole in long-term use produces more mature follicles and successful pregnancies than its short-term usage [32]. The most common side effects of letrozole include hot flashes, headaches, dizziness, weakness, bone pain, muscle or joint pain, swelling, and weight gain.

Gonadotropins

Gonadotropins are hormones secreted from the anterior pituitary gland and act on the gonads to increase the production of sex hormones and stimulate ova production in females. The main gonadotropin hormones are Follicle-Stimulating Hormones (FSH) and Luteinizing Hormones (LH). Exogenous gonadotropins are used as a second-line treatment to induce ovulation in PCOS women who developed resistance to clomiphene [33]. Gonadotropins work by inducing ovulation, maintaining follicle growth, and attaining healthy follicles for fertilization with no peripheral anti- estrogenic effect. Gonadotropins in low doses offer a high ovulation rate, mono follicular development, and lower the risk of Ovarian Hyperstimulation Syndrome (OHSS) and multiple pregnancies [34]. Patients who are unsuccessful in ovulating after clomiphene treatment suffers from severe ovarian abnormality, requiring a higher threshold dose of exogenous FSH. Whereas the patients who are successful in ovulation but unable to conceive after clomiphene intake need a lower FSH threshold. Therefore, a lower dose of exogenous FSH can attain sufficient ovarian stimulation. The two most commonly used approaches for ovulation induction with gonadotropins in clinical practice are the low-dose step-up and the low-dose step-down protocols. The chronic low dose protocols will reduce the risk of multiple follicular developments and their associated perils, including multiple pregnancies and OHSS. Additionally, the gonadotropin treatment is quite expensive, time-consuming and requires continuous monitoring by expert [35].

Glucocorticoids

Glucocorticoids are a class of corticosteroids having steroidal skeleton and secreted from the adrenal glands in stress response and effective at reducing inflammation and suppressing the immune system [36]. Glucocorticoids such as prednisone and dexamethasone (Figure 3) have been utilized in the anovulation treatment. In PCOS patients resistant to clomiphene treatment and having normal androgen levels, the addition of dexamethasone in high dose and short duration to clomiphene displayed a favorable response for induction of ovulation with minimal anti-estrogenic effect on the endometrium and higher ovulation and pregnancy rates. In PCOS patients with elevated androgen levels, only the low dexamethasone dose was efficient in increasing ovulation and pregnancy rate. Additionally, in PCOS patients, the addition of glucocorticoids during induction of ovulation by letrozole showed substantial improvement in folliculogenesis, ovulation, and pregnancy. However, glucocorticoids usage is associated with potentially adverse effects on insulin sensitivity; hence, its prolonged use must be avoided [37].

Laparoscopic Ovarian Diathermy

Laparoscopic ovarian drilling with laser or diathermy is a surgical treatment used to destroy part of the ovary in PCOS patients with anovulation [38]. It is recommended as a second-line treatment in clomiphene-resistant PCOS women who cannot undergo gonadotropin treatment because of high cost and continuous monitoring. In clomiphene-resistant PCOS women undergoing LOD versus gonadotropin treatment, the pregnancy rate was lower, whereas no difference in ovulation or pregnancy, live birth, and miscarriage rate was observed. In addition, ovarian drilling was ineffective in improving metabolic abnormalities, and in some PCOS patients, it exhibited temporary fertility advantages and required adjuvant therapy after drilling with clomiphene. LOD was more effective in patients with high LH levels, and after surgery, a substantial decrease in LH and androgen levels was observed. Furthermore, in some women (63%-85%), LOD retained the menstrual cycle and caused a prolonged positive effect on the reproductive system [39].

In vitro Fertilization

In Vitro Fertilization (IVF) is an assistive reproductive technology that involves fertilizing an egg with sperm “in vitro.” After the fertilized egg experiences embryo culture, it is stored or implanted in the uterus for creating a successful pregnancy. The in vitro fertilization technique is primarily used in patients where other treatments, including clomiphene citrate, letrozole, gonadotropins, etc., were unsuccessful. It is one of the last options to attain pregnancy in PCOS women [40]. However, in some patients with concomitant diseases, IVF is the first option. IVF in PCOS women have displayed decent pregnancy and live birth rates with reduced risk of multiple pregnancies. Therefore it is one of the rational options to accomplish pregnancy in PCOS women. However, the IVF procedure is expensive with no guarantee of success and can take patients’ emotional/psychological toll. Additionally, other drawbacks of in vitro fertilization include higher chances of ovarian hyper-stimulation syndrome (OHSS), multiple pregnancies (around 20-30%), ectopic pregnancy, and risk of prematurity and low birth weight in babies [41].

Therapy for Insulin Resistance in PCOS Women

The occurrence of insulin resistance measured by compromised glucose tolerance and its incidence rate is much higher in PCOS women than women with no PCOS and the same age and weight. Insulin resistance is associated with diabetes, metabolic syndrome, and in later stages with cardiovascular issues [42]. The treatment of PCOS with diabetes needs proper lifestyle changes including, diet and exercise and proper medications. The most common medicine to improve insulin resistance in PCOS patients is metformin (Figure 4) [43]. Metformin is an oral antidiabetic drug that belongs to the biguanide class, sold under the brand name Glucophage to treat type 2 diabetes mellitus. It is used as a first-line drug for treating type 2 diabetes, particularly in obese patients; however, it works more effectively in non-obese PCOS women than obese PCOS patients. It is used as a second-line agent to treat infertility in patients suffering from polycystic ovary syndrome. It is related to an increase in the menstrual cycle, improvement in ovulation, and reduction in circulating androgen level. In addition, metformin can support weight loss by enhancing metabolic functions [44]. Metformin’s clinical role is to obstruct glucose production, reduce glucose uptake by the intestine and increase insulin sensitivity in peripheral tissues. In PCOS women, metformin improves ovulation induction by lowering insulin levels and varying the insulin effect on ovarian androgen biosynthesis, theca cell proliferation, and endometrial growth [45]. Moreover, it can inhibit ovarian gluconeogenesis and therefore lowering ovarian androgen production. Metformin’s safe profile makes it the most commonly used drug in treating glucose intolerance and elevated diabetes risk in PCOS women. Metformin is given in numerous routines with focus and monitoring on patient tolerance. The target dose for metformin is 1500-2550 mg/day, which is achieved slowly by beginning with 500mg/day metformin for one week followed by 1000mg/day for another week and then 1500mg/day. Primarily the metformin exhibits response at the dose of 1000mg/day only in some patients the dose reaches 1500 or 2000 mg/day. Metformin also works efficiently in combination with clomiphene and gonadotropins. Clomiphene can improve ovulation and pregnancy rate, whereas gonadotropins encourage mono ovulation and decrease the dosage and duration of gonadotropins and the risk of canceled cycles. The most common complications associated with metformin use are nausea, diarrhea, weakness, flatulence, myalgia, hypoglycemia, and abdominal pain. Thiazolidinediones (Figure 4), also known as glitazones, are another class of insulin-sensitizing drug that has displayed good ovulation and pregnancy rates [46]. These drugs improve insulin sensitivity by increasing the ovulation rate and glucose tolerance and reducing circulating androgen. Troglitazone, rosiglitazone, and pioglitazone molecules of the thiazolidinediones class have been studied extensively, however in animal studies; these molecules possess hepatotoxicity, cardiovascular risk, weight gain, and reproductive toxicity and therefore resulted in restricted use in PCOS women [47].

fig 4

Figure 4: Chemical structure of drugs for the treatment of insulin resistance in PCOS women

Therapy for Menstrual Dysfunction in PCOS Women

PCOS patients mainly suffer from abnormal menstrual patterns because of prolonged anovulation, and these menstrual irregularities usually have a history dating back to menarche [48]. Some PCOS women have oligomenorrhea, menstrual bleeding <9 menstrual periods per year, or secondary amenorrhea, which is the absence of menstruation for six months. In addition, other consequences of anovulatory menstrual cycles include dysfunctional uterine bleeding and infertility. Ongoing anovulation can increase the risk of endometrial hyperplasia and carcinoma. Therefore, it must be treated on time. The most common approach to treat menstrual abnormalities in PCOS women is oral contraceptives [49]. In PCOS women who do not wish for pregnancy, hormonal contraceptives are the first-line treatment for menstrual irregularities. PCOS women are administered using progestin such as medroxyprogesterone (Figure 4) or oral contraceptive with a combination of estrogen and progestin to reduce circulating androgens, maintain regular menstrual cycles, and reduce the risk of endometrial hyperplasia and cancer. Additionally, metformin is used to improve insulin resistance and menstrual irregularities in PCOS women who cannot take or tolerate hormonal contraceptives or lifestyle changes that have no positive effect on them. Metformin can reduce free testosterone levels, cure metabolic and glycemic abnormalities and maintain regular menstrual cycles.

Therapy for Hyperandrogenism Related Symptoms in PCOS Women

Hyperandrogenism is one of the principal features of PCOS and is clinically displayed as hirsutism, acne, and alopecia, etc. [50]. The hyperandrogenism symptoms vary from patient to patient, and subsequently, its treatment.

Hirsutism

Hirsutism is a condition in women that results in excessive terminal hair in androgen-dependent areas of the body. This disorder mainly occurs because of increased androgen action on hair follicles or upsurge circulating level of androgens or amplified sensitivity of hair follicles to normal levels of circulating androgens. Treatment options for hirsutism in women with PCOS or without PCOS are the same. They include therapies that aim to local expressions of hirsutism or target underlying causes using proper medications [51]. The effective therapies that target the local expressions of hirsutism include hair removal using physical means such as shaving, laser therapy, electrolysis, topical treatment, etc. Pharmacological treatment is focused on blocking the androgen action at hair follicles or restricting androgen production [52].

Medications under pharmacological treatment generally take around six months to show a significant effect on hair growth. Patients intolerant to medical therapy are treated with a combination of local measures and drug treatment. Several medicines have been studied for the treatment of hirsutism in PCOS patients, and the most effective drug options are oral contraceptives, antiandrogens, and topical cream. Low-dose Oral Contraceptive Pills (OCPs) are mainly used in women who do not wish to conceive. Birth control pills or oral contraceptives comprising estrogen and progestin are used to treat hirsutism caused by androgen production; however, the selection of oral contraceptives is substantial because some of the progestins also have an androgenic effect. The low-dose OCPs available in the market include ethinyl estradiol (Figure 5) in doses ranging from 15-35g. OCPs with less androgenic progestin such as norgestimate, gestodene, and desogestrel (Figure 5) are good options for hirsutism treatment [53]. Anti-androgens, a drug that blocks androgens from binding to the receptor, are prescribed after six months of ineffective oral contraceptive treatment. Response to antiandrogen in hirsutism treatment is prolonged and sometimes takes around 18 months, and the most commonly used antiandrogens are spironolactone (Aldactone) and flutamide (Eulexin) (Figure 5). Spironolactone is safe and low- cost drug that possesses moderate antiandrogenic effects when monitored in high doses (100-200 mg daily). It works as dose-dependent competitive inhibitors of the androgen receptor and demonstrates effectiveness on hirsutism treatment. Flutamide is non-steroidal, selective antiandrogen with no progestogenic effect and equally effective as spironolactone, but its application required hepatic function monitoring. In addition, estrogen-progestin combination therapy, including a combination of OCPs, effectively reduces terminal hair growth and acne formation in PCOS patients.

fig 5

Figure 5: Chemical structure of drugs for the treatment of hyperandrogenism-related symptoms in PCOS women

Moreover, topical cream naming Eflornithine (Vaniqa) (Figure 5) is a prescription cream that displayed effectiveness in slowing down the growth rate of excessive facial hair in women [54]. Eflornithine is ineffectual in completely removing the existing hair. Therefore, it is used in combination with laser therapy to enhance its response. Gonadotropin-releasing hormone agonist (Gn-RHa) including, leuprolide (Lupron), is effective in women with severe insulin resistance who are unresponsive to combination hormonal therapy or not able to tolerate oral contraceptive pills [55]. It works by suppressing pituitary hormones, reducing androgen and estradiol secretion, and subsequently reducing the severity of hirsutism; however, the Gn-RHa treatment is expensive, and its use is associated with long-term consequences as hot flushes, bone demineralization, atrophic vaginitis. In some PCOS women with elevated adrenal androgen levels, glucocorticoids suppress adrenal androgen secretion [56]. Glucocorticoids such as prednisone and dexamethasone have shown efficiency against hirsutism in patients with classic congenital adrenal hyperplasia and retained normal ovulatory cycles. In addition, insulin-lowering agents are beneficial in patients struggling with terminal hair growth. Metformin and thiazolidinediones have shown effectiveness in lowering ovarian androgen secretion by improving insulin sensitivity. Metformin therapy has shown improvement in clinical manifestations of hyperandrogenism [57].

Acne and Alopecia

For acne treatment, both oral contraceptive pills and antiandrogens have been used successfully, whereas for alopecia, there are no extensive trials, but oral contraceptive pills and antiandrogens are administered [58,59]. Oral contraceptive pills treatment has shown a reduction in inflammatory acne count around 30-60% and is very useful in patients with deep-seated nodules or relapsing on isotretinoin. For alopecia treatment, spironolactone has shown some effect in few studies similar to finasteride.

PCOS Treatment with Natural Products

Natural products have been in immense use throughout human evolution. Several natural products from plants are used to cure various types of diseases in humans. Correspondingly, the natural molecules affecting the various pathological aspects of PCOS play a significant role in overcoming PCOS-related symptoms [60].

Inositol

Inositol is a vitamin-like substance with a basic chemical formula similar to glucose (C6H12O6) and is present in many plants and animals. Inositol exists in different stereoisomers with Myo-inositol (Myo-Ins) and D-chiro-inositol (D-Chiro-Ins) (Figure 6) the most common [61]. Both the isomers are the second messenger of insulin. The Myo-Ins (expression of glucose transporters and cellular glucose uptake) and D-Chiro-Ins (glycogen synthesis and storage) are involved in different functions. Furthermore, physiologically the Myo-Ins is converted into D-Chiro-Ins through the activation of the insulin-dependent epimerase enzyme. PCOS women mostly exhibit compromised inositol metabolism and insulin resistance, causing a reduction in the intracellular conversion of Myo-Ins to D-Chiro-Ins inositol [62]. Several studies suggested that the dietary supplementation of Myo- Ins, alone in combination with D-Chiro-Ins, effectively improves metabolic and hormonal profile, reduces hyperandrogenism, refining oocyte quality, and maintains a regular menstrual cycle. Mainly, in obese patients, the 40:1 ratio of Myo-Ins and D-Chiro-Ins was most effective in restoring ovulation and normalizing the progesterone, LH, SHBG, estradiol, and testosterone level [63]. Inositol can efficiently regulate glucose metabolism, and therefore in PCOS treatment, it can utilize competently.

fig 6

Figure 6: The chemical structure of natural products is effective in the treatment of PCOS

Flavonoids

Naringenin (Figure 6) is a tasteless and colorless flavanone present primarily in grapefruit and in various fruits and herbs [64]. Studies with naringenin in PCOS women suggest that it can decrease the level of testosterone and estradiol and increase the concentration of enzymes involved in scavenging reactive oxygen specie. Additionally, naringenin exhibited positive cytoprotective and anti-inflammatory results in the animal model, inhibited PCOS-associated weight gain, and reduced serum glucose levels [64]. Another flavonoid that positively affects PCOS treatment is rutin (Figure 6), a plant pigment found in certain fruits and vegetables. In obese mice, rutin can control obesity and insulin resistance, and rutin treatment is significantly effective against hyperandrogenism and infertility.

Vitamins

Vitamin C (Figure 6), also called ascorbic acid, is a micronutrient essential for cells and tissues’ physiological and healthy growth. It is a water-soluble vitamin with antioxidant properties and can restore fat-soluble vitamin E (Figure 6) antioxidant nature. In PCOS rats, it was observed that vitamin C level was controlled throughout the menstrual cycle. It plays a significant role in regulating the menstrual cycle and ovarian functions [65]. Vitamin E, also known as tocopherol, is a fat-soluble vitamin with antioxidant properties, and it neutralizes free radicals and promotes cell renewal. Because of its anticoagulant and antioxidant properties, Vitamin E displays the ability to improve endometrial thickness in women with idiopathic infertility. It effectively reduced oxidative stress and subsequently reduced the exogenous human menopausal gonadotropin; however, its intake does not affect the pregnancy rate [66]. Vitamin D (Figure 6) a fat-soluble secosteroid essential for calcium homeostasis and bone mineralization. In humans, vitamin D3, known as cholecalciferol and vitamin D2, also called ergocalciferol, are the most common forms of Vitamin D. Recent reports suggest that vitamin D deficiency plays a part in insulin resistance and inflammation, dyslipidemia, and infertility in PCOS women. Therefore, Vitamin D as a supplement may reduce insulin resistance and hyperandrogenism in patients with PCOS [67]. In addition, it was observed that the average vitamin D level in women helps attain more endometrium thickness and, therefore, increases the chances of pregnancy. It is evident that vitamins affect the various pathological features of PCOS; therefore, further study is required to establish the positive impact of vitamins in PCOS treatment.

Omega-3 Fatty Acids

Omega-3 fatty acids are polyunsaturated fatty acids, and their three primary forms are Alpha- Linolenic Acid (ALA), Eicosapentaenoic Acid (EPA), and Docosahexaenoic Acid (DHA). The ALA is found in plant oil such as flaxseed, soya bean, and canola oil. The biologically active Eicosapentaenoic Acid (EPA) and Docosahexaenoic Acid (DHA) are common in fish and other seafood. Omega-3 fatty acids are notable for their antioxidant, anti-inflammatory, anti-obesity, and insulin-sensitizing activity. Reports suggest that omega 3- fatty acids control insulin resistance and maintain total cholesterol, triglyceride, and low-density lipoprotein. Though no confirmation data is available suggesting the direct effect of omega-3 fatty acids on BMI, fasting insulin and glucose, and HDL< FSH, LH, SHGB, and total testosterone. In PCOS women, Omega-3 fatty acid supplements may decrease inflammation because of a reduction in high-sensitivity C-reactive protein and an increase in adiponectin level [68]. It’s recommended to administer omega-3-fatty acids in PCOS women with inflammatory and cardiovascular-related symptoms [69]. The most common side effects of omega-3-fatty acids include mild gastrointestinal discomfort, intestinal gas, nausea, diarrhea, headache, and synergistic effects. It is not recommended during antiplatelet and anticoagulant treatment, and its use requires continuous monitoring in obese PCOS patients.

Herbal Plants in PCOS Treatment

At present, no perfect treatment is available for the PCOS symptoms. Therefore, herbal plants bearing active compounds are practical alternatives to available drugs and have attracted much attention in recent years [70]. The treatment of PCOS women with M. spicata (spearmint) tea twice a day exhibited a positive effect and decreased the level of free and total testosterone, increased the FSH and LH level, and subsequently decreased the hirsutism. The oral treatment with cinnamon (C. Zeylancam) can improve insulin sensitivity, and PCOS women can experience a significant decrease in insulin resistance. The Maitake mushroom (Hen-of-the-wood) extract co- treatment with clomiphene citrate significantly improved insulin sensitivity and supported ovulation in PCOS patients [71]. The O. Majorana (Sweet Marjoram) tea treatment can improve insulin sensitivity and act as an antiandrogen, subsequently decreasing fasting insulin levels and DHEA-S [72]. In combination with metformin, the fenugreek (T. foenum graceum) seeds also show insulin sensitivity, reduce polycystic ovaries, and improve menstrual cycles [73]. Additionally, the plant has a large amount of phytoestrogen, including raspberry, licorice, soya been, etc. are having antiandrogenic properties and are therefore effective in decreasing androgen levels in PCOS patients [74]. The plants having an antioxidant property such as C. Sinensis (Green tea), B. Vulgaria (bamboo), P. granatum I. (Pomegranate juice), etc. significantly improve serum level of sex hormone and reduce oxidative stress [75].

Conclusion

PCOS is a severe heterogeneous disorder found in women with no complete understanding of its pathophysiology. No permanent therapy is available for PCOS. However, its treatment is symptom-based. PCOS-associated symptoms include anovulation, insulin resistance, menstrual dysfunction, hirsutism, hyperandrogenism, acne, and alopecia. PCOS women are susceptible to obesity, diabetes, and adverse cardiotoxicity. The review article provides comprehensive information regarding the most common therapies advantageous in treating PCOS symptoms. Several approved drugs applicable in the treatment of various PCOS symptoms have been discussed in detail. In addition, the natural products and herbal plants exhibiting beneficial effects in the preliminary examination on PCOS women have been included in the article. Substantial work is required to understand the pathophysiology and genetics of PCOS syndrome to develop specific treatment and to delay the long-term effects of PCOS in women. Furthermore, extensive research is needed to investigate more drugs like chemical compounds and natural products to discover a suitable cure for improving PCOS symptoms. The information presented here is beneficial to researchers, clinicians, and the pharmaceutical industry and promotes finding and developing PCOS treatment.

