Who tests, who doesn't, and why? Uptake of mobile HIV counseling and testing in the Kilimanjaro Region of Tanzania.

BACKGROUND: Optimally, expanded HIV testing programs should reduce barriers to testing while attracting new and high-risk testers. We assessed barriers to testing and HIV risk among clients participating in mobile voluntary counseling and testing (MVCT) campaigns in four rural villages in the Kilimanjaro Region of Tanzania. METHODS: Between December 2007 and April 2008, 878 MVCT participants and 506 randomly selected community residents who did not access MVCT were surveyed. Gender-specific logistic regression models were used to describe differences in socioeconomic characteristics, HIV exposure risk, testing histories, HIV related stigma, and attitudes toward testing between MVCT participants and community residents who did not access MVCT. Gender-specific logistic regression models were used to describe differences in socioeconomic characteristics, HIV exposure risk, testing histories, HIV related stigma, and attitudes toward testing, between the two groups. RESULTS: MVCT clients reported greater HIV exposure risk (OR 1.20 [1.04 to 1.38] for males; OR 1.11 [1.03 to 1.19] for females). Female MVCT clients were more likely to report low household expenditures (OR 1.47 [1.04 to 2.05]), male clients reported higher rates of unstable income sources (OR 1.99 [1.22 to 3.24]). First-time testers were more likely than non-testers to cite distance to testing sites as a reason for not having previously tested (OR 2.17 [1.05 to 4.48] for males; OR 5.95 [2.85 to 12.45] for females). HIV-related stigma, fears of testing or test disclosure, and not being able to leave work were strongly associated with non-participation in MVCT (ORs from 0.11 to 0.84). CONCLUSIONS: MVCT attracted clients with increased exposure risk and fewer economic resources; HIV related stigma and testing-related fears remained barriers to testing. MVCT did not disproportionately attract either first-time or frequent repeat testers. Educational campaigns to reduce stigma and fears of testing could improve the effectiveness of MVCT in attracting new and high-risk populations.

The increasing impact of human immunodeficiency virus infections, sexually transmitted diseases, and viral hepatitis in Durham County, North Carolina: a call for coordinated and integrated services.

BACKGROUND: Durham County, North Carolina, faces high rates of human immunodeficiency virus (HIV) infection (with or without progression to AIDS) and sexually transmitted diseases (STDs). We explored the use of health care services and the prevalence of coinfections, among HIV-infected residents, and we recorded community perspectives on HIV-related issues. METHODS: We evaluated data on diagnostic codes, outpatient visits, and hospitalizations for individuals with HIV infection, STDs, and/or hepatitis B or C who visited Duke University Hospital System (DUHS). Viral loads for HIV-infected patients receiving care were estimated for 2009. We conducted geospatial mapping to determine disease trends and used focus groups and key informant interviews to identify barriers and solutions to improving testing and care. RESULTS: We identified substantial increases in HIV/STDs in the southern regions of the county. During the 5-year period, 1,291 adults with HIV infection, 4,245 with STDs, and 2,182 with hepatitis B or C were evaluated at DUHS. Among HIV-infected persons, 13.9% and 21.8% were coinfected with an STD or hepatitis B or C, respectively. In 2009, 65.7% of HIV-infected persons receiving care had undetectable viral loads. Barriers to testing included stigma, fear, and denial of risk, while treatment barriers included costs, transportation, and low medical literacy. LIMITATIONS: Data for health care utilization and HIV load were available from different periods. Focus groups were conducted among a convenience sample, but they represented a diverse population. CONCLUSIONS: Durham County has experienced an increase in the number of HIV-infected persons in the county, and coinfections with STDs and hepatitis B or C are common. Multiple barriers to testing/treatment exist in the community. Coordinated care models are needed to improve access to HIV care and to reduce testing and treatment barriers.

Crossing the cultural divide: assessing the needs of a local immigrant community

Gemstone Team CARE (Community Assessment of Resident Experiences)

Emergency Department Efficiency in an Academic Hospital: A Simulation Study

Gemstone Team HOPE (Hospital Optimal Productivity Enterprise)

Legacy Resource Management Program Archaeological Reconnaissance Survey, United States Naval Academy, Annapolis, MD.

