**Meet the editors**

Dr. Md Anwarul Azim Majumder, a medical educationist and public health specialist, is currently working as the Director of Medical Education in the Faculty of Medical Sciences at the University of the West Indies, Cave Hill Campus, Barbados, West Indies. He worked previously at the University of Bradford, UK, Universiti Sains Malaysia, Malaysia and Centre for Medical Edu-

cation, Bangladesh, and has been actively involved in the innovation and experimentation of medical education. He is also the Executive Editor of the *South East Asia Journal of Public Health* (published by the Public Health Foundation, Bangladesh) and the Editor-in-Chief of the *Journal of Advances in Medical Education and Practice*. He has published a number of peer-reviewed papers on medical education and health care.

Dr. Russell Kabir is a public health researcher and is currently working as a senior lecturer in research methods at the Department of Medical Science and Public Health of Anglia Ruskin University, UK. He obtained his MSc and PhD degrees from Middlesex University, UK. His first degree was a Bachelor of Dental Surgery from the University of Dhaka, Bangladesh. He has authored/

co-authored many journal articles and book chapters. He is a member of the International Epidemiological Association and Fellow of the Higher Education Academy, UK. Dr. Kabir is interested in interdisciplinary research in emerging and re-emerging public health problems with a special focus on maternal health, climate change and dental public health issues.

Dr. Sayeeda Rahman is a clinical pharmacologist and an associate fellow of the Higher Education Academy, UK. She received her first degree in Pharmacy (BPharm and MPharm) from the University of Dhaka, Bangladesh, an MBA from Dundee University, UK, and a PhD from Universiti Sains Malaysia, Malaysia. She is trained in various aspects of public health and medical education.

Her research interests include diabetes and cardiovascular diseases. She has contributed to medical sciences with her research publications. Dr. Rahman has work experience at university level (Bangladesh, Malaysia, and the UK), and at different national and multinational pharmaceutical companies in Bangladesh. She is currently working at the University of Bradford, UK, and is actively engaged in widening participation in medical education.

Contents

**Preface VII**

**Section 1 Infectious Diseases 1**

Geane Lopes Flores

**Health Problem 25**

**Philippines 47**

**Section 2 Policies, Plans and Programs 73**

**Backgrounds in Germany 75** Marlen Niederberger and Meike Keller

Geoffrey Meads and Amanda Lees

Chapter 1 **Emergence of New Epidemiological Hepatitis B and C Profiles**

Chapter 2 **Emerging and Re-emerging Arboviral Diseases as a Global**

Chapter 3 **The Evolution of Entomological Research with Focus on**

Ferdinand V. Salazar and Kaymart A. Gimutao

Chapter 4 **Mixed Methods Studies in Health Promotion: A Case-Study**

Chapter 5 **Developing Community Health and Cohesion Through**

**Based on the Life Situations of Young People of Refugee**

**Diversity: An Evidence Synthesis for Faith-Based Agencies 91**

Livia Melo Villar, Helena Medina Cruz, Moyra Machado Portilho, Jakeline Ribeiro Barbosa, Ana Carolina Fonseca da Mendonça and

Serena Marchi, Claudia Maria Trombetta and Emanuele Montomoli

**Emerging and Re-emerging Mosquito-Borne Infections in the**

**in High Risk Groups in Latin America 3**

## Contents

## **Preface XI**

#### **Section 1 Infectious Diseases 1**


Chapter 6 **Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the National Comprehensive Cancer Control Program 107** Sherri L. Stewart, Nikki S. Hayes, Angela R. Moore, Robert Bailey II, Phaeydra M. Brown and Ena Wanliss Chapter 7 **Taking it to the Pulpit: Repositioning FBOs as Critical Agencies in the HIV/AIDS Response in South Africa 127** Edlyne Eze Anugwom

Preface

Modern public health aims to improve the quality of life and provide health care for all. Public health deals with a wide range of individuals and collaborates with various organiza‐ tions, departments and agencies to improve health, forestall disease, and promote well-be‐ ing. The field of public health is constantly evolving in response to the needs of communities and populations that are facing demographic, epidemiological and technologi‐ cal challenges. To overcome these challenges, health professionals need conduct research to generate evidence-based policies to improve the health of the community. Throughout the course of this book, a number of emerging and re-emerging public health issues from differ‐ ent countries are discussed and attempts are made to illustrate a balanced and evidence-

We divided the chapters into two sections: infectious diseases and policies, plans and pro‐ grams. The infectious diseases section contains three chapters from Brazil, Italy and the Phil‐ ippines, which evaluate three emerging and re-emerging public health issues in three continents. The chapter from Brazil discusses the emergence of new epidemiological hepati‐ tis B and C profiles in high-risk groups in Latin America. The second chapter from Italy highlights the emerging and re-emerging arboviral diseases as a global health problem. The last chapter is from the Philippines which maps the evolution of entomological research with a focus on emerging and re-emerging mosquito-borne infections in that country.

The policies, plans, and programs section includes chapters from Germany, the UK, the USA, South Africa, South Korea, and Brazil. The first chapter from Germany discusses the status of health promotion in relation to the living situation of young refugees. The next chapter examines the relationship of increasing socio-demographic and organizational di‐ versity to community health development in the UK with particular focus on the contribu‐ tion and involvement of faith-oriented agencies to the processes of community cohesion required to underpin public health improvements. The third chapter provides a summary of the National Comprehensive Cancer Control Program (NCCCP) in the USA, and highlights specific examples of interventions implemented and successes achieved to aid cancer plan‐ ning in other countries. The chapter from South Africa evaluates the role of the Faith-Based Organizations (FBOs) involved in the HIV/AIDS response and how FBOs can be reposi‐ tioned and further empowered to serve as critical agencies. The penultimate chapter ex‐ plores the relationship between the social capital and self-rated health status of South Korean women with disabilities. The last chapter discusses the dilemmas and impasses in

public health policies directed to use of alcohol and other drugs in Brazil.

based approach towards tackling major public health problems.

Chapter 8 **An Exploratory Study on the Association Between Social Capital and Self-Rated Health of South Korean Women with Disabilities 143**

Jung Youn Park, Ji Young Park and Soo Hyun Sung

Chapter 9 **Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs in Brazil 157**

> Maria Cristina Gonçalves Vicentin, Jacqueline Isaac Machado Brigagão and Pedro Paulo Freire Piani

## Preface

Chapter 6 **Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the National Comprehensive**

Chapter 7 **Taking it to the Pulpit: Repositioning FBOs as Critical Agencies in the HIV/AIDS Response in South Africa 127**

Chapter 8 **An Exploratory Study on the Association Between Social**

Jung Youn Park, Ji Young Park and Soo Hyun Sung

Chapter 9 **Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs**

Brigagão and Pedro Paulo Freire Piani

Sherri L. Stewart, Nikki S. Hayes, Angela R. Moore, Robert Bailey II,

**Capital and Self-Rated Health of South Korean Women with**

Maria Cristina Gonçalves Vicentin, Jacqueline Isaac Machado

**Cancer Control Program 107**

Edlyne Eze Anugwom

**VI** Contents

**Disabilities 143**

**in Brazil 157**

Phaeydra M. Brown and Ena Wanliss

Modern public health aims to improve the quality of life and provide health care for all. Public health deals with a wide range of individuals and collaborates with various organiza‐ tions, departments and agencies to improve health, forestall disease, and promote well-be‐ ing. The field of public health is constantly evolving in response to the needs of communities and populations that are facing demographic, epidemiological and technologi‐ cal challenges. To overcome these challenges, health professionals need conduct research to generate evidence-based policies to improve the health of the community. Throughout the course of this book, a number of emerging and re-emerging public health issues from differ‐ ent countries are discussed and attempts are made to illustrate a balanced and evidencebased approach towards tackling major public health problems.

We divided the chapters into two sections: infectious diseases and policies, plans and pro‐ grams. The infectious diseases section contains three chapters from Brazil, Italy and the Phil‐ ippines, which evaluate three emerging and re-emerging public health issues in three continents. The chapter from Brazil discusses the emergence of new epidemiological hepati‐ tis B and C profiles in high-risk groups in Latin America. The second chapter from Italy highlights the emerging and re-emerging arboviral diseases as a global health problem. The last chapter is from the Philippines which maps the evolution of entomological research with a focus on emerging and re-emerging mosquito-borne infections in that country.

The policies, plans, and programs section includes chapters from Germany, the UK, the USA, South Africa, South Korea, and Brazil. The first chapter from Germany discusses the status of health promotion in relation to the living situation of young refugees. The next chapter examines the relationship of increasing socio-demographic and organizational di‐ versity to community health development in the UK with particular focus on the contribu‐ tion and involvement of faith-oriented agencies to the processes of community cohesion required to underpin public health improvements. The third chapter provides a summary of the National Comprehensive Cancer Control Program (NCCCP) in the USA, and highlights specific examples of interventions implemented and successes achieved to aid cancer plan‐ ning in other countries. The chapter from South Africa evaluates the role of the Faith-Based Organizations (FBOs) involved in the HIV/AIDS response and how FBOs can be reposi‐ tioned and further empowered to serve as critical agencies. The penultimate chapter ex‐ plores the relationship between the social capital and self-rated health status of South Korean women with disabilities. The last chapter discusses the dilemmas and impasses in public health policies directed to use of alcohol and other drugs in Brazil.

We wish to express our gratefulness to IntechOpen for providing us with the opportunity to edit the book. We owe a very special gratitude to Ms. Maja Bozicevic, Author Service Man‐ ager, IntechOpen, for her steadfast, thorough and consistent support and guidance in re‐ viewing and finalizing the chapters received from the authors. Of course, we could not have developed this book without the submission of chapters from the authors of various coun‐ tries. We are grateful for their support, which gives the book a global flavor. The emerging and re-emerging public health issues from different countries will provide relevant evidence for health professionals to tackle priority public health problems in other parts of the world. The ultimate goal is to improve the health of the people of our global village!

#### **Dr. Md. Anwarul Azim Majumder**

Director of Medical Education Faculty of Medical Sciences The University of the West Indies Cave Hill Campus Barbados, West Indies

#### **Dr. Russell Kabir**

**Infectious Diseases**

**Section 1**

Senior Lecturer Department of Medical Science and Public Health Faculty of Medical Science Anglia Ruskin University Chelmsford, Essex, UK

#### **Dr. Sayeeda Rahman**

Lecturer Department of Clinical Sciences School of Pharmacy and Medical Sciences Faculty of Life Sciences University of Bradford West Yorkshire, Bradford, UK

**Section 1**

**Infectious Diseases**

We wish to express our gratefulness to IntechOpen for providing us with the opportunity to edit the book. We owe a very special gratitude to Ms. Maja Bozicevic, Author Service Man‐ ager, IntechOpen, for her steadfast, thorough and consistent support and guidance in re‐ viewing and finalizing the chapters received from the authors. Of course, we could not have developed this book without the submission of chapters from the authors of various coun‐ tries. We are grateful for their support, which gives the book a global flavor. The emerging and re-emerging public health issues from different countries will provide relevant evidence for health professionals to tackle priority public health problems in other parts of the world.

> **Dr. Md. Anwarul Azim Majumder** Director of Medical Education Faculty of Medical Sciences The University of the West Indies

Department of Medical Science and Public Health

Cave Hill Campus Barbados, West Indies

> **Dr. Russell Kabir** Senior Lecturer

> > Lecturer

Faculty of Medical Science Anglia Ruskin University Chelmsford, Essex, UK **Dr. Sayeeda Rahman**

Department of Clinical Sciences

West Yorkshire, Bradford, UK

Faculty of Life Sciences University of Bradford

School of Pharmacy and Medical Sciences

The ultimate goal is to improve the health of the people of our global village!

VIII Preface

**Chapter 1**

. It includes

**Provisional chapter**

**Emergence of New Epidemiological Hepatitis B and C**

**Emergence of New Epidemiological Hepatitis B and C** 

Latin America includes Mexico, the islands of the Caribbean and Central and South America, which possess a rich cultural and natural heritage. A narrative literature review was made to determine epidemiological hepatitis B and C profiles in high risk groups in Latin America, such as, drug users, hemophiliacs, and chronic kidney disease (CKD), human immunodeficiency virus (HIV) infected individuals. Using data from international databases that disseminate published quality studies. All studies with desired information regarding site and study population were included. It was observed that HBV prevalence diminished in several groups, probably due to implementation of HBV vaccination in various Latin America Countries (LACs). On the other hand, HCV prevalence is high among high risk groups compared to general population, but different values were observed in LAC, probably due to different access to education programs, assays evaluated, population size and type of recruitment. Due to chronicity of HBV and HCV, it is important to increase access to diagnosis, HBV vaccination and implementation of education programs

**Keywords:** HBV, HCV, prevalence, HIV, chronic kidney disease, coagulopathy, illicit

The Latin American and Caribbean region encloses the Spanish, Portuguese and French-

speaking countries of the American continent and covers almost 22,000,000 km2

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.79174

**Profiles in High Risk Groups in Latin America**

**Profiles in High Risk Groups in Latin America**

Livia Melo Villar, Helena Medina Cruz,

Livia Melo Villar, Helena Medina Cruz,

http://dx.doi.org/10.5772/intechopen.79174

Geane Lopes Flores

Geane Lopes Flores

**Abstract**

substance abuse

**1. Introduction**

Ana Carolina Fonseca da Mendonça and

Ana Carolina Fonseca da Mendonça and

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Moyra Machado Portilho, Jakeline Ribeiro Barbosa,

Moyra Machado Portilho, Jakeline Ribeiro Barbosa,

to high risk groups to diminish burden of these infections.

#### **Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America**

DOI: 10.5772/intechopen.79174

Livia Melo Villar, Helena Medina Cruz, Moyra Machado Portilho, Jakeline Ribeiro Barbosa, Ana Carolina Fonseca da Mendonça and Geane Lopes Flores Livia Melo Villar, Helena Medina Cruz, Moyra Machado Portilho, Jakeline Ribeiro Barbosa, Ana Carolina Fonseca da Mendonça and Geane Lopes Flores

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79174

#### **Abstract**

Latin America includes Mexico, the islands of the Caribbean and Central and South America, which possess a rich cultural and natural heritage. A narrative literature review was made to determine epidemiological hepatitis B and C profiles in high risk groups in Latin America, such as, drug users, hemophiliacs, and chronic kidney disease (CKD), human immunodeficiency virus (HIV) infected individuals. Using data from international databases that disseminate published quality studies. All studies with desired information regarding site and study population were included. It was observed that HBV prevalence diminished in several groups, probably due to implementation of HBV vaccination in various Latin America Countries (LACs). On the other hand, HCV prevalence is high among high risk groups compared to general population, but different values were observed in LAC, probably due to different access to education programs, assays evaluated, population size and type of recruitment. Due to chronicity of HBV and HCV, it is important to increase access to diagnosis, HBV vaccination and implementation of education programs to high risk groups to diminish burden of these infections.

**Keywords:** HBV, HCV, prevalence, HIV, chronic kidney disease, coagulopathy, illicit substance abuse

#### **1. Introduction**

The Latin American and Caribbean region encloses the Spanish, Portuguese and Frenchspeaking countries of the American continent and covers almost 22,000,000 km2 . It includes

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, El Salvador, Ecuador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Dominican Republic, Uruguay and Venezuela, which possess a rich cultural and natural heritage [1].

and evidence-based care. This type of review gives comprehensive background for understanding current knowledge and highlighting the significance of new research in this area.

Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America

http://dx.doi.org/10.5772/intechopen.79174

5

A narrative review of the literature was done using SCIELO, LILACS and MEDLINE® database searches in an iterative manner during December to April 2018 to retrieve articles related to current and historical epidemiological profile of hepatitis B and C in the countries of Latin

Search terms included "hepatitis B," "hepatitis C," "HIV," "illicit substance," "drug user", "CKD", "dialysis", "coagulopathy", "prevalence", "epidemiology", "Latin America". The reference lists

All authors independently read each article in full text, evaluated the relevance and quality of retrieved articles to include the data, and recorded the main findings of each study to include the relevant articles in **Table 1**. Primary and secondary studies were included in the review,

HIV infection can increase clinical complications of liver disease associated to HBV and HCV, such as increasing the risk of developing cirrhosis up to five times in those co-infected with HIV/HCV [12]. With antiretroviral therapy and a significant increase in the life expectancy of people living with HIV, liver disease in patients with HCV and/or HBV infection has become

In Latin America and the Caribbean, the prevalence of HBV and HCV in people living with HIV is quite variable. Moreover, few data are available, unlike data for Europe and the United States [12]. Over the world, 10% of people infected with HIV are also coinfected with HBV [13], since both viruses has the parenteral and sexual pathways as a route of infection, coinfec-

According Tengan et al. [15], estimated prevalence of HBsAg in LAC ranged from 2.0% (95% CI 1.0–5.0%) to 15.0% (95% CI 9.0–24.0%) and pooled prevalence was 7.0% (95% CI 7.0–7.0%). They also observed a drop in HBsAg prevalence from 8.0% (95% CI 8.0–9.0%) in the 12 studies published from 1999 to 2006 to 6.0% (95% CI 5.0–6.0%) in 16 studies published from 2007 to 2016. The decrease in HBsAg prevalence could be related to implementation of vaccination

In Brazil, HBsAg prevalence in HIV infected individuals ranges from 1.9 to 10.3% according geographical regions [15–18]. Tengan et al. [15] reported HBsAg prevalence in HIV of 3.3% in

of each article found were also reviewed in detail to find additional articles.

**3.1. Hepatitis B and C prevalence in patients infected by HIV**

the leading cause of non-AIDS-related deaths in this population.

**2. Methodology**

America and the Caribbean.

but duplicate studies were removed.

tion of these two viruses are common [14].

against hepatitis B.

**3. Results and discussion**

Clinical manifestation of hepatitis B and C virus infection varies in both acute and chronic disease. HBV acute phase could be subclinical or anicteric hepatitis to icteric hepatitis and in some cases fulminant hepatitis. Acute Hepatitis C is often asymptomatic and leads to chronic infection in about 75% of cases. During the chronic phase, manifestations range from an asymptomatic carrier state to chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Extrahepatic manifestations can occur in both acute and chronic infection. Pathophysiology is based on the inflammatory response to the virus that replicates in the hepatocyte [2–4].

Viral hepatitis is an important public health issue over the world, but there is still some gaps regarding the prevalence of these viruses in Latin America. Hepatitis B virus (HBV) infection has a heterogeneous distribution in Latin America and it is estimated at least 7–12 million people infected by virus [5]. Most of Latin American countries presented low seroprevalence (less than 2% of HBsAg positivity), including Mexico, Honduras, Nicaragua, Costa Rica, Panama, Cuba, Paraguay, Uruguay, Chile, Argentina, Peru and North Colombia. Intermediate seroprevalence (2.0–8.0% of HBsAg) are observed in Central America (Guatemala, Belize, El Salvador, Honduras, Haiti the Dominican Republic and Puerto Rico), Ecuador, Venezuela, Guyana, Surinam, French Guyana and South of Brazil. High seroprevalence (>8% of HBsAg presence) are observed in Peru, South Colombia, Northern Bolivia and Northern Brazil; however, these reports are primarily estimates [6–9].