References

  1. Ndefo UA, Eaton A, Green MR (2013) Polycystic ovary syndrome: a review of treatment options with a focus on pharmacological approaches. Physical Therapy 38: 336-355. [crossref]
  2. El Hayek S, Bitar L, Hamdar LH, Mirza FG, Daoud G (2016) Poly Cystic Ovarian Syndrome: An Updated Overview. Front Physiol 7: 124. [crossref]
  3. Gambineri A, Patton L, Altieri P, Pagotto U, Pizzi C, et al. (2012) Polycystic ovary syndrome is a risk factor for type 2 diabetes: results from a long-term prospective study. Diabetes 61: 2369-2374. [crossref]
  4. Kshetrimayum C, Sharma A, Mishra VV, Kumar S (2019) Polycystic ovarian syndrome: Environmental/occupational, lifestyle factors; an overview. J Turk Ger Gynecol Assoc 2: 255-263. [crossref]
  5. Wawrzkiewicz-Jałowiecka A, Kowalczyk K, Trybek P, Jarosz T, Radosz P, et al. (2020) In Search of New Therapeutics-Molecular Aspects of the PCOS Pathophysiology: Genetics, Hormones, Metabolism and Beyond. Int J Mol Sci 21: 7054. [crossref]
  6. Shagufta, Ahmad I (2021) The race to treat COVID-19: Potential therapeutic agents for the prevention and treatment of SARS-CoV-2. J. Med. Chem 213: 113-157. [crossref]
  7. Shagufta, Ahmad I, Mathew S, Rehman S (2020) Recent progress in selective estrogen receptor down regulators (SERDs) for the treatment of breast cancer. RSC Medicinal Chemistry 11: 438-454. [crossref]
  8. Shagufta, Ahmad I (2020) Transition metal complexes as proteasome inhibitors for cancer treatment. Inorganica Chimica Acta 506: 119-521.
  9. Shagufta, Ahmad I (2018) Tamoxifen a pioneering drug: An update on the therapeutic potential of tamoxifen derivatives. European Journal of Medicinal Chemistry 143: 515-531. [crossref]
  10. Shagufta, Ahmad I (2017) An insight into the therapeutic potential of quinazoline derivatives as anticancer agents. Med Chem Comm 8: 871-885. [crossref]
  11. Shagufta, Ahmad I, Panda G (2017) Quest for steroidomimetics: Amino acids derived steroidal and non-steroidal architectures. European Journal of Medicinal Chemistry 133: 139-151. [crossref]
  12. Shagufta, Ahmad I (2016) Recent insight into the biological activities of synthetic xanthone derivatives. European Journal of Medicinal Chemistry 116: 267-280. [crossref]
  13. Ahmad I, Shagufta (2015) Recent developments in steroidal and non-steroidal aromatase inhibitors for the chemoprevention of estrogen-dependent breast cancer. European Journal of Medicinal Chemistry 102: 375-386. [crossref]
  14. Ahmad I, Shagufta (2015) Sulfones: An important class of organic compounds with diverse biological activities. International Journal of Pharmacy and Pharmaceutical Sciences 7: 19-27.
  15. Harris HR, Titus LJ, Cramer DW, Terry KL (2017) Long and irregular menstrual cycles, polycystic ovary syndrome, and ovarian cancer risk in a population-based case-control study. Int J Cancer 140: 285-291. [crossref]
  16. Witchel SF, Oberfield SE, Peña AS (2019) Polycystic Ovary Syndrome: Pathophysiology, Presentation, and Treatment with Emphasis on Adolescent Girls. J Endocr Soc 3: 1545-1573. [crossref]
  17. Amini L, Valian K, Avvalshahr HS, Montaeri A (2014) Self-Confidence in Women with and without Polycystic Ovary Syndrome. J Family Reprod Health 8: 113-116. [crossref]
  18. Pasquali R, Pelusi C, Genghini S, Cacciari M, Gambineri A (2003) Obesity and reproductive disorders in women. Hum Reprod Update 9: 359-372. [crossref]
  19. Sam S (2007) Obesity and Polycystic Ovary Syndrome. Obes Manag 3: 69-73. [crossref]
  20. Zhang X, Zheng Y, Guo Y, Lai Z (2019) The Effect of Low Carbohydrate Diet on Polycystic Ovary Syndrome: A Meta-Analysis of Randomized Controlled Trials. Int J Endocrinol 2019: 4386401. [crossref]
  21. Harrison CL, Lombard CB, Moran LJ, Teede HJ (2011) Exercise therapy in polycystic ovary syndrome: a systematic review. Human Reproduction Update 17: 171-183. [crossref]
  22. Luo D, Yang Q, Zhou L, Wang H, Li F, et al. (2020) Comparative Effects of Three Kinds of Bariatric Surgery: A Randomized Case–Control Study in Obese Patients. Diabetes Therapy 11: 175-183. [crossref]
  23. Lee R, Mathew CJ, Jose MT, Elshaikh AO, Shah L, et al. (2020) A Review of the Impact of Bariatric Surgery in Women with Polycystic Ovary Syndrome. Cureus 12: e10811. [crossref]
  24. Franks S, Hardy K (2020) What causes anovulation in polycystic ovary syndrome? Current Opinion in Endocrine and Metabolic Research 12: 59-65.
  25. Xu XL, Deng SL, Lian ZX, Yu K (2021) Estrogen Receptors in Polycystic Ovary Syndrome. Cells 10: 459. [crossref]
  26. Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, et al. (2007) Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med 356: 551-566. [crossref]
  27. Wang L, Wen X, Lv S, Zhao J, Yang T, et al. (2019) Comparison of endometrial receptivity of clomiphene citrate versus letrozole in women with polycystic ovary syndrome: A randomized controlled study. Gynecological Endocrinology 35: 862-865. [crossref]
  28. Kishk EA (2018) Comparison of tamoxifen and clomiphene citrate for induction of ovulation in cases with thin endometrium. Evidence Based Women’s Health Journal 8: 288-292.
  29. Aref NK, Ahmed WAS, Ahmed MR, Sedik WF (2019) A new look at low-dose aspirin: Co- administration with tamoxifen in ovulation induction in anovulatory PCOS women. Journal of Gynecology Obstetrics and Human Reproduction 48: 673-675. [crossref]
  30. Pavone ME, Bulun SE (2013) Clinical review: The use of aromatase inhibitors for ovulation induction and superovulation. J Clin Endocrinol Metab 98: 1838-1844. [crossref]
  31. Carroll N, Palmer JR (2001) A comparison of intrauterine versus intracervical insemination in fertile single women. Fertil Steril 75: 656-660. [crossref]
  32. El-Aziz MMA, Fouad MS, Ouf TF (2019) Short letrozole therapy vs extended (long) letrozole therapy for induction of ovulation in women with polycystic ovary syndrome. Egyptian Journal of Hospital Medicine 74: 1884-1890. [crossref]
  33. Sastre ME, Prat MO, Checa MA, Carreras RC (2009) Current trends in the treatment of polycystic ovary syndrome with desire for children. Ther Clin Risk Manag 5: 353-360. [crossref]
  34. Homburg R, Hendriks ML, Konig TE, Anderson RA, Balen AH, et al. (2012) Clomifene citrate or low-dose FSH for thefirst-line treatment of infertile women with anovulation associated with polycystic ovary syndrome: aprospective randomized multinational study. Hum Reprod 27: 468-473. [crossref]
  35. Ege S, Bademkıran MH, Peker N, Tahaoglu AE, Çaça FNH, et al. (2020) A comparison between a combination of letrozole and clomiphene citrate versus gonadotropins for ovulation induction in infertile patients with clomiphene citrate resistant polycystic ovary syndrome-A retrospective study. Ginekologia Polska 91: 185-188. [crossref]
  36. Elnashar A, Abdelmageed E, Fayed M, Sharaf M (2006) Clomiphene citrate and dexamethazone in treatment of clomiphene citrate-resistant polycystic ovary syndrome: a prospective placebo- controlled study. Hum Reprod 21: 1805-1808. [crossref]
  37. Suh S, Park MK (2017) Glucocorticoid-Induced Diabetes Mellitus: An Important but Overlooked Problem. Endocrinol Metab (Seoul) 32: 180-189. [crossref]
  38. Mitra S, Nayak PK, Agrawal S (2015) Laparoscopic ovarian drilling: An alternative but not the ultimate in the management of polycystic ovary syndrome. J Nat Sci Biol Med 6: 40-48. [crossref]
  39. Al-Fadhli R, Tulandi T (2004) Laparoscopic treatment of polycystic ovaries: is its place diminishing? Curr Opin Obstet Gynecol 16: 295-298. [crossref]
  40. Tang K, Wu L, Luo Y, Gong B (2021) In vitro fertilization outcomes in women with polycystic ovary syndrome: A meta-analysis. European Journal of Obstetrics and Gynecology and Reproductive Biology 259: 146-152. [crossref]
  41. Refaat B, Dalton E, Ledger WL (2015) Ectopic pregnancy secondary to in vitro fertilisation-embryo transfer: pathogenic mechanisms and management strategies. Reprod Biol Endocrinol 13: 30. [crossref]
  42. Ehrmann DA (2005) Polycystic ovary syndrome. N Engl J Med 352: 1223-1236.
  43. Onalan G, Goktolga U, Ceyhan T, Bagis T, Onalan R, et al. (2005) Predictive value of glucose-insulin ratio in PCOS and profile of women who will benefit from metformin therapy: obese, lean, hyper or normoinsulinemic? Eur J Obstet Gynecol Reprod Biol 123: 204-211. [crossref]
  44. Yerevanian A, Soukas AA (2019) Metformin: Mechanisms in Human Obesity and Weight Loss. Curr Obes Rep 8: 156-164. [crossref]
  45. Mahamed RR, Maganhin CC, Sasso GRS, de Jesus Simões M, Baracat MCP, et al. (2018) Metformin improves ovarian follicle dynamics by reducing theca cell proliferation and CYP-17 expression in an androgenized rat model. J Ovarian Res 11: 18. [crossref]
  46. Rouzi AA, Ardawi MS (2006) A randomized controlled trial of the efficacy of rosiglitazone and clomiphene citrateversus metformin and clomiphene citrate in women with clomiphene citrate- resistant polycystic ovarysyndrome. Fertility and sterility 85: 428-435. [crossref]
  47. Froment P, Touraine P (2006) Thiazolidinediones and Fertility in Polycystic Ovary Syndrome (PCOS). PPAR Res 2006: 73986. [crossref]
  48. Ezeh U, Ezeh C, Pisarska MD, Azziz R (2021) Menstrual dysfunction in polycystic ovary syndrome: association with dynamic state insulin resistance rather than hyperandrogenism. Fertil Steril 115: 1557-1568. [crossref]
  49. Shah D, Patil M (2018) National PCOS Working Group. Consensus Statement on the Use of Oral Contraceptive Pills in Polycystic Ovarian Syndrome Women in India. J Hum Reprod Sci 11: 96-118. [crossref]
  50. Baptiste CG, Battista MC, Trottier A, Baillargeon JP (2010) Insulin and hyperandrogenism in women with polycystic ovary syndrome. J Steroid Biochem Mol Biol 122: 42-52. [crossref]
  51. Spritzer PM, Barone CR, Oliveira FB (2016) Hirsutism in Polycystic Ovary Syndrome: Pathophysiology and Management. Curr Pharm Des 22: 5603-5613. [crossref]
  52. Calaf J, López E, Millet A, Alcañiz J, Fortuny A, et al. (2007) Long-term efficacy and tolerability of flutamide combined with oral contraception in moderate to severe hirsutism: a 12-month, double-blind, parallel clinical trial. J Clin Endocrinol Metab 92: 3446-3452. [crossref]
  53. Fraison E, Kostova E, Moran LJ, Bilal S, Ee CC, et al. (2020) Metformin versus the combined oral contraceptive pill for hirsutism, acne, and menstrual pattern in polycystic ovary syndrome. Cochrane Database Syst Rev 8: CD005552. [crossref]
  54. Kumar A, Naguib YW, Shi YC, Cui Z (2016) A method to improve the efficacy of topical eflornithine hydrochloride cream. Drug Deliv 23: 1495-1501. [crossref]
  55. Azziz R, Ochoa TM, Bradley EL, Potter HD, Boots LR (1995) Leuprolide and estrogen versus oral contraceptive pills for the treatment of hirsutism: a prospective randomized study. J Clin Endocrinol Metab 80: 3406-3411. [crossref]
  56. Azziz R, Black V, Hines GA, Fox LM, Boots LR (1998) Adrenal androgen excess in the polycystic ovary syndrome: sensitivity and responsively of the hypothalamic-pituitary-adrenal axis. J Clin Endocrinol Metab 83: 2317-2323. [crossref]
  57. Sanoee MF, Neghab N, Rabiee S, Amiri I (2011) Metformin therapy decreases hyperandrogenism and ovarian volume in women with polycystic ovary syndrome. Iran J Med Sci 36: 90-95. [crossref]
  58. Huber J, Walch K (2006) Treating acne with oral contraceptives: use of lower doses. Contraception 73: 23-29. [crossref]
  59. Shapiro J (2007) Clinical practice. Hair loss in women. N Engl J Med 357: 1620-1630. [crossref]
  60. Iervolino M, Lepore E, Forte G, Laganà AS, Buzzaccarini G, et al. (2021) Natural Molecules in the Management of Polycystic Ovary Syndrome (PCOS): An Analytical Review. Nutrients 13: 1677. [crossref]
  61. Unfer V, Facchinetti F, Orrù B, Giordani B, Nestler J (2017) Myo-inositol effects in women with PCOS: a meta-analysis of randomized controlled trials. Endocr Connect 6: 647-658. [crossref]
  62. Laganà AS, Garzon S, Casarin J, Franchi M, Ghezzi F (2018) Inositol in polycystic ovary syndrome: Restoring fertility through a pathophysiology-based approach. Trends Endocrinol Metab 29: 768-780. [crossref]
  63. Roseff S, Montenegro M (2020) Inositol treatment for PCOS should be science-based and not arbitrary. J. Endocrinol 2020: 6461254. [crossref]
  64. Kicinska A, Kampa RP, Daniluk J, Sek A, Jarmuszkiewicz W, et al. (2020) Regulation of the mitochondrial bk ca channel by the citrus flavonoid naringenin as a potential means of preventing cell damage. Molecules 25: 3010. [Crossref]
  65. Olaniyan OT, Femi A, Iliya G, Ayobami D, Godam E, et al. (2019) Vitamin C suppresses ovarian pathophysiology in experimental polycystic ovarian syndrome. Pathophysiology 26: 331-341. [Crossref]
  66. Chen J, Guo Q, Pei YH, Ren QL, Chi L, et al. (2020) Effect of a short-term vitamin E supplementation on oxidative stress in infertile PCOS women under ovulation induction: A retrospective cohort study. BMC Womens Health 20: 69. [Crossref]
  67. Miao CY, Fang XJ, Chen Y, Zhang Q (2020) Effect of vitamin D supplementation on polycystic ovary syndrome: A meta-analysis. Ther. Med 19: 2641-2649. [Crossref]
  68. Tosatti JAG, Alves MT, Cândido AL, Reis FM, Araújo VE, et al. (2021) Influence of n-3 fatty acid supplementation on inflammatory and oxidative stress markers in patients with polycystic ovary syndrome: A systematic review and meta-analysis. J. Nutr 125: 657-668. [Crossref]
  69. Wekker V, Van Dammen L, Koning A, Heida KY, Painter RC, et al. (2020) Long-term cardiometabolic disease risk in women with PCOS: A systematic review and meta-analysis. Hum Reprod 26: 942-960. [Crossref]
  70. Kwon CY, Cho IH, Park KS (2020) Therapeutic Effects and Mechanisms of Herbal Medicines for Treating Polycystic Ovary Syndrome: A Review. Front Pharmacol 11: 1192. [Crossref]
  71. Chen JT, Tominaga K, Sato Y, Anzai H, Matsuoka R (2010) Maitake mushroom (Grifola frondosa) extract induces ovulation in patients with polycystic ovary syndrome: a possible monotherapy and a combination therapy after failure with first-line clomiphene citrate. J Altern Complement Med 16: 1295-1299. [Crossref]
  72. Haj-Husein I, Tukan S, Alkazaleh F (2016) The effect of marjoram (Origanum majorana) tea on the hormonal profile of women with polycystic ovary syndrome: a randomised controlled pilot study. J Human Nutrition Dietetics 29: 105-111. [Crossref]
  73. Bashtian MH, Emami SA, Mousavifar N, Esmaily HA, Mahmoudi M, et al. (2013) Evaluation of Fenugreek (Trigonella foenum-graceum L.), Effects Seeds Extract on Insulin Resistance in Women with Polycystic Ovarian Syndrome. Iran J Pharm Res 12: 475-481. [Crossref]
  74. Rajan RK, M SS, Balaji B (2017) Soy isoflavones exert beneficial effects on letrozole-induced rat Polycystic Ovary Syndrome (PCOS) model through antiandrogenic mechanism. Pharm Biol 55: 242-251. [Crossref]
  75. Soumya V, Muzib YI, Venkatesh P (2016) A novel method of extraction of bamboo seed oil (Bambusa bambos Druce) and its promising effect on metabolic symptoms of experimentally induced polycystic ovarian disease. Indian J Pharmacol 48: 162-167. [Crossref]
fig 2

Heart Involvement in Hemoglobinopathies: Two Case Reports and Brief Review of Litterature

DOI: 10.31038/JCCP.2022511

Background

Hereditary haemoglobin disorders, also termed haemoglobinopathies, include mainly beta -thalassemia and sickle cell disease and represent the most common monogenic disorders in human. Cardiac complications are still a leading cause of mortality and morbidity in patients with haemoglobinopathy, have dramatically reduced in patient populations receiving modern regular therapy and follow-up.

Abstract

Τhe two main determinants of cardiovascular phenotype in haemoglobinopathy patients are the underlying molecular defect responsible for the main disease and the therapy applied for its management. The spectrum of cardiovascular manifestations in haemoglobinopathies is wide and includes ventricular dysfunction, pulmonary hypertension, thromboembolic events.

We report a case of thalassemia and one of sickle cell disease having different clinic phenotype with brief literature review.