The Archaeological Reconnaissance Survey of United States Naval Academy will provide the Navy with a rich understanding of the history of this property. A National Register of Historic Places District, such as the Academy, deserves a thorough analysis of its past, in order to preserve what exists and to plan for the future. The goal of this project is to investigate the history of the Academy through traditional historic research, innovative computer analysis of historic maps, oral history interviews, and tract histories. This information has been synthesized to provide the Navy with a planning tool for Public Works, a concise look at the cartographic history of the Academy, and reference manual of the vast amounts of information which have been gathered during the course of this project. This information can serve as a reference tool to help the Public Works department comply with Section 106 regulations of the Historic Sites Preservation Act, with regard to construction. It can also serve as a source of cartographic history for those interested in the Academy's physical development, and as a way of preserving the culture of residents in Annapolis. This program and archaeological survey will ultimately serve to add to the rich history of the United States Naval Academy while preserving an important part of our nation's heritage.

Trash: a local solution to a global problem

Gemstone Team GREEN JUSTICE

Carbon Markets: Past, Present, and Future

Carbon markets are substantial and they are expanding. There are many lessons from experiences over the past eight years: fewer free allowances, better management of market-sensitive information, and a recognition that trading systems require adjustments that have consequences for market participants and market confidence. Moreover, the emerging international architecture features separate emissions trading systems serving distinct jurisdictions. These programs are complemented by a variety of other types of policies alongside the carbon markets. This sits in sharp contrast to the integrated global trading architecture envisioned 15 years ago by the designers of the Kyoto Protocol and raises a suite of new questions. In this new architecture, jurisdictions with emissions trading have to decide how, whether, and when to link with one another, and policymakers overseeing carbon markets must confront how to measure the comparability of efforts among markets and relative to a variety of other policy approaches.

Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Future requirements for and supply of ophthalmologists for an aging population in Singapore.

BACKGROUND: Singapore's population, as that of many other countries, is aging; this is likely to lead to an increase in eye diseases and the demand for eye care. Since ophthalmologist training is long and expensive, early planning is essential. This paper forecasts workforce and training requirements for Singapore up to the year 2040 under several plausible future scenarios. METHODS: The Singapore Eye Care Workforce Model was created as a continuous time compartment model with explicit workforce stocks using system dynamics. The model has three modules: prevalence of eye disease, demand, and workforce requirements. The model is used to simulate the prevalence of eye diseases, patient visits, and workforce requirements for the public sector under different scenarios in order to determine training requirements. RESULTS: Four scenarios were constructed. Under the baseline business-as-usual scenario, the required number of ophthalmologists is projected to increase by 117% from 2015 to 2040. Under the current policy scenario (assuming an increase of service uptake due to increased awareness, availability, and accessibility of eye care services), the increase will be 175%, while under the new model of care scenario (considering the additional effect of providing some services by non-ophthalmologists) the increase will only be 150%. The moderated workload scenario (assuming in addition a reduction of the clinical workload) projects an increase in the required number of ophthalmologists of 192% by 2040. Considering the uncertainties in the projected demand for eye care services, under the business-as-usual scenario, a residency intake of 8-22 residents per year is required, 17-21 under the current policy scenario, 14-18 under the new model of care scenario, and, under the moderated workload scenario, an intake of 18-23 residents per year is required. CONCLUSIONS: The results show that under all scenarios considered, Singapore's aging and growing population will result in an almost doubling of the number of Singaporeans with eye conditions, a significant increase in public sector eye care demand and, consequently, a greater requirement for ophthalmologists.