Hepatitis C virus (HCV) infection prevalence varies from 1.2 to 1.6% in Peru, Mexico, Venezuela, Argentina and Brazil where almost 80% were viremic [9]. According the same study, genotype 1 was the most frequent detected, but genotype 1b was the most prevalent in all countries except in Peru where genotype 1a was the highest prevalent. Díez-Padrisa et al. [7] reported that Grenada, Bolivia, Haiti, Trinidad and Tobago and El Salvador have the highest prevalence (≥2.5%) in Latin America.

Epidemiological studies to determine HBV and HCV prevalence are important, principally among high risk population, such as human immunodeficiency virus (HIV) infected subjects, drug users, hemophiliacs and chronic kidney patients. HIV individuals coinfected with HBV or HCV could present clinical complications of liver disease and increased risk of developing cirrhosis. Individuals who are drug and alcohol abusers are at risk of becoming infected with HBV or HCV due to unprotected sexual practices that are common to these users besides the sharing of needles and syringes [10]. Chronic kidney disease (CKD) and coagulopathy patients are often exposed to blood, such as during hemodialysis or blood components transfusion where the risk of contracting viral infections is also very high [11].

Knowing the scenario of HBV and HCV infection in Latin American countries (LAC) is important to raise awareness among the population and health professionals, strengthening preventive measures mainly among the high-risk population, increasing access to diagnosis, improving the attendance of the diagnosed cases, treatment and monitoring [7]. In this chapter, a narrative literature review was undertaken to give information for developing policies and evidence-based care. This type of review gives comprehensive background for understanding current knowledge and highlighting the significance of new research in this area.

## **2. Methodology**

Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, El Salvador, Ecuador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Dominican Republic, Uruguay

Clinical manifestation of hepatitis B and C virus infection varies in both acute and chronic disease. HBV acute phase could be subclinical or anicteric hepatitis to icteric hepatitis and in some cases fulminant hepatitis. Acute Hepatitis C is often asymptomatic and leads to chronic infection in about 75% of cases. During the chronic phase, manifestations range from an asymptomatic carrier state to chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Extrahepatic manifestations can occur in both acute and chronic infection. Pathophysiology is based on the inflammatory response to the virus that replicates in the hepatocyte [2–4].

Viral hepatitis is an important public health issue over the world, but there is still some gaps regarding the prevalence of these viruses in Latin America. Hepatitis B virus (HBV) infection has a heterogeneous distribution in Latin America and it is estimated at least 7–12 million people infected by virus [5]. Most of Latin American countries presented low seroprevalence (less than 2% of HBsAg positivity), including Mexico, Honduras, Nicaragua, Costa Rica, Panama, Cuba, Paraguay, Uruguay, Chile, Argentina, Peru and North Colombia. Intermediate seroprevalence (2.0–8.0% of HBsAg) are observed in Central America (Guatemala, Belize, El Salvador, Honduras, Haiti the Dominican Republic and Puerto Rico), Ecuador, Venezuela, Guyana, Surinam, French Guyana and South of Brazil. High seroprevalence (>8% of HBsAg presence) are observed in Peru, South Colombia, Northern Bolivia and Northern Brazil; how-

Hepatitis C virus (HCV) infection prevalence varies from 1.2 to 1.6% in Peru, Mexico, Venezuela, Argentina and Brazil where almost 80% were viremic [9]. According the same study, genotype 1 was the most frequent detected, but genotype 1b was the most prevalent in all countries except in Peru where genotype 1a was the highest prevalent. Díez-Padrisa et al. [7] reported that Grenada, Bolivia, Haiti, Trinidad and Tobago and El Salvador have the

Epidemiological studies to determine HBV and HCV prevalence are important, principally among high risk population, such as human immunodeficiency virus (HIV) infected subjects, drug users, hemophiliacs and chronic kidney patients. HIV individuals coinfected with HBV or HCV could present clinical complications of liver disease and increased risk of developing cirrhosis. Individuals who are drug and alcohol abusers are at risk of becoming infected with HBV or HCV due to unprotected sexual practices that are common to these users besides the sharing of needles and syringes [10]. Chronic kidney disease (CKD) and coagulopathy patients are often exposed to blood, such as during hemodialysis or blood components trans-

Knowing the scenario of HBV and HCV infection in Latin American countries (LAC) is important to raise awareness among the population and health professionals, strengthening preventive measures mainly among the high-risk population, increasing access to diagnosis, improving the attendance of the diagnosed cases, treatment and monitoring [7]. In this chapter, a narrative literature review was undertaken to give information for developing policies

fusion where the risk of contracting viral infections is also very high [11].

and Venezuela, which possess a rich cultural and natural heritage [1].

4 Public Health - Emerging and Re-emerging Issues

ever, these reports are primarily estimates [6–9].

highest prevalence (≥2.5%) in Latin America.

A narrative review of the literature was done using SCIELO, LILACS and MEDLINE® database searches in an iterative manner during December to April 2018 to retrieve articles related to current and historical epidemiological profile of hepatitis B and C in the countries of Latin America and the Caribbean.

Search terms included "hepatitis B," "hepatitis C," "HIV," "illicit substance," "drug user", "CKD", "dialysis", "coagulopathy", "prevalence", "epidemiology", "Latin America". The reference lists of each article found were also reviewed in detail to find additional articles.

All authors independently read each article in full text, evaluated the relevance and quality of retrieved articles to include the data, and recorded the main findings of each study to include the relevant articles in **Table 1**. Primary and secondary studies were included in the review, but duplicate studies were removed.

## **3. Results and discussion**

## **3.1. Hepatitis B and C prevalence in patients infected by HIV**

HIV infection can increase clinical complications of liver disease associated to HBV and HCV, such as increasing the risk of developing cirrhosis up to five times in those co-infected with HIV/HCV [12]. With antiretroviral therapy and a significant increase in the life expectancy of people living with HIV, liver disease in patients with HCV and/or HBV infection has become the leading cause of non-AIDS-related deaths in this population.

In Latin America and the Caribbean, the prevalence of HBV and HCV in people living with HIV is quite variable. Moreover, few data are available, unlike data for Europe and the United States [12]. Over the world, 10% of people infected with HIV are also coinfected with HBV [13], since both viruses has the parenteral and sexual pathways as a route of infection, coinfection of these two viruses are common [14].

According Tengan et al. [15], estimated prevalence of HBsAg in LAC ranged from 2.0% (95% CI 1.0–5.0%) to 15.0% (95% CI 9.0–24.0%) and pooled prevalence was 7.0% (95% CI 7.0–7.0%). They also observed a drop in HBsAg prevalence from 8.0% (95% CI 8.0–9.0%) in the 12 studies published from 1999 to 2006 to 6.0% (95% CI 5.0–6.0%) in 16 studies published from 2007 to 2016. The decrease in HBsAg prevalence could be related to implementation of vaccination against hepatitis B.

In Brazil, HBsAg prevalence in HIV infected individuals ranges from 1.9 to 10.3% according geographical regions [15–18]. Tengan et al. [15] reported HBsAg prevalence in HIV of 3.3% in


Germano et al.

Brazil

2010

Primary study

750 individuals and both

Risk population, HBV, HCV,

Voluntary Counseling and Testing

Latin America and prevalence

Users of illicit drugs, HBV, HCV,

Latin America and prevalence

Risk population, of illicit drugs,

HBV, HCV, Latin America and

prevalence

Center

genders,

[42]

Oliveira et al. [30]

Oliveira-Filho

Brazil

2013

Primary study

384 individuals and both

genders

et al. [41] Pazeto et al. [30] Cortês et al. [37]

Santos-Cruz et

[36]

Ferreira et al. [79] Marchesini et al.

Brazil

2007

Primary study

[32]

Matos et al. [33] Novaes et al. [32]

Andrade et al.

Brazil

2017

Primary study,

66 individuals, 28.4

and most were male

200 individuals and year

of 2005

 years

transversal

[29]

Frost et al. [48] Valtuille et al. [61]

Argentina

2002

Primary study

1994–2000

Mexico

2006

Primary study

Brazil

2009

Primary study,

314 individuals and male

transversal

gender

Brazil

2013

Primary study

149 individuals and both

genders

Brazil

2009

Primary study

1095 individuals and

Hemodialysis, HBV, HCV, Latin

Dialysis units

America and prevalence

Users of illicit drugs, HBV, HCV,

Public health clinics.

Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America

Latin America and prevalence

Users of illicit drugs, HBV, HCV,

Latin America and prevalence

Users of illicit drugs, HBV, HCV,

Latin America and prevalence

Users of illicit drugs, HBV, HCV,

Latin America and prevalence

http://dx.doi.org/10.5772/intechopen.79174

Users of illicit drugs, HBV, HCV,

Latin America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

7

disease, HBV, HCV, Latin

America and prevalence

both genders

205 individuals and both

genders

 al.

Brazil

2013

Primary study

160 individuals, ages

18–24, both genders from

2010 to 2011

Brazil

2013

Primary study

90 individuals and both

genders

Brazil

2012

Primary study

Individuals and both

Risk population, HBV, HCV,

Alcoholic individuals

Latin America and prevalence

Risk population, HBV, HCV,

Alcoholic individuals

Latin America and prevalence

Users of illicit drugs, HBV, HCV,

Latin America and prevalence

genders

Brazil

1999

Primary study

102 individuals and both

genders

**Country**

**Year** 

**Type of study**

**Methodology**

**Key findings**

**Comments, if any**


Alonso et al. [38]

Latin

2015

Secondary study/

53 studies included both

Injecting drug users, HBV, HCV,

Latin America and prevalence

analyze database/

genders

systematic review

America and

Caribe

Degenhardt et

[28]

Bautista-Amorocho et al.

Colombia

2014

Primary study

275 individuals,

HIV, HBV, HCV, Latin America

2009–2010, both genders

and prevalence

s

[14]

Mejia et al. [50]

Weissenbacher

Argentina

2003

Primary study

174 individuals, average

of 30 genders

years and both

et al. [45] Sheehan et al. [40]

Caiaffa et al. [46] Osimani et al. [43]

Monsalvand

Venezuela

2007

Primary study

197 individuals of both

Risk population, HBV, HCV,

Latin America and prevalence

Injecting drug users, HBV, HCV,

Latin America and prevalence

Injecting drug users, HBV, HCV,

Drug-treatment centers

Latin America and prevalence

genders

Castillo et al. [51]

Reyes et al. [47]

Lopes et al. [53]

Brazil

2009

Primary study

691 individuals, both

genders and 2005–2006

Porto Rico

2006

Primary study

400 individuals of both

genders

Uruguay

2003

Secondary study/

367 individuals, both

Users of illicit drugs, HBV, HCV,

Latin America and prevalence

genders and aging over

analyze database/

systematic review

18 years

Brazil

2006

Primary study

Argentina

2012

Primary study

205 individuals, age

Injecting drug users, HBV, HCV,

Latin America and prevalence

18–65

years, 2005–2006

and both genders

1144 individuals,

Injecting drug users, HBV, HCV,

Latin America and prevalence

1998–2001 and both

genders

Colombia

2004

Conference

No information

Injecting drug users, HBV, Latin

Summaries of a conference

America and prevalence

Injecting drug users, HBV, HCV,

Latin America and prevalence

 al.

Latin

2017

Secondary study/

976 studies/individuals

Injecting drug users, HBV, HCV,

Global study

6 Public Health - Emerging and Re-emerging Issues

Latin America and prevalence

analyze database/

15–64 genders

years, both

systematic review

America and

**Country**

**Year** 

**Type of study**

**Methodology**

**Key findings**

**Comments, if any**


Oliveira-Penido

Mexico

2008

Primary study

884 patients, between 41

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

HIV, HBV, HCV, Latin America

People living with HIV/AIDS

http://dx.doi.org/10.5772/intechopen.79174

and prevalence

and 60 majority male

years old and the

et al. [75] Leão et al. [76] Guimarães et al.

Brazil

2017

Primary study,

181 patients and the

majority male

cross-sectional study

[78]

de Jesus et al. [74]

Ribeiro Barbosa

Brazil

2017

Primary study,

798 patients

cross-sectional study

et al. [17] Callegaro et al.

Brazil

2006

Primary study

798 patients and year of

2000–2002

[72]

Carrilho et al. [80]

Ferreira et al. [81]

Tengan et al. [12]

Latin

2016

Systematic review

37 studies

American

countries

Greer et al. [19] Flores et al. [16]

Brazil

2017

Primary study,

409 individuals

HIV, HBV, HCV, Latin America

HCV+ our HBV+ individuals

9

and prevalence

cross-sectional study

Brazil

2017

Primary study

1241 HIV positive and

HIV, HBV, HCV, Latin America

and prevalence

1232 HIV negative

subjects

Brazil

2006

Primary study

1095 patients

Brazil

2004

Primary study

813 patients, 149

hemodialysis workers

and 772 healthy controls

Brazil

2013

Primary study

798 patients

Brazil

2010

Primary study,

236 patients and year

cross-sectional study

of 1995

**Country**

**Year** 

**Type of study**

**Methodology**

**Key findings**

**Comments, if any**


Marinovich et

[62]

Méndez-Chacon

Peru

2005

Primary study

128 patients and year

of 2000

et al. [59] Pujol et al. [60]

Gonzalez et al.

Chile

2000

Primary study

Year of 1995

[65]

Santana et al. [65] Cabezas et al. [67]

López et al. [59] González Michaca

Uruguay

2000

Cross-sectional

235 patients

study

et al. [68] Méndez-Sanchez

Mexico

2004

Primary study

149 patients

> et al. [69]

Paniagua et al.

Mexico

2010

Primary study,

368 patients and mean

cross-sectional study

age of 52 years

[77]

Uruguay

2005

Cross-sectional

409 patients

study

Cuba

2010

Primary study

Year of 1995

Cuba

2009

Multi-center analysis

Year of 1995

Venezuela

1996

Primary study

227 patients

 al.

Argentina

2012

Primary study

13,466 with mean age of

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

8 Public Health - Emerging and Re-emerging Issues

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence and

prevalence

Hemodialysis, chronic kidney

Multi-transfused patients

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

Hemodialysis, chronic kidney

Spread in hemodialysis

disease, HBV, HCV, Latin

America and prevalence

60.4 years

**Country**

**Year** 

**Type of study**

**Methodology**

**Key findings**

**Comments, if any**


**Table 1.** Main characteristics of studies included in the review according country and type of individuals. Colombia, 3.1% in Venezuela, 6.1–8.5% in Chile, 3.3–14.5% in Argentina, 5.1–10.3% in Cuba. Occult hepatitis B infection (OBI) has been reported in 3.8% of HIV infected individuals from Central West region in Brazil and 12% of Colombian HIV people [20, 21]. HBV genotype A was the most detected in studies from Brazil and Argentina while genotype F was most found

Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America

http://dx.doi.org/10.5772/intechopen.79174

All over the world, HIV/HCV coinfection is reported in 4% of HIV-infected people and prob

ability of HCV infection is six times higher in people living with HIV than in the general population [23]. Recently, a systematic review reported prevalence of HIV/HCV co-infection in Latin America of 8% varying from 5 to almost 50% according countries [23]. In LAC, the estimated seroprevalence of HCV infection varied from 0.8 to 58.5% (mean 17.37; median 10.91), with the highest in Argentina (58.5%) and Brazil (53.5%) and the lowest in Venezuela

The differences in HCV prevalence observed in LAC were probably due to difference in assays used and characteristics of the population included. In addition, it was observed that HCV prevalence is higher in HIV infected individuals compared to general population in

Recent studies found anti-HCV prevalence in HIV infected individuals of 1.3% in Northeast Brazil, 4.6% in Southeast Brazil, 12.9% in South Brazil, 6.9–9.7% in Midwest Brazil [16, 17,

This high rate of coinfection among these viruses is probably due to the common transmission of these infections, especially among high risk individuals, such as injecting drug users (IDU) living with HIV. Health preventive measures for reducing HBV and HCV infection in these

According to United Nations Office on Drugs and Crime (UNODC) [27], around 5% of the global adult population used illicit substance at least once in 2015 and 0.6% of global adult population suffer from drug use disorders [27]. The consumption of psychoactive substances is related to risks and damages of great social magnitude: unprotected sexual practices, shar

ing of syringes and needles, as well as exposure to sexually transmitted and parenteral infec

(IDU) is estimated at 7.4%, suggesting that 880,000 IDU are infected with HBV [27].

tions, such as HBV [10]. Worldwide prevalence of HBV infection among injecting drug users

In Latin America, the most consumed illicit substance by individuals at drug treatment is Cannabis (around 45%), followed by Cocaine (almost 40%). Recent systematic review demon

strated that HBsAg prevalence varies from 2 to 10% among people who inject drug (PWID) in Latin America countries [28]. In this review, studies published from 2011 to 2017 were included and most of PWID were young (aging less than 25 years), had history of arrest and

Most of prevalence studies of HBV in illicit substance users (ISU) in Latin America were con

ducted in Brazil, followed by Argentina, Colombia, Mexico and Uruguay. In Northern Brazil,

individuals could reduce the prevalence of hepatitis viruses in Latin America region.

–26]. In all of these studies, HCV genotype 1 was the most prevalent.

**3.2. HBV and HCV infection in illicit substance users**


11





in Colombia [17, 19

–22].

(0.7%) and Colombia (0.8%) [12].

Latin America countries [12].

incarceration, and use opioid.

24

Colombia, 3.1% in Venezuela, 6.1–8.5% in Chile, 3.3–14.5% in Argentina, 5.1–10.3% in Cuba. Occult hepatitis B infection (OBI) has been reported in 3.8% of HIV infected individuals from Central West region in Brazil and 12% of Colombian HIV people [20, 21]. HBV genotype A was the most detected in studies from Brazil and Argentina while genotype F was most found in Colombia [17, 19–22].

All over the world, HIV/HCV coinfection is reported in 4% of HIV-infected people and probability of HCV infection is six times higher in people living with HIV than in the general population [23]. Recently, a systematic review reported prevalence of HIV/HCV co-infection in Latin America of 8% varying from 5 to almost 50% according countries [23]. In LAC, the estimated seroprevalence of HCV infection varied from 0.8 to 58.5% (mean 17.37; median 10.91), with the highest in Argentina (58.5%) and Brazil (53.5%) and the lowest in Venezuela (0.7%) and Colombia (0.8%) [12].

The differences in HCV prevalence observed in LAC were probably due to difference in assays used and characteristics of the population included. In addition, it was observed that HCV prevalence is higher in HIV infected individuals compared to general population in Latin America countries [12].

Recent studies found anti-HCV prevalence in HIV infected individuals of 1.3% in Northeast Brazil, 4.6% in Southeast Brazil, 12.9% in South Brazil, 6.9–9.7% in Midwest Brazil [16, 17, 24–26]. In all of these studies, HCV genotype 1 was the most prevalent.