Keywords

Heart failure, Hemoglobinopathies, Mortality

Case One

A patient 32-year-old male who was receiving periodic transfusions with intermittent chelation therapy for Cooley’s Anaemia came to our clinic with complaint of dyspnoea on exertion (DOE) in the past two years. The patient was followed up at the haematology department. He had a splenectomy at three years old. On the physical examination the patient had a global heart failure chart, high abundance ascites and hepatomegaly. He was in rapid atrial fibrillation. After treatment of congestion and slowing atrial fibrillation, the patient was explored by an echocardiography. Severe LV systolic dysfunction with a LVEF of about 20%; mitral regurgitation up to moderate degree was observed (Figure 1). The right ventricle is very dilated with massive and laminar tricuspid insufficiency due to lack of coaptation of the cusps thus creating a tricuspid hiatus. A restrictive filling pattern in both ventricles with both ventricular systolic dysfunctions were evident in this patient, also a lower right ventricular function: free wall TDI peak systolic velocity was 7 cm/sec. The patient was probed by MRI revealing advanced hepatic and cardiac hemochromatosis. Endocrine pancreas is also reached in view of high glycaemic dosage relating to secondary diabetes. Our patient died while in hospital because he had an electrical storm.

fig 1

Figure 1: Echocardiography: four chamber 2D apical view : Biventricular dilated cardiomyopathy

Case Two

A patient 28-year-old male who was receiving periodic transfusions with intermittent chelation therapy for Sickle cell disease (SCD) came to our clinic with complaint of dyspnoea on exertion (DOE) in the past two years. The patient was followed up at the haematology department; she was on foldin, hydrea and vitamin C. On the physical examination the patient had only an enlarged jugular vein, high abundance ascites and hepatomegaly. At the electrocardiogram revealed a regular rhythm and a complete right bundle brunch block. At echocardiography, LVEF was about 60%. The right ventricle is much dilated (Figure 2) with massive tricuspid insufficiency due to a diastasis in tricuspid valve. A lower right ventricular function: free wall TDI peak systolic velocity was 4 cm/sec. Estimation of systolic pulmonary artery pressure from tricuspid insufficiency was about 120 mmHg which was very high and supra-systemic. The patient was explored by cardiac CT-scan revealing advanced pulmonary hemochromatosis (Figure 3), no pulmonary emboli and very enlarged right cardiac cavities. Our patient died of acute chest syndrome during hospitalization.

fig 2

Figure 2: Cardiac CT scan : very dilated right ventricle in a SCD patient

fig 3

Figure 3: Pulmonary CT scan: Pulmoary hemochromatosis in a SCD patient

Discussion

Thalassemia heart disease involves mainly left ventricular dysfunction caused by transfusion-induced iron overload. In addition to the left ventricular abnormalities right ventricular dysfunction represents a common, yet less well explored complication in the cardiopulmonary spectrum of the disease. Biventricular dilated cardiomyopathy is still considered as the leading cause of mortality in patients with betathalassemia major [1,2]. In B-Thalassemia , the defect in haemoglobin is quantitative, characterized by a reduction or total depletion of 𝛽 chain synthesis, and the severity of 𝛽 chain deficiency determines the clinical phenotype, which extends from the severe and transfusion-dependent thalassaemia major to the milder and often transfusion-independent thalassaemia intermedia [3]. The heart takes up physiologic amounts of iron through transferrin receptors, but this process is tightly regulated and does not lead to iron overload. When transferrin-binding capacity is exceeded, circulating low molecular weight non-transferrin-bound iron (NTBI) species appear. NTBI is oxidatively active and can enter through nonspecific, poor-regulated cation channels in the heart, leading to cardiac iron overload [4]. Pulmonary hypertension (PH) in thalassemia is associated with vasoconstriction, vascular smooth muscle proliferation, and irregular endothelium in pulmonary arteries with associated thrombosis. These conditions all contribute to luminal narrowing, and eventual right ventricular failure. It includes plexiform and concentric medial hyperplastic pulmonary vascular lesions, and in situ pulmonary artery thrombosis [5,6]. These pulmonary vascular abnormalities may have resulted from chronic embolic disease in other patients [5]. Advancing age and a history of splenectomy are major risk factors for PH in this population [7,8]. Another phenomena can explains this phenomena as the process of haemolysis disables the arginine-nitric oxide pathway through the simultaneous release of erythrocyte arginase and cell-free haemoglobin Both nitric oxide and its obligate substrate arginine are rapidly consumed [9]. Outcome of heart failure, in advanced cardiac iron overload states, is dismal [10-12]. Compared to reported 3-month mortality rate of 58% in the pre-chelation era, recent findings indicate an improved prognosis over older series. Five-year survival was 48% and positively associated with left ventricular systolic function. All deaths occurred among patients with biventricular cardiomyopathy, shortly after involvement. Such improved survival is explained by the widespread use of chelation treatment and possibly also by better management of anaemia and use of angiotensin-converting enzyme inhibitors. Although LV Iron overload cardiomyopathy is a leading cause of death in patients with thalassaemia major this complication appears to be uncommon in SCD patients. Left ventricular dysfunction due to sickle cell disease is rare [13]. In SCD, the defect in haemoglobin is qualitative, as a substitution at the sixth amino acid residue in the 𝛽 chain results in synthesis of an abnormal haemoglobin, termed haemoglobin S, instead of the normal haemoglobin A [14]. Left ventricular systolic dysfunction is uncommon in patients with SCD: A meta-analysis of 19 controlled case studies has shown similar LV ejection fraction (LVEF) in homozygous S patients compared to healthy controls [15]. Accordingly, the prevalence of an LVEF < 50 % is low, ranging from 0% to 2.5% in ultrasound cohorts studies and 0% to 4% in smaller CMR studies [16,17]. SCD-related PH involves several mechanisms. First, as pulmonary pressure is the product of flow and pulmonary vascular resistances, high cardiac output in SCD induces elevated pulmonary pressure whether pulmonary vascular resistances are altered or not [18,19]. Second, chronic volume overload might lead to LV failure and subsequent pulmonary venous hypertension [20,21]. Third, intravascular haemolysis could induce pulmonary arterial vasculopathy mainly driven by nitric oxide scavenging due to free plasma haemoglobin [22]. Finally, several other mechanisms may participate including, chronic hypoxaemia, post-embolic PH, SCD-related lung injury, chronic liver disease, and asplenia.

In SCD, the pulmonary vascular bed is commonly affected [23]. Pneumonia may be difficult to distinguish from pulmonary infarction and both may coexist. Intravascular sickling may cause pulmonary vascular occlusion in the absence of radiologic changes, and in some patients bone marrow and fat released from infarcted bone may embolize to the lungs [24]. In the autopsy series of Gerry et al, 30% of adults and 22% of children had right ventricular hypertrophy. Three of these patients had had right ventricular failure, considered to be due to cor pulmonale [25].

Conclusion

The main cardiac involvement during major beta thalassemia is left ventricular dysfunction or in extreme cases biventricular dilated cardiomyopathy on the other hand sickle cell disease mainly causes right ventricular dilatation and dysfunction secondary to sickle cell lung pathology. A major near-term issue to address is the establishment of criteria for early disease-specific treatment of patients with MBT and SCD to avoid cardiovascular complications

Abbreviations

DOE: Dyspnoea on Exertion
 
MRI: Magnetic Resonance Imaging
 
SCD: Sickle Cell Disease

LVEF: Left Ventricle Ejection Fraction

MBT: Major Beta-thalassemia

References

  1. Grisaru D, Rachmilewitz EA, Mosseri M, Gotsman M, Lafair JS, et al. (1990) Cardiopulmonary assessment in beta-thalassemia major. Chest 98:1138‑42. [crossref]
  2. Levy RI, Moskowitz J (1982) Cardiovascular research: decades of progress, a decade of promise. Science 217: 121-12 [crossref]
  3. Rund D, Rachmilewitz E (2005) Beta-thalassemia. N Engl J Med 353: 1135-1146.
  4. Wood JC (2009) Cardiac complications in thalassemia major. Hemoglobin 33: 81-86.
  5. Sonakul D, Pacharee P, Thakerngpol K (1988) Pathologic findings in 76 autopsy cases of thalassemia. Birth Defects Orig Artic Ser 23: 157-176. [crossref]
  6. Morris CR, Gladwin MT, Kato GJ (2008) Nitric oxide and arginine dysregulation: a novel pathway to pulmonary hypertension in hemolytic disorders. Curr Mol Med 8: 620-632. [crossref]
  7. Atichartakarn V, Likittanasombat K, Chuncharunee S, Chandanamattha P, Worapongpaiboon S et al. (2003) Pulmonary arterial hypertension in previously splenectomized patients with beta-thalassemic disorders. Int J Hematol 78: 139-145. [crossref]
  8. Phrommintikul A, Sukonthasarn A, Kanjanavanit R, Nawarawong W (2006) Splenectomy: a strong risk factor for pulmonary hypertension in patients with thalassaemia. Heart Br Card Soc 92: 1467-1472. [crossref]
  9. Rother RP, Bell L, Hillmen P, Gladwin MT (2005) The clinical sequelae of intravascular hemolysis and extracellular plasma hemoglobin: a novel mechanism of human disease. JAMA 293: 1653-1662. [crossref]
  10. Engle MA, Erlandson M, Smith CH (1964) Late Cardiac Complications Of Chronic, Severe, Refractory Anemia With Hemochromatosis. Circulation 30: 698-705. [crossref]
  11. Engle MA (1969) Cardiac involvement in Cooley’s anemia. Ann N Y Acad Sci 119: 694-702. [crossref]
  12. Felker GM, Thompson RE, Hare JM, et al. (2000) Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 342: 1077-1084. [crossref]
  13. Falk RH, Hood WB (1982) The heart in sickle cell anemia. Arch Intern Med 142: 1680-1684.
  14. Rees DC, Williams TN, Gladwin MT (2010) Sickle-cell disease. The Lancet 376: 2018-2031.
  15. Poludasu S, Ramkissoon K, Salciccioli L, Kamran H, Lazar JM (2013) Left ventricular systolic function in sickle cell anemia: a meta-analysis. J Card Fail 19: 333-341. [crossref]
  16. Desai AA, Patel AR, Ahmad H, Groth JV, Thiruvoipati T, et al. (2014) Mechanistic Insights and Characterization of Sickle Cell Disease Associated Cardiomyopathy. Circ Cardiovasc Imaging 7: 430-437. [crossref]
  17. Wood JC, Tyszka JM, Carson S, Nelson MD, Coates TD (2004) Myocardial iron loading in transfusion-dependent thalassemia and sickle cell disease. Blood 103: 1934-1936. [crossref]
  18. Mushemi-Blake S, Melikian N, Drasar E, Bhan A, Lunt A, et al. (2015) Pulmonary Haemodynamics in Sickle Cell Disease Are Driven Predominantly by a High-Output State Rather Than Elevated Pulmonary Vascular Resistance: A Prospective 3-Dimensional Echocardiography/Doppler Study. Connes P, éditeur. PLOS ONE 10: 0135472. [crossref]
  19. Caughey MC, Hinderliter AL, Jones SK, Shah SP, Ataga KI (2012) Hemodynamic Characteristics and Predictors of Pulmonary Hypertension in Patients with Sickle Cell Disease. Am J Cardiol 109: 1353-135 [crossref]
  20. Junqueira FP, Fernandes JL, Cunha GM, T A Kubo T, M A O Lima C, et al. (2013) Right and left ventricular function and myocardial scarring in adult patients with sickle cell disease: a comprehensive magnetic resonance assessment of hepatic and myocardial iron overload. J Cardiovasc Magn Reson 15: 83. [crossref]
  21. Fonseca GHH, Souza R, Salemi VMC, Jardim CVP, Gualandro SFM (2012) Pulmonary hypertension diagnosed by right heart catheterisation in sickle cell disease. Eur Respir J 39: 112-118. [crossref]
  22. Farmakis D, Aessopos A (2011) Pulmonary Hypertension Associated With Hemoglobinopathies: Prevalent But Overlooked. Circulation 123: 1227-1232. [crossref]
  23. Bromberg PA (1974) Pulmonary aspects of sickle cell disease. Arch Intern Med 133: 652-657
  24. Baroldi G (1969) High Resistance of the Human Myocardium to Shock and Red Blood Cell Aggregation (Sludge). Cardiology 54: 271-277. [crossref]
  25. Gerry JL, Bulkley BH, Hutchins GM (1978) Clinicopathologic analysis of cardiac dysfunction in 52 patients with sickle cell anemia. Am J Cardiol 42: 211-216. [crossref]
fig 1

Specification of a Model of Multiculturalism about Entrepreneurial Migratory Flows

DOI: 10.31038/ASMHS.2022623

Abstract

The objectives of this study were to explore the relationships between categories around the undertaking of migratory flows in order to specify a model for their systematic study. A documentary, exploratory and transversal study was carried out with an intentional selection of sources indexed to international repositories; Dialnet, Latindex and Redalyc, considering the publication period from 2007 to 2019, as well as the search for keywords. A relationship structure was observed between three preponderant categories in the literature: acculturation, multiculturalism and interculturalism in which significant differences were established with respect to selected extracts from the consulted literature. However, there was no appreciable collaborative and consensual learning among the judges who evaluated the marks in three qualification rounds, although the design of the research limits the findings to the informative sample. These results demonstrate the specification of a model in order to establish differences between the categories and anticipate exclusion or inclusion scenarios between migratory flows and native communities, as well as the relevance of entrepreneurship in the local development of both groups.

Keywords

Migration, Entrepreneurship, Development, Setting, Acculturation

Introduction

Roughly, migratory flows allude to a process of passage, stay and return that has been explained by three epistemic foundations: a) acculturation; B) selectivity and c) identity. It is a multidimensional process in which each phase and each dimension unveils the differences between governors and governed in terms of sustainable, human and local development policies, and mainly explains the asymmetries between migratory flows and native spheres [1].

The concept of migration is multidimensional, but the studies related to migrant cultures with respect to native cultures have focused on a generalizing concept of rupture, crossing, stay and return in the economic and occupational order. Many occupational studies, emphasizing dependence, conformity, and obedience of migrant cultures with respect to native culture, are destined for human, local and regional development only with migrant cooperation in services or agroindustrial activities [2]. The phenomenon of migration has been approached from an ethnocentric, polyculture or multicultural approach, focusing on the adjustment of migrant cultures with respect to the laws, values, and norms of native cultures [3]. In that sense, substantial justice from multiculturalism is the integration of social justice and cultural justice, or, the concatenation of economic, political and social rights with respect to cultural differences and self-determination.

From these approaches, migration has been understood as a process of acculturation, assimilation, adaptation, and selectivity of talents with respect to an internal labor market that demands the environment and the capacities required to carry out local development, through the distribution of the labor force in strategic sectors such as agro-industry or services. The selectivity of talents that moved from emerging to developed countries is only possible in the cases of the so-called economy 4.0 [4].

This is because the perspectives of migration have considered the native cultures as active and vital in the development process whereas migrant cultures are passive or collaborative in the endogenous development of native cultures, coupled with substance justice, as antecedent of interculturalism, the concepts of impartiality such as granting rights to minorities, self-government or political and legal autonomy, polyethics or equality dissemination guarantees among members of a group, as well as the specificity and cultural legitimacy embodied in dialogue, negotiation and co-responsibility subscribe to the construction of a new model for the study of migrant cultures in relation to native cultures ([3]: page 255).

In this sense, the notion of social justice was linked to the consequences of immigration as it warned about asymmetries in terms of rights and obligations, opportunities and capabilities, as well as between commitments and responsibilities between migrant cultures and native cultures [5].

Well, the study of migratory flows no longer as passive entities and dependent on native cultures gestate in the work of entrepreneurship and innovation that distinguish this new wave of its predecessors focused on compliance and obedience, now observed at migration as active and innovative entities. These are migratory flows with civic virtues oriented towards a sense of identity and belonging to a universal community, observed by their degree of empathy, commitment, altruism, solidarity, satisfaction and happiness [5].

The theoretical, conceptual, empirical and hypothetical frameworks with respect to entrepreneurial migratory flows are grouped into 1) acculturation, assimilation, and adaptation; 2) selectivity and human capital; 3) identity, spheres, networks, and multi and intercultural flows.

The acultural, assimilative or adaptive perspective distinguishes migrants and natives not only from the place of origin, its uses, and customs but also its objectives, tasks, and goals. It is logic of profit and utility as a preponderant and determining factor of the relations between migratory and native flows. In this sense, development policies with such an approach highlight the achievements and scope of programs based on sustainable rather than human or local development, since it is assumed that the labor market will generate and disseminate the bases for establishing the quality of life and subjective well-being related to health, education, and employment. These are sector programs and strategies in which support and incentives, as well as financing, are aimed at containing migratory flows according to the needs of the labor market [6].

In this way, entrepreneurial migrant flows are circumscribed to the inclusion and social protection policies that the receiving State implements in order to promote development in the economy of industrial production and services. Migrants are considered a skilled and specialized workforce, a fundamental part of the gearing of the productive and service sectors. It is assumed that the State must protect the interests of the natives by postponing the stay of migrants and encouraging their abilities; knowledge, and skills from and with the corresponding occupational health [7].

The selectivity approach considers that the development will be gestated from the policies of business promotion and market opening. Regionalism and multilateralism are essential to encourage sustained development and, immediately, human and local development. The aim is to promote policies for evaluation, accreditation, and certification of the quality of the processes and achievements of institutions and organizations sponsored by business development policies, as well as market-opening policies. In this process of selectivity, migratory flows are evaluated by their degree of intellectual capital in relation to the requirements of the labor market [8].

The undertaking of migratory flows is considered as a phase or instance subsequent to the implementation of business promotion policies, but above all, as a result of health, educational and labor policies with emphasis on the evaluation, accreditation, and certification of objectives, tasks and goals both institutional and organizational, since, it is precisely in these instances where the asymmetries between natives and migrants are resolved in favor of sustainable, human and local development. It is considered that the selection of the best talents, intellectual capitals, skills, and knowledge will build a culture of entrepreneurship, innovation, and success [9].

The paradigm of identity, unlike acculturation and selectivity, warns that the asymmetries between migrants and natives are due to the establishment of spheres, networks and flows since migrants establish relations of empathy and commitment by virtue of their abilities and the natives are organized rather in terms of a culture of domination. Among other differences, the migrant customs and practices are oriented and tolerated by the natives from their consensual diversity, which means, the migrants are considered as different in their traditions, but at the same time, indispensable for the development of the country. A receiver as the economy that expels those [10].

Therefore, the policies implemented from this approach recognize the differences between migrants and natives that will determine sustained, human and local development. That is to say, programs and strategies do not seek to dilute asymmetries, but to increase them in favor of the recognition, admiration, and respect of personal attributes, organizational innovations, state integrality and national competitive advantages [11].

This is how development policies are properly structured based on differences between migrants and natives, but the approach distances and approaches groups according to programs and strategies implemented at different levels: sustainable, human and local [12].

From the theoretical point of view, the study of migration supposes, without a doubt, the establishment of an agenda, which from a thorough review of the literature (that is, the state of the art, the state of the question or of the state of knowledge), alluding to the issue of migration. In effect, starting from an epistemological criterion, two major groups of theoretical discussion approaches are established [13].

Since it was about social work, it was thought to privilege the “intervention”; however, the concept of intervention has been questioned and even replaced by the term of intercession. Indeed, in the past with the Benefactor State, social work would have to contribute to economic and social development. Instead, now paradoxically, with neoliberalism in between, society comes to participate more; however, the work of social work is to promote dialogue, management, and evaluation. In other words: intercession, mediation between the State and organizations. Social work will intercede in the communication of the different actors of civil society. This is your future [9].

Entrepreneurship consists of empowering opportunities (including the generation of their own opportunities); as well as optimize resources and strengthen capacities [14]. Entrepreneurship is also a historical process in which levels of development are reflected according to migratory flows. Therefore, the learning of entrepreneurship is, undoubtedly, an indicator of development.

In this sense, social work has generated models for the study of entrepreneurship, understood as learning from actors involved in the journey and stay with an entrepreneurial culture so that, upon return, with the use of certain capital, learning, the knowledge and skills, favorably affect, in this case, in the commercialization of a product (organic coffee).

Studies related to knowledge networks, also known as neural networks, have established associations between different variables, such as beliefs, attitudes, intentions, and behaviors; in order to demonstrate a node learning (group) with respect to a neuron (or network system).

In the case of migratory flows [Exit (expulsion) ⇨ Crossing (travel) ⇨ Stay (residence-work) ⇨ Return (return to the place of origin)] is possible to note the degree of entrepreneurship, if they are considered as nodes in a particular network of migrants returning to their place of origin, provided with resources, skills, knowledge and expertise; all this oriented to investment in the local economy [15].

However, studies of migratory flows have focused their interest on the dominant native cultures by proposing laws, values, and norms are ethnocentric, polycultural or multicultural, although they limit the entrepreneurial capacities of migratory flows, they can adapt, assimilate the dominant lifestyles and be selected according to their skills and knowledge to achieve their insertion in society [16].

Precisely, the objective of this work was to explore the relationships between the categories of acculturation, multiculturalism and interculturalism reported in the literature from 2007 to 2019 in repositories such as; Dialnet, Latindex, and Redalyc in order to specify a model for the study of the phenomenon in endogenous development with local entrepreneurship.

Method

A documentary, exploratory and transversal study was carried out. A non-probabilistic selection of sources indexed to Dialnet, Latindex and Redalyc was made, considering the period of publication from 1999 to 2017, as well as the key words: “migration”, “entrepreneurship”, “inclusion”, “development” and “networks”.

An array of content analysis in order to set the agenda, axes and discussion topics related to migration was used. The matrix includes the coding, weighting of judges’ evaluations around the revised information (Table 1).

Table 1: Content Analysis Matrix

Model

Indicator Coding Weighing

Interpretation

Acultural Adaptation, assimilation and return 0 = vertical exclusion, 1 = horizontal exclusion, 2 = vertical inclusion, 3 = horizontal inclusión 0 to 1 0 points as vertical exclusion threshold Agenda, axes and discussion topics focused on exclusion and social injustice
Multicultural Insertion, Selectivity andreincersion 0 = vertical exclusion, 1 = horizontal exclusion, 2 = vertical inclusion, 3 = horizontal inclusión 11 to 20 points as selective inclusion threshold : vertical Agenda, axes and discussion topics focused on social justice based on the legal framework and native culture
Intercultural Entrepreneurship andinnovation 0 = vertical exclusion, 1 = horizontal exclusion, 2 = vertical inclusion, 3 = horizontal inclusión 21 to 30 points as horizontal social inclusion threshold Agenda, axes and discussion topics focused on participation, dialogue and co-responsibility between migrant and native cultures

Source: self-made

The coding was established by judges who evaluated the findings matrix (Table 1A in the annex) based on criteria such as 0 = vertical exclusion, 1 = horizontal exclusion, 2 = vertical inclusion and 3 = horizontal inclusion.

