This article substantiates the relevance of ethical understanding and regulatory restrictions on the process of implementing a system of cognitive expert systems in healthcare. The key provisions of the axiological approach to digital healthcare strategies are defined, which should take into account national and regional conditions with mandatory dynamic interaction of all stakeholders, guaranteeing, among other things, international pluralism and basic community. Based on the analysis of a number of systems, it was revealed that the main thing in the process of developing and using expert systems is the correctness, reliability of medical information and professional assessment of the results of the systems activities. Which not only does not contradict, but also accepts the solution to the problem with the mandatory systematic inclusion of basic ethical standards in the process of developing technical solutions based on artificial intelligence and active parallel legislative initiative.
Background Diabetes is a leading global public health challenge with 537 million cases worldwide in 2021 and significant economic and societal burdens. Despite global initiatives, feasibility constraints limit widespread implementation of diabetes prevention/control measures. The key to facilitating the implementation of diabetes prevention and control measures lies in prioritise them. Objectives This study aimed to determine the priority of diabetes prevention and control measures in China from the feasibility perspective. Methods From January to February 2021, an online survey was administered to professionals specifically responsible for implementing chronic disease prevention and control programs in 488 national demonstration areas in China. The survey assessed the importance and feasibility of 44 diabetes prevention and control measures across 10 dimensions. The Importance-Performance Analysis (IPA) model categorized these indicators into four quadrants: Highest Priority (high importance and feasibility), Priority Improvement (high importance, low feasibility), Lowest Priority (low importance and feasibility), and Secondary Improvement (low importance, high feasibility). Results Quadrant 1 (‘Highest Priority’) included health education, community action, high-risk discovery and intervention, and medical insurance and family doctors, which should be maintained and strengthened. Quadrant 2 (‘Priority Improvement’) included patient management and complication screening, necessitating targeted efforts to enhance implementation. Quadrant 3 (‘Lowest Priority’) included personal health services assessment follow-up, environmental support, sugar reduction policy, and diabetes co-infection prevention, indicating a risk of overinvestment. No indicators were categorized into Quadrant 4 (‘Secondary Priority’). Conclusions Prioritizing diabetes prevention and control measures based on feasibility maximizes the utilization of limited resources, providing implementable recommendations for policymakers.
Senhor Editor,
Inicialmente, parabenizamos a Revista Brasileira de Medicina de Família e Comunidade pela publicação do artigo “Cuidados paliativos na Atenção Primária à Saúde: perspectiva de médicos e enfermeiros preceptores em Saúde da Família”.1 O estudo traz importantes dados sobre o panorama da saúde brasileira, destacando o aumento de doenças crônicas não transmissíveis e o envelhecimento populacional. Diante disso, se faz indispensável a maior aplicabilidade dos cuidados paliativos no Sistema Único de Saúde (SUS).1
Javier Sánchez-Gálvez, Javier Sánchez-Gálvez, Santiago Martínez-Isasi
et al.
IntroductionSilver-releasing dressings are used in the treatment of infected wounds. Despite their widespread use, neither the amount of silver released nor the potential in vivo toxicity is known. The aim of this study was to evaluate the cytotoxic effects and the amount of silver released from commercially available dressings with infected wounds.MethodsThe review was conducted according to the PRISMA statement. The Web of Science, PubMed, Embase, Scopus, and CINAHL databases were searched for studies from 2002 through December 2022. The criteria were as follows: population (human patients with infected wounds); intervention (commercial dressings with clinical silver authorized for use in humans); and outcomes (concentrations of silver ions released into tissues and plasma). Any study based on silver-free dressings, experimental dressings, or dressings not for clinical use in humans should be excluded. According to the type of study, systematic reviews, experimental, quasi-experimental, and observational studies in English, Spanish, or Portuguese were considered. The quality of the selected studies was assessed using the JBI critical appraisal tools. Studies that assessed at least 65% of the included items were included. Data were extracted independently by two reviewers.Results740 articles were found and five were finally selected (all of them quasi-experimental). Heterogeneity was found in terms of study design, application of silver dressings, and methods of assessment, which limited the comparability between studies.ConclusionIn vivo comparative studies of clinical dressings for control of infection lack a standardized methodology that allows observation of all the variables of silver performance at local and systemic levels, as well as evaluation of its cytotoxicity. It cannot be concluded whether the assessed concentrations of released silver in commercial dressings for the topical treatment of infected wounds are cytotoxic to skin cells.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022351041, PROSPERO [CRD42022351041].