This high rate of coinfection among these viruses is probably due to the common transmission of these infections, especially among high risk individuals, such as injecting drug users (IDU) living with HIV. Health preventive measures for reducing HBV and HCV infection in these individuals could reduce the prevalence of hepatitis viruses in Latin America region.

## **3.2. HBV and HCV infection in illicit substance users**

**Authors** Toscano and

Brazil

2017

Primary study

2242 individuals

HIV, HBV, HCV, Latin America

People living with HIV/AIDS

and prevalence

HIV, HBV, HCV, Latin America

and prevalence

HIV, HBV, HCV, Latin America

People living with HIV/AIDS

10 Public Health - Emerging and Re-emerging Issues

and prevalence

HIV, HBV, HCV, Latin America

People living with HIV/AIDS

and prevalence

HIV, HBV, HCV, Latin America

People living with HIV/AIDS

and prevalence

HIV, HBV, HCV, Latin America

People living with HIV/AIDS

and prevalence

Corrêa [18]

Oliveira et al. [21]

Freitas et al. [24] Brandão et al. [25]

Tizzot et al. [26] Bautista-Amorocho et al.

Colombia

2014

Primary study

[20]

Quarleri et al. [22] Ballester et al. [95] Cuba

Beltrân et al. [71]

Laguna-Torres

Peru

2005

Cross-sectional

351 patients and year of

Hemophilia, HBV, HCV, Latin

America and prevalence

Hemophilia, HBV, HCV, Latin

Multi-transfused patients

Multi-transfused patients

America and prevalence

Hemophilia, HBV, HCV, Latin America and prevalence

Hemophilia, HBV, HCV, Latin

Patients with hemophilia A

America and prevalence

multi-center study

2003–2004

et al. [97] Vinelli and

Honduras

2005

Cross-sectional

502 patients and year of

2002–2005

study

Lorenzana [94]

Remesar et al.

Argentina

2005

Multi-center, crosssectional study

504 patients

[100]

Ferreira et al. [98]

**Table 1.**

Brazil

2014

Secondary study,

9122 patients

analyze database

Main characteristics of studies included in the review according country and type of individuals.

Colombia

2005

Primary study

500 individuals

2005

Primary study

318 individuals

Argentina

2007

Primary study

593 individuals

HIV, HBV, HCV, Latin America

People living with HIV/AIDS

and prevalence

Hemophilia, HBV, HCV, Latin

Multi-transfused patients

America and prevalence

Hemophilia, HBV, HCV, Latin

**Groups:** hemophilia, hemodialysis,

acute bleeding, ontological illnesses

and sickle cell disease or thalassemia

Multi-transfused patients

America and prevalence

Brazil

2016

Primary study

303 individuals and

mean age 41.2 years 275 individuals and year

of 2009–2010

Brazil

2015

Primary study

495 individuals

Brazil

2004

Primary study

848 individuals

Brazil

2016

Primary study

505 individuals

**Country**

**Year** 

**Type of study**

**Methodology**

**Key findings**

**Comments, if any**

**study**

According to United Nations Office on Drugs and Crime (UNODC) [27], around 5% of the global adult population used illicit substance at least once in 2015 and 0.6% of global adult population suffer from drug use disorders [27]. The consumption of psychoactive substances is related to risks and damages of great social magnitude: unprotected sexual practices, sharing of syringes and needles, as well as exposure to sexually transmitted and parenteral infections, such as HBV [10]. Worldwide prevalence of HBV infection among injecting drug users (IDU) is estimated at 7.4%, suggesting that 880,000 IDU are infected with HBV [27].

In Latin America, the most consumed illicit substance by individuals at drug treatment is Cannabis (around 45%), followed by Cocaine (almost 40%). Recent systematic review demonstrated that HBsAg prevalence varies from 2 to 10% among people who inject drug (PWID) in Latin America countries [28]. In this review, studies published from 2011 to 2017 were included and most of PWID were young (aging less than 25 years), had history of arrest and incarceration, and use opioid.

Most of prevalence studies of HBV in illicit substance users (ISU) in Latin America were conducted in Brazil, followed by Argentina, Colombia, Mexico and Uruguay. In Northern Brazil, HBV prevalence (anti-HBc positivity) was 36.7% in ISU, genotypes A, D and F were found and risk factors were: (i) male gender, (ii) age above 35 years, (iii) anti-HIV positivity, (iv) tattoos, (v) the use of injected drugs, (vi) the use of illicit drugs for more than 3 years, (vii) sexual relations without protection, (viii) sexual relations with another DU, and (ix) more than 10 sexual partners in the past 24 months [29]. In Southeast Brazil, anti-HBc prevalence around 55% was found among IDU in 1999 and IDU living with HIV in 2007. It is important to observe that HBsAg prevalence drops from 7.8 to 3.4% in this region what could be the result of vaccination campaigns [30–32]. Occult HBV infection (OBI) of 12.7% was also documented in IDU from Central West region of Brazil demonstrating a high prevalence of OBI in this population [33].

and the blood exposure to infectious materials through the extracorporeal circulation for a prolonged period. Moreover, hemodialysis patients may require blood transfusion, frequent hospitalizations and surgery, which increase opportunities for nosocomial infection exposure [11]. Most frequent viral infections reported hemodialysis units are HBV, HCV and HIV [54]. These infections influence negatively the survival of the hemodialysis patients and those

Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America

http://dx.doi.org/10.5772/intechopen.79174

13

Worldwide, HCV prevalence among patients on hemodialysis varies from as low as 1 to up to 70% [56] and the dialysis-related risk of HCV infection development is estimated at 2% per year [54]. Anti-HCV prevalence is low in Latin America (about 1.23%) [57] and varies from country to country, between regions of the same country and even among hemodialysis patients [58]. High anti-HCV prevalence was found in hemodialysis patients in Peru (59%) and from them, 4.5% had mixed infection with hepatitis B (HBsAg positive) [59]. In Venezuela, a study conducted in four hemodialysis units found 71% of anti-HCV and 25% of

In Argentina, a study demonstrated a drop in anti-HCV prevalence in a same hemodialysis unit showing prevalence of 41.5% in 1994; 26.9% in 1996; 12% in 1998 and 8.5% in 2000 [61]. According to the Chronic Dialysis Registry of Argentina, anti-HCV prevalence decreased

In Chile, anti-HCV prevalence varied from 30% in hemodialysis patients at 1993 to 13% 2 years later [64, 65]. In Cuba, despite the implementation of anti-HCV screening in 1995, high anti-HCV positivity was found in hemodialysis patients in 2009 (76%) and 2010 (18.8%) [66, 67]. In Mexico, anti-HCV prevalence of 10.2% was observed in CKD patients and 12.7% in those at hemodialysis [68]. Years later, a study showed that among 149 patients in hemodialysis, 6.7% presented anti-HCV antibodies and from them, 5% presented HCV RNA [69]. Anti-HCV prevalence of 6.3, 6.5, 59% in hemodialysis patients from Uruguay, Colombia, Peru

In Brazil, some studies have been performed to evaluate HCV prevalence in different hemodialysis units. In 2006, among 70 patients of the south region undergoing hemodialysis, seven (10%) presented HCV infection [72]. Still in 2006, but in Salvador city (Northeast Brazil), the anti-HCV prevalence among hemodialysis patients was 10.5% with detectable HCV RNA in 73.6% of them. In this study, the most frequent HCV genotype was genotype 1 followed by genotypes 3 and 2 [73]. In North region, anti-HCV prevalences from 4 to 14% were found in 7 dialysis center in Para State in 2013. In this study, HCV RNA was detected in 5.3% of the patients and genotype 1 was the most frequent, followed by genotypes 2 and 3 [74]. Recently, Barbosa-Ribeiro et al. [17] found 12.6% of anti-HCV prevalence in Hemodialysis patients at Northeast Brazil. In Southeast region, anti-HCV prevalence of 13 and 14.8% was found in 2008

HBV prevalence varies in CKD patients in Latin America. In Mexico [77] found 7.1% of HBsAg prevalence in 10 hemodialysis units at 2010 and two of them were co-infected with HCV (0.5%) [77]. In Uruguay, HBsAg prevalence of 1% was found in hemodialysis patients probably due to mandatory screening of blood donors and patients for HBsAg since 1981 [71].

from 2% in 2004 to 1% in 2011 and global HCV prevalence was 4.9% in 2011 [62, 63].

undergoing renal transplant [55].

HBsAg among hemodialysis patients [60].

[59, 70, 71].

and 2010 years [75, 76].

Among non-injecting drug users (NIDU) (crack, alcohol, marijuana, cocaine), HBsAg prevalence varies from 0.1 to 6.2% according geographical regions in Brazil showing a low risk in this group compared to IDU [34–37].

HCV prevalence varies among ISU in Latin America. Degenhardt et al. [28] estimates prevalences less than 40% and higher than 80% among IDU in Latin America. A recent review included studies from 2000 to 2013 conducted in Argentina, Brazil, Colombia, Dominican Republic, Mexico, Panama, Peru, Puerto Rico, Uruguay and Venezuela [38]. Anti-HCV prevalence in ISU was below 7% in the majority of studies included in this review, but anti-HCV rates from 30 to 67% were found in ISU in Argentina and Brazil [39–41].

In NIDU, anti-HCV ranged from 0 to 10% with the highest values found in Brazil (8%), and Uruguay (10% in 2003) [42]. Studies conducted in alcohol abusers found 5.6% of anti-HCV in Southeast Brazil [37] and 15% in Southern Brazil [43] what could reflect the diminish in anti-HCV prevalence in this group. The pooled value for HCV prevalence in NIDU was 3.6% (95% CI 2.6–4.5%) [38].

HCV infection rate for IDU varied considerably between and within countries. The highest values were reported in Argentina (55% in 2001) [44], Brazil (53% in 1998, 46% in 2001) [45], Puerto Rico (89% in 2006) [46] and Mexico (Ciudad Juarez and Tijuana) (96% in 2005) [47]. Studies in Colombia (Bogota) found anti-HCV prevalence of 0 and 1.7% in IDU [48, 49]. Pooled regional anti-HCV prevalence among IDU was 49% (95% CI 22.6–76.3%) with significant heterogeneity among studies [38].

HCV current infection (both anti-HCV and HCV-RNA) varies from 0% in drug users from Venezuela [50] to almost 60% in IDU in North Brazil [41]. Only three studies from Brazil [41, 51–53] determined HCV genotypes. The study from Pará found a high prevalence of genotype 1b (42%), especially in NIDU (50%), while in the other two studies, individuals had genotype 1a in over 60%.

### **3.3. Hepatitis B and C prevalence in patients with chronic kidney disease patients under dialysis treatment**

It is well known that patients undergoing dialysis treatment are at increased risk for contracting viral infections. The reasons may be their underlying impaired cellular immunity and the blood exposure to infectious materials through the extracorporeal circulation for a prolonged period. Moreover, hemodialysis patients may require blood transfusion, frequent hospitalizations and surgery, which increase opportunities for nosocomial infection exposure [11]. Most frequent viral infections reported hemodialysis units are HBV, HCV and HIV [54]. These infections influence negatively the survival of the hemodialysis patients and those undergoing renal transplant [55].

HBV prevalence (anti-HBc positivity) was 36.7% in ISU, genotypes A, D and F were found and risk factors were: (i) male gender, (ii) age above 35 years, (iii) anti-HIV positivity, (iv) tattoos, (v) the use of injected drugs, (vi) the use of illicit drugs for more than 3 years, (vii) sexual relations without protection, (viii) sexual relations with another DU, and (ix) more than 10 sexual partners in the past 24 months [29]. In Southeast Brazil, anti-HBc prevalence around 55% was found among IDU in 1999 and IDU living with HIV in 2007. It is important to observe that HBsAg prevalence drops from 7.8 to 3.4% in this region what could be the result of vaccination campaigns [30–32]. Occult HBV infection (OBI) of 12.7% was also documented in IDU from Central West region of Brazil demonstrating a high prevalence of OBI in this

Among non-injecting drug users (NIDU) (crack, alcohol, marijuana, cocaine), HBsAg prevalence varies from 0.1 to 6.2% according geographical regions in Brazil showing a low risk in

HCV prevalence varies among ISU in Latin America. Degenhardt et al. [28] estimates prevalences less than 40% and higher than 80% among IDU in Latin America. A recent review included studies from 2000 to 2013 conducted in Argentina, Brazil, Colombia, Dominican Republic, Mexico, Panama, Peru, Puerto Rico, Uruguay and Venezuela [38]. Anti-HCV prevalence in ISU was below 7% in the majority of studies included in this review, but anti-HCV

In NIDU, anti-HCV ranged from 0 to 10% with the highest values found in Brazil (8%), and Uruguay (10% in 2003) [42]. Studies conducted in alcohol abusers found 5.6% of anti-HCV in Southeast Brazil [37] and 15% in Southern Brazil [43] what could reflect the diminish in anti-HCV prevalence in this group. The pooled value for HCV prevalence in NIDU was 3.6%

HCV infection rate for IDU varied considerably between and within countries. The highest values were reported in Argentina (55% in 2001) [44], Brazil (53% in 1998, 46% in 2001) [45], Puerto Rico (89% in 2006) [46] and Mexico (Ciudad Juarez and Tijuana) (96% in 2005) [47]. Studies in Colombia (Bogota) found anti-HCV prevalence of 0 and 1.7% in IDU [48, 49]. Pooled regional anti-HCV prevalence among IDU was 49% (95% CI 22.6–76.3%) with signifi-

HCV current infection (both anti-HCV and HCV-RNA) varies from 0% in drug users from Venezuela [50] to almost 60% in IDU in North Brazil [41]. Only three studies from Brazil [41, 51–53] determined HCV genotypes. The study from Pará found a high prevalence of genotype 1b (42%), especially in NIDU (50%), while in the other two studies, individuals had genotype

It is well known that patients undergoing dialysis treatment are at increased risk for contracting viral infections. The reasons may be their underlying impaired cellular immunity

**3.3. Hepatitis B and C prevalence in patients with chronic kidney disease patients** 

rates from 30 to 67% were found in ISU in Argentina and Brazil [39–41].

population [33].

(95% CI 2.6–4.5%) [38].

1a in over 60%.

**under dialysis treatment**

cant heterogeneity among studies [38].

this group compared to IDU [34–37].

12 Public Health - Emerging and Re-emerging Issues

Worldwide, HCV prevalence among patients on hemodialysis varies from as low as 1 to up to 70% [56] and the dialysis-related risk of HCV infection development is estimated at 2% per year [54]. Anti-HCV prevalence is low in Latin America (about 1.23%) [57] and varies from country to country, between regions of the same country and even among hemodialysis patients [58]. High anti-HCV prevalence was found in hemodialysis patients in Peru (59%) and from them, 4.5% had mixed infection with hepatitis B (HBsAg positive) [59]. In Venezuela, a study conducted in four hemodialysis units found 71% of anti-HCV and 25% of HBsAg among hemodialysis patients [60].

In Argentina, a study demonstrated a drop in anti-HCV prevalence in a same hemodialysis unit showing prevalence of 41.5% in 1994; 26.9% in 1996; 12% in 1998 and 8.5% in 2000 [61]. According to the Chronic Dialysis Registry of Argentina, anti-HCV prevalence decreased from 2% in 2004 to 1% in 2011 and global HCV prevalence was 4.9% in 2011 [62, 63].

In Chile, anti-HCV prevalence varied from 30% in hemodialysis patients at 1993 to 13% 2 years later [64, 65]. In Cuba, despite the implementation of anti-HCV screening in 1995, high anti-HCV positivity was found in hemodialysis patients in 2009 (76%) and 2010 (18.8%) [66, 67]. In Mexico, anti-HCV prevalence of 10.2% was observed in CKD patients and 12.7% in those at hemodialysis [68]. Years later, a study showed that among 149 patients in hemodialysis, 6.7% presented anti-HCV antibodies and from them, 5% presented HCV RNA [69]. Anti-HCV prevalence of 6.3, 6.5, 59% in hemodialysis patients from Uruguay, Colombia, Peru [59, 70, 71].

In Brazil, some studies have been performed to evaluate HCV prevalence in different hemodialysis units. In 2006, among 70 patients of the south region undergoing hemodialysis, seven (10%) presented HCV infection [72]. Still in 2006, but in Salvador city (Northeast Brazil), the anti-HCV prevalence among hemodialysis patients was 10.5% with detectable HCV RNA in 73.6% of them. In this study, the most frequent HCV genotype was genotype 1 followed by genotypes 3 and 2 [73]. In North region, anti-HCV prevalences from 4 to 14% were found in 7 dialysis center in Para State in 2013. In this study, HCV RNA was detected in 5.3% of the patients and genotype 1 was the most frequent, followed by genotypes 2 and 3 [74]. Recently, Barbosa-Ribeiro et al. [17] found 12.6% of anti-HCV prevalence in Hemodialysis patients at Northeast Brazil. In Southeast region, anti-HCV prevalence of 13 and 14.8% was found in 2008 and 2010 years [75, 76].

HBV prevalence varies in CKD patients in Latin America. In Mexico [77] found 7.1% of HBsAg prevalence in 10 hemodialysis units at 2010 and two of them were co-infected with HCV (0.5%) [77]. In Uruguay, HBsAg prevalence of 1% was found in hemodialysis patients probably due to mandatory screening of blood donors and patients for HBsAg since 1981 [71]. In Brazil, prevalence of HBsAg of 0, 2.4, 7, 10, 34.1% were reported in hemodialysis center in Southeast, Central, Northeast, South and Midwest regions of Brazil [78–82]. HBsAg prevalence of 4.5, 25, 1.4% was found in hemodialysis patients in Peru, Venezuela, Cuba [59, 67].

cities of Bogotá and Medellin in 2003 presented 32.2% of anti-HCV [74]. In Peru, a study with multi-transfused patients from the seven largest hospitals in the country revealed 56.6% of anti-HCV prevalence [97]. In Honduras, 8 hospitals in the cities of Tegucigalpa and San Pedro Sula identified anti-HCV prevalence of 26.9% [94]. In Mexico, 46.3% of anti-HCV prevalence was found in hemophiliacs at 2008 [93]. In Argentina, 42.7% of anti-HCV positivity was found in hemophiliacs from 2002 to 2004 [100]. As the same was found for HBV, Ferreira et al. [98] observed a decrease in anti-HCV prevalence from 24.2% in 2007 to 4.7% in 2012. However, recent study in coagulopathy patients from Northeast Brazil found 47% of anti-HCV preva-

Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America

http://dx.doi.org/10.5772/intechopen.79174

15

In Latin America countries, HBV and HCV infection are still great public health problem in individuals infected by HIV, CKD patients, coagulopathy patients, illicit substance abusers. Prevalences of these infections are higher in these individuals compared to general population and different patterns of epidemiology were found between and within countries probably due to differences in access to diagnosis and treatment in these regions. A fall in the prevalence of HBV and HCV infection has been observed in these groups due to HBV immunization and HCV screening especially among CKD and coagulopathy patients. However, outbreaks still happen in these groups showing the importance of education programs to

The recommendations for each group are: among CKD and coagulopathy individuals, it is important to provide access to sensitive methods of diagnosis, screening of blood products and equipment and HBV vaccination. Among ISUs and HIV infected individuals, it is important to provide access to diagnosis, increase prevention and education campaigns to reduce the risk of acquiring HBV and HCV due to risky sexual behavior or sharing of needles and syringes. Vaccination against HBV should also be a priority in these groups. All these recommendations must be made in all countries of Latin America since epidemiological differences between HBV and HCV infection among countries is based on the different investments made

The authors would like to thank the financial support of Fundação de Amparo a Pesquisa do Estado do Rio de Janeiro (FAPERJ), Brazilian National Counsel of Technological and Scientific

lence [17].