For example: the information related to “Identity, globalization and equity” was evaluated on Thursdays as a content or extract of vertical exclusion, as the dominant culture prevails as regards migrant cultures disseminated in identities such as diaspora, ferry wheels or nomads. The latter oriented to equity by a multicultural legal framework that raises the self-determination of groups as long as these conform to the laws of the recipient country.

The weighting threshold, considering that three models prevail for the study of the migratory phenomenon: acculturation, multiculturalism and interculturalism, was structured as: 0 to 10 information oriented to the study of vertical exclusion, from 11 to 20 information directed towards the selective exclusion vertical and 21 to 30 information oriented to the study of horizontal inclusion.

Following the same example of “identity, globalization and equity”, it reached a score of 9, evidencing that it is information oriented to the study of exclusion, focused on the vertical asymmetries between the dominant cultures that may be the native with respect to the migrant cultures that can be identities such as: nomads, diaspora and ferry wheel.

The threshold of 0 to 10 points of 30 possible was interpreted as a reflection of an agenda, axes and content issues related to exclusion and social injustice for evidencing asymmetries between native cultures and migrant cultures regarding economic, political, social and sexual rights .

The threshold of 11 to 20 points out of 30 possible was interpreted as a reflection of a genre, axes and debate topics focused on the possibility of dialogue between migrant and native cultures with respect to human development, health, education and employment, which, being equitable, substantially improves the selectivity of talents and directly affects productivity as well as competitiveness.

The threshold of 21 to 30 points was interpreted as a reflection of an agenda, axes and discussion topics focused on the social inclusion of migrant cultures through dialogue with native cultures. This supposes a deliberative participation, whether informed or reasoned with respect to equity in terms of economic, political and social rights.

Based on the Delphi technique, the content of the concepts and indicators of migratory flows was analyzed with respect to development: sustainable, human and local, as well as with inclusion and social protection.

The information was compared and integrated considering, year, author, concept, technique and findings in order to be able to synthesize the information and expose it to 10 expert judges in the problem, who evaluated the content following the criterion of vertical exclusion, horizontal exclusion, vertical and horizontal inclusion to highlight the differences and similarities between migrant cultures and native cultures.

The confidentiality and anonymity of the judges was guaranteed in writing with respect to their responses, as well as the results of the study, which informed the participants that these findings would not negatively or positively affect their economic, political and social status.

Two tables or matrices were drawn up to show the differences and similarities in terms of the categories of development and social protection, indicators of exclusion and vertical as well as horizontal inclusion.

A model of trajectories and axes of dependency relations between the variables used in the revision of the literature was specified in order to be able to discuss the scope and limits of the results, as well as future research lines concerning the problem, the phenomenon and object of study.

Results

Table 2 shows the descriptive values of the instrument or matrix of content analysis, which demonstrate the normal distribution of the coded responses of the literature consulted and the expert judges who evaluated the contents.

Table 2: Instrument Descriptions

E

M S K A C1 C2 C3

R1

χ2 Df p χ2 df p χ2 df

p

e1

2,67

0,89 0,75 0,70 13,25 14

<,05

e2

2,91

0,83 0,73 0,76 15,23 14

<,05

e3

2,03 0,94 0,60 0,77 14,36 18 <,05
e4 2,43 0,85 0,84 0,73 13,26 10

<,05

e5

2,78 0,80 0,63 0,78 14,36 13 <,05
e6 2,15 0,81 0,61 0,83 15,47 11 <,05

e7

2,09 0,96 0,59 0,82 14,25 11 <,05
e8 2,79 0,85 0,73 0,84 14,23 15

<,05

e9

2,56 0,87 0,64 0,74 14,56 13

<,05

e10

2,75 0,93 0,83 0,72 15,42 12 <,05
R2

e1

2,90 0,94 0,63 0,80 13,25 17 <,05
e2 2,86 0,96 0,74 0,85 15,49 15 <,05

e3

2,75 0,98 0,84 0,89 13,46 10 <,05
e4 2,98 0,89 0,74 0,83 14,35 15

<,05

e5

2,84 0,85 0,77 0,67 14,35 16 <,05
e6 2,70 0,88 0,80 0,84 14,35 13

<,05

e7

2,84 0,99 0,82 0,88 13,24 12 <,05
e8 2,80 0,94 0,73 0,73 15,32 12

<,05

e9

2,78 0,93 0,72 0,72 13.45 13 <,05
e10 2,45 0,84 0,89 0,75 15.46 16

<,05

R3

e1 2,63 0,79 0,82 0,84 15,47 13

<,05

e2

2,70 0,84 0,80 0,85 14,35 15 <,05
e3 2,64 0,85 0,73 0,80 15,47 18 <,05

e4

2,53 0,96 0,86 0,83 15,46 13 <,05
e5 2,58 0,98 0,75 0,74 14,36 15 <,05

e6

2,51 0,99 0,77 0,77 14,38 13 <,05
e7 2,43 0,86 0,63 0,85 16,54 15

<,05

e8

2,58 0,88 0,85 0,73 16,58 12 <,05
e9 2,50 0,84 0,95 0,75 13,24 11

<,05

e10

2,74 0,82 0,82 0,80 12,34

13

<,05

Source: Elaborated with data study
E: Extract, R: Round, M: Median, S: Standard Deviation, K: Kurtosis, A: Asimetry, C: Category: C1: Acultural, C2: Multicultural, C3: Intercultural; χ2: ji squared, DF: Degree Fredom, P: Level of significance.

It is possible to appreciate a consensus based on the relationships between extracts and categories, but not in terms of collaborative learning between the sources since the first round includes equal or less consensus for the first and second, but favorable for the third category.

That is, the literature consulted seems to agree on differences between acculturation, multiculturalism and interculturalism with respect to the selected extracts, but only for this intercultural category are there consensuses in the qualifications of judges as the evaluation rounds go on.

Ell means that acculturation and multiculturalism seem to be controversial for judges in relation to interculturalism. Entrepreneurial migratory flows seem to be assumed as part of a system of balances between resources and demands, opportunities and challenges, resources and capacities among political and social actors, although the lack of consensus regarding their structure of relationships, communication and motivation seems to indicate that these are emerging phenomena that literature has not been able to assess.

Figure 1 shows the relationships between the categories with respect to the extracts qualified by expert judges in the subject areas.

fig 1

Figure 1: Structure of Categorical Relationships.
Source: Elaborated wit data study.
E: Extract, C: Category: C1: Acultural, C2: Multicultural, C3: Intercultural; relations between categories and extracts.

It is possible to appreciate that there are relations close to the unity between the categories established by the literature and the extracts qualified by expert judges, although category 2 and category 3 maintain a close relationship to zero, suggesting that multiculturalism and interculturalism are mutually scenarios Exclusive to the entrepreneurial local development.

In contrast, acculturation and interculturalism seem to converge in terms of endogenous entrepreneurial development, suggesting that it is an antecedent and consequent relationship. That is to say, interculturalism will emerge from acculturation and not from multiculturalism.

Discussion

Within the framework of male and female gender relations focused on employment opportunities and capacities, the discussion of the similarities and differences between the concepts of human, sustainable and local development can be located in two indicators of social development: 1) the dignity of life and 2) the quality of life [17], as well as at the institutional level regarding its lack of coordination at the different levels of government, federal, state and municipal [18].

The dignity of life refers to human and social rights as mediators of public action and social necessity [17]. It is to say, it is assumed from the social development approach that the differences of rights between men and women are gestated after both identities, masculine and feminine, are victims of a crucible of violations of their rights. This is so because, even though they are different in their opportunities and capacities, they share common development problems and strategies.

This is the case of quality of life, refers to health; nutrition, housing, education, environment, culture and longevity ([17]: 66). These are opportunities and capacities for access and usefulness of each of these privileges, once again circumscribed between the recognition and ignorance of female identity and masculine identity.

In this way, social development is the product of public and private actions, programs and strategies aimed at dignity and health, reflected in the quality of life, but at the same time part of a vicious circle of similarity (shared problem) and differentiation (development privileges). Therefore, it is necessary to have a state rectory [18].

From this definition of social development, it will be possible to derive the differences and similarities between human, sustainable and local development. It will be essential to establish the definitions, objectives, instruments and goals that distinguish them, since the scarcity or lack of dignity and quality of life is the common denominator [19].

However, it is necessary to consider that the differences related to employment opportunities and capacities between men and women are limited to the imperfections of the labor market ([17]: 66). Therefore, the policies of collection and redistribution will be fundamental to clarify the solidarity that characterizes masculine identities and feminine identities, mainly cooperation oriented to their development [20].

From a matrix around sustainable, human and local dimensions, it is possible to notice differences and similarities if the diagnosis is considered in terms of the absence or scarcity of rights, objectives, instruments and goals (Table 3).

Table 3: Matrix of similarities and differences in development

Dimension

Diagnostics (absence or inefficiency, inefficiency and ineffectiveness of rights) Objectives (effectiveness of rights) Instruments (efficiency of rights)

Goals  (rights, effectiveness)

Sustainable (generation of health, educational and employment opportunities with an emphasis on social equality: female claim, afro-descendant, indigenist and older adult to overcome poverty) State dismantling (page 72); lack of leadership of SEDESOL (minute 6:25), federal, state and municipal lack of coordination (minute 4:15), polarization (minute 3:48), social inequality (p.74), containment and reduction of public expenditure (pp. 71 and 72), business exemptions and reduction of state employment ( p.72), discontinuous growth (p.70), limited business contribution (p.71), competition in services and commerce (p.71), state malformation; macroeconomic management (p.72), extreme poverty (minute 3:30), feminization of poverty (p.73) by race and age (p.74), educational lag, access to health, access to housing, income (p. 7:50 to 9:13) Interinstitutional coordination (minute 6:35) restoration of civil trust (p.72), social integration (p.73). Social policy: focus, coordinate and influence (minute 4:00 to 5:00), institutional scaffolding (minute 4: 48), public investment (page 71), social dialogue (page 73), representation and governance (p. 72), solidarity and social integration (p.71), governmental responsibility (p.73); transparency (p.73), national crusade against hunger (minute 7:10), popular insurance affiliation (minute 8: 20), subsidy and productive linkage (9: 10) Sustained growth (p.70).
Human (capacity building for dignity and quality of life in health, education and employment) Mobility requirements (p.66 and 67), institutional precariousness (p.67), informal work (p.68), unemployment (p.70). Overcoming poverty (p.68), strengthening human capital (p.69). Universal care (p.67); education (p.66). Family welfare (page 68).
Local (Public and private support and services through cooperative solidarity) Abandonment of state centrality (p.74), end of assistentialism and paternalism (p.75), political corruption and social untying (p.71), institutional administrative centralism (p.71), scarcity of fiscal resources, monetary precariousness, labor exclusion (p.67), social distrust (p.72). Employment opportunities (page 66), promotion of positive interactions between cultures and communities (p.75). Social and economic compensation (p.66), migration and remittances (p.67), social capital (p.66 and 68), solidarity and trust (p.69), promotion of survival strategies (p.69). Labor stability (p.70) , equitable remuneration (p.66 ).

Source: Modified from [17,18]

In this way, sustainable development refers to an area in which the State generates opportunities and contributes to the capacities of civil society to reduce inequalities between cultures, localities, communities, families and individuals [21].

If sustainable development orients social equality in order to overcome the poverty of the most excluded sectors, then human development will focus on the promotion of health, education and labor rights in order to establish capacity building that will culminate in the scope of dignity and quality of life [22].

In this way, human needs and expectations will correspond to the policies of strengthening human capital through social care in general and education in particular, generating the desired social well-being [23].

However, the abandonment of the welfare paternalism of the state rectory supposes local policies focused on the reconstruction of the social fabric and the recovery of civil trust through the promotion of solidary and cooperative relations, social and economic compensations, indicated by labor equity and remunerative [24].

In each of the dimensions of sustained development, human and local, the effectiveness, efficiency and effectiveness of rights is the central issue in the state and civil agenda, deriving in cultures, races, gender identities, ages, levels of education and income [25] .

The differences and similarities between the sustained, human and local developments allow observing the inequality between men and women, among other items. This is so, because the problems, objectives, instruments and goals seem to disfavor the feminine identity over the masculine identity not only evidenced in the poor number, but also in the opportunities generated by institutions and companies, which favor a competition logic focused on the conviction of success, an essential attribute of male identity and to the detriment of conservation ethics, a fundamental feature of female identity [26].

In this way, policies of sustained, human and local development, focusing their emphasis on competence rather than solidarity, will favor male identity, but at the same time they not only exclude female identity in the health, education or labor fields. , but also confine the male identity to these areas bypassing the relative to family as is the case of paternity rights [27].

The phenomenon of masculine youth migratory flows can be understood from the asymmetries and similarities between the processes of inclusion and social protection, considering that human rights are the universal and integral implementation instrument [28,29].

That is to say that social inclusion, being an ethics, vocation and discourse of equality, not only implies the exercise of rights in the foundation of programs and strategies, but also is aimed at reducing the barriers that inhibit the construction of citizenship , cohesion, belonging and democratic life. Through administrative decentralization, social recognition, the social pact, the negotiation of conflicts and the expansion of rights for their social redistribution [30].

If social inclusion is reflected in social protection as synonymous with social assistance, then masculinities in their youth and migratory flows would have ample possibilities of being included and protected, but this last question implies social assistance related to progressivity, equality, integrality, institution, participation, transparency, accessibility and accountability [31].

In other words, social and economic rights must not only be guaranteed by the State, they must be inserted in a policy, program and strategy aimed at eradicating inequalities, indicated by their regression in terms of opacity of resources and inaccessibility of information [32].

In this way, the similarities and differences between inclusion and social protection are central issues in the political and civil agenda, mainly in relation to a diagnosis of inequality and social exclusion, as well as in the objectives, instruments and goals aimed at the inclusion of from protection [33].

“Grosso modo” (Table 4), social inclusion is the effect of social protection understood as a policy, program and integral strategy for managing demands and redistribution of resources in order to regulate: 1) social assistance, 2) social security and 3) the labor market [28].

Table 4: Matrix of differences and similarities between protection and social inclusion

Dimension

Diagnosis (lack of efficacy, efficiency and effective rights) Objective (effectiveness of rights) Instrument (efficiency of rights)

Goal (effectiveness of rights)

Inclusion (ethics, vocation and discourses of social equality for the exercise of social and economic rights) Ethics of inequality (p.332), distortion of citizenship (p.332), absence of cohesion, social belonging and democratic life (p.332), Equality in well-being (page 332), dignity, autonomy and freedom (page 344), democratic participation (page 344), universality of rights (page 346). Decentralization of responsibilities (page 346), social recognition without distinction of gender, race, ethnicity, age, belonging to specific socioeconomic groups or geographic location (page 332), social pacts (page 333), conflict negotiation (p. 333), expansion of rights (p.333), cohesion and social identity (p.333). Social redistribution (p.332), discourses of rights (p.332),
Protection (Implementation of economic and social rights based on standards of progressivity, equality, integrality, institutionality, participation, transparency, access and accountability) Policy of social inequality (p.332), regressivity that inhibits the exercise of social and economic rights (p.333), illegality and labor informality (minute 4: 33), multidimensional poverty (minute 6:49), differential needs (p. minute 9: 35), transitional (minute: 9:55) and chronic (minute 10:10), female uniparental leadership (minute 11: 22). Municipal operational technical coordination (minute 17:40), information and opaque management (minute 18:35), Reduction of social inequality (p.332) from integrality (minute 6:20), identification of demands and guarantee of access to resources (minute: 3:21), promotion of decent work (minute 4:06), focused on income (minute 2: 10), Universal policies (p.332), horizontal integrality (minute 6:50), vertical administration (7: 10 minute), sectoral transversality (minute 8: 03), institutional coordination (minute 16:40), promotion of human rights; economic and social with an inalienable sense (p.331 and 332), coverage of needs (p.335), conflict control systems (minute 20:15), Social assistance, contributory social security and regulation of the labor market (minute 15: 10 to 16: 25). Multi-sectoriality of state intervention (minute 6: 49); legal commitments (p.332), social security (p.342) and social assistance (p.342)

Source: Modified from [28,29]

That is to say that social exclusion, indicated by social inequality and determined by the regression of economic and social rights, is reflected in illegality and labor informality, multidimensional poverty, differentiated needs, and directly impacts single-parent families headed by women; It supposes a lack of technical and operational municipal coordination fed by an absence of informative transparency and accountability, justifies social protection [34].

In this sense, social protection is the implementation of strategies and mechanisms of assistance, security and the labor market as part of universal, comprehensive policies, verticality in its elaboration and horizontal implementation. It implies a sectoral transverse condition; an institutional coordination in the coverage of needs and a control of conflicts between political and civil actors [35].

Understood as a strategy of assistance, security and labor regulation, the differences and similarities between social inclusion as an ethic derived from social protection show that: 1) migrant flows occupy a place in the integration of social protection through demographic bonus; however, 2) migrant masculine identities would only be a priority while they are in a productive age; 3) both migrant flows and masculine identities are more prone to state exclusion, since it prioritizes the sectors of the future [36].

From the intercession model of social work, which proposes the incidence of contextual repertoires on narratives and discourses, fifteen former migrants settled in Xilitla, SLP, in the Huasteca Potosina, were interviewed in order to interpret and establish the influence, they had throughout their journey, stay and return, all this in the face of acculturation, selectivity, identity and governance; as well as before the rationality: economic, multicultural, intercultural and ethnocentric, having as evident background to the enterprising culture of the EU [37-47].

The former migrant traders of organic coffee had an apprenticeship in entrepreneurship based on the transparency of the management of their micro-enterprise. Each peso was used for the development of your business. The merchants without experience in migration had an apprenticeship of the enterprise based on the specificity of their sales. Each weight should be invested in a single product.

A specification refers to the establishment of axes, trajectories, relationships and hypotheses around a process in which the variables reviewed in the state of knowledge reflect a particular context or scenario, but their expected relationships anticipate conflicts and changes.

In this way, a preponderant axis: the integrality of the public policies on the other nodes; diversity, security, activism and co-responsibility. Each path of dependency relationship between each of the five factors allows the establishment of hypotheses that can be contrasted in the immediate future if the theoretical, conceptual and empirical frameworks reviewed in the state of knowledge are fulfilled.

The model proposes the study of entrepreneurial migratory flows based on the leadership of the State through the integrality of social policies, as well as the diversification of social protection and public social security, although in another aspect, movements for social security They propose a co-responsibility in the management and administration of public services in the field of social entrepreneurship.

It is a model delimited by two political and social actors around the establishment of a business promotion system that is distinguished by its degree of social protection, comprehensive strategies, local security and openness to social demands, as well as the construction of a co-government or governance indicated by its degree of co-responsibility.

However, the co-governance or governance scheme also implies the inclusion of other public and private sectors and actors, such as joint-stock companies and cooperative societies. This means that the model is limited to two actors that, although they are the predominant axes of co-government, whose management and administration capacity is regulated by civil organizations and government institutions.

In this way, the selection of indexed sources can be extended to repositories such as EBSCO, SCOPUS, ELSELVIER or SCIELO. This would include variables that explain the dialogue between the governors and the governed in terms of entrepreneurship, mainly in terms of the innovation of development policies.

In the case of the Delphi technique used to analyze the content and its specification in a model, it could be complemented with the neural network technique in order to be able to establish possible scenarios from available data and feasible dependency relationships. It is the same case of the data mining technique, which would delimit the study scenario to a context and space in which entrepreneurship contrasts with protectionism or corruption.

Regarding the model of complex trajectories of interdependence between the factors subtracted from the literature consulted, it is possible to amplify such a model using the logic of structures, which warns measurement errors that can indicate the similarity or difference of constructs in the explanation of a problematic.

Finally, in relation to the works of [9,13], in which entrepreneurship has its origin in local identity, regional roots, attachment to the place, and the sense of community as a substantial part of the uses and customs oriented to profit and profit. Present work rather considers that it is the interdependence between migrant and native cultures that generates an entrepreneurial hybrid, and that although the local identity is its foundation, also the labor expectations that drive the crossing, the stay and the return of migrants is a factor determinant of a migrant’s work cycle.