Maryam Fakhrzad, Ali Akbar Fazaeli, Yadollah Hamidi
Background: Catastrophic health expenditure (CHE) has been explained as a growth in spending for health care services that exceeds 40% of total household income. Therefore, devoting a large portion of household resources to health care services can greatly threaten to standards of living in the short and long term. The present study was an attempt to evaluate the financial contribution of Iranian households in health care services system in Hamadan Province in 2017.Methods: This cross-sectional study reflected on spending for health care services. For this purpose, the data were extracted from the household expenditure statistics published in the database of the Statistical Center of Iran. Accordingly, among the common econometric models associated with the subject matter, the logit model was employed, and the data were then analyzed using the Stata 14 software.Results: The study findings revealed that 8.9% of the total household costs had been allocated to health care services. The results also showed that 3.5% of the households faced catastrophic cost among all the studied households. Upon examining the factors, significant relationship was further observed between the probability of exposure to CHE and living in rural areas, income decile group, number of employees, and marital status in the households concerned.Conclusion: It was concluded that poor distribution of health care services, unequal distribution of income and wealth among jobs, as well as socioeconomic conditions could influence CHE. Therefore, there is a need to plan and develop policies for better access to health care services.
The article is assigned to the researcheses of problems of public administration in the national security from the point of view of retrospective analysis. The emphasis is on respect for the fact that the state policy in the spheres of national security and defense is focused on the defense of the most important rights, legal interests and guarantees, in particular, man and citizen - their life and dignity, constitutional rights and freedoms, safe living conditions; society - its democratic values, prosperity and conditions for sustainable development; the state - its constitutional order, sovereignty, territorial integrity and inviolability; territory, environment - from emergencies. The outlined postulates occupy a prominent place in domestic legislation and become a fundamental basis for the implementation of various programs and concepts aimed at their practical implementation in public life. At the same time, in order to achieve the outlined aspects, the question of the theoretical foundations of public administration of national security in the context of retrospective analysis shall be important. Based on the results of doctrinal and comprehensive research, it is concluded that the theoretical and methodological difficulties of the retrospective concept of "national security" also allow us to conclude that it is expedient to consider not only the concept of "security" but also the concepts of "nation" and "nationalism" to find out what meaning is embedded in the concepts of "national interests" and "national values". Therefore, an important step that to some extent allows us to reach a consensus on the concept of "national security" is to consider the concept of "nation" and the phenomenon of the phenomenon called "nationalism". At the same time, the isolation of certain factors in the context of national security should be considered a temporary aspect, as it is only possible to assert the priority of certain national interests in these areas in a historical period of society and state, and hence the corresponding priority ensuring their implementation. Moreover, the long-term preference of one or another area under certain conditions may even be a threat to national security. Ignoring national interests in other areas ultimately leads first to a reduction in the potential of the state, and then to an integrated level of national security. The advantage that can be given to one or another sphere of national security is justified only under certain extraordinary conditions.
Senthil Amudhan, Kavita Jangam, Kalaivani Mani
et al.