**4. Conclusion(s)**

prevent the transmission of these viruses.

**Acknowledgements**

**Conflict of interest**

The authors declare no conflict of interest.

in health, especially those related to diagnosis and prevention.

Development (CNPq), and Oswaldo Cruz Foundation (FIOCRUZ).

Among patients undergoing hemodialysis, it is relatively common to observe occult hepatitis B cases due to vial of transmission and prolonged vascular access [83]. In Brazil, prevalence of OBI of 1.5, 3 and 15% was found in Northeast and Southeast region of Brazil [83–85]. HBV genotype A was the most prevalent in these studies.

## **3.4. HBV and HCV infection among coagulopathy patients**

Hereditary coagulopathies are hemorrhagic diseases resulting from deficiency of one or more plasma coagulation proteins, implying a reduction in the formation of thrombin which is a key factor for blood clotting. Among hereditary hemorrhagic disorders, hemophilia (type A and B) and von Willebrand's disease (VWD) are the most common [86]. Hemophilia A and B are X-linked hemorrhagic disorders caused by mutations in the factor VIII and factor IX genes, affecting almost exclusively male individuals. Both factors play a role in the intrinsic pathway of blood clotting and the affected individuals present severe, moderate and mild forms of disease defined by plasma coagulation factor levels [87]. While VWD is caused by a decreased or dysfunction of the protein called Von Willebrand Factor (VWF) and affects both genders. The diversity of mutations leads to the appearance of several clinical manifestations, manifesting with platelet dysfunction associated with the decrease of serum levels of factor VIII [88].

Worldwide, it is estimated that hemophilia affects 1 in 5000 newborns while VWD reaches from 0.8 to 2% of the population. According to the 2015 global annual report of the World Federation of Hemophilia, which included data from more than 304,000 people with hereditary coagulopathy from 111 countries, 49.7% of the cases were from hemophilia A, 9.9% from hemophilia B, 24.6% of DVW and 13.9% of other coagulopathies [86].

The treatment of coagulopathies is based on the replacement of the deficient coagulation factor, when there are hemorrhagic manifestations or as primary prophylaxis. This therapy increases the survival of these patients and their success in preventing the different hemorrhagic manifestations [89, 90]. On the other hand, due to multiple blood transfusions and use of cryoprecipitate, elaborated from a pool of frozen human plasma, these individuals are at risk for transmission of infectious agents, such as hepatitis B and C viruses [91, 92].

Most of viral infections occurred before 1985, when inactivation techniques were introduced in clotting factor concentrates. Thus, countries in Latin America, as well as other regions of the world, suffer the impact of these viral infections, which have evolved into chronic cases of the disease.

HBsAg prevalences were 2.4, 6, 24, 33.3 and 42% in coagulopathy patients from Mexico, Honduras, Cuba, Colombia, Peru [93–97]. In Brazil, it was possible to observe a significant decrease in the prevalence of HBsAg over the years, being 2.3% in 2007 and 1.0% in 2012 [98].

Regarding anti-HCV prevalence in coagulopathy patients, a universal screening in 1995 identified 51.6% of anti-HCV in hemophiliac patients from Cuba [95]. In 2007 to 2010, anti-HCV prevalence was 39.03% in this group in Cuba [99]. While in Colombia, patients from the cities of Bogotá and Medellin in 2003 presented 32.2% of anti-HCV [74]. In Peru, a study with multi-transfused patients from the seven largest hospitals in the country revealed 56.6% of anti-HCV prevalence [97]. In Honduras, 8 hospitals in the cities of Tegucigalpa and San Pedro Sula identified anti-HCV prevalence of 26.9% [94]. In Mexico, 46.3% of anti-HCV prevalence was found in hemophiliacs at 2008 [93]. In Argentina, 42.7% of anti-HCV positivity was found in hemophiliacs from 2002 to 2004 [100]. As the same was found for HBV, Ferreira et al. [98] observed a decrease in anti-HCV prevalence from 24.2% in 2007 to 4.7% in 2012. However, recent study in coagulopathy patients from Northeast Brazil found 47% of anti-HCV prevalence [17].

## **4. Conclusion(s)**

In Brazil, prevalence of HBsAg of 0, 2.4, 7, 10, 34.1% were reported in hemodialysis center in Southeast, Central, Northeast, South and Midwest regions of Brazil [78–82]. HBsAg prevalence of 4.5, 25, 1.4% was found in hemodialysis patients in Peru, Venezuela, Cuba [59, 67].

Among patients undergoing hemodialysis, it is relatively common to observe occult hepatitis B cases due to vial of transmission and prolonged vascular access [83]. In Brazil, prevalence of OBI of 1.5, 3 and 15% was found in Northeast and Southeast region of Brazil [83–85]. HBV

Hereditary coagulopathies are hemorrhagic diseases resulting from deficiency of one or more plasma coagulation proteins, implying a reduction in the formation of thrombin which is a key factor for blood clotting. Among hereditary hemorrhagic disorders, hemophilia (type A and B) and von Willebrand's disease (VWD) are the most common [86]. Hemophilia A and B are X-linked hemorrhagic disorders caused by mutations in the factor VIII and factor IX genes, affecting almost exclusively male individuals. Both factors play a role in the intrinsic pathway of blood clotting and the affected individuals present severe, moderate and mild forms of disease defined by plasma coagulation factor levels [87]. While VWD is caused by a decreased or dysfunction of the protein called Von Willebrand Factor (VWF) and affects both genders. The diversity of mutations leads to the appearance of several clinical manifestations, manifesting with platelet dysfunction associated with the decrease of serum levels of factor VIII [88]. Worldwide, it is estimated that hemophilia affects 1 in 5000 newborns while VWD reaches from 0.8 to 2% of the population. According to the 2015 global annual report of the World Federation of Hemophilia, which included data from more than 304,000 people with hereditary coagulopathy from 111 countries, 49.7% of the cases were from hemophilia A, 9.9% from

The treatment of coagulopathies is based on the replacement of the deficient coagulation factor, when there are hemorrhagic manifestations or as primary prophylaxis. This therapy increases the survival of these patients and their success in preventing the different hemorrhagic manifestations [89, 90]. On the other hand, due to multiple blood transfusions and use of cryoprecipitate, elaborated from a pool of frozen human plasma, these individuals are at

Most of viral infections occurred before 1985, when inactivation techniques were introduced in clotting factor concentrates. Thus, countries in Latin America, as well as other regions of the world, suffer the impact of these viral infections, which have evolved into chronic cases

HBsAg prevalences were 2.4, 6, 24, 33.3 and 42% in coagulopathy patients from Mexico, Honduras, Cuba, Colombia, Peru [93–97]. In Brazil, it was possible to observe a significant decrease in the prevalence of HBsAg over the years, being 2.3% in 2007 and 1.0% in 2012 [98]. Regarding anti-HCV prevalence in coagulopathy patients, a universal screening in 1995 identified 51.6% of anti-HCV in hemophiliac patients from Cuba [95]. In 2007 to 2010, anti-HCV prevalence was 39.03% in this group in Cuba [99]. While in Colombia, patients from the

risk for transmission of infectious agents, such as hepatitis B and C viruses [91, 92].

genotype A was the most prevalent in these studies.

14 Public Health - Emerging and Re-emerging Issues

**3.4. HBV and HCV infection among coagulopathy patients**

hemophilia B, 24.6% of DVW and 13.9% of other coagulopathies [86].

of the disease.

In Latin America countries, HBV and HCV infection are still great public health problem in individuals infected by HIV, CKD patients, coagulopathy patients, illicit substance abusers. Prevalences of these infections are higher in these individuals compared to general population and different patterns of epidemiology were found between and within countries probably due to differences in access to diagnosis and treatment in these regions. A fall in the prevalence of HBV and HCV infection has been observed in these groups due to HBV immunization and HCV screening especially among CKD and coagulopathy patients. However, outbreaks still happen in these groups showing the importance of education programs to prevent the transmission of these viruses.

The recommendations for each group are: among CKD and coagulopathy individuals, it is important to provide access to sensitive methods of diagnosis, screening of blood products and equipment and HBV vaccination. Among ISUs and HIV infected individuals, it is important to provide access to diagnosis, increase prevention and education campaigns to reduce the risk of acquiring HBV and HCV due to risky sexual behavior or sharing of needles and syringes. Vaccination against HBV should also be a priority in these groups. All these recommendations must be made in all countries of Latin America since epidemiological differences between HBV and HCV infection among countries is based on the different investments made in health, especially those related to diagnosis and prevention.

## **Acknowledgements**

The authors would like to thank the financial support of Fundação de Amparo a Pesquisa do Estado do Rio de Janeiro (FAPERJ), Brazilian National Counsel of Technological and Scientific Development (CNPq), and Oswaldo Cruz Foundation (FIOCRUZ).

## **Conflict of interest**

The authors declare no conflict of interest.

## **Author details**

Livia Melo Villar\*, Helena Medina Cruz, Moyra Machado Portilho, Jakeline Ribeiro Barbosa, Ana Carolina Fonseca da Mendonça and Geane Lopes Flores

[11] Karkar A, Abdelrahman M, Ghacha R, Malik TQ. Prevention of viral transmission in HD units: The value of isolation. Saudi Journal of Kidney Diseases and Transplantation.

Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America

http://dx.doi.org/10.5772/intechopen.79174

17

[12] Tengan FM, Ibrahim KY, Dantas BP, Manchiero C, Magri MC, Bernardo WM. Seroprevalence of hepatitis C virus among people living with HIV/AIDS in Latin America

and the Caribbean: A systematic review. BMC Infectious Diseases. 2016;**16**(1):663 [13] Sun H-Y, Sheng W-H, Tsai M-S, Lee K-Y, Chang S-Y, Hung C-C. Hepatitis B virus coinfection in human immunodeficiency virus-infected patients: A review. World Journal of

[14] Konopnicki D, Mocroft A, de Wit S, Antunes F, Ledergerber B, Katlama C, et al. Hepatitis B and HIV: Prevalence, AIDS progression, response to highly active antiretroviral ther-

[15] Tengan FM, Abdala E, Nascimento M, Bernardo WM, Barone AA. Prevalence of hepatitis B in people living with HIV/AIDS in Latin America and the Caribbean: A systematic review and meta-analysis. BMC Infectious Diseases. 2017;**17**(1):587. DOI: 10.1186/

[16] Flores GL, de Almeida AJ, Miguel JC, Cruz HM, Portilho MM, Scalioni Lde P, Marques VA, Lewis-Ximenez LL, Lampe E, Villar LM. A cross section study to determine the prevalence of antibodies against HIV infection among hepatitis B and C infected individuals. International Journal of Environmental Research and Public Health 2016;**13**(3).

[17] Ribeiro Barbosa J, Sousa Bezerra C, Carvalho-Costa FA, Pimentel de Azevedo C, Lopes Flores G, Baima Colares JK, Malta Lima D, Lampe E, Melo Villar L. Cross-sectional study to determine the prevalence of hepatitis B and C virus infection in high risk groups in the northeast region of Brazil. International Journal of Environmental Research and Public

[18] Toscano AL, Corrêa MC. Evolution of hepatitis B serological markers in HIV coinfected patients: A case study. Revista de Saúde Pública. 2017;**51**(0):24. DOI: 10.1590/

[19] Greer AE, Ou SS, Wilson E, Piwowar-Manning E, Forman MS, McCauley M, Gamble T, Ruangyuttikarn C, Hosseinipour MC, Kumarasamy N, Nyirenda M, Grinsztejn B, Pilotto JH, Kosashunhanan N, Gonçalves de Melo M, Makhema J, Akelo V, Panchia R, Badal-Faesen S, Chen YQ, Cohen MS, Eshleman SH, Thio CL, Valsamakis A. Comparison of hepatitis B virus infection in HIV-infected and HIV-uninfected participants enrolled in a multinational clinical trial: HPTN 052. Journal of Acquired Immune Deficiency

[20] Bautista-Amorocho H, Castellanos-Domínguez YZ, Rodríguez-Villamizar LA, Velandia-Cruz SA, Becerra-Peña JA, Farfán-García AE. Epidemiology, risk factors and genotypes of 16. HBV in HIV-infected patients in the northeast region of Colombia: High prevalence of occult hepatitis B and F3 subgenotype dominance. PLoS One. 2014;**9**(12):e114272.

Syndromes. 2017;**76**(4):388-393. DOI: 10.1097/QAI.0000000000001511

Gastroenterology. 2014;**20**(40):14598-14614. DOI: 10.3748/wjg.v20.i40.14598

apy and increased mortality in the Euro SIDA cohort. AIDS. 2005;**19**:593-601

2006;**17**(2):183-188

s12879-017-2695-z

pii: E314. DOI: 10.3390/ijerph13030314

S1518-8787.2017051006693

DOI: 10.1371/journal.pone.0114272

Health 2017;**14**(7). pii: E793. DOI: 10.3390/ijerph14070793

\*Address all correspondence to: lvillar@ioc.fiocruz.br

Viral Hepatitis Laboratory, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil

## **References**


[11] Karkar A, Abdelrahman M, Ghacha R, Malik TQ. Prevention of viral transmission in HD units: The value of isolation. Saudi Journal of Kidney Diseases and Transplantation. 2006;**17**(2):183-188

**Author details**

16 Public Health - Emerging and Re-emerging Issues

**References**

OUERJ; 2015. 215 p

Livia Melo Villar\*, Helena Medina Cruz, Moyra Machado Portilho, Jakeline Ribeiro Barbosa,

[1] World Heritage Convention. Latin America and the Caribbean. [Internet]. 2018. Available

[2] de Paula VS, Bottecchia M, Villar LM, Cortes VF, Scalioni LP, dos Santos DL, Baroni MT, Cunha RS, Martins TP. Manual de Hepatites Virais. 1st ed. Rio de Janeiro: Rede Sirius;

[3] Mohr R, Boesecke C, Wasmuth J-C. Hepatitis B. In: Mauss, Berg, Rockstroh, Sarrazin, Wedemeyer, editors. Hepatology: A Clinical Textbook. 8th ed. Druckerei Heinrich

[4] Boesecke C, Wasmuth J-C. Hepatitis C. In: Mauss, Berg, Rockstroh, Sarrazin, Wedemeyer, editors. Hepatology: A Clinical Textbook. 8th ed. Druckerei Heinrich GmbH; 2017.

[5] Roman S, Jose-Abrego A, Fierro NA, Escobedo-Melendez G, Ojeda-Granados C, Martinez-Lopez E, Panduro A. Hepatitis B virus infection in Latin America: A genomic medicine approach. World Journal of Gastroenterology. 2014;**20**(23):7181-7196. DOI:

[6] Alvarado-Mora MV, Pinho JR. Epidemiological update of hepatitis B, C and delta in Latin America. Antiviral Therapy. 2013;**18**(3 Pt B):429-433. DOI: 10.3851/IMP2595

[7] Díez-Padrisa N, Castellanos LG, PAHO Viral Hepatitis Working Group. Viral hepatitis in Latin America and the Caribbean: A public health challenge. Revista Panamericana de

[8] Zampino R, Boemio A, Sagnelli C, Alessio L, Adinolfi LE, Sagnelli E, Coppola N. Hepatitis B virus burden in developing countries. World Journal of Gastroenterology.

[9] Gower E, Estes C, Blach S, Razavi-Shearer K, Razavi H.Global epidemiology and genotype distribution of the hepatitis C virus infection. Journal of Hepatology. 2014;**61**(Suppl 1):

[10] Cella WR, Rech K, Paraboni MLR, Cichota LC. Prevalence of hepatitis B and C in therapeutic communities of drug addicts and alcohol users. Perspectiva, Erechim.

Ana Carolina Fonseca da Mendonça and Geane Lopes Flores

Viral Hepatitis Laboratory, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil

from: http://whc.unesco.org/en/lac/ [Accessed: 2018-04-01]

GmbH; 2017. pp. 39-54. ISBN: 978-3-941727-22-9

pp. 55-68. ISBN: 978-3-941727-22-9

Salud Pública. 2013;**34**(4):275-281

S45-S57. DOI: 10.1016/j.jhep.2014.07.027

2015;**39**(145):109-120

2015;**21**(42):11941-11953. DOI: 10.3748/wjg.v21.i42.11941

10.3748/wjg.v20.i23.7181

\*Address all correspondence to: lvillar@ioc.fiocruz.br


[21] Oliveira MP, Lemes PS, Matos MA, Del-Rios NH, Carneiro MA, Silva ÁM, Lopes CL, Teles SA, Aires RS, Lago BV, Araujo NM, Martins RM. Overt and occult hepatitis B virus infection among treatment-naïve HIV-infected patients in Brazil. Journal of Medical Virology. 2016;**88**(7):1222-1229. DOI: 10.1002/jmv.24462

[31] Oliveira SA, Hacker MA, Oliveira ML, Yoshida CF, Telles PR, Bastos FI. A window of opportunity: Declining rates of hepatitis B virus infection among injection drug users in Rio de Janeiro, and prospects for targeted hepatitis B vaccination. Revista Panamericana

Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America

http://dx.doi.org/10.5772/intechopen.79174

19

[32] Marchesini AM, Prá-Baldi ZP, Mesquita F, Bueno R, Buchalla CM. Hepatitis B and C among injecting drug users living with HIV in São Paulo, Brazil. Revista de Saúde

[33] Matos MA, Ferreira RC, Rodrigues FP, Marinho TA, Lopes CL, Novais AC, Motta-Castro AR, Teles SA, Souto FJ, Martins RM. Occult hepatitis B virus infection among injecting drug users in the Central-West Region of Brazil. Memórias do Instituto Oswaldo Cruz. 2013;**108**(3). pii: S0074-02762013000300386. DOI: 10.1590/S0074-02762013000300019

[34] Ferreira RC, Rodrigues FP, Teles SA, Lopes CL, Motta-Castro AR, Novais AC, Souto FJ, Martins RM. Prevalence of hepatitis B virus and risk factors in Brazilian non-injecting drug users. Journal of Medical Virology. 2009;**81**(4):602-609. DOI: 10.1002/jmv.21464

[35] Pazeto DL, Pazeto CL, Bertolini DA, Hoss KA. Prevalência de marcadores sorológicos de hepatite B em pacientes internados para tratamento de alcoolismo em uma unidade de saúde mental do oeste catarinense. Revista Brasileira de Análises Clínicas. 2012;**44**:87-92

[36] Santos Cruz M, Andrade T, Bastos FI, Leal E, Bertoni N, Villar LM, Tiesmaki M, Fischer B. Key drug use, health and socio-economic characteristics of young crack users in two Brazilian cities. The International Journal on Drug Policy. 2013;**24**(5):432-438. DOI:

[37] Cortes VF, Taveira A, Cruz HM, Reis AA, Cezar JS, Silva BS, D'Assunção CF, Lampe E, Villar LM. Prevalence of hepatitis B and C virus infection among alcoholic individuals: Importance of screening and vaccination. Revista do Instituto de Medicina Tropical de

[38] Alonso M, Gutzman A, Mazin R, Pinzon CE, Reveiz L, Ghidinelli M. Hepatitis C in key populations in Latin America and the Caribbean: Systematic review and metaanalysis. International Journal of Public Health. 2015;**60**(7):789-798. DOI: 10.1007/s00038-

[39] Cocozella DR, Albuquerque MM, Borzi S, et al. Prevalence of hepatic involvement, alcoholism, hepatis B, C and HIV in patients with background history of drug use. Acta Gas

[40] Sheehan HB, Benetucci J, Muzzio E, et al. High rates of serum selenium deficiency among HIV- and HCV-infected and uninfected drug users in Buenos Aires, Argentina.