Subsequently, it is recommended: a) to carry out an intensive processing of information in other repositories; b) adopt other content analysis techniques; c) generate integral models, that include entrepreneurial migratory flows and entrepreneurial spheres; c) as well as the discussion between the historical identity of the place of origin with respect to the labor expectation of the migrant receiving context.

Conclusion

The contribution of this work to the state of the question lies in the establishment of five assumptions that explain the trajectories of interdependence between five nodes or factors used in the state of the matter and specified in a model for addressing entrepreneurial migratory flows. It deals with the integrality, diversification, security, participation and co-responsibility of the political and social actors in the construction of a system of co-management and co-administration of resources and public services related to social entrepreneurship, business development, microfinance or microcredit focused on the localities that receive or boost migratory flows.

The discussion about social entrepreneurship, as a process of state management or administration, or, because of civil participation in self-management and self-organization, is being rethought towards models of co-government, co-management, co-administration and co-responsibility, which they indicate a rapprochement of public administration with organized civil society, but in terms of social protection, policies, strategies and programs are disjointed. Therefore, opening the debate is necessary to establish an integral system of social entrepreneurship, at least between the governors and the governed.

References

  1. García C (2019) Dimensions of the theory of human development. Ehquidad 11: 27-54.
  2. Sánchez A, Juárez M, Bustos JMY, García C (2018) Contraste de un modelo de expectativas laborales en exmigrantes del centro de México. Gestión de las Personas y Tecnología 32: 21-36.
  3. Cruz E (2014) Multiculturalism, interculturalism and autonomy. Social Studies 43: 243-269.
  4. González M, Iglesias C (2015) Decisions on housing tenure and acculturation of the foreign population resident in Spain. Economic Trimester 82: 183-209.
  5. Tena J (2010) Towards a definition of civic virtue. Convergence 53: 311-337.
  6. Carreón J (2013) Discourses on labor migration, return and social reincession based on group identity in Xilitla, micro-region of Huasteca Potosina (Mexico). In L. CANO (coord.), Poverty and social inequality. Challenges for the reconfiguration of social policy. (pp. 153-174). Mexico: UNAM-ENTS.
  7. Sánchez A, Quintero ML, Sánchez R, Fierro E, García C (2017) Governance of social entrepreneurship: Specification of a model for the study of local innovation. Nomads 51: 21.
  8. Carreón J (2016) Human development: Governance and social entrepreneurship. Mexico: UNAM-ENTS 143.
  9. García C, Carreón J, Hernández J, Bustos JM (2016) Governance of risk from the perception of threats and the sense of the community. In S. VÁZQUEZ, BG Cid, E. MONTEMAYOR (coord.), Risks and social work (pp. 71-94). Mexico: UAT.
  10. Carreón J, Hernández J, Quintero Ml (2016) Specification of a local development model”. In D. Del-CALLEJO, ME CANAL and G. HERNÁNDEZ (coord.), Methodological guidelines for the study of development (pp. 149-168). Mexico: Universidad Veracruzana.
  11. Carreón J, Hernández J, Bustos JM, García C (2017) Business promotion policies and their effects on risk perceptions in coffee growers in Xilitla, San Luis Potosí, central Mexico. Poiesis 32: 33-51.
  12. Rodríguez RF (2010) Xenophobic speech and agenda setting. A case study in the Canary Islands press (Spain). Latin Magazine of Social Communication 65: 222-230.
  13. Carreón J, Morales M, Rivera B, Garcia C, Hernández J (2014b) Migrant entrepreneur and trader: State of knowledge. Tlatemoani 15: 1-30.
  14. García C (2018) Coffee farming enterprise in migrants from the huasteca region of central Mexico. Equidad & Desarrollo 30: 119-147.
  15. Campillo C (2012) The strategic management of municipal information. Analysis of issues, their treatment and irruption in the municipality of Elche (1995-2007). Magazine of Strategy, Trend and Innovation of Communication 3: 149-170.
  16. Albert MC, Espinar E, Hernández MI (2010) The immigrants as a threat. Migratory processes in Spanish television. Convergence 53: 49-68.
  17. Sojo C (2006) Social development, integration and public policies. Luminar Social and Humanistic Studies 4: 65-76.
  18. Robles R (2013) Ministry of Social Development. Interview on eleven TV.
  19. Carreón J, Hernández J, Morales MI, Rivera Bl, Limón GA, et al. (2014a). Towards the construction of a civil sphere of identity and public security. Realities 4: 23-36.
  20. Carreón J, Hernández J, García C (2015) Migratory identity in the establishment of an agenda. Dialogues of Law and Politics 16: 69-87.
  21. Fuentes F, Sánchez S (2010) Analysis of the entrepreneur profile: A gender perspective. Applied Economics Studies 28: 1-28.
  22. García C (2008) The psychosocial dynamics of the migratory communities. Approaches 1: 137-152.
  23. Gutiérrez R (2013) The linguistic dimension of international migrations. Languages and Migrations 5: 11-28.
  24. García C, Carreón J, Hernández J, Aguilar A, Rosas F, et al. (2015) Differences in reliability against risk, uncertainty and conflict between coffee farmers in Xilitla, Mexico. Eureka 12: 73-93.
  25. Long H (2013) The relationships between learning orientation, market orientation, entrepreneurial orientation, and firm performance. Management Review 20: 37-46.
  26. Rentería V (2015) Socioeconomic panorama of international migration originated in Latin America and the Caribbean: state of the art. University Act 25: 40-50.
  27. Yepes I (2014) Scenarios of Latin American migration: Transnational family life between Europe and Latin America. Roles of the CEIC 107: 1-27.
  28. Martínez R (2011) Inclusive social protection: A comprehensive look, a rights approach. Seminar, Argentine social protection in Latin American perspective: inclusion and integrity challenges.
  29. Cecchini S, Filgueira F, Martinez R, Rossel S (2015) Social protection instruments. Latin American roads towards universalization. New York: UN-ECLAC. 321.
  30. Rodríguez A (2009) New perspectives to understand business entrepreneurship. Thought and Management 26: 94-119.
  31. Yuangion Y (2011) The impact of strong ties on entrepreneurial intention. An empirical study based on the mediating role of self-efficacy. Journal Entrepreneurship 3: 147-158.
  32. Amujo O, Otubango O, Adeyinka B (2013) Business news configuration of stakeholders opinions and perceptions of corporate reputation of some business organizations. International Journal of Management and Strategie 6: 1-27.
  33. Ariza M (2002) Migration of family and transnationality in the context of globalization: some points of reflection. Mexican Journal of Sociology 64: 53-84.
  34. Trimano L, Emanuelli P (2012) Social representations and citizen practices in the rural community: A contribution from strategic communication. Latin Magazine of Social Communication. 67: 494-510.
  35. Ferreiro F (2013) Women and entrepreneurship: A special reference to business incubators in Galicia. RIPS 12: 81-101.
  36. García C, Bustos Jm, Carreón J, Hernández J (2017) Theoretical and conceptual frameworks around local development. Margin 85: 1-11.
  37. Sandoval FR, Carreón J, García C, Valdés O (2015) Formalization of dependency relationships between water and social variables for the management of sustainable local development. Kaleidoscope 2: 85-93.
  38. Anguiano M, Cruz R, García R (2013) International migration of return. Trajectories and labor reintegration of Veracruz migrants. Population Papers 19: 115-147.
  39. Barrón A (2013) Unemployment among agricultural day laborers, an emerging phenomenon. Development Problems Magazine 175: 55-79.
  40. Fuentes G, Ortiz L (2012) The Central American migrant passing through Mexico, a review of his social status from the perspective of human rights. Convergence 58: 157-182.
  41. Gavazzo N (2011) Actions and reactions: Forms of discrimination against Bolivian migrants in Buenos Aires. Journal of Social Sciences 24: 50-83.
  42. Granados J, Pizarro K (2013) Paso del Norte, how far you are staying. Implications of return migration to Mexico. Demographic and Urban Studies 28: 469-496.
  43. Izcarra S (2011) Migratory networks versus labor demand: the elements that shape the migratory processes. Convergence 57: 39-59.
  44. Martínez G (2014) Chiapas: social change, migration and life course. Revista Mexicana de Sociología 76: 347-382.
  45. Pérez M, Rivera M, Uribe I (2014) Migration from the perspective of employers of an agro-industry in the Altos de Jalisco, Mexico. Social Studies 43: 112-136.
  46. Sabino J (2014) Internal migration and size of locality in Mexico. Demographic and Urban Studies 29: 443-479.
  47. Wieviorka M (2007) Identities, globalization and inequality. Puebla: UIA.
fig 2

Talking about Menstruation: A Path to Strength Peers’ Commitment Fostering Health Literacy

DOI: 10.31038/AWHC.2022513

Abstract

A paradigm shift in education is currently happen, with a change in the core concepts and practices. There is no doubt that this global challenge of implementing multichannel education boosted the opportunity to acquire digital skills. The excessive use of technology showed a double-edged sword effect, it allowed us to continue working and communicating, especially since the pandemic’s onset, but on the other hand, social skills were weakened by digital isolation. No one knows who is not hidden behind a screen nor can access the body language, which is a valuable tool in the teaching-learning process.

Meanwhile, now that we are expectant and eager to return to normalcy, the growing lack of motivation and poor social interactions come across in the academic community. This evidence highlights how urgent it is to promote strategies to engage, support, and strengthen peer relationships.

The perception of this established emptiness in interpersonal relationships, lead on the great challenge that was to get across the menstruation topic, that cuts across all generations and ages, and is still a subject where there are many alternative conceptions, about which there is little opening to talk about. One academic forum was implemented to speak openly about taboos and overcome constraints, strategies such as games, critical questions, and challenges were presented to be solved with cooperative work, allowing connections between peers and developing their sense of belonging to the same community. Thirty-six health care university students strongly participated by sharing their time, talent, and expertise, making this forum an extremely enriching learning experience for all stakeholders. The results revealed that non-formal approach, not only increases literacy, but also breaks barriers and opens new possibilities for students to actively engage with peers.

Keywords

Menstruation forum, Collaborative learning, Non-formal activities, Peer commitment, Health literacy

Introduction

In a context of social isolation, not only as a consequence of the pandemic, but also due the increasingly growing dependency on technologies and social media, the dissemination of strategies that promote global health literacy should be a priority social responsibility of all educational institutions.

Based on the fact that the young European people are falling in trust, demonstrating a decline in community commitment, the insightful outcomes of non-formal educational methodologies have proven to be an increasingly useful tool for lifelong learning, collaborative work, team building, and project development.

In the European arena of academic education, a structured and conscious change in teaching and learning processes is on process [1,2]. More innovative and dynamic learning environments, linking education to robust formal and non-formal methodologies, are being applied in various contexts. However, for multifactorial reasons the student-centred learning, outlined by the Bologna process, remains under-developed and the promotion of active and meaningful learning is far away from reaching its full potential.

When some particular situation is able to disturb the whole world like what is still happening due to COVID-19 pandemic, world consciousness changes in all areas of society. Despite all negative impacts and changes to daily life, online teaching-learning processes during the lockdown period, undoubtedly accelerated digital skills acquisition and the development of online learning platforms’ potential. Not intending to set obstacles neither to minimize educational digital innovation, some major drawbacks in the on-line process were perceived, namely: it is not suitable for hands-on practical experience; self-motivation, essential time management, and informatics previous skills are needed; as well as the negative impact in the relationship between knowledge and social attitudes. It is unquestionably that face-to-face feedback is more personalized and that a cautious professor can more easily understand non-verbal signals indicating constraints or difficulties in the learning process. Finally, the social isolation undermined the sense of belonging that is crucial for a meaningful learning experience.

In agreement with the fact that the collaborative learning process is a widely recognised pedagogical practice that promotes socialization helping learners to capitalize on one another’s specific skills and gain relevant insights [3,4], this was the chosen strategy to implement our contents. There are several educational approaches that can be applied in order to build knowledge with collaboration, strengthening the social bounds, and mutual engagement in academic contexts [3,5,6]. All of them share the teamwork and can be a strong approach to be implemented in this period of returning to traditional classes, since they reinforce positive interdependence, individual and group accountability, interpersonal and social skills, and also the relevant feelings of belonging.

The positive effects of youth learning engagement are not restricted to changes in the academic environment and community. These young people will continue their journey outside the university campus passing on information, performing positive social changes and pinpointing gaps in society education. Considering that health literacy is often low, even among health care students, and that the menstruation topic is still a subject mainly analysed as a physiological event, not being naturally approached in all its scopes, we believe that a change of the mind-set about menstruation can have a significant impact on youth education/proactivity [7-11].

Being aware that it is necessary to build trust to overcome resistance to change, we share one experience in implementing a collaborative learning experience using the community forum model as a non-formal approach. The forum was designed to deepen menstruation issues, break down taboos and look into menstruation over the dominant preconcert and simultaneously strength and rescue the peer commitment between students.

Spreading reliable knowledge on a non-formal way with students from university health degrees, granted us confidence that health literacy will be improved in the context where people act. Nonetheless, more than contributing to promote health literacy, this paper intends to describe a forum that can be replicated as a methodology and strength the spirit of community.

Methodology

The organization of an academic forum involves a lot of previous work in contextualised planning, challenging, and sequential activities. The participants in this activity were 36 health courses students (future nurses, nutritionists, and physiotherapists), including 14 male and 22 female. These data were used to understand menstruation literacy in these two groups.

After gathering the expectations of the students, an ice breaker activity was used to start working on an unfamiliar environment and get all involved with the issue. In this specific forum the activity chosen was a network game, where alternative conceptions on the subject had emerged. The main steps to apply the network game were: (1) main words related with menstruation were written and placed inside envelopes; (2) participants were divided into groups. In each group, the spokesperson picked one envelope, read the word and everyone had to think about concepts associated with that main word; (3) the wool ball was launched from an element to another until all elements have contributed with a related idea; (4) the person holding the ball of wool began and so the construction of the web of words.

Three initial questions were distributed among students: one regarding biological knowledge, one about menstrual perception practices and another one regarding concern hygiene awareness. The anonymous answers were posted it on the wall.

The concepts inherent to menstruation were initially developed by the students that shared prior knowledge, describing, labelling and explaining some images that were presented. After a brain storming, the concepts consolidation guaranteed that all doubts were clarified.

As a team strengthening and engaging activity, the bowling bottle game was performed to deconstruct pre-existent myths. The bowling game was developed in three distinct steps: (1) each participant wrote a story of customs, a myth or taboo about menstruation and sticked it around one bottle, facing inwards; (2) the bottles were arranged as a bowling game and, one at a time, participants throwed a ball and overturn bottles; (3) the overturned sentence(s) were read and a scientific explanation, when it exists, was shared to clarify or deconstruct the social custom.

The acquisition and/or consolidation of knowledge was evaluated in a more classic way using a quiz, containing six questions regarding biological knowledge, four questions about menstrual perception practices and four questions concern hygiene awareness. The questions were adapted from the [8], and some of them were reformulated to accept closed answers as intended in a questionnaire applied on the kahoot platform.

The main findings of all forums were obtained by using a hand evaluation approach. Participants drew their hand on a piece of paper and recorded it in the drawing according to the scheme: thumb finger – to “point-out” something good, something they really enjoyed; index finger – to “highlight” something they would like to emphasize; middle finger – to “improve” something they did not like so much; ring finger – to “engage” with something they treasured from the activity/event; and in the little finger – to “others” little things they want to add.

Furthermore, the time for coffee break and socialization was very important since a non-formal environment was required. Although the methodology only strengthened the most relevant non formal tools, it was not on propose to minimize all the essential procedures for the implementation of the event. The Figure 1 details the timeline for all activities that were applied in this forum.

fig 1

Figure 1: Timeline diagram representing all moments of the academic forum

Results

The academic forum was applied to 36 undergraduate students from Atlântica Health School, Portugal. More than an innovative environment, the forum provided a more intimate learning experience. The students strongly participated and there was a generalized commitment with all the proposed activities in a relaxed environment, sharing and questioning emerging spontaneously in an explicit student’s complicity.

Getting into the forum results, the 36 students’ initial expectations were generally low, 35% of the students were more interested in curriculum enrichment, or even with little interest on the topic and 65% expressed the look for knowledge and curiosity about the strategy.

The rescue and students’ engagement started with the use of their assets in a non-formal ice breaker activity. The outstanding word cloud resulting from the network game (Figure 2), firmly helped participants to share their personal stories and built meaningful relationships through the topic.

fig 2

Figure 2: One example of a web of words obtained on the network game

Expanding the issue with collaborative work always boosts the team energy and motivation, and improve participants ability to problem solving. So, a vigorous collaboration among peers and professors was applied, to overcome the misconceptions surrounding the menstruation issue. The entire team worked in the bottle bowling game and, more than highlight that the empirical evidence about menstruation awareness still remain in Portuguese society, results revealed that their clarification go further when we work together.

The myth more citrated were associated with menstrual perception practices and hygiene awareness, for example: “walking barefoot make the menstrual cramps worse”; “can´t take a bath”, “during menstruation can´t was the hair, otherwise you get crazy” and “can´t bake because cakes don´t grow”. Other myths that may have some connection with the cultural legacy were: “can´t go to the cemetery” and “do not cook neither smell pork, it will spoil the meat”. Since some ideas came up several times, the number of repetitions was registered on the bottle cap as showed in Figure 3.

fig 3

Figure 3: Diagram of the bowling game represented the bottles with the sentences and the number of repetitions

Back to the wall, the anonymous answers to the three starting questions showed incoherent, disorganized answers, only revealing empirical knowledge with a lack of scientific support, and not suitable at all for students in the health area.

After experiencing this team learning approach, the global results of the Kahoot questionnaire revealed higher percentage of right answers in biological knowledge questions (91%), followed by menstrual perceptions (69%) and hygiene awareness (64%). Comparisons between males and females showed an overall female tendency for higher scores (Figure 4).

fig 4

Figure 4: Questionnaire percentage results organised by group of questions and sex

These results are in agreement with the final balance made for students who shared orally their difficulties in solving the questionnaire. Boys highlighted that their knowledge of the subject had improved considerably, that they never felt so comfortable talking about the topic and it was an excellent experience to be able to share the information with more experienced colleagues.

Despite this positive output, the forum success was only validated by comparison between the initial expectations of the students and the assessment about the forum that they performed at the end of the entire event (hand evaluation). This linked comparative analysis is represented in Figure 5.

fig 5

Figure 5: Expectations and evaluation of the academic forum process

The hand evaluation exercise showed that students really pointed out, highlighted and engaged with the non-formal methodologies. In the “point out finger”, knowledge and empowerment in general, and specifically environmentally friendly new hygiene products, obtained 55%. Non-formal activities, socialization and proximity obtained the remaining 45% of answers. The 39% of the “highlight finger” opinions revealed openness to talk and the contact with all menstrual hygiene products whilst 36% indicated non-formal and dynamism, and the last 25% myths and demystification. Nothing to declare got the majority of the statements from the “improve finger” (61%) and some students suggested that the subject deserves more time. The “engage finger” shared 50% with the non-formal approach, and 50% with the menstrual subject and ecological products. The “little finger” revealed opinions and adjectives that support carrying out more similar initiatives.

Figure 5 indicates the transformation of the initial expectations into the main findings obtained at the end of the event. The dynamic process represents the forum and reveals a significant change between the initial and final ideas and/or concepts of the students. The gaps and the initial curiosities resulted in very positive evaluations and one of the findings was the verbalization of a lasting commitment to the theme and method.

Conclusions

Despite clearly living in a time of great technological challenges, the exclusive application of education technology is not a magic solution for everything or for everyone.

The implemented actions aim to create tools that can be applied and used in different contexts, to reverse significant learning losses but also to implement new strategies to recover social emotional learning. Empower people, regardless of social and cultural background, fostering agents of well-being, in their local environment to promote positive social changes; it is a huge promotion of health literacy.

According to other studies that highlighted better learning achievements in university institutions through collaborative non-formal education, this focus on the student helps them to maintain a constant motivation and affection towards their study [12-14]. The analysed forum proved to be a strong tool for brainstorming matters important to public health that are outside the syllabus. Based on collaborative learning, students were cognitively, socially, and emotionally challenged to critical thinking. By talking freely about one of the oldest non issues, the menstruation, they acquired relevant insights and tacit knowledge, and strengthened all interpersonal relationships, allowing the build of constructive relationships, improving communication and trust.