The Olympic Games and urban displacement: the case of Beijing

Urban spectacles such as the Olympic Games have been long perceived as being able to impose desired effects in the city that act as host. This kind of urban boost may include the creation of new jobs and revenue for local community, growth in tourism and convention business, improvements to city infrastructure and environment, and the stimulation of broad reform in the social, political and institutional realm. Nevertheless at the other end of the debate, the potentially detrimental impacts of Olympic urban development, particularly on disadvantaged and vulnerable groups, have also been increasingly noticed in recent years and subsequently cited by a number of high profile anti-Olympic groups to campaign against Olympic bids and awards. The common areas of concern over Olympic-related projects include the cost and debts risk, environmental threat, the occurrence of social imbalance, and disruption and disturbance of existing community life. Among these issues, displacement of low income households and squatter communities resulting from Olympic-inspired urban renewal are comparatively under-explored and have emerged as an imperative area for research inquiry. This is particularly the case where many other problems have become less prominent. Changing a city’s demographic landscape, particularly displacing lower income people from the area proposed for a profitable development is a highly contentious matter in its own right. Some see it as a natural and inevitable outgrowth of the process of urban evolution, without which cities cannot move towards a more attractive location for consumption-based business. Others believe it reflects urban crises and conflicts, highlighting the market failures, polarization and injustice. Regardless of perception,these phenomena are visible everywhere in post-industrial cities and particularly cannot be ignored when planning for the Olympic Games and other mega-events. The aim of this paper is to start the process of placing the displacement issue in the context of Olympic preparation and to seek a better understanding of their interrelations. In order to develop a better understanding of this issue in terms of cause, process, influential factors and its implication on planning policy, this paper studies the topic from both theoretic and empirical angles. It portrays various situations where the Olympics may trigger or facilitate displacement in host cities during the preparation of the Games, identifies several major variables that may affect the process and the overall outcome, and explores what could be learnt in generic terms for planning Olympic oriented infrastructure so that ill-effects to the local community can be effectively controlled. The paper concludes that the selection of development sites, the integration of Olympic facilities with the city’s fabric, the diversity of housing type produced for local residents and the dynamics of the new socioeconomic structure.

Replacing rubber plantations by rain forest in Southwest China - Who would gain and how much?

The cultivation of rubber trees in Xishuangbanna Prefecture in China’s Yunnan Province has triggered an unprecedented economic development but it is also associated with severe environmental problems. Rubber plantations are encroaching the indigenous rainforests at a large scale and a high speed in Xishuangbanna. Many rare plant and animal species are endangered by this development, the natural water management is disturbed and even the microclimate in this region has changed over the past years. The present study aims at an assessment of the environmental benefits accruing from a reforestation project partly reversing the deforestation that has taken place over the past years. To this end a Contingent Valuation survey has been conducted in Xishuangbanna to elicit local residents’ willingness to pay for this reforestation program that converts existing rubber plantations back into forest. It is shown that local people's awareness of the environmental problems caused by increasing rubber plantation is quite high and that in spite of the economic advantages of rubber plantation there is a positive willingness among the local population to contribute financially to a reduction of existing rubber plantations for the sake of a partial restoration of the local rainforest. These results could be used for the practical implementation of a PES (Payments for Eco-System Services) system for reforestation in Xishuangbanna.

REDUCING DIESEL DEPENDENCE IN NUNAVUT: INTEGRATING RENEWABLE ENERGY TECHNOLOGIES THROUGH POLICY ACTIONS

In the last fifty years, Nunavut has developed a deep dependence on diesel for virtually all of its energy needs, including electricity. This dependence has created a number of economic, environmental and health related challenges in the territory, with an estimated 20% of the territory’s annual budget being spent on energy, thereby limiting the Government of Nunavut’s ability to address other essential infrastructure and societal needs, such as education, nutrition and health care and housing. One solution to address this diesel dependency is the use of renewable energy technologies (RETs), such as wind, solar and hydropower. As such, this thesis explores energy alternatives in Nunavut, and through RETScreen renewable energy simulations, found that solar power and wind power are technically viable options for Nunavut communities and a potentially successful means to offset diesel-generated electricity in Nunavut. However, through this analysis it was also discovered that accurate data or renewable resources are often unavailable for most Nunavut communities. Moreover, through qualitative open-ended interviews, the perspectives of Nunavut residents with regards to developing RETs in Nunavut were explored, and it was found that respondents generally supported the use of renewable energy in their communities, while acknowledging that there still remains a knowledge gap among residents regarding renewable energy, stemming from a lack of communication between the communities, government and the utility company. In addition, the perceived challenges, opportunities and gaps that exist with regards to renewable energy policy and program development were discussed with government policy-makers through further interviews, and it was discovered that often government departments work largely independently of each other rather than collaboratively, creating gaps and oversights in renewable energy policy in Nunavut. Combined, the results of this thesis were used to develop a number of recommended policy actions that could be undertaken by the territorial and federal government to support a shift towards renewable energy in order to develop a sustainable and self-sufficient energy plan in Nunavut. They include: gathering accurate renewable resource data in Nunavut; increasing community consultations on the subject of renewable energy; building strong partnerships with universities, colleges and industry; developing a knowledge sharing network; and finally increasing accessibility to renewable energy programs and policies in Nunavut.