Abstract Background There is an increasing need for Mental Health Promotion (MHP) among adolescents, especially in developing countries with limited resources and rapid socio-demographic transition. With the growing burden of mental health problems among adolescents (suicide, depression) and their preferences to seek help from their peers, improving Mental Health Literacy (MHL) and behaviours for First Aid in Mental Health (MH-FA) becomes crucial to promote their mental health. Methods Schools are ideal settings for reaching the vulnerable adolescents. The proposed study evaluates the effectiveness of a classroom-based teacher-led integrated school mental health intervention called SUMS (MHP + MHL + MH-FA). The study will involve a pragmatic, cluster-randomised waitlist-controlled design to evaluate the effectiveness of SUMS intervention using schools as unit-of-randomisation. The study will be conducted in Srinivaspura taluka (Sub-district) of Kolar district (administrative unit of health) of Karnataka in collaboration with a multi-disciplinary expert team from NIMHANS (National Institute of Mental Health And Neuro Sciences), Bangalore-India and Department of Education, Government of Karnataka, India. A total of 8 schools (400 students studying in 6–8 grade) from Srinivaspura taluka will be randomised into intervention and waitlist control group. The intervention group will receive SUMS intervention through 10–15 h of classroom sessions. The primary outcome is the improvement in positive mental health literacy, as measured by the Mental Health-Promoting Knowledge (MHPK-10) scale. Changes in MH-FA knowledge and intentions, Mental health stigma, help-seeking and resilience are assessed as secondary outcomes. Data will be collected at baseline, 6-weeks, 6-months and 12-months post-intervention. The waitlist-control schools will receive the interventions at the end of the 12-month follow-up assessment in intervention-schools. Discussion This is the first study to integrate Mental Health Literacy with Mental Health Promotion and behaviours for First Aid in Mental Health to promote mental health well-being among adolescent school children in India. With a need to build a more substantial evidence base on School Mental Health Promotion approaches in developing countries, the study findings will have implications for implementing and operationalising Health and Wellness Ambassador initiative in India. Trial registration Clinical Trials Registry - India, CTRI/2019/07/020394. Registered prospectively on 29 July 2019. ( ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=35724&EncHid=&userName=sums ).
Introduction: Local health departments are currently limited in their ability to use life expectancy (LE) as a benchmark for improving community health. In collaboration with the Baltimore City Health Department, our aim was to develop a web-based tool to estimate the potential lives saved and gains in LE in specific neighborhoods following interventions targeting achievable reductions in preventable deaths.Methods: The PROLONGER (ImPROved LONGEvity through Reductions in Cause-Specific Deaths) tool utilizes a novel Lives Saved Simulation model to estimate neighborhood-level potential change in LE after specified reduction in cause-specific mortality. This analysis uses 2012–2016 deaths in Baltimore City residents; a 20% reduction in heart disease mortality is shown as a case study.Results: According to PROLONGER, if heart disease deaths could be reduced by 20% in a given neighborhood in Baltimore City, there could be up to a 2.3-year increase in neighborhood LE. The neighborhoods with highest expected LE increase are not the same as those with highest heart disease mortality burden or lowest overall life expectancies.Discussion: PROLONGER is a practical resource for local health officials in prioritizing scarce resources to improve health outcomes. Focusing programs based on potential LE impact at the neighborhood level could lend new information for targeting of place-based public health interventions.
The British Journal of Sports Medicine (BJSM) has worked diligently to position itself as ‘a multi-media platform that provides original research, reviews and debate relating to clinically-relevant aspects of sport and exercise medicine, including physiotherapy, physical therapy, and rehabilitation’.1 Its global community and partnership network includes well over 10 000 sport and exercise medicine (SEM) physicians and sport physiotherapists—each with an ethical obligation to prioritise athlete health, safety and well-being . When the BJSM chooses to amplify an issue, the sport and exercise medicine community listens. When the BJSM chooses to remain silent, as it has on the impact of racism, colonialism and white supremacy on athlete health, safety and well-being, that silence speaks volumes. Racism is a human rights issue and a public health issue. The murder of George Floyd has become the catalyst for reflection, reckoning and reform the world over. The BJSM is not exempt. Much like the Translating Research into Injury Prevention Practice model2 would suggest, the BJSM must better understand the presentation and burden of racism, colonialism and white supremacy, and identify factors that …
Joycelyn Cudjoe, Sabianca Delva, Mia Cajita
et al.
BACKGROUND: Health literacy is a significant determinant of health behaviors, but the pathways through which health literacy influences health behaviors are not completely clear nor consistent. The purpose of this systematic review is to critically appraise studies that have empirically tested the potential pathways linking health literacy to health behavior.
METHODS: We performed searches of the electronic databases PubMed, Embase, and CINAHL to identify studies that proposed a conceptual framework and empirically tested the proposed mechanism through which health literacy influences certain health behaviors. Twenty eligible studies were included for analysis.