The implementation of non-formal methods is not by itself a guarantee of success. The chosen activities and the timing of their application were key to promote the participation and engagement of the students, one of the most important criteria for successful dynamics. Doubtless, brainstorming around the several inaccurate biased ideas was the moment when the contribution, building of awareness, learning, and transference of knowledge fulfilled most participants, confirming that we become stronger when working together sharing ideas and knowledge. By getting into reflection teamwork maximized the available potential to achieve the needed results and, therefore, contributed more effectively towards a successful outcome.

Nonetheless, despite all the efforts expended previously, the reward finally came when all the evaluation processes applied, such as observation of body language, formal responses to questionnaires, and evaluation of the entire forum were very positive and encouraging. Feedback opinions such as “great and amazing engagement with non-formal methodologies” showed that it was possible to overcome all participants’ expectations and allowed the validation of the total event.

The forum validation was fundamental to add value on the research consolidation and to support a continuous improvement. To rescue students’ commitment, all academic community need training and additional support on a set of tools, not only to assess the learning levels of their students, but also to rescue their social emotional learning skills.

Community should be prepared to change their mind-set, taking the challenge of non-formal methods and embrace engaging activities. All in all, the initial low expectations of the menstruation forum were transformed in very positive outputs.

Empower people with knowledge to recognize the influence of their emotions on their attitudes, grant that they bring home a message about emotional literacy. As a consequence, not only a better self-awareness is expected, but also the improvement of the relationship and structure of the community, where our youth and young adults belong.

References

  1. EHEA – European Higher Education Area (2015) Widening participation for equity and growth: A strategy for the development of the social dimension and lifelong learning in the European Higher Education Area to 2020.
  2. EHEA – European Higher Education Area (2020) Bologna Process Implementation Report.
  3. Le JJ, Wubbels T (2018) Collaborative learning practices: teacher and student perceived obstacles to effective student collaboration. Cambridge Journal of Education 48: 103-122.
  4. Kromydas T (2017) Rethinking higher education and its relationship with social inequalities: past knowledge, present state and future potential. Palgrave Commun 3.
  5. Millis BJ (2010) Why faculty should adopt cooperative learning approaches. In: Millis BJV, Sterling V (eds.) Cooperative learning in higher education-across the disciplines, across the academy (pp. 1-11). Stylus Publishing.
  6. Scager K, J Boonstra, T Peeters, J Vulperhorst, F Wiegant (2017) Collaborative Learning in Higher Education: Evoking Positive Interdependence. CBE-Life Sciences Education 15: 1-9.
  7. Eschler J, A Menking, S Fox, U Backonja (2019) Defining Menstrual Literacy With the Aim of Evaluating Mobile Menstrual Tracking Applications. CIN: Computers, Informatics, Nursing 37: 638-646.
  8. Pires AM, AC Sousa (2020) Girls experience of menstruation: One Portuguese reality. Case Report Review Open Access 1: 118.
  9. PEN-Period Empowerment Network Project (2020) Period Empowerment Handbook: Re-educating society about menstruation through youth work. Terram Pacis Editorial TPOER-012-PEH/25-MAY-20.
  10. Sousa AC, AM Pires (2020) Opinion: Menstruation One of the Oldest Non-Issues. Womens Health Science Journal 4: 000148.
  11. Armour M, K Parry, C Curry, T Ferfolja, M Parker, et al (2021) Using an online intervention to improve menstrual health literacy and self-management in young women: a pilot study.
  12. Grajcevci A, Shala A (2016) Formal and Non-Formal Education in the New Era. Action Researcher in Education 7: 119-130.
  13. Rocca C, La M, Margottini, R Capobianco (2014) Collaborative Learning in Higher Education. Open Journal of Social Sciences 2: 61-66.
  14. Walsh L, Kahn P (2009) Collaborative Working in Higher Education. The Social Academy.
fig 4

Mind Genomics Cartographies of Everyday Anxiety Producers

DOI: 10.31038/ASMHS.2022622

Abstract

In 15 parallel studies dealing sources of anxiety, public and private, separate groups of approximately 120 respondents each evaluated different combinations (vignettes) of messages about anxiety -provoking situations. The vignettes presented the nature of the situation, the effect on people, the effort to contain the problem, and the individual’s response to the situation. Each respondent evaluated 60 unique combinations of these vignettes, rating each vignette on a 9-point scale (1=Can deal with it.9= Cannot deal with it.) Data suggest that the basic level of anxiety is approximately the same across the 15 sources of anxiety, but that the elements, the messages dramatically differ in their respective abilities to drive or to reduce anxiety. Surprising, many of the so-called efforts to deal with the anxiety, especially from the sources outside one’s family (e.g., government, local hospitals, etc.) increased anxiety, rather than diminishing it. The database (Deal with It!) shows the contribution to insights and to the social record from databases of studies of social situations, created in a systematic manner according to experimental design of ideas (Mind Genomics.)

Introduction

Anxiety is a leitmotif of our times, with a popular and an academic, as well as an artistic literature virtually unfathomable. A sense of the vastness of our concern may be given by today’s arbiter of social internet, Google, which counts the number of available websites dealing with a topic. Table 1 presents Google Scholar hits for different topics dealing with anxiety. The table is sorted by number of hits. These topics constitute the 15 assessed in the Deal With It! set of Mind Genomics cartographies.

Table 1: Google Scholar hits for the topic coupled with ‘anxiety’. Data up to2003

 

 Topic

Hits as of 2003

1 Relationships

 1,130,000

2 Environment

 954,000

3 Social Interactions

 413,000

4 War

 372,000

5 Sexual Failure

145,000

6 Lose Health

 116,000

7 Aging

111,000

8 Failure of Health Care

 109,000

9 Lose Income

 57,700

10 Obesity

 56,300

11 Infectious Disease

 40,500

12 Phobias

 26,800

13 Terrorism

 20,900

14 Franken Food (Genetically modified)

 18,800

15 Lose Assets

 18,000

Anxiety pervades our life. It is the bread and butter of psychologists and others in the helping professions.. It is the topic of numerous self-help websites. And it is something familiar to many of us. Anxiety comes in such variety that the sheer vastness of the topic suffices to make one anxious, just dealing with that unwieldly richness.

This paper deals with anxiety as a situation presented in text form to a respondent, instructed to rate the degree that she or he can ‘deal’ with the situation or cannot deal with the specific described situation. We avoid the general topic of ‘anxiety’ and present the topic as something with which a person can deal. That is, we make the situation somewhat concrete by particularizing the events.

The origin of these studies emerged from consumer research promoted at first by an ingredients company, McCormick & Company, in 2001, but with a focus on food, not anxiety. That early focus led to a set of 30 parallel studies in what makes people really desire a food, called naturally ‘Crave It!’ [1,2]. The success of Crave It! quickly led to several other series of so-called It! studies, focusing first on food, then on beverages, on good-for-you foods, and finally and snack foods.

The early focus on foods also sparked focus on the approach to study situations. The major study to emerge was the use of this It! approach to study the responses to anxiety provoking situations. Rather than dealing with topics that were positive, the effort was focused on understanding how the different aspects of an anxiety-producing situation drive the response of ‘Can deal with it (rating = 1).to. Cannot deal with it (rating = 9)’. This paper presents an extensive analysis of those data.

Since the early research in 2003, Mind Genomics has been applied to anxiety-relevant situations,, such as the anxiety of teens in a doctor’s office [3]; anxiety in social situations [4], anxiety about the toxicity of house plans [5], and anxiety in the midst of a crisis in the pharmaceutical industry [6] The hallmark of these studies is the disciplined deconstruction of the issues into messages, their recombination by experimental design, the analysis of the new combinations, and the emergence of insight data about how people make decisions using the information provided [7,8].

Combining Mind Genomics with Anxiety – A Step by Step Development of the It! Cartography

The easiest way to understand what Mind Genomics may contribute to the study of anxiety is through an experiment, or in this case 15 experiments, run simultaneously, with similar patterns of elements, and similar patterns of analysis [4]. We call these experiments ‘cartographies’ because they ‘map out a terrain’ rather than focus on affirming or falsifying a hypothesis in the tradition of the more typical hypothetico-deductive approach to science. That is, we search for patterns, for regularities, upon which hypotheses can be developed. In sum, Mind Genomics as we see below is ‘hypothesis-generating.’

Step 1 – Create the Raw Material

The basic input for the Mind Genomics study is a topic, followed by a set of questions presenting different aspects of that topic and ‘telling a story’, and finally each question giving a set of answers which provide specific information. These answers take the form of a stand-alone phrases. Later the actual test stimuli will comprise vignettes, combinations of these answers (but never the questions.) It is vital that the answers, the elements, be able to stand alone, and make sense.

Figure 1 presents the 15 studies. The viewpoint of an It! project or even a single Mind Genomics cartography that there may be important things in a topic, the precision of learning will not be increased by repeating the same experiment many times, producing precision. It is better to cover many different topics, even if the coverage is more error prone because the resources are more fruitfully expended studying different topics, not the same topic with more people.

fig 1

Figure 1: The 15 studies, shown by the 15 topics. The figure shows the ‘wall of choice.’ Respondents could see the available studies, choose one, and do the corresponding Mind Genomics study

Table 1 presents the three of the studies (Terrorism, Infectious Disease, Obesity). Table 1 shows the four questions, nine answers for each question, language and topic attempting to be parallel across the 15 studies. It was impossible to make the elements exactly parallel, since it was also vital to have the elements seem real and relevant.

Across the 15 studies and 36 elements per study, there were 540 elements. The 36 elements for a study were divided into the four questions. Within each question the types of elements were to be similar to each other across studies, although often this requirement some editing and wordsmanship to make the element both match the anxiety provoking situation, but be similar in form to the other elements of this type across the remaining 14 studies. Table 2 gives a sense of the 36 elements created for three parallel studies; terrorism, Infectious disease, and obesity, respectively

Table 2: Example of elements for three parallel studies; terrorism, infectious disease, and obesity

 

 Terrorism

 Infectious disease

Obesity

  Question 1: What is happening?
A1 The media talking about potential terrorism acts… The media talking about diseases that are spread by human contact or by the air… The media talking about the increase in obesity…
A2 A bomb threat for a building that is a false alarm… You have a dry cough and don’t feel so good… You’ve added a few pounds…
A3 A bomb under your car… You are getting a fever and don’t feel so good… You’ve added a lot of extra weight….
A4 Bombs blowing up in the middle of a building… You have some red bumps on your skin and don’t feel so good… You can’t take the weight off…
A5 Fire raging through a building… Your feel really run down… You can lose it….but you just can’t keep the weight off…
A6 Contamination of the food supply… You have been on an airplane that just came from some place that has some known infectious diseases People look at your body and judge you…
A7 A deadly disease like smallpox or anthrax let loose…. You have to travel to a place that has some known infectious diseases You just can’t control the eating…
A8 A Computer virus let loose that impacts your everyday businesses… You know the disease has arrived in your country You eat right, exercise, and still can’t keep the weight off…
A9 A dirty nuclear bomb set off … You have to touch people that you know have some infectious disease You are uncomfortable because of your weight doing what everyone does naturally…
Question 2: Who is affected?
B1 In a non-populated area… No one you know is affected… You tell no one how you are affected…
B2 In a heavily populated area… People you work with OR will be working with are affected… People you work with are affected by your size…
B3 An area crowded with children… Children are affected… Your children are affected by your size…
B4 An area crowded with senior citizens… Senior citizens are affected… Your parents are affected by your size…
B5 An area filled with tourists… Tourists are affected… Strangers are affected by your size
B6 When you least expect it… You never expected it to happen to you or someone close to you…. You never expected it to happen to you or someone close to you….
B7 During a Yellow alert… People are getting sick in the location you have to travel to… People around you are embarrassed…
B8 During an Orange alert… Your health office warns you not to travel to this location… People around you are so judgmental…
B9 During a Red alert… The area you are traveling to is going to be or is quarantined People around you don’t see you for who you are…
Question 3: How do you react?
C1 You are all alone… and you feel helpless… You think about it when you are all alone…and you feel so helpless You think about it when you are all alone…and you feel so helpless
C2 You think about it, you just can’t stop thinking about it… and you feel uneasy…. When you think about it, you just can’t stop…. When you think about it, you just can’t stop….
C3 You’d drive any distance to get away from it… You’d drive any distance to get away from it… You’d drive any distance to get away from it…
C4 You are scared … inside and out You are scared … inside and out You are scared … inside and out
C5 You experience it all … seeing, smelling, tasting You experience it in all your senses… You experience it in all your senses…
C6 All the stress just builds up… you feel overwhelmed All the stress just builds up… you feel overwhelmed All the stress just builds up… you feel overwhelmed
C7 You experience temporary memory loss because there’s just too much to take in…. You experience temporary memory loss because there’s just too much to take in…. You experience temporary memory loss because there’s just too much to take in….
C8 While surrounded by family and friends…. Family and Friends play a big role in your life… Family and Friends play a big role in your life…
C9 At a special moment… in your life At a turning point in your life…. At a turning point in your life….
Question 4: Who or what can help ?
D1 You trust that God will keep you safe You trust your God will help you get through this You trust your God will help you get through this
D2 You believe that international cooperation in the United Nations will keep you safe You believe Charities will help you get through this You believe your doctor will help you get through this
D3 You think United Nations Forces will keep you safe You believe whatever insurance you have will help you get through this You believe talking to a therapist will help you get through this
D4 You believe that Homeland Defense will keep you safe You trust that the government and the airports will stop this from entering your country You believe talking to diet counselor will help you get through this
D5 You believe that the Center for Disease Control will keep you safe You believe your Local Hospital will get you through this You believe a plastic surgeon will help you get through this
D6 You think that your Local police will keep you safe You trust your doctor will get you through this You believe that the food industry will work to help you find the right foods to eat
D7 You think that your Local hospital will keep you safe You believe your company will help you get through this You believe work will help you get through this
D8 It’s important for the Media will keep you informed It’s important for the Media to keep you informed It’s important for the Media to keep you informed
D9 You need to contact your friends and family to make sure they are OK… Your family and friends will help get you through this… Your family and friends will help until you get through this…

Step 2: Create Vignettes according to an Experimental Design

The heart of Mind Genomics is the use of combinations of stimuli, these combinations indicated by the underlying design. The design itself is simply a shell, ensuring that the elements are statistically independent of each other (allowing for OLS, ordinary east squares regression), and that the elements are laid out in such a way that each element appears equally often, and is absent an equal number of times from the full set of vignettes.

With the 4×9 design, the most popular during the early years, 2000-2006, a total of 60 combinations, called hence vignettes, comprised at most one element from a question, but quite often one or two of the questions was deliberated not allowed to contribute an element. The benefit of the design is that is can be automatically populated simply by a replacement table. The researcher need not have to think about the statistically issues. Figure 2 shows an example of a vignette comprising four elements. By design some vignettes comprised four elements (one answer from each question), other vignettes comprised three elements (one of the for questions did not contribute an element), and still other vignettes comprised two elements (two of the four questions did not contribute an element.) Each element appeared equally often.

fig 2

Figure 2: Example of a four-element vignette for Terrorism

Each respondent evaluated a unique set of vignettes. The uniqueness was established by a permutation scheme which kept the mathematical structure intact but simply permuted the elements. This produces 60 unique combinations for each respondent. The experimental designed was prescribed by a permutation approach [8,9], and automatically embedded in the technology.

The rationale for the incomplete experimental design is the downstream ability to perform an OLS (ordinary least squares) regression analysis on the data of each individual respondent. This is known as a within-subjects design. Were there even as few as one respondent, it would still be possible to create a model showing the number of rating points that could be attributed to each of the 36 elements. That property of individual-level modeling will become important for clustering the data together to create mind-sets, an important aspect of Mind Genomics

Figure 2 presents a sample vignette that the respondent was shown. The vignette is simple, comprising simply the elements prescribed by the underlying experimental design, these elements simply placed there without any effort to connect that. The rating scale appears at the bottom. Although many marketing professionals prefer to test concepts which are full, more polished, with better production value, the reality is that the focus is on the respondent’s evaluation of the different vignettes, and the discovery regarding which specific elements drive the response. It is counterproductive, in fact, to make the vignette ore dense, more connected. The respondent ends up wading through additional ‘stuff’ to get to the information. It is the information, not the connectives, which are importance, and as a consequence, the spare structure shown in Figure 2 is ideal. The respondent does not get fatigued.

Step 3: Acquire Respondents

The respondents were invited to participate by an online-panel provider, Open Venue LTD, headquartered in Toronto, but providing respondents in both Canada and the United States. The respondent was invited to the general study by Open Venue Ltd. The respondents who participated was led to the ‘wall of available studies.’ Studies whose quotas were filled (approximately 120 completed respondents) ‘disappeared’ from the wall, so only the available studies with incomplete quotas appear for the choice.

The respondent was allowed to pick any study. Once the respondent selected the study, the respondent was led to the appropriate website. The first slide was the orientation slide (Figure 3). The orientation slide provides very little information about the study. Rather, the slide describes the topic by a few words, moves into the rating scale, and states that all the vignettes differ from each other. This last statement, viz., no repeat vignettes, emerged from exit interviews, where respondents said that they felt they were evaluating the same vignettes The reality is that the respondents were evaluating the same elements, but different combinations of the elements.

fig 3

Figure 3: The orientation page at the start of each of the 15 Deal With It! studies. The only thing which changed from study to study is the name of the topic (Welcome to the Deal With It! Terrorism Study)

It is worth noting that the majority of Mind Genomics studies conducted during the past 25 years have been studies in which a third party, e.g., Open Venue Ltd., has used its panel. Respondents do not like to spend 10 minutes of their time unless they feel that their efforts are valuable, or unless there is a reciprocal arrangement of give/receive on both ends. The number of completes for a compensated study, here about 33%, is far greater than the number of completes were these studies to rely upon the donated time of respondents without compensation. No matter how interesting or exciting the study, most respondents really want ‘something’ in the way of compensation.

Step 4: Surface Analysis – How Many Respondents Participated vs. How Many Dropped Out?

The objective in this Mind Genomics It! study was to recruit approximately 120 respondents for each of the 15 studies, or approximately 1800 respondents. Figure 1 shows the ‘wall’. The respondent who participates could choose any of the studies available on the ‘wall.’ Without an artificial limitation, there would have been a preponderance of respondents choosing sexual failure, aging and war. To ensure an approximately equal number of respondents for each study, once the study reached about 120-125 completed respondents, the choice of the study disappeared. This strategy ensure the base sizes.

As part of the overall effort to balance the base size, the studies were launched at the same time, and the number of log-ins, as the number of completes were recorded on a daily basis for the first few days, and then done again after a three day hiatus. The rate of log-ins gives a sense of the interest in the topic. Figure 4 shows the cumulative number of log-ins over a two week period.

fig 4

Figure 4: Cumulative log-ins for each study over a two week period. (No study exceed 125 respondents after successful log-in)

The key information in Figure 4 comes from the shape of the curve, and the number of log-ins need to reach the target quota of 120 respondents. The patterns can be deconstructed as follows:

a. Steep at first – lots of respondents are interested. Most of the topics are like that. Examples are Relationships and Phobias

b. Less steep at first – not as many respondents immediately interested. The best example is aging.

c. Concave downwards – the curve goes up, flattens into an asymptote. The study starts off strong but then fewer respondents are interested at the end. Example are Environment, Obesity

d. Linear all the way – the curve keeps going up in a straight line. The level of interest is the same from start to finish Examples are is Relationships and Aging.

e. Level at day 15 is low. The number of logins to reach quota is smaller. People are interested in the topic. The best example is Lose Income.

f. Level at day 15 is high. The number of logins to reach quota is higher. Many more people ‘drop out of the experiment along the way, so they are not counted as part of the quota. Good examples are Relationship and Aging

The second surface analysis is to understand who participated. Knowing WHO the respondent is for many studies helps only when one wants to identify the specifics of the target population either because the study is most pertinent to them now or because there may emerge a strong linkage between the results of the study and the particular applicability of those results to a self-defined group. Thus, respondents were instructed to provide information about their interests and lifestyle, as well as on their previous behaviors. This information should make the study more relevant as a source of information about what concerns people.

When we deal with 15 different studies, these studies dealing with different causes of anxiety and frustration, the patterns of who participated across the 15 studies interesting, even if there is no practical application as yet. Furthermore, the pattern of participation becomes even more interesting when one realizes that the respondents were free to select the study which interested them. After the respondent finished evaluating the test vignettes, the respondent completed a self-profiling questionnaire, telling the researcher about themself. The questionnaire instructs the respondent to self-classify in terms of gender, age, income, location where living, how severe is their experience with the anxiety, how frequently they experience the situation, the location, the ways they use to cope with the anxiety, and so forth.