Selective migration from deprived areas in Northern Ireland and the spatial distribution of inequalities: implications for monitoring health and inequalities in health

Much of the evidence suggesting that inequalities in health have been increasing over the last two decades has come from studies that compared the changes in relative health status of areas over time. Such studies ignore the movement of people between areas. This paper examines the population movement between small areas in Northern Ireland in the year prior to the 1991 census as well as the geographical distribution of migrants to Northern Ireland over the same period. It shows that deprived areas tended to become depopulated and that those who left these areas were the more affluent residents. While immigrants differed a little from the indigenous population, the overall effect of their distribution would be to maintain the geographical socio-economic status quo. The selective movement of people between areas would result in the distribution of health and ill-health becoming more polarized, i.e. produce a picture of widening inequalities between areas even though the distribution between individuals is unchanged. These processes suggest potential significant problems with the area-based approaches to monitoring health and inequalities in health.

The effect of type of hip protector and resident characteristics on adherence to use of hip protectors in nursing and residential homes - an exploratory study

Objectives: To investigate the factors influencing the acceptability of hip protectors to residents of nursing and residential homes, especially the effect of hip protector type, and resident characteristics. Design: A randomised controlled trial with 12 weeks follow-up. Participants were randomised to receive either Safehips or HipSaverTM hip protectors. Setting/Participants: 109 residents aged 61 to 98 years from seven residential homes and two nursing homes in Northern Ireland. Main outcome measures: Percentage day-time use of the hip protectors over 12 weeks and ongoing use at 12 weeks. Results: 42% (119/285) of residents invited to enter the studyagreed to take part, and 109 started to wear the hip protectors. 43.1% (47/109) were still using them at 12 weeks. Mean percentage day-time use for all residents during 12 weeks was 48.6%. There was no significant difference in percentage day-time use (p=0.40), or use at 12 weeks (p=0.56) between the residents wearing Safehips and HipSaverTM protectors. Greater percentage daytime use of hip protectors was associated with being resident in a home for the elderlymentallyinfirm (75.1%, pp0.0005), having a low (12 or less) Barthel score (61.1%, pp0.0005), and having been injured in a fall in the last 12 months (57.3%, p=0.012). Conclusions: The type of hip protector appeared to make no difference to their continued use by residents. Residents with a historyof a fall and those who are physicallyand mentallyincapacitated appear to be more likelyto wear hip protectors. These residents, who are at high risk of falling, are also highlydependent on nursing staff. Efforts to increase hip protector use in residential and nursing home should focus on staff, who are in the best position to advise and influence residents and their relatives.

Is big best? Queen size, usurpation and nest closure in a primitively eusocial sweat bee (Lasioglossum malachurum).

For primitively eusocial insects in which a single foundress establishes a nest at the start of the colony cycle, the solitary provisioning phase before first worker emergence represents a risky period when other, nestless foundresses may attempt to usurp the nest. In the primitively eusocial sweat bee Lasioglossum malachurum (Hymenoptera, Halictidae), spring foundresses compete for nests which are dug into hard soil. Nest-searching foundresses (‘floaters’) frequently inspected nests during this solitary phase and thereby exerted a usurpation pressure on resident queens. Usurpation has been hypothesised to increase across the solitary provisioning phase and favour closure of nests at an aggregation, marking the termination of the solitary provisioning phase by foundresses, before worker emergence. However, our experimental and observational data suggest that usurpation pressure may remain constant or even decrease across the solitary provisioning phase and therefore cannot explain nest closure before first worker emergence. Levels of aggression during encounters between residents and floaters were surprisingly low (9% of encounters across 2 years), and the outcome of confrontations was in favour of residents (resident maintains residency in 94% of encounters across 2 years). Residents were significantly larger than floaters. However, the relationship between queen size and offspring production, though positive, was not statistically significant. Size therefore seems to confer a considerable advantage to a queen during the solitary provisioning phase in terms of nest residency, but its importance in terms of worker production appears marginal. Factors other than intraspecific usurpation need to be invoked to explain the break in provisioning activity of a foundress before first worker emergence.