KEY RESULTS: The 20 studies addressed various health behaviors: chronic disease self-management (n = 8), medication adherence (n = 2), overall health status (n = 4), oral care (n = 1), cancer screening (n = 1), shared decision-making (n = 1), health information sharing (n = 1), physical activity and eating behaviors (n = 1), and emergency department visits (n = 1). Most studies were conducted in the United States (n = 13) and used a cross-sectional design (n = 15). The Short Test of Functional Health Literacy in Adults was commonly used to assess health literacy levels. Selection of variables and their operationalization were informed by a theoretical model in 12 studies. Age, gender, race/ethnicity, and insurance status were reported antecedents to health literacy. The most commonly tested mediators were self-efficacy (n = 8) and disease knowledge (n = 4). Fit indices reported in the studies ranged from acceptable to excellent.
DISCUSSION: Current evidence supports self-efficacy as a mediator between health literacy and health behavior. Further research is needed to identify how health literacy interplays with known psychosocial factors to inform people's use of preventive care services. Future studies should include more disadvantaged populations such as immigrants with high disease burden and those with low health literacy. Theory-based, empirically tested health literacy models can serve as the conceptual basis for developing effective health interventions to improve health behaviors and ultimately decrease the burden of disease in such vulnerable populations. [HLRP: Health Literacy Research and Practice. 2020;4(1):e21–e44.]
PLAIN LANGUAGE SUMMARY: This review systemically compiles, and critically appraises 20 existing studies that test conceptual frameworks that propose potential pathways through which health literacy affects health behaviors. The findings from this review can help inform the development of health literacy-focused interventions to improve the health behaviors of populations with disease burdens.
Andrew Clark, PhD, Jacqueline Tate, PhD, Umesh Parashar, MD
et al.
Summary: Background: Infant rotavirus vaccines have led to substantial reductions in hospital admissions and deaths due to gastroenteritis, but some studies have reported an elevated risk of intussusception, a rare bowel disorder. This analysis aimed to provide evidence on the potential mortality reduction benefits and intussusception risks of current rotavirus vaccination schedules, and to explore whether alternative schedules could have advantages. Methods: All 135 low-income and middle-income countries, defined by gross national income per capita of less than US$12 236 in the 2018 fiscal year, were included in the model. Mortality reduction benefits and intussusception risks of rotavirus vaccination were modelled by use of an Excel-based static cohort model with a finely disaggregated age structure. Numbers of rotavirus gastroenteritis deaths and intussusception deaths in each week of age were calculated for all infants born in the year 2015 between birth and age 5·0 years, with and without restrictions on age at administration. Benefit–risk ratios (rotavirus gastroenteritis deaths prevented per excess intussusception death) and other indicators were calculated for two vaccination schedules currently recommended by WHO and 16 alternative schedules. Of these schedules, it was assumed that between one and three doses would be given; the first dose of the rotavirus vaccine would be co-administered with either BCG or diphtheria–tetanus–pertussis (DTP)1; and the second or third dose would be co-administered with either DTP1, DTP2, DTP3, or measles (Meas)1. Findings: A three-dose schedule co-administered with DTP (without age restrictions) could prevent about 74 000 (95% uncertainty interval 59 000–100 000) rotavirus gastroenteritis deaths (38% reduction) and could lead to 201 (77–550) excess intussusception deaths (1·4% increase) compared with no vaccination, resulting in a benefit–risk ratio of 369:1 (160:1–895:1). The benefit–risk ratio was most favourable when the relative risk of intussusception was assumed to decline with the national under-5 mortality rate (2386:1) and least favourable with pessimistic assumptions about access to hospital for intussusception treatment (168:1). Schedules that involve giving the first dose with BCG and the second with DTP1 had the fewest excess intussusception deaths and most favourable benefit–risk ratios. Interpretation: Rotavirus vaccines have a favourable benefit–risk profile in LMICs. Neonatal schedules have the potential to prevent more rotavirus gastroenteritis deaths and cause fewer excess intussusception deaths than the schedules currently recommended by WHO, but more efficacious rotavirus vaccines would be needed to achieve more substantial mortality reduction benefits. Funding: Bill & Melinda Gates Foundation.
Purpose: The population with limited English proficiency (LEP) in California is growing. We sought to determine whether enough primary care physicians (PCPs) have the language skills to meet patient needs.
Methods: The authors determined the number of PCPs who self-report proficiency in the five most common non-English languages spoken in California (Spanish, Cantonese, Mandarin, Tagalog, and Vietnamese) using Medical Board of California data from 2013 to 2015. The authors estimated LEP populations during 2011?2015 using Census data. They calculated PCP supply (the ratio of PCPs/100,000 LEP individuals) compared to a federal standard to judge adequacy. They performed a sensitivity analysis adjusting the percentage of LEP patients in a bilingual physicians' practice from 100% to the percentage of LEP individuals in California who spoke that language.