Table 4 shows a reduced form, with the 15 topics as the data columns, the rows showing a few of the self-profiling questions answer by the respondent. We do not look at many classification levels, simply because the vast amount of data would simply overwhelm. Table 4 shows by shaded cells the most frequent anxiety situation for each of the classification questions. It is clear from Table that respondents have varying degrees of interest in the topic. The data do not suggest randomness. Rather, the frequency of choice of a topic may indirectly reflect the basic interest in the topic. The clearest evidence of that is the is the comparison of two topics situated next to each other in Table 4. The data speak for themselves. These are aging and sexual failure, respectively, with 123 and 124 respondents, respectively.

Age 31-50 Aging chosen by 38 respondents, sexual failure by 64 respondents

Age 51-7 4 Aging chosen by 81 respondents, sexual failure by 41 respondents

(other ages not shown in Table 3)

Table 3: The composition of respondents who participated in the 15 Deal With It! studies. The columns show the studies. The rows show a partial breakout of the subgroups, defined both how he the respondent experiences the anxiety, and who the respondent is from a geo-demographic viewpoint

table 3(1)

table 3(2)

Step 5: Relating the Elements to the Ratings Using Regression Modeling

The essence of Mind Genomics is the ability to relate the presence/absence of the elements to the response, using regression analysis. The fact that the combination were systematically created means that we can actually measure the degree of ‘causation’, viz., that the presence of a specific element actually covaries in a specific way with the rating.

The first step when we relate the elements to the ratings is to decide whether the ratings need to be ‘transformed.’ For most basic science it is entirely adequate to work with the original rating scales, and apply statistical procedures to the ratings. When we deal with the world of application, however, we face a problem. The problem is simple, and is stated something like the following: ‘What does a 7.08 mean?’ Is a 7.08 good or bad? What should i do with that rating of 7.08? The foregoing question uses the value of 7.08 just as an example.

Fortunately, the issue of ‘what does a scale point mean’ is not a new one. The consumer researchers often have opted for yes/no scales, and have converted the rating scale to a binary scale. Thus, in conventional consumer research the respondent might be instructed to rate ‘purchase intent’ on a five point scale, ranging from 1=definitely not buy 5=definitely buy. Rather than working with the actual rating assigned by the respondent, the consumer researcher may transform the rating to a more easily understand binary scale. The typical consumer researcher will transform the ratings 1, 2, and 3 to 0, and the ratings 4 and 5 to 100, respectively. The thus data which had started out as a simple scale (often called a category scale or a Likert scale) becomes a binary scale (not buy/buy.)

The foregoing analysis was done for these data. The respondents used a 9-point scale. The transformation was ratings 1-6 → 0, and ratings 7 → 100, respectively. As a prophylactic measure prior to regression, a vanishingly small random number (<10-5) was added to each transformed rating. The rationale was to ensure that the regression analysis would work even when a respondent assigned all vignettes a rating of 1-6 (which would transform to 0) or a rating of 7-9 (which would transform to 100.) The regression analysis requires a vanishingly small bit of variability in the dependent variable, the transformed ratings.

After the ratings were transformed, the Mind Genomics program separately estimated the following equation for each respondent: Transformed Rating (Binary) = k0 + k1(A1) + k2(A2). k36(D9.) The analysis was straightforward for the simple reason that the 60 vignettes evaluated by each respondent constituted a self-standing experimental design. That is, the data are ‘readable’ down to a base size of one respondent. One would never base the conclusion on one respondent so the approach is either to average the corresponding coefficients from the models of all respondents OR put in all the respondents from a single group into one analysis.

The equation provides a useful summary of the patterns in the data. We can think of the equation as showing the contributions of the different elements to the binary response of either I can’t deal with this (ratings 7-9, now converted to 100), or the binary response of I can deal with this, or may/may not be able to deal with this (ratings 1-6.)

As an analogy, think of a statue standing on its base. The base is the additive constant. The base can be low (low additive constant), or high, or very high (very high additive constant.) Following the base are the different parts of the statue that can be placed atop one another. The parts can be small (low positive coefficients) and can even take away some of the base and thus reduce the height (negative coefficients.) Or the parts can be large (high coefficients), or can even take away a lot of the base (high negative coefficients.)

The analogy of the statue goes one step further, namely the height can be calculated by adding together the additive constant (the base), and the coefficients of up to four elements, as long as the elements come from different questions. The elements can either add to the height (positive coefficients) or diminish the height (negative coefficients.)

Step 5: The Strongest Anxiety-producing Situations as shown by the Additive Constant

The additive constant provides a measure of basic likelihood to say, ‘I can’t deal with it’ (viz., ratings 7-9) in the absence of elements. The underlying 4×9 experiment design ensured that every vignette was populated by a minimum of two elements, a maximum of four elements, and that each of the four questions could contribute at most one element. The additive constant ends up being a purely estimated parameter, one useful to estimate the likely response to the (presumed) anxiety-provoking situation.

Previous studies with Mind Genomics suggest very low additive constants for items or services which do not excite interest. Examples include credit cards, whose additive constants hover around 10-20. To build interest in the credit card is hard. The offeror will have to discover elements which have high coefficients, elements to be added to the offering. In contrast, there are items which enjoy high additive constants, such as pizza, with an additive constant around 65-70. That means that in the absence of any elements, and just knowing the offering of pizza, around 65-70% of the responses will be positive. Returning to th example of th credit card, only 10% of the responses will be positive when the respondent knows the offering is a credit card. Again, other elements have to add to the offering.

Table 4 shows the 15 additive constants, one for each topic. The columns show the 15 studies. The rows show the key groups beginning with total panel, then genders, and then ages. There were other classification groups, but in the interest of clarity, only these are presented.

Table 4: The additive constants for the total panel and for key subgroups. Additive constants of 30 or higher are highlighted

table 4

To allow the patterns to emerge more clearly, all the additive constants of value 30 or higher are shown in shaded form. These are the anxiety provoking situations which, in theory, would generate at least 30% ratings of 7-9 (cannot deal with it), in the absence of elements.

The pattern of anxiety-provoking situations is clear from the additive constant. The big effects occur most strongly with ‘Lose Income.’ Then there are five more, ranging from obesity to relationships which are quite strong. The lowest level is occupied by Franken Foods (viz., non GMO), War, and Terrorism. Keep in mind that this study was run in 2003, after 9/11. Yet there is no free floating anxiety operative for terrorism as there is for losing one’s income, obesity, and sexual failure, three events or conditions which are real.

The ‘Deal with It!’ studies were open to everyone. The period around 2003 would see studies filling up into the hundreds of respondents. Surprisingly, however, The Deal with It study filled up very slowly, with most of the respondent being women, typically around three out of every four respondents. Nonetheless with the within-subjects design, even the 30 or so male respondents provide statistically stable data. That stability allows us to compare males and females. Females are anxious at a basic level about losing income, and losing assets respectively These are the important gender differences, viz., high additive constant, and large difference between the genders.

Step 6: The Elements Which Provoke the Strongest Anxiety Responses, and the Elements Which Provoke the Smallest Anxiety Response

The set of 15 studies provides 540 elements, each with a coefficient from the total panel showing the degree to which the element drives a rating of 7-9, viz., i cannot deal with what is being presented. Fortunately, the additive constants are similar to each other, and need not be considered. Recall that the additive constant is the predisposition for a respondent to feel anxiety (rate 7-9) in the absence of elements. Since the additive constants are reasonably close to each other (Table 4), we can feel comfortable looking at the magnitudes of the coefficients.

Table 5 shows the elements which provoke the great amounts of anxiety, namely elements with coefficients of +10 or higher for the total panel. Of the seven great anxiety-provoking elements, surprising three of these end up being statements about who will help you get through this (viz., loss of health being helped by charities and one’s company; the United Nations will keep us safe from terrorism.) There is no clear pattern for these severe anxiety-provoking elements, other than they are impersonal symbols of authority.

Table 5: Elements which reduce anxiety

Elements which reduce anxiety (Bigger negative = More Anxiety Reducing)

Study

Element

Coeff

Relationships Your family and friends will help until you get through this…

-12

Relationships You trust your God will help you get through this

-12

Lose your income You trust your God will help you find new income

-12

Lose your health You trust your God will help you get through this

-10

Lose assets You trust your God will help you get through this

-10

Social interactions You trust your God will help you get through this

-10

Relationships Family and Friends play a big role in your life…

-8

Aging Your family and friends will help get you through this…

-8

Sex failure You believe passage of time will help you get through this

-8

Lose your assets You trust your God will help you get through this

-8

War It’s important for the Media to keep you informed

-7

Lose your assets People you work with are affected by this situation…

-7

Aging You trust your God will help you get through this

-7

Obesity Your family and friends will help until you get through this…

-7

Lose your health Family and Friends play a big role in your life….

-7

Sex failure No one you know is affected by this situation…

-7

Obesity Family and Friends play a big role in your life…

-7

Lose your assets Family and Friends play a big role in your life…

-7

The second tier of elements, coefficients between 11 and 20, comprise mostly solutions. It is surprising that the presumed help to reduce anxiety instead ends up provoking anxiety (Table 4a).

Table 4a: Strongest anxiety-producing elements

Study

Elements which very strongly drive anxiety

Coeff

Lose Assets You lose your home….

25

Lose Health You believe Charities will help you get through this

25

Lose Health You believe your company will help you get through this

22

Terrorism A bomb under your car…

21

Aging Living in an old age home….

20

Terrorism A dirty nuclear bomb set off …

20

Terrorism You believe that international cooperation in the United Nations will keep you safe

20

Elements which strongly drive anxiety
Aging You believe your plastic surgeon you have will help you get through this

19

Terrorism You think United Nations Forces will keep you safe

19

Relationships You believe dating services will help you get through this

18

Aging You believe Charities will help you get through this

17

Environment You trust that the Local government will keep the earth and you safe

17

Failure of Health Care You believe Charities will help you get through this

17

Relationships You believe talking to a lawyer or the courts will help you get through this

17

Sexual Failure You were raped….

17

Environment You trust that the Environmental Protection Agency will keep the earth and you safe

16

Environment You believe that the Businesses impacted will work to keep the earth and you safe

16

environment A radioactive plume of dust over you….

16

Lose Health You believe whatever Supplemental insurance you have will help you get through this

16

War A dirty nuclear bomb set off…

16

Environment You trust that the government will keep the earth and you safe

15

Income Loss You believe your insurance will help you find new income

15

Infectious Disease You believe Charities will help you get through this

15

Lose Assets You believe Charities will help you get through this

15

Lose Health Your doctor says you don’t have long to live…

15

Sexual Failure You believe dating services will help you get through this

15

Social Interactions You believe taking the right drugs will help you get through this

15

Social Interactions You believe Food or Drink will help you get through this

15

Terrorism Bombs blowing up in the middle of a building…

15

Aging You believe your company will help you get through this

14

Environment

You believe that international cooperation will keep the earth and you safe

14

Infectious Disease You believe your company will help you get through this

14

Failure of Health Care You believe your company will help you get through this

14

Terrorism A deadly disease like smallpox or anthrax let loose….

14

Infectious Disease You believe whatever insurance you have will help you get through this

13

Lose Health Losing control of your bodily functions….

13

Infectious Disease You trust that the government and the airports will stop this from entering your country in a big way

12

Failure of Health Care The medical procedures you need are not covered by your insurance….

12

Lose Health Your body eating itself away from within….

12

Lose Health You believe whatever insurance you have will help you get through this

12

Relationships You believe Food or Drink will help you get through this

12

Relationships You believe Charities will help you get through this

12

Social Interactions You believe Charities will help you get through this

12

Terrorism You believe that the Center for Disease Control will keep you safe

12

Income Loss You trust the government will help you find new income

11

Income Loss You lose your job because you have done something wrong…

11

Failure of Health Care You believe your Local Hospital will get you through this

11

Lose Assets You believe Local government services will help you get through this

11

Obesity You believe that the food industry will work to help you find the right foods to eat

11

Phobias You’re afraid of speaking in public….and you must give a very important speech for your company to an audience of thousands….

11

Phobias You’re afraid of spiders crawling near you…. and you have to reach in a dark musty space….

11

Environment You believe that Greenpeace will keep the earth and you safe

10

Frankenfoods You trust the government will keep the earth and you safe

10

Infectious Disease You have to touch people that you know have some infectious disease….

10

Failure of Health Care You believe whatever Supplemental insurance you have will help you get through this

10

Lose Assets You lose your pension…

10

Lose Assets You lose your car…

10

Lose Health You believe your Local Hospital will get you through this

10

Social Interactions Afraid to go out of the house….

10

Terrorism Contamination of the food supply…

10

Terrorism You believe that Homeland Defense will keep you safe

10

The Deal With It! studies were designed with ‘helping or ameliorating’ elements expected to score low on the 9-point scale, and thus expected to generate low coefficients, presumably negative one in the regression model (after binary transformation.) A negative coefficient tells us the degree to which adding the element to the vignette is expected to reduce the rating, below 7-9 anywhere to 1-6. We focus here on the elements with high negative coefficients, elements expected to drive the ratings down to around 1-3.

Table 5 shows those elements generating coefficients of -12 to -7. There are far fewer elements which reduce the rating of anxiety (viz., which move the rating from 7-9.) God and family and friends are the key elements which reduce anxiety. The other efforts, bringing in government, companies, etc., not only did not reduce anxiety, but rather increased anxiety, as Table 4 shows.

Step 7 – Most Seemingly Reasonable Solutions End Up Backfiring

One of the ingoing theses of the Deal With It! study is that the solutions selected would be effective, maybe perhaps strongly effective at times, weakly effective at others. The presumption was that those respondents suffering most severely would generate the biggest negative coefficients. Towards this end, the next analysis considered only those respondents who self-reported that they perceive themselves to suffer from the problem, and furthermore, rated their suffering extremely high (viz., 5 on a 5 point scale.) For these respondents we then looked at the performance of all elements which presented ‘solutions,’ or at least potential solutions.

Table 6 shows the coefficients for the elements. The only elements which appear in Table 6 are those which score strongly either in ability to decrease anxiety (high negative coefficients, -10 or lower), or on their ability to increase anxiety (high positive coefficients, +10 or higher.)

Table 6: Strong performing elements either reducing anxiety (negative coefficients +10.) The elements in the table are chosen from presume ‘solutions to the problem dealt with in the particular study.’ The table is sorted by the coefficients of those who say they ‘suffer extremely’ from the topic of the individual study

table 6(1)

table 6(2)

Table 6 surprised, because very few of the elements thought to be solutions to the problem are perceived as solutions. Rather, most of them are perceived as increasing anxiety, rather than decreasing anxiety. That is, the solutions are perceived as problems, not solutions. The only real solution appears to be God, which will be dealt with in the last analysis.

Step 8: In God We Trust

This analysis was occasioned by the observation that across the 10 studies where God was mentioned, most of them featured God as a believable reducer of anxiety, viz., someone or something which can help people ‘Deal With It’. Table 7 shows that in most of the studies and among the three groups (total, sufferer, extreme sufferer), the statement about God reduces the anxiety. The coefficients are mostly negative, many of them strongly negative, with values -10 or lower. These results suggest that at least as of 2003, Americans may have been become more secular, but God was still a comforting thought and presence to them across many of the topic issues causing anxiety.

Table 7: Coefficients for elements mentioning God, reported for Total Panel, for those self-reporting that they suffer anxiety regarding the study topic, or suffer extreme anxiety regarding the topic study

table 7

Step 9 – Uncovering Mind-sets based upon Anxiety-provoking Elements

A hallmark of the Mind Genomics approach is the hypothesis that people differ from each other in their responses to the various situations and ‘things’ in their everyday world, especially those situations and things which call forth emotional responses. The underlying difference among people is not new; individual differences have been recognized since the time of Aristotle and Plato, as well as Machiavelli, not to mention writers, poets, politicians, and the like [10,11]

The contribution of Mind Genomics is the ability to use a small, short experiment, inexpensive and scalable experiment to uncover patterns of responses to the everyday, working at the level of the granular experience. In doing so, Mind Genomics follows a well-trod path, finding its roots in psychology (especially those of individual differences), and consumer research (psychographic segmentation; [12]).

The segmentation approach for Mind Genomics works with the set of coefficients from the study, clustering the coefficients [13]. Those respondents in the same cluster are ‘similar to each other’ based upon the pattern of the coefficients. Those respondents in different clusters are ‘dissimilar to each other,’ again based on the pattern of coefficients. The clustering method is a mathematical treatment of the data, attempting to put the ‘things’ (here the respondents) into a small set of meaningful, interpretable groups.

The studies here featured different groups of elements, customized to fit the specific topic. As a consequence, the cluster analysis had to be conducted separately for each study. To get a sense of the different mind-sets, we created two clusters or mind-sets, doing separately for each of the 15 topics. Table 8 shows the base sizes and the additive constant for each of the mind-sets. For the most part, the additive constants for the two complementary mind-sets are similar in magnitude. It will be in the patterns of coefficients where the differences occur, generally in the elements which provoke anxiety (viz., the positive coefficients).

Table 8: Base sizes and additive constants for the two complementary mind-sets (MS1, MS2) for each topic

table 8

The elements which drive the strongest anxiety for the two mind-sets (now called Types) appear at the top of Table 9. We use the phrase Mind-Set Types to denote the fact that the mind-sets were developed separately for each topic. The elements which reduce the anxiety, appear in the bottom of Table 9. Keeping in mind that each study was subject to its own clustering analysis, it appears that there are two themes running through the mind-sets, themes which reveal themselves from the positive coefficients (anxiety-provokers), but not from the negative coefficients (anxiety-reducers).

Table 9: Elements which most strongly drive anxiety (top of table) and which most strongly reduce anxiety (bottom of table) for the 15 topics, for the two mind-set types

 Topic

Mind-Set Type A Anxiety Provokers

Mind-Set Type B Anxiety-Provokers

Aging Living in an old age home…. 30 You believe Charities will help you get through this 32
Environment A radioactive plume of dust over you…. 28 You trust that the Environmental Protection Agency will keep the earth and you safe 31
Lose Health Insurance The medical procedures you need are not covered by your insurance…. 15 You believe your Local Hospital will get you through this 37
Franken Food You are scared … inside and out 11 You trust the government will keep the earth and you safe 21
Lose Income You lose your job because you have done something wrong… 14 You believe your insurance will help you find new income 25
Infectious Disease You have to touch people that you know have some infectious disease…. 16 You believe Charities will help you get through this 31
Lose Health Your doctor says you don’t have long to live… 32 You believe Charities will help you get through this 39
Lose Assets You lose your home…. 34 You believe Charities will help you get through this 33
Obesity You just can’t control the eating… 12 You believe a plastic surgeon will help you get through this 26
Phobias You’re afraid of flying….and you must fly across the ocean…. 17 You believe Charities will help you get through this 23
Relationships You believe dating services will help you get through this 5 You believe dating services will help you get through this 32
Sexual Failure You were raped…. 21 You believe dating services will help you get through this 37
Social Interactions You just can’t function…. 14 You believe Food or Drink will help you get through this 28
Terrorism A dirty nuclear bomb set off … 39 You think United Nations Forces will keep you safe 34
War A dirty nuclear bomb set off… 23 You believe international cooperation in the United Nations will keep you safe 28
Topic MindSet A- Anxiety Reducers Mind-Set B – Anxiety Reducers
Aging You trust your God will help you get through this -12 Not having as much energy as you used to…. -10
Environment You believe that Greenpeace will keep the earth and you safe -10 You trust that God will keep the earth and you safe -6
Lose Health Insurance You trust your God will help you get through this -15 You are scared … inside and out -15
Franken Food You believe international cooperation will keep the earth and you safe -6 It’s important for the Media to keep you informed -11
Lose Income You trust your God will help you find new income -18 Business downturns that result in layoffs in your company…. -7
Infectious Disease You trust your God will help you get through this -11 Your family and friends will help get you through this… -5
Lose Health You trust your God will help you get through this -19 Family and Friends play a big role in your life…. -7
Lose Assets You trust your God will help you get through this -10 A burglar steals your jewelry and other things that are important to you… -10
Obesity Family and Friends play a big role in your life… -11 You trust your God will help you get through this -10
Phobias You trust your God will help you get through this -13 You’re afraid of being in crowds…. and you must go shopping at Christmas time…. -9
Relationships Not getting along with your partner… 10 Not getting along with your partner… -7
Sexual Failure You believe passage of time will help you get through this -11 You have performance issues…. -11
Social Interactions You believe talking to a therapist will help you get through this -15 You trust your God will help you get through this -8
Terrorism A Computer virus let loose that impacts your everyday businesses… -2 You need to contact your friends and family to make sure they are OK… -11
War You trust that God will keep you safe -14 Seeing my friends or family getting called up to go fight… -5

The underlying pattern which continues to emerge is that Mind-Set A respondents strongly to actual events which are presumed to provoke anxiety. In contrast, Mind-Set B respondents respond strongly to social institutions which presumably should reduce anxiety but for respondents in this second group of 15 mind-sets ends up increasing anxiety.