[41] Oliveira-Filho AB, Sawada L, Pinto LC, et al. HCV infection among cocaine users in the state of Para, Brazilian Amazon. Archives of Virology. 2013;**158**(7):1555-1560. DOI:

Public Health Nutrition. 2012;**15**(3):538-545. DOI: 10.1017/S1368980011001364

São Paulo. 2017;**59**:e47. DOI: 10.1590/S1678-9946201759047

troenterologica Latinoamericana. 2003;**33**(4):177-181

de Salud Pública. 2005;**18**(4-5):271-277

Pública. 2007;**41**(Suppl 2):57-63

10.1016/j.drugpo.2013.03.012

10.1007/s00705-013-1627-5

015-0708-5


[31] Oliveira SA, Hacker MA, Oliveira ML, Yoshida CF, Telles PR, Bastos FI. A window of opportunity: Declining rates of hepatitis B virus infection among injection drug users in Rio de Janeiro, and prospects for targeted hepatitis B vaccination. Revista Panamericana de Salud Pública. 2005;**18**(4-5):271-277

[21] Oliveira MP, Lemes PS, Matos MA, Del-Rios NH, Carneiro MA, Silva ÁM, Lopes CL, Teles SA, Aires RS, Lago BV, Araujo NM, Martins RM. Overt and occult hepatitis B virus infection among treatment-naïve HIV-infected patients in Brazil. Journal of Medical

[22] Quarleri J, Moretti F, Bouzas MB, Laufer N, Carrillo MG, Giuliano SF, Pérez H, Cahn P, Salomon H. Hepatitis B virus genotype distribution and its lamivudine-resistant mutants in HIV-coinfected patients with chronic and occult hepatitis B. AIDS Research

[23] Platt L, Easterbrook P, Gower E, McDonald B, Sabin K, McGowan C, Yanny I, Razavi H, Vickerman P. Prevalence and burden of HCV co-infection in people living with HIV: A global systematic review and meta-analysis. The Lancet Infectious Diseases.

[24] Freitas SZ, Teles SA, Lorenzo PC, Puga MA, Tanaka TS, Thomaz DY, Martins RM, Druzian AF, Lindenberg AS, Torres MS, Pereira SA, Villar LM, Lampe E, Motta-Castro AR. HIV and HCV coinfection: Prevalence, associated factors and genotype characterization in the Midwest Region of Brazil. Revista do Instituto de Medicina Tropical de São

[25] Brandão NA, Pfrimer IA, Martelli CM, Turchi MD. Prevalence of hepatitis B and C infection and associated factors in people living with HIV in Midwestern Brazil. The Brazilian

Journal of Infectious Diseases. 2015;**19**(4):426-430. DOI: 10.1016/j.bjid.2015.02.001 [26] Tizzot MR, Grisbach C, Beltrame MH, Messias-Reason IJ. Seroprevalence of HCV markers among HIV infected patients from Curitiba and metropolitan region. Revista da Associação Médica Brasileira (1992). 2016;62(1):65-71. DOI:10.1590/1806-9282.62.01.65

[27] United Nations Office on Drugs and Crime, World Drug Report 2017. ISBN: 978-92-1- 148291-1, eISBN: 978-92-1-060623-3, United Nations publication, Sales No. E.17.XI.6 [28] Degenhardt L, Peacock A, Colledge S, Leung J, Grebely J, Vickerman P, Stone J, Cunningham EB, Trickey A, Dumchev K, Lynskey M, Griffiths P, Mattick RP, Hickman M, Larney S. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: A multistage systematic review. The Lancet Global Health. 2017;**5**(12):e1192-e1207. DOI: 10.1016/

[29] Andrade AP, Pacheco SD, Silva FQ, Pinheiro LM, Castro JA, Amaral CE, Hermes RB, Fischer B, Pinho JR, Lemos JA, Oliveira-Filho AB. Characterization of hepatitis B virus infection in illicit drug users in the Marajó Archipelago, northern Brazil. Archives of

[30] Oliveira ML, Bastos FI, Telles PR, Yoshida CF, Schatzmayr HG, Paetzold U, Pauli G, Schreier E. Prevalence and risk factors for HBV, HCV and HDV infections among injecting drug users from Rio de Janeiro, Brazil. Brazilian Journal of Medical and Biological

Virology. 2017;**162**(1):227-233. DOI: 10.1007/s00705-016-3060-z

Virology. 2016;**88**(7):1222-1229. DOI: 10.1002/jmv.24462

2016;**16**(7):797-808. DOI: 10.1016/S1473-3099(15)00485-5

and Human Retroviruses. 2007;**23**(4):525-531

Paulo. 2014;**56**(6):517-524

18 Public Health - Emerging and Re-emerging Issues

S2214-109X(17)30375-3

Research. 1999;**32**(9):1107-1114


[42] Germano FN, dos Santos CA, Honscha G, et al. Prevalence of hepatitis C virus among users attending a voluntary testing centre in Rio Grande, southern Brazil: Predictive factors and hepatitis C virus genotypes. International Journal of STD & AIDS. 2010;**21**(7): 466-471. DOI: 10.1258/ijsa.2009.009089

[53] Lopes CL, Teles SA, Espirito-Santo MP, et al. Prevalence, risk factors and genotypes of hepatitis C virus infection among drug users, Central-Western Brazil. Revista de Saúde

Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America

http://dx.doi.org/10.5772/intechopen.79174

21

[54] Bernieh B. Viral hepatitis in hemodialysis: An update. Journal of Translational Internal

[55] Edey M, Barraclough K, Johnson DW. Review article: Hepatitis B and dialysis. Nephrol-

[56] Khedmat H, Amini M, Ghamar-Chehreh ME, Agah S. Hepatitis C virus infection in dialysis patients. Saudi Journal of Kidney Diseases and Transplantation. 2014;**25**:1-8 [57] Marinaki S, Kolovou K, Sakellariou S, Boletis JN, Delladetsima JK. Hepatitis B in renal transplant patients. World Journal of Hepatology. 2017;**9**(25):1054-1063. DOI: 10.4254/

[58] Gómez-Gutierrez C, Chávez-Tapia NC, Ponciano-Rodriguez G, Uribe M, Méndez-Sanches N. Prevalence of hepatitis C vírus infection among patients undergoing haemodialysis in Latin America. Annals of Hepatology. 2015;**14**:807-814. DOI:

[59] Méndez Chacón P, Vidalón A, Vildosola H. Risk factors for hepatitis C in hemodialysis and its impact on the waiting list for kidney transplantation. Revista de Gastroenterología

[60] Pujol FH, Ponce JG, Lema MG, Capriles F, devesa M, Sirit F, Salazar M, Vásquez G, Monsalve F, Blitz-Dorfman L. High incidence of hepatitis C virus infection in hemodialysis patients in units with high prevalence. Journal of Clinical Microbiology.

[61] Valtuille R, Moretto H, Lef L, Rendo P, Fernández JL. Decline of high hepatitis C virus prevalence in a hemodialysis unit with no isolation measures during a 6-year follow-up.

[62] Marinovich S, Lavorato C, Rosa-Diez G, Bisigniano L, Fernández V, Hansen-Krogh D. The lack of income is associated with reduced survival in chronic haemodialysis.

[63] Gaite LA, Marciano S, Galdame OA, Gadano AC. Hepatitis C in Argentina: Epidemiology

[64] Rodríguez MI, Estay R, Soto JR, Wolff C, Plubins L, Child R, Armas R. Prevalence of hepatitis C virus antibodies in a hemodialysis unit. Revista Médica de Chile. 1993;**121**(2):

[65] Gonzalez R, Vollrath V, Pereira J, Covarrubias C, Vacarezza A, Chianale J. Prevalence of hepatitis C virus RNA in hemodialysis patients: Comparison of four antibody assays.

Nefrología. 2012;**32**(1):79-88. DOI: 10.3265/Nefrologia.pre2011.Nov.11110

and treatment. Hepatic Medicine. 2014;**6**:35-43. DOI: 10.2147/HMER.S57774

Pública. 2009;**43**(Suppl 1):43-50. DOI: 10.1590/S0034-89102009000800008

Medicine. 2015;**3**(3):93-105. DOI: 10.1515/jtim-2015-0018

wjh.v7.i3.548

10.5604/16652681.1171751

del Perú. 2005;**25**(1):12-18

Clinical Nephrology. 2002;**57**:371-375

Nephron. 1995;**69**(2):181-182

1996;**34**:1633-1636

152-155

ogy. 2010;**15**:137-145. DOI: 10.1111/j.1440-1797.2009.01268.x


[53] Lopes CL, Teles SA, Espirito-Santo MP, et al. Prevalence, risk factors and genotypes of hepatitis C virus infection among drug users, Central-Western Brazil. Revista de Saúde Pública. 2009;**43**(Suppl 1):43-50. DOI: 10.1590/S0034-89102009000800008

[42] Germano FN, dos Santos CA, Honscha G, et al. Prevalence of hepatitis C virus among users attending a voluntary testing centre in Rio Grande, southern Brazil: Predictive factors and hepatitis C virus genotypes. International Journal of STD & AIDS. 2010;**21**(7):

[43] Osimani ML, Latorre L, editors. Usuarios de cocaina: Prácticas de riesgo y prevalencia de infecciones por VIH, hepatitis B, hepatitis C y T pallidum. Montevideo: Instituto

[44] Galperim B, Cheinquer H, Stein A, Fonseca A, Lunge V, Ikuta N. Prevalência do vírus da hepatite C em pacientes alcoólicos: Papel dos fatores de risco parenterais. Arquivos de

[45] Weissenbacher M, Rossi D, Radulich G, et al. High sero prevalence of blood borne viruses among street-recruited injection drug users from Buenos Aires, Argentina.

[46] Caiaffa WT, Bastos FI, Freitas LL, et al. The contribution of two Brazilian multi-center studies to the assessment of HIV and HCV infection and prevention strategies among injecting drug users: The AjUDE-Brasil I and II Projects. Cadernos de Saúde Pública.

[47] Reyes JC, Colon HM, Robles RR, et al. Prevalence and correlates of hepatitis C virus infection among street-recruited injection drug users in San Juan, Puerto Rico. Journal of

[48] Frost SD, Brouwer KC, Firestone Cruz MA, et al. Respondent-driven sampling of injection drug users in two U.S.-Mexico border cities: Recruitment dynamics and impact on estimates of HIV and syphilis prevalence. Journal of Urban Health: Bulletin of the New York

Academy of Medicine. 2006;**83**(Suppl 6):i83-i97. DOI: 10.1007/s11524-006-9104-z

[49] Bautista Amorocho H, Moreno J, BZ, López H, ML. Ausencia de infección por virus de la hepatitis C en usuarios de drogas ilícitas en la ciudad de Bucaramanga, Colombia's Absence of hepatitis C infection among illegal drug users in Bucaramanga, Colombia.

[50] Mejia I, Perez A. Low seroprevalence in a risky environment: An analysis of risk and protective factors based on findings from an IDU study in Bogota, Colombia. In: 15th International Conference on the Reduction of Drug Related Harm. Melbourne, Australia;

[51] Monsalve-Castillo F, Gómez-Gamboa L, Albillos A, et al. Virus de hepatitis C en poblaciones de riesgo a adquirir la infección. Venezuela. Revista Española de Enfermedades

[52] Novais AC, Lopes CL, Reis NR, et al. Prevalence of hepatitis C virus infection and associated factors among male illicit drug users in Cuiaba, Mato Grosso, Brazil. Memórias do Instituto Oswaldo Cruz. 2009;**104**(6):892-896. DOI: 10.1590/S0074-02762009000600012

Clinical Infectious Diseases. 2003;**37**(Suppl 5):S348-S352. DOI: 10.1086/377560

2006;**22**(4):771-782. DOI: 10.1590/S0102-311X2006000400016

Revista Colombiana de Gastroenterología. 2011;**26**(1):15-20

Urban Health. 2006;**83**(6):1105-1113. DOI: 10.1007/s11524-006-9109-7

466-471. DOI: 10.1258/ijsa.2009.009089

20 Public Health - Emerging and Re-emerging Issues

Gastroenterologia. 2006;**43**:81-84

IDES; 2003

2004

Digestivas. 2007;**99**(6):315-319


[66] Santana RR, Martinez Z, Martinez MT, Mato J. Hepatitis C virus present in hemodialysis units from Cuban western region. Revista Cubana de Medicina. 2009;**48**:28-35

[79] Ferreira RC, Teles SA, Dias MA, Tavares VR, Silva SA, Gomes SA, et al. Hepatitis B virus infection profile in hemodialysis patients in Central Brazil: Prevalence, risk factors, and

Emergence of New Epidemiological Hepatitis B and C Profiles in High Risk Groups in Latin America

http://dx.doi.org/10.5772/intechopen.79174

23

[80] Carrilho FJ, Moraes CR, Pinho JR, Mello IM, Bertolini DA, Lemos MF, et al. Hepatitis B virus infection in haemodialysis centres from Santa Catarina state, southern Brazil. Predictive risk factors for infection and molecular epidemiology. BMC Public Health. 2004;**4**:13 [81] Moreira RC, Deguti MM, Lemos MF, Saraceni CP, Oba IT, Spina AMM, Nascimento-Lima AS, Fares J, Azevedo RS, Gomes-Gouvêa MS, Carrilho FJ, Pinho JR. HBV markers in haemodialysis Brazilian patients: A prospective 12-month follow-up. Memórias do

[82] Fontenele AMM, Filho NS, Ferreira ASP. Occult hepatitis B in patients on hemodialysis:

[83] Albuquerque ACC, Coelho MRCD, lemos MF, Moreira RC. Occult hepatitis B vírus infection in hemodialysis patients in Recife, state of Pernambuco, Brazil. Revista da

[84] Fontenele AM, Gainer JB, da Silva E, Silva DV, Cruz Santos MD, Salgado JV, Salgado Filho N, Ferreira AS. Occult hepatitis B among patients with chronic renal failure on hemodialysis from a capital city in Northeast Brazil. Hemodialysis International.

[85] Motta JS, Mello FC, Lago BV, Perez RM, Gomes SA, Figueiredo FF. Occult hepatitis B vírus infection and lamivudine resistant mutations in isolates from renal patients undergoing hemodialysis. Journal of Gastroenterology and Hepatology. 2010;**25**:101-106. DOI:

[86] World Federation of Hemophilia (WFH). Report on the Annual Global Survey 2015. Canadá. [Internet]. 2016. Available from: http://www1.wfh.org/publications/files/pdf-

[87] Franchini M, Mannucci PM. Past, present and future of hemophilia: A narrative review.

[88] Federici AB, Santagostino E, Rumi MG, Russo A, Mancuso ME, Soffredini R, Mannucci PM, Colombo M. The natural history of hepatitis C virus infection in Italian patients with Von Willebrand's disease: A cohort study. Haematologica. 2006;**91**(4):503-508 [89] Mannucci PM, Tuddenham EGD. The hemophiliac—From royal genes to gene therapy.