Results: Of 19,310 PCPs in California, 15,933 (83%) provided information about languages they speak. There were 5,203 (33%) Spanish-, 486 (3%) Cantonese-, 986 (6%) Mandarin-, 956 (6%) Tagalog-, and 671 (4%) Vietnamese-speaking PCPs. PCP supply, compared to a federal standard, was adequate if we assumed that bilingual PCPs only care for LEP patients. However, if one assumes the number of LEP patients in a PCP's practice reflects the percentage in the general population, there is a large PCP undersupply for all languages.
Conclusion: Estimates of access to language-concordant PCPs for LEP individuals are sensitive to assumptions about the percentage of LEP patients in a PCP's panel. Ensuring language-concordant access will require deliberate effort to match LEP patients with bilingual PCPs.
Elham Mohebbi, Ali Akbar Haghdoost, Alireza Noroozi
et al.
Background<br /> Providing population-based data on awareness, attitude and practice of drug and stimulant use has policy implications. A national study was conducted among Iranian general population to explore life time prevalence, awareness and attitudes toward opioids and stimulant use.<br /> <br /> Methods<br /> We recruited subjects from 5 provinces with heterogenic pattern of drug use. Participants were selected using stratified multistage cluster sampling. Data were collected using a validated self-administered questionnaire. Logistic regression model was applied to identify the variables that are associated with drug and stimulant use.<br /> <br /> Results<br /> In total 2065 respondents including 1155 men (33.96 ± 10.40 years old) and 910 women (35.45 ± 12.21 years old) were recruited. Two-third of respondents had good awareness about adverse effects of opioid use. Corresponding figure in terms of stimulants was 81.4%. Almost 95% of participants reported a negative attitude towards either opioid or stimulant use. The lifetime prevalence of opioid use and stimulant use were 12.9% (men: 21.5%, women: 4.0%) and 7.3% (men: 9.6%, women: 4.9%), respectively. Gender (adjusted odds ratio [AOR]M/W = 6.92; 95% CI: 2.92, 16.42), education (AORundergraduate/diploma or less = 0.49; 95% CI: 0.26, 0.90), and marital status (AORothers/single = 2.13; 95% CI: 1.36, 3.33) were significantly related with opioid use. With respect to stimulant use, age was negatively associated with the outcome (AOR60+/20-29 years = 0.08: 95% CI; 0.01, 0.98) and men were 2 times more likely than women to use stimulants (ORM/W=2.15: 95% CI: 0.83, 5.56). In addition, marital status (AOROthers/singles = 3.45; 95% CI: 1.09, 10.93), and awareness (AORWeak and moderate/good = 0.40; 95% CI: 0.25, 0.61) were independently correlated with stimulants use.<br /> <br /> Conclusion<br /> While the attitude of Iranian adults toward opioid and stimulant use was negative, their awareness was not that adequate to prevent the drug use. Men and those with lower socio-economic status (SES) should be the focus of health promotion programs regarding opioid use. However, regarding stimulants use, promotion programs should target younger age groups and those with higher SES status.
Ashish D Nimbarte, Suman Kanti Chowdhury, Christopher W. Moore
Background: Repetitive handling of heavy concrete blocks has been associated with the risk of low back and shoulder injuries among the masons. Several interventions have been proposed to reduce the risk of musculoskeletal disorders among the masons. A new intervention, a lift-assist handle, was tested in this study. Objective: The effectiveness of the lift-assist handle in masonry work was assessed using the shoulder and low back kinematics during block lifting/lowering tasks performed at two heights. Methods: In a laboratory setting, seven male subjects performed with- and without-lift handle assisted block lifting tasks at two different heights. Optical motion capture system and biomechanical modeling software were used to record and model each dynamic trial. Effect of lifting height and use of a lift-assist handle on range of motion of the shoulder and trunk were tested. Results: The use of lift-assist handle significantly reduced trunk motion and increased shoulder motion. Lifting height had a significant effect on shoulder kinematics only. When height was increased from 17to 29 inches, the ranges of motion of shoulder abduction-adduction and internal rotation significantly increased. Additionally, block lifting/ lowering task duration decreased by 26% when the lift-assist handle was used. Conclusions: While potential benefits to lower back health were found with the lift-assist handle, increased shoulder motion may increase the risk of shoulder injuries. The findings of this study emphasize the need for an in-depth analysis of assistive devices prior to implementation to ensure that there are no unintended consequences of their use that could negate their benefit
Jill M Williams, M. Steinberg, Alex Kenefake
et al.