The story is different when we look at the elements which reduce anxiety (bottom of Table 9). Mind-Set Type A believes in the elements which presumably ameliorate anxiety, being designed to do so. In contrast, Mind-Set Type B, which showed the aberrant responses to helping elements (provoking anxiety) appear to be totally random in what ends up ameliorating anxiety (viz., elements with highest negative elements). Generally their negative numbers are far smaller than the negative numbers of Mind-Set Type A, suggest two radically different groups when it comes to what seems to drive anxiety.

Discussion and Conclusions

A cursory exploration of the topic of ‘anxiety’ brings up tens of thousands of ‘hits’ and many papers dealing with the manifold dimensions of anxiety. One could look at the topic of anxiety from deep inside the person, such as the approach espoused by psychoanalysis, or perhaps move a little more to the surface with cognitive behavioral therapy. Certainly, anxiety is no stranger to the world of clinical psychology, or business psychology, because of its prevalence and potentially damaging effects. Clinical psychology can teach us a lot about anxiety, from cause to manifestation to effects.

Moving beyond the clinical world is the effects of anxiety on the person’s performance in the world, experiences, and interactions with the world of the everyday. Whether this be anxieties about what a person doe (e.g., relationships, sexual failure, etc.), to who a person is (e.g., aging), to what external events occur (e.g., lose health, lose assets), there is the need to understand the surround of this life-relevant interaction. There has been a lot published on these different, relevant aspects of anxiety. A Google Search of the phrase ‘Anxiety in everyday life’ brings up 12.5 million hits as of this writing (winter, 2022.) The same phrase in Google Scholar (r) as of winter, 2022, brings up 1.6 million hits. When we limit the search to end at 2003, the number of hits drops to 155,000.

The foregoing observations tell us that there is a great interest in the topic of anxiety. At the same time, a search through the literature, or in Google Scholar (r) reveals the scattered nature of the topic. Each author focuses on that which is interesting, going in deeply. One does not have any sense of the world of anxiety dealt with in the coherent way done by a set of parallel Mind Genomics cartographies. The goal of the Mind Cartography is to systemize the data, and create understanding of the topic from the point of view of the everyday. Mind Genomics approach provides a way to understand anxiety and to allay it in a way which seems both practical and theoretical, working at the level of the granular, and yet giving a vision of a galaxy of such topics. Relevant data for the topics might be assembled painstakingly from the published literature, but without a coherent set of raw data underlying the studies. With Mind Genomics, a few weeks, and a modest budget, the entire study can be repeated. The integrated database of the granular aspects of daily experience promote new-to-the-world discoveries, easily found, analyzed, synthesized, and integrated in both current thinking and visions of new vistas.

Acknowledgments

The author would like to acknowledge the early collaborations with Jacqueline H. Beckley and Hollis Ashman (deceased), which led to the IT! studies, one of which was Deal With It! presented here.

References

  1. Beckley J, Moskowitz HR (2002) Databasing the consumer mind: the crave it!, drink it!, buy it! & healthy you! databases. In Institute of Food Technologists, Annual Meeting, Anaheim, California.
  2. Moskowitz HR (2004) Evolving Conjoint Analysis: From Rational Features/Benefits to an Off-the-Shelf Marketing Database. In Marketing Research and Modeling: Progress and Prospects 215-230. Springer, Boston, MA.
  3. Gabay G, Moskowitz HR (2015) Mind Genomics: What Professional Conduct Enhances the Emotional Wellbeing of Teens at the Hospital? Journal of Psychological Abnormalities Child 4: 147.
  4. Gofman A (2009) Extending psychophysics methods to evaluating potential social anxiety factors. Medicine 17: 1337-1342.
  5. Keene SA, Kalk TN, Clark DG, Colquhoun TA, Moskowitz HR (2017) Indoor plant toxicity concerns some consumers. In; Proceedings of the 2017 Annual Meeting of the International Plant Propagators’ Society, pp. 361-366.
  6. Moskowitz H, Rabino S, Gofman A, Moskowitz D (2007) Effective and confident communications in the midst of a major crisis: An experiment in the pharmaceutical context. International Journal of Pharmaceutical and Healthcare Marketing 1: 318-348.
  7. Moskowitz HR, Gofman A (2007) Selling blue elephants: How to make great products that people want before they even know they want them. Pearson Education.
  8. Moskowitz HR, Gofman A, Beckley J, Ashman H (2006) Founding a new science: Mind genomics. Journal of Sensory Studies 21: 266-307.
  9. Gofman A, Moskowitz H (2010) Isomorphic permuted experimental designs and their application in conjoint analysis. Journal of Sensory Studies 25: 127-145.
  10. Stanovich KE (1999) Who is rational?: Studies of individual differences in reasoning. Psychology Press.
  11. Stanovich KE, West RF (2000) Individual differences in reasoning: Implications for the rationality debate? Behavioral and brain sciences 23: 645-665.
  12. Wells WD (1975) Psychographics: A critical review. Journal of marketing research 12: 196-213.
  13. Diday E, Simon JC (1976) Clustering analysis. In: Digital Pattern Recognition (pp. 47-94.) Springer, Berlin, Heidelberg.

Aging Offenders, Mental Health and Reentry Challenges

DOI: 10.31038/ASMHS.2022621

Introduction

Older prisoners represent one of the fastest growing demographics in correctional facilities. Indeed, the number of state inmates aged 55 and older tripled from 2001 to 2016 comprising 13% of the total United States (U.S.) prison population [1-3]. The graying of our nation’s prisons is estimated to continue as experts project older inmates will constitute one-third (over 400,000) of the total prison population by 2030 [4]; a trend that goes beyond U.S. borders [5,6]. By way of example, the United Kingdom reported a 159% increase in prisoners aged 50 to 59 and a staggering 243% rise in prisoners aged 60 and above over the past two decades [7]. Many of these older inmates will be released to the community requiring support and assistance with immediate needs such as food, housing and transportation; often neglected, however, are linkages to mental health (MH) treatment and related services. This is especially important since it is not likely that the MH needs of inmates were adequately addressed prior to release, nor is it likely that sufficient plans, if any, were made to monitor these needs upon reentry.  While scholars argue that the correlation between MH and criminal behavior is largely indirect [8], we know that the mentally ill (MI), are more likely to return to prison when their conditions are not addressed in the community [9-11].

Literature Review

Statistics demonstrate the scope of the problem: a national survey finds that over two-thirds (68%) of older prison inmates report having a history of a MH disorder and almost one-quarter (22.6%) report to have experienced serious psychological distress (SPD) [9]. In addition to this, over one-quarter of inmates 55 and older report having a drug abuse or dependence disorder with nearly one-fifth reporting drug use at the time of their offense [12]. Estimates suggest, however, that only 40% of state prisoners and 26% of federal prisoners who met the threshold for past 30-day SPD reported they were receiving treatment [13], with their likelihood of receiving treatment on release being even lower [14,15]. Moreover, despite the importance, most leave prison with only several weeks of prescription medications and no plan in place for acquiring refills [16,17]. A survey on the transitional health care of released offenders reported that 13 states provided 2 weeks or less of prescription medication to MI offenders, 11 states dispensed enough for 30-days, and one state gave out a 2-month supply [17]. This is disconcerting when we consider that untreated or unmedicated persons with MI are at greater odds of clinical decompensation affecting all areas of life [16,18]. Moreover, most MI offenders have no health insurance on release with more than half (60%) reporting no benefits 8 to 10 months following discharge [19], further negating their ability to receive needed treatment in the community.

The strong link between long-term MH and poor physical health [20,21] means that for older offenders with MI, their clinical conditions are often further compromised by chronic health problems as they age. Indeed, older offenders are more likely to suffer from a variety of chronic diseases and comorbid disorders such as hypertension, heart disease, cancer and diabetes, with more than half reporting a minimum of one disability [13,22-24]. Additionally, older inmates’ psychopathology may be compromised by impaired cognitive function [25]; the clinical and symptomatic nature of which can be further exacerbated by the incarceration experience [26]. Thus, coupled with the challenges related to their MH and physical health needs on reentry, intellectual deterioration can further compromise the social and/or occupational functioning of older offenders [25,27], all of which can severely hinder their ability to successfully reintegrate into society.

A related reentry challenge for aging offenders is their greater likelihood of experiencing disengagement from family and friends, reducing vital social support networks [28,29]. In their study of recently released prisoners in Massachusetts, [29] found social support to be weakest among older releasees and those with a history of MI and addiction; 40% of older offenders and 30% with MI and addiction reported no family support on release. This is not unexpected given that older offenders, particularly those with MH and substance use disorders are more likely to have experienced conflict with family and friends or be estranged due to extended periods of separation [29,30].

It is clear then, that in addition to the more typical challenges of reentry, older offenders with MI have complex and special long-term needs which are further compounded by physical health issues and social functioning that often worsens with age. This is particularly salient among offender populations as they have been found to prematurely age; this is also referred to as “accelerated aging”, which defines the “threshold for older adults in this population to begin at 50 or 55” or in some studies even younger [31]. High-risk lifestyles (e.g., drug use, crime), socio-economic disadvantage, lack of preventative health care, and stressors of the carceral environment are said to age offenders physiologically 10 to 15 years beyond their chronological age [32-34].

Due to myriad problems and extensive medical needs, older offenders are one of the most expensive populations to house in prison, and therefore, we should be exceedingly focused on their reentry success.  Indeed, it is estimated that institutional healthcare costs of geriatric offenders are two to three times that of younger inmates [23]. The Pennsylvania Department of Corrections (PADOC), for example, reports medication costs at an astronomical rate of $3.2 million per month for inmates 50 and older independent of other healthcare costs, along with three long-term special care units at a cost of $500 per day per inmate [35]. Moreover, those with MIs are more likely to have disciplinary problems [36,37] with associated institutional expenses estimated to exceed 9 million dollars each year in the U.S. [38]; additionally, misconduct often leads to longer stays in prison [11], increasing overall housing costs.

Mental Health Court and Reentry

We suggest expanding the use of mental health courts (MHCs) in facilitating the reentry process to help fill the gap in providing support, structure and resources to this vulnerable population. Based on the drug court model which focuses on problem-solving in a non-adversarial setting, MHCs offer individualized treatment plans along with judicial supervision in a supportive environment. In our experience working with Strategies That Result In Developing Emotional Stability (STRIDES), a federal MHC program in the Eastern District of Pennsylvania, the participants were assisted in all areas of life that went beyond what is typically provided in drug and most specialty courts such as linkages to treatment, housing and work opportunities. STRIDES’ participants received help with acquiring driver’s and occupational licensing, clothing and groceries, and they were connected with agencies and volunteers to assist with parenting, financial literacy and ancillary legal needs. We observed older offenders, who with the help of the STRIDES Program, were able to stay productive and successfully navigate the many challenges faced during the transition to community supervision. Thus, MHC teams comprised of judges, attorneys, supervision and treatment agencies that collaborate to provide the best outcomes for their participants are uniquely positioned to help older offenders with their myriad complicated issues.

MHCs can be an excellent adjunct to reentry for inmates with further criminal justice monitoring as part of parole/mandatory release programs and special initiatives for older inmates such as medical or elderly release programs. In addition to providing the much-needed support and services, MHC participants could earn time off supervision for successful participation, therefore limiting further involvement in the criminal justice system and producing cost savings. Moreover, MHCs have overall been found to reduce recidivism [39-43], the primary goal of reentry, but they also demonstrate success in other important areas including reductions in hospitalizations, increased medication compliance, and other indicators of mental health recovery as well as the lessening of criminogenic needs (e.g., pro-criminal attitudes, antisocial patterns) [44-46].

We are cognizant that even though there are over 450 MHCs in 46 states (as of yearend 2020; [47]), the ability of these courts to handle the burgeoning population of older MI offenders isn’t realistic, thus, it is essential that potential participants are carefully selected based on those who would most benefit from the available services. Consideration could also be given to the utilization of other types of specialty courts (e.g., reentry courts, veterans’ courts) that are able to serve the complex treatment and other needs of the MI and provide the necessary interventions to improve their reentry process.

“Absent significant changes in sentencing and release policies, the number of aging and infirm men and women confined in US prisons will continue to grow. The rising tide of aging prisoners in the United States makes imperative renewed and careful thinking about how to protect the rights of the elderly while in prison” [30]. While we agree with the argument made by Human Rights Watch, we suggest that these protections must extend beyond the prison walls to include reentry, community supervision and the entire reintegration process. Moreover, aside from more principled considerations, a concerted effort must be established to assist those who are advanced in age and in poor mental health so that we can make a more sensible use of limited financial and human resources and allow these often-neglected offenders to become productive members of society in a more dignified manner.

References

  1. Carson EA (2020) Prisoners in 2019 (NCJ-255115). Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.
  2. Carson EA, Anderson E (2016) Prisoners in 2015 (NCJ 25022). Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.
  3. Carson EA, Cowhig MP (2020) Mortality in State and Federal prisons, 2001-2016 – Statistical tables (NCJ 251920). Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.
  4. American Civil Liberties Unions (2012). At America’s expense: The mass incarceration of the elderly. New York, NY.
  5. Seaward J, Wangmo T, Vogel T, Graf M, Egli-Alge M, et al. (2021) What characterizes a good mental health professional in court-mandated treatment settings?: Findings from a qualitative study with older patients with mental health care professionals. BMC Psychology 9: 121.
  6. Sodhi-Berry N, Knuiman M, Alan J, Morgan VA, Preen DB (2015) Pre- and post-sentence mental health service use by a population cohort of older offenders (≥45 years) in Western Australia. Social Psychiatry and Psychiatric Epidemiology 50: 1097-1110. [crossref]
  7. parliament.UK (2020). Aging prison population.
  8. Skeem JL, Winter E, Kennealy PJ, Louden JE, Tatar JR II (2014) Offenders with mental illness have criminogenic needs too: Toward recidivism reduction. Law and Human Behavior 38: 212-224. [crossref]
  9. Bronson J, Berzofsky M (2017) Indicators of Mental Health Problems Reported by Prisoners and Jail (NCJ-250612). Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.
  10. Houser KA, Saum CA, Hiller ML (2019) Mental health, substance abuse, co-occurring disorders, and 3-year recidivism of felony parolees. Criminal Justice & Behavior 46: 1237-1254.
  11. James DJ, Glaze LE (2006) Mental health problems of prison and jail inmates (NCJ 213600). Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.
  12. Bronson J, Stroop J, Zimmer S, Berzofsky M (2017) Drug use, dependence, and abuse among state prisoners and jail inmates, 2007-2009 (NCJ-250546). Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.
  13. Maruschak LM, Bronson J, Alper M (2021) Survey of prison inmates, 2016 disabilities reported by prisoners (NCJ 252642). Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.
  14. Lurigio AJ (2001) Effective services for parolees with mental illness. Crime & Delinquency 47: 446-461.
  15. Petersilia J (2003) When prisoners come home: Parole and prisoner reentry. New York, NY: Oxford University Press.
  16. Binswanger IA, Nowels C, Corsi KF, Long J, Booth RE, et al. (2011) “From the prison door right to the sidewalk, everything went downhill,” A qualitative study of the health experiences of recently released inmates. International Journal of Law and Psychiatry 34: 249-255. [crossref]
  17. Flanagan NA (2006) Transitional health care for offenders being released from United States prisons. Canadian Journal of Nursing Research Archive 36: 38-58. [crossref]
  18. Mayo Clinic (2020) Schizophrenia.
  19. Baillargeon J, Hoge SK, Penn JV (2010) Addressing the challenges of community reentry among released inmates with serious mental illness. American Journal of Community Psychology 46: 361-375. [crossref]
  20. Kendrick T (1996) Cardiovascular and respiratory risk factors and symptoms among general practice patients with long-term mental illness. British Journal of Psychiatry 169: 733-739. [crossref]
  21. Osborn DPJ (2001) The poor physical health of people with mental illness. The Western Journal of Medicine 175: 329-332. [crossref]
  22. Gates ML, Staples-Horne M, Walker V, Turney A (2017) Substance use disorders and related health problems in an aging offender population. Journal of Health Care for the Poor and Underserved 28: 132-154. [crossref]
  23. Schlager M (2013) Rethinking the reentry paradigm: A blueprint for action. Durham N.C.: Carolina Academic Press.
  24. Skarupski KA, Gross A, Schrack JA, Deal JA, Eber GB (2018) The health of America’s aging prison population. Epidemiologic Reviews 40: 157-165. [crossref]
  25. Calipari ES (2018) Boosting motivation and cognitive deficits in mental illness.
  26. Baidawia S, Trottera, O’Connor DW (2016) An integrated exploration of factors associated with psychological distress among older prisoners. The Journal of Forensic Psychiatry & Psychology 27: 815-834.
  27. Hugo J, Ganguli M (2014) Dementia and cognitive impairment: Epidemiology, diagnosis, and treatment. Clinics in Geriatric Medicine 30: 421-442. [crossref]
  28. Wyse J (2018) Older men’s social integration after prison. International Journal of Offender Therapy and Comparative Criminology 62: 2153-2173. [crossref]
  29. Western B, Braga AA, Davis J, Sirois C (2015) Stress and hardship after prison. American Journal of Sociology 120: 1512-1547. [crossref]
  30. Human Rights Watch (2012) Old behind bars: The aging prison population in the United States. Washington, DC.
  31. Bryson WC, Cotton BP, Barry LC, Bruce ML, Piel J, et al. (2019) Mental health treatment among older adults with mental illness on parole or probation. Health Justice 7: 4.
  32. Aday RH (2003) Aging prisoners: Crisis in American corrections. Westport, CT: Praeger.
  33. Aday RH, Krabill JJ (2012) Older and geriatric offenders: Critical issues for the 21st In L. Gideon (Ed.), Special needs offenders in correctional institutions (pp. 203-232). Thousand Oaks, CA: Sage.
  34. Wahidin A, Aday RH (2010) Later life and imprisonment. In D. Dannefer & C. Phillipson (Eds.), The SAGE handbook of social gerontology (pp. 587-596). Thousand Oaks, CA: Sage.
  35. Pennsylvania Department of Corrections (2020-2021) FY 2020-2021 Budget.
  36. Houser KA, Welsh W (2014) Examining the association between co-occurring disorders and seriousness of misconduct by female prison inmates. Criminal Justice & Behavior 41: 650-666.
  37. Houser KA, Belenko S, Brennan PK (2012) The effects of mental health and substance abuse disorders on institutional misconduct among female inmates. Justice Quarterly 29: 799-828.
  38. Lovell D, Jemelka R (1996) When inmates misbehave: The costs of discipline. The Prison Journal 76: 33-44.
  39. Anestis JC, Carbonell JL (2014) Stopping the revolving door: Effectiveness of mental health court in reducing recidivism by mentally ill offenders. Psychiatric Services 65: 1105-1112. [crossref]
  40. Costopoulos JS, Wellman BL (2017) The effectiveness of one mental health court: Overcoming criminal history. Psychological Injury and Law 10: 254-263.
  41. Hiday VA, Ray B (2010) Arrests two years after exiting a well-established mental health court. Psychiatric Services 61: 463-468. [crossref]
  42. Lowder EM, Desmarais SL, Baucom DJ (2016) Recidivism following mental health court exit: Between and within-group comparisons. Law and Human Behavior 40: 118-127. [crossref]
  43. McNiel DE, Binder RL (2007) Effectiveness of a mental health court in reducing criminal recidivism and violence. The American journal of psychiatry 164: 1395-1403. [crossref]
  44. Campbell MA, Canales DD, Wei R, Totten AE, MacAulay WAC, et al. (2015) Multidimensional evaluation of a mental health court: Adherence to the risk-need-responsivity model. Law and Human Behavior 39: 489-502. [crossref]
  45. Han W, Redlich AD (2016) The impact of community treatment on recidivism among mental health court participants. Psychiatric Services 67: 384-390.
  46. Wells BC (2015) Why a federal mental health court? The District of Utah’s pioneering rise court. The Judges’ Journal 54: 14-17.
  47. National Drug Court Resource Center (2021).