[90] Srivastava A, Brewer AK, Mauser-Bunschoten EP, Key NS, Kitchen S, Llinas A, Ludlam CA, Mahlangu JN, Mulder K, Poon MC, Street A. Treatment Guidelines Working Group on Behalf of the World Federation of Hemophilia. Guidelines for the management of

[91] Zhubi B, Mekaj Y, Baruti Z, Bunjaku I, Belegu M. Transfusion-transmitted infections in haemophilia patients. Bosnian Journal of Basic Medical Sciences. 2009;**9**(4):271-277

Orphanet Journal of Rare Diseases. 2012;**7**:24. DOI: 10.1186/1750-1172-7-24

The New England Journal of Medicine. 2001;**344**(23):1773-1779

hemophilia. Haemophilia. 2013;**19**(1):e1-e47

genotypes. Memórias do Instituto Oswaldo Cruz. 2006;**101**:689-692

Instituto Oswaldo Cruz. 2010;**105**:107-108

2015;**19**(3):353-359. DOI: 10.1111/hdi.12285

10.1111/j.1440-1746.2009.05972.x

1669.pdf. Acesso: 15.dez.2017

A review. Annals of Hepatology. 2013;**12**:359-363

Sociedade Brasileira de Medicina Tropical. 2012;**45**:558-562


[79] Ferreira RC, Teles SA, Dias MA, Tavares VR, Silva SA, Gomes SA, et al. Hepatitis B virus infection profile in hemodialysis patients in Central Brazil: Prevalence, risk factors, and genotypes. Memórias do Instituto Oswaldo Cruz. 2006;**101**:689-692

[66] Santana RR, Martinez Z, Martinez MT, Mato J. Hepatitis C virus present in hemodialysis units from Cuban western region. Revista Cubana de Medicina. 2009;**48**:28-35

[67] Cabezas EP, Rodriguez RP, Falagán C, Zamora L, Fernández J. B and C hepatitis in

[68] González-Michaca L, Mercado A, Gamba G. Hepatitis C viral in patients with terminal chronic kidney failure. I. Prevalence. Revista de Investigación Clínica. 2000;**52**:246-254 [69] Méndez-Sanchez N, Motola-Kuba D, Chavez-Tapia NC, Bahena J, Correa-Rotter R, Uribe M. Prevalence of hepatitis C virus infection among hemodialysis patients at a tertiary-care hospital in Mexico-city, Mexico. Journal of Clinical Microbiology. 2004;**42**:

[70] López L, López P, Arago A, Rodríguez I, López J, Lima E, Insagaray J, Bentancor N. Risk factors for hepatitis B and C in multi-transfused patients in Uruguay. Journal of Clinical

[71] Beltrân M, Navas M-C, De la Hoz F, Muñoz MM, Jaramillo S, Estrada C, Cortés LP, Arbelâez MP, Donado J, Barco G, Luna M, Adolfo UG, Maldonado A, Restrepo JC, Correa G, Borda P, Rey G, Neira M, Estrada A, Yepes S, Beltrân O, Pacheco J, Villegas I, Boshell J. Hepatitis C virus seroprevalence in multi-transfused patients in Colombia. Journal of Clinical Virology. 2005;**34**:S33-S38. DOI: 10.1016/S1386-6532(05)80032-0 [72] Callegaro FP, Kupski C, Nascimento RC, Schmitt VM. Comportamento da hepatite viral C nos pacientes em programa de hemodiálise do Hospital São Lucas de PUCRS. Scientia

[73] Silva LK, Silva MB, Rodart IF, Lopes GB, Costa FQ, Melo ME, Gusmão E, Reis MG. Prevalence of hepatitis C virus (HCV) infection and HCV genotypes of hemodialysis patients in Salvador, Northeastern Brazil. Brazilian Journal of Medical and Biological

[74] Rodrigues de Freitas MG, Alves A, Costa de Almeida MK, Silva A. Prevalence of hepatitis C vírus infection and genotypes in patient with chronic kidney disease undergoing hemodialysis. Journal of Medical Virology. 2013;**85**:1741-1745. DOI: 10.1002/jmv.23654

[75] Oliveira-Penido JMM, Caiaffa WT, Guimarães M, Caetano EVC, Carvalho AR. The seroprevalence of HCV in patients submitted to hemodialysis and health professionals in the

[76] Leão JR, Pace FHL, Chebli JMF. Infecção pelo vírus da hepatite C em pacientes em hemodiálise: Prevalência e fatores de risco. Arquivos de Gastroenterologia. 2010;**47**:

[77] Paniagua R, Villasís-Keever A, Prado-Uribe Mdel C, Ventura-García MD, Alcántara-Ortega G, Ponce de Leon SR, Cure-Bolt N, Rangel-Frausto S. Elevated prevalence of hepatitis B in Mexican hemodialysis patients. A multicentric survey. Archives of Medical

[78] Guimarães MNC, Facincani T, Santos SSD. Hepatitis B status in hemodialysis patients. Arquivos de Gastroenterologia. 2017;**54**(4):356-358. DOI: 10.1590/s0004-2803.201700000-34

Research. 2006;**39**(5):595-602. DOI: 10.1590/S0100-879X2006000500005

state of Minas Gerais, Southwest Brazil. Nefrología. 2008;**28**:178-185

Research. 2010;**41**(4):251-254. DOI: 10.1016/j.arcmed.2010.05.001

patients with hemodialysis. Medisan. 2010;**14**:141

4321-4322. DOI: 10.1128/JCM.42.9.4321-4322.2004

Virology. 2005;**34**(Suppl 2):S69-S74

22 Public Health - Emerging and Re-emerging Issues

Medica. 2006;**16**:115-118

28-34. DOI: 10.1590


[92] Papadopoulos N, Argiana V, Deutsch M. Hepatitis C infection in patients with hereditary bleeding disorders: Epidemiology, natural history, and management. Annals of Gastroenterology. 2018;**31**:35-41

**Chapter 2**

**Provisional chapter**

**Emerging and Re-emerging Arboviral Diseases as a**

**Emerging and Re-emerging Arboviral Diseases as a** 

Newly emerging or re-emerging infections continue to pose significant global public health threats. This chapter provides an overview of the combinations of factors that led to the emergence of arthropod-borne viruses as human and veterinary health threats, in order to understand the risk associated and how this can be mitigated. Considering the history of emergence of some arboviruses, these epidemics have occurred globally as a result of climate and socioeconomic changes that have allowed the spread to new geographical areas of viruses previously confined to specific ecological niches such as West Nile and Chikungunya, or viruses considered under control such as Dengue, Japanese encephalitis, and Yellow fever. Moreover, the greatest risk for humans derives from the ability of these viruses to adopt transmission cycles involving highly anthropophilic mosquito species. Finally, many other arboviruses are largely ignored despite their potential to emerge globally. The recent epidemic spread of Zika virus throughout the Americas is the evidence that arboviruses are likely to continually emerge and re-emerge and that improved scientific technologies and knowledge is essential to deal with future vector-borne epidemics. Research priorities should therefore focus on surveillance systems and vector control tools,

as well as on the development of antiviral molecules or candidate vaccine.

**Keywords:** arbovirus, emerging infectious diseases, dengue, Chikungunya, yellow

Arthropod-borne viruses (arboviruses) are important cause of animal and human disease worldwide, infecting millions of individuals and causing a large social and economic burden.

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.77382

**Global Health Problem**

**Global Health Problem**

http://dx.doi.org/10.5772/intechopen.77382

fever, West Nile, Zika virus

**1. Introduction to arboviruses**

Emanuele Montomoli

Emanuele Montomoli

**Abstract**

Serena Marchi, Claudia Maria Trombetta and

Serena Marchi, Claudia Maria Trombetta and

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter


#### **Emerging and Re-emerging Arboviral Diseases as a Global Health Problem Emerging and Re-emerging Arboviral Diseases as a Global Health Problem**

DOI: 10.5772/intechopen.77382

Serena Marchi, Claudia Maria Trombetta and Emanuele Montomoli Serena Marchi, Claudia Maria Trombetta and Emanuele Montomoli

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.77382

#### **Abstract**

[92] Papadopoulos N, Argiana V, Deutsch M. Hepatitis C infection in patients with hereditary bleeding disorders: Epidemiology, natural history, and management. Annals of

[93] Calderon GM, Gonzalez-Velazquez F, Gonzalez-Bonilla CR, Novelo-Garza B, Terrazas JJ, Martinez-Rodriguez ML, et al. Prevalence and risk factors of hepatitis C virus, hepatitis B virus and human immunodeficiency in multiply transfused recipients in Mexico.

[94] Vinelli E, Lorenzana I. Transfusion-transmitted infections in multi-transfused patients

[95] Ballester JM, Rivero RA, Villaescusa R, Merlín JC, Arce AA, Castillo D, Lam RM, Ballester A, Almaguer M, Melians SM, Aparicio JL. Hepatitis C virus antibodies and other markers of blood-transfusion-transmitted infection in multi-transfused Cuban

[96] Beltrán M, Navas MC, Arbeláez MP, Donado J, Jaramillo S, De la Hoz F, Estrada C, Cortés LP, Maldonado A, Rey G. Grupo Epiblood Colombia. Seroprevalence of hepatitis B virus and human immunodeficiency virus infection in a population of multiply-

[97] Laguna-Torres VA, Pérez-Bao J, Chauca G, Sovero M, Blichtein D, Chunga A, Flores W, Retamal A, Mendoza S, Cruz M, Monge Z, Lavalle M, Gutiérrez J, Málaga J, Soto E, Loayza N, Bolívar D, Reyna R, Mendoza C, Oré M, González J, Suárez M, Montano SM, Sánchez JL, Sateren W, Bautista CT, Olson JG, Xueref S. Epidemiology of transfusiontransmitted infections among multi-transfused patients in seven hospitals in Peru.

[98] Ferreira AA, Leite ICG, Bustamante-Teixeira MT, Guerra MR. Hemophilia A in Brazil: Epidemiology and treatment developments. Journal of Blood Medicine. 2014;**5**:

[99] Castillo-González D, Lardoeyt-Ferrer R, Almagro-Vázquez D, Lam-Díaz RM, Lavaut-Sánchez K, Gutiérrez-Díaz A, Campo-Díaz M, Álvarez-Vega N, Salinas-González JL, Fernández-Águila JD, Agramonte-Llanes O. Prevalence of hemophilia in six cuban provinces. Revista Cubana de Hematología, Inmunología y Hemoterapia. 2014;**30**:155-161

[100] Remesar M, Gamba C, Kuperman S, Marcosa MA, Miguez G, Caldarola S, Pérez-Bianco R, Manterola A, Del Pozo A. Antibodies to hepatitis C and other viral markersin multitransfused patients from Argentina. Journal of Clinical Virology. 2005;**34**(Suppl 2):

in Honduras. Journal of Clinical Virology. 2005;**34**:S53-S60

patients. Journal of Clinical Virology. 2005;**34**:S39-SS4

Journal of Clinical Virology. 2005;**34**:S61-S68

175-184

S20-S26

transfused patients in Colombia. Biomédica. 2009;**29**:232-243

Gastroenterology. 2018;**31**:35-41

24 Public Health - Emerging and Re-emerging Issues

Transfusion. 2009;**49**:2200-2207

Newly emerging or re-emerging infections continue to pose significant global public health threats. This chapter provides an overview of the combinations of factors that led to the emergence of arthropod-borne viruses as human and veterinary health threats, in order to understand the risk associated and how this can be mitigated. Considering the history of emergence of some arboviruses, these epidemics have occurred globally as a result of climate and socioeconomic changes that have allowed the spread to new geographical areas of viruses previously confined to specific ecological niches such as West Nile and Chikungunya, or viruses considered under control such as Dengue, Japanese encephalitis, and Yellow fever. Moreover, the greatest risk for humans derives from the ability of these viruses to adopt transmission cycles involving highly anthropophilic mosquito species. Finally, many other arboviruses are largely ignored despite their potential to emerge globally. The recent epidemic spread of Zika virus throughout the Americas is the evidence that arboviruses are likely to continually emerge and re-emerge and that improved scientific technologies and knowledge is essential to deal with future vector-borne epidemics. Research priorities should therefore focus on surveillance systems and vector control tools, as well as on the development of antiviral molecules or candidate vaccine.

**Keywords:** arbovirus, emerging infectious diseases, dengue, Chikungunya, yellow fever, West Nile, Zika virus

#### **1. Introduction to arboviruses**

Arthropod-borne viruses (arboviruses) are important cause of animal and human disease worldwide, infecting millions of individuals and causing a large social and economic burden.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

These viruses are generally transmitted by arthropod vectors to their vertebrate host and circulate among wild animals serving as reservoir in sylvatic life cycle. Through spillover transmission from enzootic amplification cycles, humans can be infected as incidental and dead-end hosts. By contrast, some arboviruses undergo urban cycle involving humans as amplifying hosts and causing several epidemics in urban areas [1–3].

ecological niches facilitating the contact with naïve individuals causing outbreaks of high magnitude due to lower herd immunity [2]. The greatest health risk of arboviral emergence comes from extensive tropical urbanization and the colonization of this expanding habitat by the highly anthropophilic mosquito, *Ae. aegypti*, together with the recent invasion into the Americas, Europe and Africa of *Ae. albopictus* that could enhance transmission of these viruses

Emerging and Re-emerging Arboviral Diseases as a Global Health Problem

http://dx.doi.org/10.5772/intechopen.77382

27

More than 500 species of viruses are registered in the International Catalog of Arboviruses and this estimate is continuously increasing. While many current arboviruses do not appear to be human or animal pathogens, this large number of widely different and highly adaptable arboviruses provides an immense resource for the emergence of new pathogens in the

Recent global changes in climate and human behavior are important determinants of arbovirus emergence. The viral transmission can be limited by the ecology of the host or of the virus itself; arboviruses frequently persist at low maintenance levels until changes in single or multiple factors disrupt the transmission cycle, facilitating rapid and widespread amplification [1, 6]. Arboviruses can therefore emerge at epidemic levels due to changes in viral genetics, in the composition or dynamics of the host or vector population and/or in the environmental

As arboviruses are virtually all RNA viruses lacking proofreading functions, a high frequency of mutations associated with fast replication allows them to rapidly adapt to different environments. The high rate of genetic mutations could lead to changes in virulence, epidemiology or competence of vectors, which can occur via simple point mutations [3, 5]. Often, outbreaks of emerging arboviruses may be related to relatively small changes in viral genetics or to the introduction of new strains that have increased virulence and viremia levels in vertebrate, thereby expanding the host range and increasing amplification potential. Alternatively,

genetic changes can improve vector competence and therefore transmission rates [1].

Zoonoses exploiting complex rural or suburban ecosystems may have multiple vectors and infect a variety of vertebrate host species. Arboviral amplification can progress rapidly to epidemic levels when competent vector and vertebrate host populations meet repeatedly within a permissive environment for viral transmission and replication. Moreover, humans may be exposed to arboviruses when they invade rural environments or when bridge vectors bring viruses into peridomestic environments [1]. Deforestation associated with urbanization process has contributed to increase the contact between humans and vectors [7]. Furthermore, the expansion of urbanization has led to high concentrations of susceptible human hosts, often living in socioeconomic conditions favorable to the expansion of the vector population, facilitating viral transmission and outbreaks of epidemics [1]. Furthermore, the feeding

**2. Emerging and re-emerging arboviral infections**

**2.1. Factors associated with arbovirus emergence or invasion**

structure that often are of anthropogenic origin [1].

in temperate regions [1].

future [4].

By definition, arboviruses require an arthropod vector in the transmission cycle, in which they must replicate prior to transmission [1]. Most common arthropods include mosquitoes, flies, and ticks along with others hematophagous arthropods [2, 3]. *Aedes* mosquitoes are the most important arboviral vectors; the two main species, *Ae. aegypti* and *Ae. albopictus*, allow the transmission of medically important viruses such as chikungunya virus (CHIKV), dengue virus (DENV), and yellow fever virus (YFV) [2]. Other prevalent vectors are *Culex* mosquitoes, ticks, sandflies, and *Culicoides* [4, 5]. Arboviral maintenance and amplification cycles involve horizontal, vertical, and venereal transmission. In horizontal transmission, the virus is transmitted from an infected vector to a vertebrate host, during blood feeding. Following a viremic bloodmeal, virus enters midgut and disseminates through the alimentary tract in the vector and replicates in the salivary glands. During the following blood feeding, injection of infectious saliva allows the transmission to a new host, initiating a new transmission cycle [1, 2, 4]. Many arboviruses are also maintained in nature through a secondary cycle that involves vertical transmission from an infected female to the offspring. In this case, disseminated virus infects the developing eggs, persisting in larval and pupal stages and subsequently into adults. Moreover, venereal transmission allows the transfer of virus from a vertically infected male directly to a female during copulation [2]. The long-term survival is also enhanced by non-viremic transmission, during which infected and noninfected mosquitoes or ticks co-feed on a non-viremic host and the virus is transmitted directly between them, without necessarily infecting the vertebrate host [2, 4].

Most of the arboviruses that cause human/animal diseases belong to four virus families, *Togaviridae* (genus *Alphavirus*), *Flaviviridae* (genus *Flavivirus*), *Bunyaviridae* (genera *Orthobunyavirus, Phlebovirus*, and *Nairovirus*), and *Reoviridae* (genera *Coltivirus* and *Orbivirus*) [2, 5]. Infections in humans and animals could range from subclinical or mild to encephalic or hemorrhagic with a significant proportion of fatalities. In contrast, arthropods infected by arboviruses do not show detectable signs of infection, even though the virus may remain in the arthropod for life [4].

A high proportion of arboviruses associated with human and animal disease circulate in tropical and subtropical regions, where arthropods tend to be abundant. However, many arboviruses also circulate among wildlife species in temperate regions of the world. Despite the global distribution of viruses such as West Nile virus (WNV), DENV and now CHIKV, most other arboviruses are generally endemic but limited to specific regions of the world. Nevertheless, even within this relatively localized distribution, dispersion to distant locations can occur via animal or vector migration [4]. Global warming, deforestation, and urbanization have led to rapid expansion of the habitats of the vectors and caused enormous increase in vector-borne diseases throughout the world. Increase in international travel, shipping, and industrialization can lead to transport of infected mosquito and eggs to different new ecological niches facilitating the contact with naïve individuals causing outbreaks of high magnitude due to lower herd immunity [2]. The greatest health risk of arboviral emergence comes from extensive tropical urbanization and the colonization of this expanding habitat by the highly anthropophilic mosquito, *Ae. aegypti*, together with the recent invasion into the Americas, Europe and Africa of *Ae. albopictus* that could enhance transmission of these viruses in temperate regions [1].

More than 500 species of viruses are registered in the International Catalog of Arboviruses and this estimate is continuously increasing. While many current arboviruses do not appear to be human or animal pathogens, this large number of widely different and highly adaptable arboviruses provides an immense resource for the emergence of new pathogens in the future [4].

## **2. Emerging and re-emerging arboviral infections**

These viruses are generally transmitted by arthropod vectors to their vertebrate host and circulate among wild animals serving as reservoir in sylvatic life cycle. Through spillover transmission from enzootic amplification cycles, humans can be infected as incidental and dead-end hosts. By contrast, some arboviruses undergo urban cycle involving humans as

By definition, arboviruses require an arthropod vector in the transmission cycle, in which they must replicate prior to transmission [1]. Most common arthropods include mosquitoes, flies, and ticks along with others hematophagous arthropods [2, 3]. *Aedes* mosquitoes are the most important arboviral vectors; the two main species, *Ae. aegypti* and *Ae. albopictus*, allow the transmission of medically important viruses such as chikungunya virus (CHIKV), dengue virus (DENV), and yellow fever virus (YFV) [2]. Other prevalent vectors are *Culex* mosquitoes, ticks, sandflies, and *Culicoides* [4, 5]. Arboviral maintenance and amplification cycles involve horizontal, vertical, and venereal transmission. In horizontal transmission, the virus is transmitted from an infected vector to a vertebrate host, during blood feeding. Following a viremic bloodmeal, virus enters midgut and disseminates through the alimentary tract in the vector and replicates in the salivary glands. During the following blood feeding, injection of infectious saliva allows the transmission to a new host, initiating a new transmission cycle [1, 2, 4]. Many arboviruses are also maintained in nature through a secondary cycle that involves vertical transmission from an infected female to the offspring. In this case, disseminated virus infects the developing eggs, persisting in larval and pupal stages and subsequently into adults. Moreover, venereal transmission allows the transfer of virus from a vertically infected male directly to a female during copulation [2]. The long-term survival is also enhanced by non-viremic transmission, during which infected and noninfected mosquitoes or ticks co-feed on a non-viremic host and the virus is transmitted directly between them, without necessarily

Most of the arboviruses that cause human/animal diseases belong to four virus families, *Togaviridae* (genus *Alphavirus*), *Flaviviridae* (genus *Flavivirus*), *Bunyaviridae* (genera *Orthobunyavirus, Phlebovirus*, and *Nairovirus*), and *Reoviridae* (genera *Coltivirus* and *Orbivirus*) [2, 5]. Infections in humans and animals could range from subclinical or mild to encephalic or hemorrhagic with a significant proportion of fatalities. In contrast, arthropods infected by arboviruses do not show detectable signs of infection, even though the virus may remain in the arthropod for life [4].

A high proportion of arboviruses associated with human and animal disease circulate in tropical and subtropical regions, where arthropods tend to be abundant. However, many arboviruses also circulate among wildlife species in temperate regions of the world. Despite the global distribution of viruses such as West Nile virus (WNV), DENV and now CHIKV, most other arboviruses are generally endemic but limited to specific regions of the world. Nevertheless, even within this relatively localized distribution, dispersion to distant locations can occur via animal or vector migration [4]. Global warming, deforestation, and urbanization have led to rapid expansion of the habitats of the vectors and caused enormous increase in vector-borne diseases throughout the world. Increase in international travel, shipping, and industrialization can lead to transport of infected mosquito and eggs to different new

amplifying hosts and causing several epidemics in urban areas [1–3].

infecting the vertebrate host [2, 4].