Tobacco use is a major threat to public health in the United States, and the number one cause of preventable death. Although most smokers try to quit unaided, robust data indicate that pairing behavioral support to US Food Drug Administration-approved cessation medications significantly increase cessation rates. Those who do receive assistance in quitting usually receive very low intensity treatment, regardless of the severity of their dependence or their medical and environmental circumstances. This is in stark contrast to how other substance use disorders are treated, where there are varying levels of care depending on addiction severity and biopsychosocial circumstances. The American Society of Addiction Medicine (ASAM) developed a formal algorithm for assessing substance use disorders and determining the optimal level of care. The ASAM Patient Placement Criteria are regularly used to determine the appropriate level of care for all substance use disorders except tobacco. This paper will review key aspects of the ASAM dimensions of care and placement levels, with emphasis on how they apply to tobacco use and present case examples of typical smokers who would benefit from a higher intensity of tobacco dependence treatment. We also present current barriers to reimbursing healthcare providers for these services. We conclude with a commentary and discussion regarding recommendations for improvements in tobacco dependence treatment care.
IntroductionCohort event monitoring (CEM) is an intensive method of post-marketing surveillance for medicines safety. The method is based on prescription event monitoring, which began in the 1970s, and has since been adapted by WHO for monitoring the safety of medicines used in Public Health Programmes. CEM aims to capture all adverse events that occur in a defined group of patients after starting treatment with a specific medicine during the course of routine clinical practice.ObjectiveThe aims of this study were to describe the experiences of National Pharmacovigilance Centres (NCs) that have used CEM to monitor artemisinin-based combination therapy (ACT) for uncomplicated malaria in the African setting, to raise awareness of some of the challenges encountered during implementation and to highlight aspects of the method that require further consideration.MethodA questionnaire-based survey was conducted to capture the experiences of NCs that have implemented CEM for active post-marketing surveillance of antimalarial medicines in sub-Saharan Africa. Six NCs were identified as having implemented CEM programmes and were invited to participate in the survey; five NCs indicated willingness to participate and were sent the questionnaire to complete.ResultsFour NCs responded to the survey—Ghana, Kenya, Nigeria and Zimbabwe—providing information on the implementation of a total of six CEM programmes. Their experiences indicate that CEM has helped to build pharmacovigilance capacity within the participating NCs and at the monitoring sites, and that healthcare providers (HCPs) are generally willing to participate in implementing the CEM method. All of the programmes took longer than expected to complete: contributing factors included a prolonged enrolment period and unexpectedly slow data entry. All of the programmes exceeded their budget by 11.1–63.2 %. Data management was identified as a challenge for all participating NCs.ConclusionsThe reported experiences of four NCs that have undertaken CEM studies on ACTs indicate that CEM has helped to build pharmacovigilance capacity within NCs and monitoring sites and that HCPs are willing to participate in CEM programmes; however, the method was found to be labour intensive and data management was identified as a challenge. Reducing the workload associated with CEM, particularly in relation to data management, and integrating the method into the routine work of HCPs and NCs should be considered for future implementation.
Background The field of infertility medicine has witnessed a surge of scientific developments in recent years, but research on public attitudes towards infertility treatments has remained minimal. This study examined the social and demographic factors that affect women’s attitudes towards assisted reproductive technology (ART) in general, as well as their opinions of specific issues related to ART. Materials and Methods This cross-sectional study was conducted from March 2011 to April 2011 by means of an online survey administered to a sample of 287 women. Results Women with a longer length of awareness of ART had significantly greater attitudinal favorability towards ART. Political affiliation was also significantly related to general attitudes, as well as several specific aspects of ART issues. Conclusion The results of this study suggest that several factors influence attitudes that women hold in regards to ART. Identifying some of these factors serves as a crucial starting point for devising strategies to increase public acceptance of ART.