26 Public Health - Emerging and Re-emerging Issues

## **2.1. Factors associated with arbovirus emergence or invasion**

Recent global changes in climate and human behavior are important determinants of arbovirus emergence. The viral transmission can be limited by the ecology of the host or of the virus itself; arboviruses frequently persist at low maintenance levels until changes in single or multiple factors disrupt the transmission cycle, facilitating rapid and widespread amplification [1, 6]. Arboviruses can therefore emerge at epidemic levels due to changes in viral genetics, in the composition or dynamics of the host or vector population and/or in the environmental structure that often are of anthropogenic origin [1].

As arboviruses are virtually all RNA viruses lacking proofreading functions, a high frequency of mutations associated with fast replication allows them to rapidly adapt to different environments. The high rate of genetic mutations could lead to changes in virulence, epidemiology or competence of vectors, which can occur via simple point mutations [3, 5]. Often, outbreaks of emerging arboviruses may be related to relatively small changes in viral genetics or to the introduction of new strains that have increased virulence and viremia levels in vertebrate, thereby expanding the host range and increasing amplification potential. Alternatively, genetic changes can improve vector competence and therefore transmission rates [1].

Zoonoses exploiting complex rural or suburban ecosystems may have multiple vectors and infect a variety of vertebrate host species. Arboviral amplification can progress rapidly to epidemic levels when competent vector and vertebrate host populations meet repeatedly within a permissive environment for viral transmission and replication. Moreover, humans may be exposed to arboviruses when they invade rural environments or when bridge vectors bring viruses into peridomestic environments [1]. Deforestation associated with urbanization process has contributed to increase the contact between humans and vectors [7]. Furthermore, the expansion of urbanization has led to high concentrations of susceptible human hosts, often living in socioeconomic conditions favorable to the expansion of the vector population, facilitating viral transmission and outbreaks of epidemics [1]. Furthermore, the feeding preferences (anthropophilic and/or ornithophilic) of arthropod vectors are of fundamental importance [8–10]. Arthropods frequently exposed to the human environment, domestic animals, and livestock can undertake an adaptive process defined as domestication [8, 11]. Moreover, many of the epidemic vectors are peridomestic, naturally existing in close association with humans. The vectors of CHIKV, YFV, and Zika virus (ZIKV) all use human habitat to maintain their populations [12, 13]; thus, general living conditions along with ineffective vector control programs, can contribute to providing one component necessary for arboviral transmission [5, 7].

at risk of infection [14]. Moreover, DENV is hyperendemic in many Asian tropical regions, where two or more serotypes circulate both endemically and epidemically [1]. A total of 390 million infections, of which about 100 million symptomatic, are estimated each year, with several hundred thousand cases of DHF and thousands of deaths [15, 16]. The resurgence of DENV has been stimulated by population growth and density, urbanization and international travels, as well as changes in environmental conditions, prevalence of vectors and virus genetics. The resulting geographic expansion has been accompanied by exponential increases in cases, epidemics, and co-circulation of different serotypes. In particular, hyperendemicity in many areas of tropics and subtropics is due to serotype dispersal derived from large-scale human movements, which together with levels of preexisting immunity of the herd to specific viral serotypes have led to an increase of DHF epidemics [17, 18]. Moreover, introduction of DENV has occurred several times in temperate or subtropical climate zones in recent years. By 2010, autochthonous cases of DENV infection were identified in Europe, and in October 2012, Madeira recorded a major DENV outbreak, with over 2100 cases by March 2013 [19–21]. Furthermore, the repeated episodes of DENV local transmission (Hawaii in 2001–2002, Texas in 2005, and Florida in 2009–2011) and the wide distribution of *Ae. aegypti* and *Ae. albopictus* in the USA underscores the importance of surveillance and vector control in areas at risk of

Emerging and Re-emerging Arboviral Diseases as a Global Health Problem

http://dx.doi.org/10.5772/intechopen.77382

29

CHIKV is an *Alphavirus* of the *Togaviridae* family that circulates in enzootic cycles among nonhuman primates with multiple *Aedes* mosquitoes implicated as vectors, with *Ae. aegypti* identified as the main human vector [25]. Historically, CHIKV has been considered a highly debilitating but not life-threatening pathogen, whose infection is associated with fever, headache, myalgia, rash, and severe arthralgia. Because these symptoms often mimic those of DENV and because CHIKV circulates in DENV-endemic regions, CHIKV has long been underdiagnosed and underestimated as an important arboviral disease [1]. In Southeast Asia, CHIKV was recognized as the etiologic cause of febrile disease epidemics in the 1950s and continues to be an important pathogen [26]. Unlike in Africa, where there is evidence of a sylvatic cycle involving arboreal mosquitoes and nonhuman primates, CHIKV appears to be maintained in Asia in a strictly human-peridomestic cycle of mosquitoes [1]. CHIKV has re-emerged in 2005 in a succession of massive outbreaks in East Africa and the Southern Indian Ocean Islands [5]. The first major outbreak occurred in Kenya during 2004, followed by a large outbreak on La Réunion Island in 2005–2006 [6]. The genetic characterization indicated that the epidemic strain originated from the East/Central/South African (ECSA) lineage, but the outbreak of La Réunion was associated with a mutation on the viral envelope glycoproteins enabling more effective transmission by *Ae. albopictus* [6, 27, 28]. This new lineage, called Indian Ocean Lineage (IOL), spread quickly across the Indian Ocean Basin, India, and Southeast Asia. Moreover, infected travelers imported it into Europe, with two small outbreaks occurring in northern Italy and southern France [29–31]. Between late 2013 and beginning of 2014, autochthonous cases of CHIKV were reported in the Caribbean. The strain implicated belonged to the Asian strain, identified in the late 1950s in Southeast Asian countries [32]. Finally, a distinct East/Central/south African strain (ECSA) spread directly to Brazil in 2014 [33]. During these massive outbreaks of CHIKV, also the clinical presentation appeared to be evolving as well, with neurological manifestations and mortality. Moreover,

DENV introduction [22–24].

*2.2.2. Chikungunya virus*

Changes in the composition of vertebrate or vector host species may be related to environmental changes that expand old or create new ecological niches. Extensions of the vector range into permissive environments are often followed by invasion of the arboviruses they transmit. These invasions are generally facilitated by travel and commerce [1], constantly introducing new species of viruses and their arthropod vectors into new geographic areas. Most of these introductions are not detected until they cause an epidemic, when they are already well established and it is not possible to eliminate them from the new area [7]. An additional factor that plays a role in the generation of arboviral outbreaks is the immunity status of vertebrate hosts in the affected areas. Outbreaks registered for the first time in a new area usually involve immunologically naïve populations, exhibiting extremely high rates of attack. Even in areas where epidemics have previously occurred, rare epidemic events interspersed with significant interepidemic periods may render the younger generation susceptible to infection [5].

Following their recent local and global emergence, some arboviruses have acquired great importance in terms of public and veterinary health. The combinations of factors that led to their emergence are of fundamental importance to understand the risk associated and how this can be mitigated. Moreover, many other arboviruses are largely ignored despite their potential to emerge globally [1].

## **2.2. Emerging and re-emerging arboviruses**

#### *2.2.1. Dengue virus*

DENV (*Flaviviridae*: *Flavivirus*) is the only arbovirus that has completely evolved and adapted to the human host and its environment, eliminating the need of other animal reservoirs. There are four DENV strains, referred to as DENV1–4 serotypes, antigenically distinct but with the same epidemiology and symptomatology in humans. Generally, DENV is associated with mild clinical manifestations during interepidemic periods, but it can cause epidemics associated with a more severe disease every 3–5 years. Co-circulation of multiple serotypes (hyperendemia) is the most common risk factor associated with the emergence of the severe form of the disease, dengue hemorrhagic fever/shock syndrome (DHF/DSS), in an area [7]. Relying exclusively on humans as reservoir and amplification hosts, the maintenance of DENV is based on transmission by mosquito vectors living in close association with humans [1]. The main vector in urban environments is *Ae. aegypti*, however DENV can also be transmitted by *Ae. albopictus* in suburban, rural, and forest areas in tropical, subtropical, and temperate regions of the world where it is widely present [8, 13]. DENV is the geographically most widespread arbovirus and the most serious arboviral threat, showing high levels of endemic transmission in the Americas, south-east Asia and the western Pacific, with about 4 billion people at risk of infection [14]. Moreover, DENV is hyperendemic in many Asian tropical regions, where two or more serotypes circulate both endemically and epidemically [1]. A total of 390 million infections, of which about 100 million symptomatic, are estimated each year, with several hundred thousand cases of DHF and thousands of deaths [15, 16]. The resurgence of DENV has been stimulated by population growth and density, urbanization and international travels, as well as changes in environmental conditions, prevalence of vectors and virus genetics. The resulting geographic expansion has been accompanied by exponential increases in cases, epidemics, and co-circulation of different serotypes. In particular, hyperendemicity in many areas of tropics and subtropics is due to serotype dispersal derived from large-scale human movements, which together with levels of preexisting immunity of the herd to specific viral serotypes have led to an increase of DHF epidemics [17, 18]. Moreover, introduction of DENV has occurred several times in temperate or subtropical climate zones in recent years. By 2010, autochthonous cases of DENV infection were identified in Europe, and in October 2012, Madeira recorded a major DENV outbreak, with over 2100 cases by March 2013 [19–21]. Furthermore, the repeated episodes of DENV local transmission (Hawaii in 2001–2002, Texas in 2005, and Florida in 2009–2011) and the wide distribution of *Ae. aegypti* and *Ae. albopictus* in the USA underscores the importance of surveillance and vector control in areas at risk of DENV introduction [22–24].

#### *2.2.2. Chikungunya virus*

preferences (anthropophilic and/or ornithophilic) of arthropod vectors are of fundamental importance [8–10]. Arthropods frequently exposed to the human environment, domestic animals, and livestock can undertake an adaptive process defined as domestication [8, 11]. Moreover, many of the epidemic vectors are peridomestic, naturally existing in close association with humans. The vectors of CHIKV, YFV, and Zika virus (ZIKV) all use human habitat to maintain their populations [12, 13]; thus, general living conditions along with ineffective vector control programs, can contribute to providing one component necessary for arboviral

Changes in the composition of vertebrate or vector host species may be related to environmental changes that expand old or create new ecological niches. Extensions of the vector range into permissive environments are often followed by invasion of the arboviruses they transmit. These invasions are generally facilitated by travel and commerce [1], constantly introducing new species of viruses and their arthropod vectors into new geographic areas. Most of these introductions are not detected until they cause an epidemic, when they are already well established and it is not possible to eliminate them from the new area [7]. An additional factor that plays a role in the generation of arboviral outbreaks is the immunity status of vertebrate hosts in the affected areas. Outbreaks registered for the first time in a new area usually involve immunologically naïve populations, exhibiting extremely high rates of attack. Even in areas where epidemics have previously occurred, rare epidemic events interspersed with significant interepidemic periods may render the younger generation susceptible to infection [5].

Following their recent local and global emergence, some arboviruses have acquired great importance in terms of public and veterinary health. The combinations of factors that led to their emergence are of fundamental importance to understand the risk associated and how this can be mitigated. Moreover, many other arboviruses are largely ignored despite their

DENV (*Flaviviridae*: *Flavivirus*) is the only arbovirus that has completely evolved and adapted to the human host and its environment, eliminating the need of other animal reservoirs. There are four DENV strains, referred to as DENV1–4 serotypes, antigenically distinct but with the same epidemiology and symptomatology in humans. Generally, DENV is associated with mild clinical manifestations during interepidemic periods, but it can cause epidemics associated with a more severe disease every 3–5 years. Co-circulation of multiple serotypes (hyperendemia) is the most common risk factor associated with the emergence of the severe form of the disease, dengue hemorrhagic fever/shock syndrome (DHF/DSS), in an area [7]. Relying exclusively on humans as reservoir and amplification hosts, the maintenance of DENV is based on transmission by mosquito vectors living in close association with humans [1]. The main vector in urban environments is *Ae. aegypti*, however DENV can also be transmitted by *Ae. albopictus* in suburban, rural, and forest areas in tropical, subtropical, and temperate regions of the world where it is widely present [8, 13]. DENV is the geographically most widespread arbovirus and the most serious arboviral threat, showing high levels of endemic transmission in the Americas, south-east Asia and the western Pacific, with about 4 billion people

transmission [5, 7].

28 Public Health - Emerging and Re-emerging Issues

potential to emerge globally [1].

*2.2.1. Dengue virus*

**2.2. Emerging and re-emerging arboviruses**

CHIKV is an *Alphavirus* of the *Togaviridae* family that circulates in enzootic cycles among nonhuman primates with multiple *Aedes* mosquitoes implicated as vectors, with *Ae. aegypti* identified as the main human vector [25]. Historically, CHIKV has been considered a highly debilitating but not life-threatening pathogen, whose infection is associated with fever, headache, myalgia, rash, and severe arthralgia. Because these symptoms often mimic those of DENV and because CHIKV circulates in DENV-endemic regions, CHIKV has long been underdiagnosed and underestimated as an important arboviral disease [1]. In Southeast Asia, CHIKV was recognized as the etiologic cause of febrile disease epidemics in the 1950s and continues to be an important pathogen [26]. Unlike in Africa, where there is evidence of a sylvatic cycle involving arboreal mosquitoes and nonhuman primates, CHIKV appears to be maintained in Asia in a strictly human-peridomestic cycle of mosquitoes [1]. CHIKV has re-emerged in 2005 in a succession of massive outbreaks in East Africa and the Southern Indian Ocean Islands [5]. The first major outbreak occurred in Kenya during 2004, followed by a large outbreak on La Réunion Island in 2005–2006 [6]. The genetic characterization indicated that the epidemic strain originated from the East/Central/South African (ECSA) lineage, but the outbreak of La Réunion was associated with a mutation on the viral envelope glycoproteins enabling more effective transmission by *Ae. albopictus* [6, 27, 28]. This new lineage, called Indian Ocean Lineage (IOL), spread quickly across the Indian Ocean Basin, India, and Southeast Asia. Moreover, infected travelers imported it into Europe, with two small outbreaks occurring in northern Italy and southern France [29–31]. Between late 2013 and beginning of 2014, autochthonous cases of CHIKV were reported in the Caribbean. The strain implicated belonged to the Asian strain, identified in the late 1950s in Southeast Asian countries [32]. Finally, a distinct East/Central/south African strain (ECSA) spread directly to Brazil in 2014 [33]. During these massive outbreaks of CHIKV, also the clinical presentation appeared to be evolving as well, with neurological manifestations and mortality. Moreover, maternal infection was observed to be vertically transmitted, most commonly during birth, leading to severe disease and encephalopathy in half of neonates and resulting in long-term neurologic sequelae [34].

can initiate an urban cycle characterized by rapid human-mosquito transmission that leads to explosive outbreaks [40, 41]. The epidemiology of YFV in Africa often involves both sylvatic and urban cycles increasing the force of infection during human epidemics, that result larger than in South America [40]. In humans, YF is a severe acute illness with fever, nausea, hepatitis with jaundice, renal failure, hemorrhage, and shock with case fatality lower in Africa (20%) than in south America (40–60%) [42], suggesting a correlation between genetic factors and lethality of the infection. In Africa as well as in South America, high YF case rates likely occur due to low vaccination coverage in area of endemic transmission. According to WHO and the United Nations Children's Emergency Fund (UNICEF) estimates, only 41% of the target population had received YF vaccination in 2014, well below the recommended 80% threshold for the prevention of an epidemic [41]. However, the underlying reasons for virus amplification could be multifactorial, including the possibility of a new virus lineage emerging correlating with the expansion of YFV activity [43]. In endemic areas, deforestation has been associated with emergence of YF outbreaks due to the higher biting activity of vectors, especially in new settlements inside or near the forest frequently colonized by unvaccinated migrant populations. Moreover, perturbation in environmental conditions, such as increase in rainfall and temperatures, has been associated with an abundance of vectors enhancing YFV circulation with increased outbreaks in Africa and South America [40]. YFV could potentially emerge and disperse in a similar manner to DENV, CHIKV, and ZIKV in South America. The recent outbreak of YF in Brazil and multiple reports of cases outside endemic regions highlight the possibility of urban YF arising [8]. In fact, many cases were reported in areas considered free of virus circulation, where routine YF vaccination is not performed. A molecular study showed implicated a new YFV lineage which evolved from the lineage circulating in Brazil in the 1990s, and moved toward the Atlantic coast, the most populated area in Brazil [40]. Moreover, YFV could become the next arbovirus to emerge as a public health emergency if swift to international spread occurs. Since December 2015, YF epidemic has been reported in Angola, spreading to Kenya and the Democratic Republic of the Congo. Moreover, in April 2016, YFV was exported to China via unvaccinated workers, representing the first laboratory-documented cases of YFV in Asia [41]. This risk is particularly acute in the Asia-Pacific region, where systems for YFV surveillance and detection are largely untested and YF vaccination is limited to travelers [44]. If introduction of YFV occurs in areas with a high density of *Ae. aegypti*, it is possible that local transmission could occur and potentially spread to Southeast Asia, putting approximately 2 billion people at risk without there being

Emerging and Re-emerging Arboviral Diseases as a Global Health Problem

http://dx.doi.org/10.5772/intechopen.77382

31

WNV belongs to the Japanese encephalitis virus (JEV) serocomplex in the genus *Flavivirus.* It is maintained in nature within an enzootic transmission cycle among birds and *Culex* mosquitoes, with outbreaks caused by spillover transmission to equids and humans, which are dead-end hosts [1]. Based on serological evidences, WNV circulates in the absence of clinical disease in the majority of humans and a wide variety of different animal species, but in abundancy of *Culex* species mosquitoes WNV, may also cause epidemics with disease symptoms ranging from subclinical or mild febrile to encephalic with or without flaccid paralysis and fatality [8, 10]. WNV is distributed globally, with two main genetic lineages: Lineage 1 is widely distributed and highly invasive, whereas Lineage 2 appears to have remained

sufficient vaccine stockpiles [41].

*2.2.5. West Nile virus*

#### *2.2.3. Zika virus*

ZIKV (*Flaviviridae*: *Flavivirus*) is primarily transmitted by mosquitoes of *Aedes* genus, including not only *Ae. aegypti* for urban transmission but also *Ae. albopictus*, *Ae. poliniensis*, and *Ae. hensilli.* Recently, transmission of the virus has also been reported via sexual, neonatal, and blood transfusion. ZIKV infection can be asymptomatic or cause a mild febrile illness characterized by headaches, myalgia, fever, rash, and conjunctivitis [35]. ZIKV was isolated and associated with human disease more than 60 years ago, but remained poorly studied until an association with neurological involvement was observed. In fact, an increase in the incidence of cases of Guillain-Barré syndrome and microcephaly in neonates was observed in regions with an ongoing ZIKV epidemic [35, 36]. The first major outbreak of ZIKV was reported outside Africa in 2007 in Micronesia [37, 38], followed by a second major outbreak in French Polynesia in 2013 [39]. The largest ZIKV outbreak began in Brazil at the end of 2014 with 1.3 million cases estimated by the end of 2015. In May 2016, 47 countries and territories in the Americas, including the USA, reported autochthonous cases of ZIKV [6]. The impact of ZIKV infections on the development of the central nervous system will be defined only in the years to come; at present, the degree of developmental delay or other neurological sequelae that could have babies born to mothers affected by ZIKV is not known. Another important aspect of the future epidemiology of ZIKV infections is the possibility of blood transmission and the consequent need for blood testing in high-incidence areas [35]. In 2017, the number of reported cases that decreased dramatically in Brazil and other American countries, maybe due to the high number of infected people who have acquired protective immunity to reinfection and improved vector control strategies in countries where an epidemic has been reported. However, now the epidemic is no longer considered an international medical emergency and there may be a sharp decline in investment in research and control related to ZIKV. Although the number of ZIKV cases has declined, the risk of another major epidemic in Brazil and other tropical and subtropical countries is still significant and its intensity is difficult to predict. It is therefore essential to develop systems that allow a more accurate diagnosis of ZIKV infections to differentiate it from other flavivirus infections, in particular by using serological tests that can be performed in any developing country. Furthermore, the development of a safe vaccine is of paramount importance for the containment of ZIKV infection, in particular for immunocompromised and pregnant women, but the adverse effects in the development of Guillain-Barré syndrome and the enhancement of other flavivirus diseases by antibodies produced against ZIKV, in particular, toward a future DENV infection must be considered [35].

#### *2.2.4. Yellow fever virus*

YFV is the type of species in the *Flavivirus* genus of the family *Flaviviridae*. The primary transmission cycle occurs between nonhuman primates and a range of arboreal mosquito species mainly belonging to the genera *Aedes* and *Haemagogus*, in Africa and South America, respectively. Transmission to humans occurs as the result of frequent spillover events in the so-called zone of emergence, where the presence of *Ae. aegypti* as primary peridomestic vector can initiate an urban cycle characterized by rapid human-mosquito transmission that leads to explosive outbreaks [40, 41]. The epidemiology of YFV in Africa often involves both sylvatic and urban cycles increasing the force of infection during human epidemics, that result larger than in South America [40]. In humans, YF is a severe acute illness with fever, nausea, hepatitis with jaundice, renal failure, hemorrhage, and shock with case fatality lower in Africa (20%) than in south America (40–60%) [42], suggesting a correlation between genetic factors and lethality of the infection. In Africa as well as in South America, high YF case rates likely occur due to low vaccination coverage in area of endemic transmission. According to WHO and the United Nations Children's Emergency Fund (UNICEF) estimates, only 41% of the target population had received YF vaccination in 2014, well below the recommended 80% threshold for the prevention of an epidemic [41]. However, the underlying reasons for virus amplification could be multifactorial, including the possibility of a new virus lineage emerging correlating with the expansion of YFV activity [43]. In endemic areas, deforestation has been associated with emergence of YF outbreaks due to the higher biting activity of vectors, especially in new settlements inside or near the forest frequently colonized by unvaccinated migrant populations. Moreover, perturbation in environmental conditions, such as increase in rainfall and temperatures, has been associated with an abundance of vectors enhancing YFV circulation with increased outbreaks in Africa and South America [40]. YFV could potentially emerge and disperse in a similar manner to DENV, CHIKV, and ZIKV in South America. The recent outbreak of YF in Brazil and multiple reports of cases outside endemic regions highlight the possibility of urban YF arising [8]. In fact, many cases were reported in areas considered free of virus circulation, where routine YF vaccination is not performed. A molecular study showed implicated a new YFV lineage which evolved from the lineage circulating in Brazil in the 1990s, and moved toward the Atlantic coast, the most populated area in Brazil [40]. Moreover, YFV could become the next arbovirus to emerge as a public health emergency if swift to international spread occurs. Since December 2015, YF epidemic has been reported in Angola, spreading to Kenya and the Democratic Republic of the Congo. Moreover, in April 2016, YFV was exported to China via unvaccinated workers, representing the first laboratory-documented cases of YFV in Asia [41]. This risk is particularly acute in the Asia-Pacific region, where systems for YFV surveillance and detection are largely untested and YF vaccination is limited to travelers [44]. If introduction of YFV occurs in areas with a high density of *Ae. aegypti*, it is possible that local transmission could occur and potentially spread to Southeast Asia, putting approximately 2 billion people at risk without there being sufficient vaccine stockpiles [41].

#### *2.2.5. West Nile virus*

maternal infection was observed to be vertically transmitted, most commonly during birth, leading to severe disease and encephalopathy in half of neonates and resulting in long-term

ZIKV (*Flaviviridae*: *Flavivirus*) is primarily transmitted by mosquitoes of *Aedes* genus, including not only *Ae. aegypti* for urban transmission but also *Ae. albopictus*, *Ae. poliniensis*, and *Ae. hensilli.* Recently, transmission of the virus has also been reported via sexual, neonatal, and blood transfusion. ZIKV infection can be asymptomatic or cause a mild febrile illness characterized by headaches, myalgia, fever, rash, and conjunctivitis [35]. ZIKV was isolated and associated with human disease more than 60 years ago, but remained poorly studied until an association with neurological involvement was observed. In fact, an increase in the incidence of cases of Guillain-Barré syndrome and microcephaly in neonates was observed in regions with an ongoing ZIKV epidemic [35, 36]. The first major outbreak of ZIKV was reported outside Africa in 2007 in Micronesia [37, 38], followed by a second major outbreak in French Polynesia in 2013 [39]. The largest ZIKV outbreak began in Brazil at the end of 2014 with 1.3 million cases estimated by the end of 2015. In May 2016, 47 countries and territories in the Americas, including the USA, reported autochthonous cases of ZIKV [6]. The impact of ZIKV infections on the development of the central nervous system will be defined only in the years to come; at present, the degree of developmental delay or other neurological sequelae that could have babies born to mothers affected by ZIKV is not known. Another important aspect of the future epidemiology of ZIKV infections is the possibility of blood transmission and the consequent need for blood testing in high-incidence areas [35]. In 2017, the number of reported cases that decreased dramatically in Brazil and other American countries, maybe due to the high number of infected people who have acquired protective immunity to reinfection and improved vector control strategies in countries where an epidemic has been reported. However, now the epidemic is no longer considered an international medical emergency and there may be a sharp decline in investment in research and control related to ZIKV. Although the number of ZIKV cases has declined, the risk of another major epidemic in Brazil and other tropical and subtropical countries is still significant and its intensity is difficult to predict. It is therefore essential to develop systems that allow a more accurate diagnosis of ZIKV infections to differentiate it from other flavivirus infections, in particular by using serological tests that can be performed in any developing country. Furthermore, the development of a safe vaccine is of paramount importance for the containment of ZIKV infection, in particular for immunocompromised and pregnant women, but the adverse effects in the development of Guillain-Barré syndrome and the enhancement of other flavivirus diseases by antibodies produced against ZIKV, in particular, toward a future DENV infection must be considered [35].

YFV is the type of species in the *Flavivirus* genus of the family *Flaviviridae*. The primary transmission cycle occurs between nonhuman primates and a range of arboreal mosquito species mainly belonging to the genera *Aedes* and *Haemagogus*, in Africa and South America, respectively. Transmission to humans occurs as the result of frequent spillover events in the so-called zone of emergence, where the presence of *Ae. aegypti* as primary peridomestic vector

neurologic sequelae [34].

30 Public Health - Emerging and Re-emerging Issues

*2.2.4. Yellow fever virus*

*2.2.3. Zika virus*

WNV belongs to the Japanese encephalitis virus (JEV) serocomplex in the genus *Flavivirus.* It is maintained in nature within an enzootic transmission cycle among birds and *Culex* mosquitoes, with outbreaks caused by spillover transmission to equids and humans, which are dead-end hosts [1]. Based on serological evidences, WNV circulates in the absence of clinical disease in the majority of humans and a wide variety of different animal species, but in abundancy of *Culex* species mosquitoes WNV, may also cause epidemics with disease symptoms ranging from subclinical or mild febrile to encephalic with or without flaccid paralysis and fatality [8, 10]. WNV is distributed globally, with two main genetic lineages: Lineage 1 is widely distributed and highly invasive, whereas Lineage 2 appears to have remained enzootic in Africa. Lineage 3 and 4 have been described from single isolates in Central Europe, whereas Lineage 5 appears to be confined to India [45]. International dispersal of *Cx. pipiens* mosquitoes that appear to be closely associated with human infection and urban outbreaks, and the introduction of the house sparrow (*Passer domesticus*) as a highly competent host for most WNV strains, has provided the availability of maintenance and amplification cycle of the virus almost circumglobally. Moreover, climate changes at northern temperate latitudes, recently, have made these areas more conducive to WNV invasion [1]. Outbreaks of WNV were recorded throughout the Mediterranean basin, Central Europe, and Russia, where *Cx. pipiens* appeared to be the primary vector. In the Americas, WNV was introduced into New York during the summer of 1999. Phylogenetic evidence suggest that the invading strain was closely related to a 1998 isolate from Israel that contained a mutation causing high viremia and mortality in American crows and higher transmission competence of *Culex* mosquito species. Once the virus had been introduced in the USA, migratory birds played a major role in the dispersal of WNV throughout North America [1, 10]. WNV is now one of the most broadly distributed arboviruses in the world, as well as the most common cause of arboviral neuroinvasive disease in the USA [1, 5]. Currently, WNV vaccines are only available for equids, although human vaccines are under development [6]. However, the motivation for human vaccine development may be limited by the low attack rate that the virus exhibits in humans following epidemics. Therefore, in the near term, protection for public health will continue to rely on mosquito control [1].

in pigs [1]. The risk that JEV becomes a greater threat in the near future is quite high, given the genetic diversity of the virus and several *Aedes* species as marginal competent vectors [6]. Air transport of mosquitoes was the probable cause of JEV outbreaks on isolated Pacific Islands, demonstrating the potential of this virus to invade new areas such as the west coast of the USA. Moreover, with the spread of JEV into much of the Indian subcontinent, other destinations served by frequent routes of commerce or passenger air travel, such as Africa and Europe,

Emerging and Re-emerging Arboviral Diseases as a Global Health Problem

http://dx.doi.org/10.5772/intechopen.77382

33

Rift Valley fever virus (RVFV) is classified within the genus *Phlebovirus* in the family *Bunyaviridae* and circulates in Central West, East and South Africa and in the Arabian Peninsula [8, 51]. Infection causes severe and often fatal illness in sheep, cattle, goats and camels, with occasional spillover to humans, in which the infection shows no symptoms or a mild illness associated with fever and liver abnormalities [1, 8]. However, during RVFV epizootics, up to 10% of affected humans may develop more severe disease, including encephalitis, retinitis, and hemorrhagic fever with case fatality rate approximately 10–20% [8, 52]. RVFV is maintained in an enzootic cycle among wildlife and a wide variety of mosquito species, including *Aedes*, *Culex*, *Anopheles*, and *Mansonia*. The virus is maintained by vertical transmission in eggs of *Aedes* species during dry season, with intermittent epizootic outbreaks occur during rainy season [1, 8]. Historically, RVFV was restricted to sub-Saharan eastern Africa, especially Rift Valley of the Kenya and Tanzania. Subsequent outbreaks with human involvement have been documented in South Africa, the Nile Valley, and the Saudi Arabian Peninsula. A large outbreak in Mauritania indicated dispersal of the virus in West Africa [53, 54], demonstrating the ability of RVFV to escape historical enzootic areas. Major irrigation projects and the El Nino effect are considered to be the important factors influencing the epidemiology of RVFV [4, 55] and the movement of viremic camels along trade routes that has been suspected to be the routes of dispersal. Moreover, before the onset of the disease, humans develop viremias suitable to infect susceptible mosquitoes; uncontrolled air travel therefore could introduce RVFV into North America or Europe where susceptible wild and domestic hosts and suitable vectors reside [1, 56]. RVFV is generally considered to be a candidate for emergence and global dispersion but, as the virus is transmissible by a wide variety of mosquitoes adapted to the local habitats in Africa and *Ae. Aegypti* is not a recognized primary vector, the likelihood of expansion outside Africa and Saudi Arabia appears to be low. However, RVFV could be inadvertently introduced via infected mosquitoes into a tropical region where competent domestic *Ae. aegypti* predominate in the urban environment [8]. Nevertheless, laboratory infection has highlighted the presence of competent *Cx. Pipiens* in Southern France and Tunisia with the potential for RVFV epizootics to occur in the virus, which was introduced into countries of the Mediterranean basin [57]. Several vaccines for RVFV have been developed and appear effective; however, their use is limited. Failure to contain these outbreaks provides a source of virus to seed outbreaks into other areas of Africa and the Middle East as well as the rest of the world. With a high potential impact on wildlife, domestic animal, and human health, failure to contain RVFV could seri-

ously impact veterinary and human health in Asia, Europe, and the Americas [1, 51].

also could be at risk [1].

*2.3.1. Rift Valley fever virus*

**2.3. Arboviruses with potential of emergence**

#### *2.2.6. Japanese encephalitis virus*

JEV is the most frequent cause of mosquito-borne encephalitis globally. The public health significance and the global distribution of JEV have been progressively expanding; currently, more than 3 billion people in Asia reside in areas at risk of JE, with an estimated 50,000 symptomatic cases and 10,000 deaths occurring annually [46]. Taxonomically, JEV is placed within the genus *Flavivirus* and is the type of virus for the JEV serocomplex. JEV is maintained within an aquatic bird-*Culex* mosquito transmission cycle and is amplified within a domestic swine-*Culex* cycle. Moreover, *Culex* mosquitoes can transmit JEV to equids and humans, which are dead-end hosts for the virus. JEV is endemic in large parts of Asia and the Pacific, where mosquito vectors are present in association with rice and other irrigated crops [1, 46]. Of the five major genetic lineages, lineages 1 and 3 have been found co-circulating in subtropical and temperate latitudes and are associated with outbreaks of neuroinvasive disease. However, lineage 5 now appears to be emerging as the predominant genotype. The epidemiological significance is bounded to the fact that lineage 5 is antigenically the most diverse genotype and the current JEV vaccine shows limited efficacy against this genotype [8, 47]. Moreover, the primary mosquito vector, *Culex tritaeniorhynchus,* has been recently identified in north western Greece [48] and JEV RNA was detected in *Cx. Pipiens* mosquitoes in Italy [49], thus potentially increasing the risk of JEV emergence in Europe. In addition, the even more recent detection of autochthonous JEV coinfection during the YF outbreak in Angola [50] supports the idea that JEV may have already expanded its Asian boundaries [8]. The rapid and widespread expansion of JEV in the Asian continent was associated closely with increases in human populations, in acreage of irrigated rice and pig farming. In endemic areas of Japan, the avian-*Culex* maintenance cycle may be bypassed when vertically infected *Cx. tritaeniorhynchus* directly initiate the amplification cycle in pigs [1]. The risk that JEV becomes a greater threat in the near future is quite high, given the genetic diversity of the virus and several *Aedes* species as marginal competent vectors [6]. Air transport of mosquitoes was the probable cause of JEV outbreaks on isolated Pacific Islands, demonstrating the potential of this virus to invade new areas such as the west coast of the USA. Moreover, with the spread of JEV into much of the Indian subcontinent, other destinations served by frequent routes of commerce or passenger air travel, such as Africa and Europe, also could be at risk [1].

#### **2.3. Arboviruses with potential of emergence**

#### *2.3.1. Rift Valley fever virus*

enzootic in Africa. Lineage 3 and 4 have been described from single isolates in Central Europe, whereas Lineage 5 appears to be confined to India [45]. International dispersal of *Cx. pipiens* mosquitoes that appear to be closely associated with human infection and urban outbreaks, and the introduction of the house sparrow (*Passer domesticus*) as a highly competent host for most WNV strains, has provided the availability of maintenance and amplification cycle of the virus almost circumglobally. Moreover, climate changes at northern temperate latitudes, recently, have made these areas more conducive to WNV invasion [1]. Outbreaks of WNV were recorded throughout the Mediterranean basin, Central Europe, and Russia, where *Cx. pipiens* appeared to be the primary vector. In the Americas, WNV was introduced into New York during the summer of 1999. Phylogenetic evidence suggest that the invading strain was closely related to a 1998 isolate from Israel that contained a mutation causing high viremia and mortality in American crows and higher transmission competence of *Culex* mosquito species. Once the virus had been introduced in the USA, migratory birds played a major role in the dispersal of WNV throughout North America [1, 10]. WNV is now one of the most broadly distributed arboviruses in the world, as well as the most common cause of arboviral neuroinvasive disease in the USA [1, 5]. Currently, WNV vaccines are only available for equids, although human vaccines are under development [6]. However, the motivation for human vaccine development may be limited by the low attack rate that the virus exhibits in humans following epidemics. Therefore, in the near term, protection for public health will

JEV is the most frequent cause of mosquito-borne encephalitis globally. The public health significance and the global distribution of JEV have been progressively expanding; currently, more than 3 billion people in Asia reside in areas at risk of JE, with an estimated 50,000 symptomatic cases and 10,000 deaths occurring annually [46]. Taxonomically, JEV is placed within the genus *Flavivirus* and is the type of virus for the JEV serocomplex. JEV is maintained within an aquatic bird-*Culex* mosquito transmission cycle and is amplified within a domestic swine-*Culex* cycle. Moreover, *Culex* mosquitoes can transmit JEV to equids and humans, which are dead-end hosts for the virus. JEV is endemic in large parts of Asia and the Pacific, where mosquito vectors are present in association with rice and other irrigated crops [1, 46]. Of the five major genetic lineages, lineages 1 and 3 have been found co-circulating in subtropical and temperate latitudes and are associated with outbreaks of neuroinvasive disease. However, lineage 5 now appears to be emerging as the predominant genotype. The epidemiological significance is bounded to the fact that lineage 5 is antigenically the most diverse genotype and the current JEV vaccine shows limited efficacy against this genotype [8, 47]. Moreover, the primary mosquito vector, *Culex tritaeniorhynchus,* has been recently identified in north western Greece [48] and JEV RNA was detected in *Cx. Pipiens* mosquitoes in Italy [49], thus potentially increasing the risk of JEV emergence in Europe. In addition, the even more recent detection of autochthonous JEV coinfection during the YF outbreak in Angola [50] supports the idea that JEV may have already expanded its Asian boundaries [8]. The rapid and widespread expansion of JEV in the Asian continent was associated closely with increases in human populations, in acreage of irrigated rice and pig farming. In endemic areas of Japan, the avian-*Culex* maintenance cycle may be bypassed when vertically infected *Cx. tritaeniorhynchus* directly initiate the amplification cycle

continue to rely on mosquito control [1].

32 Public Health - Emerging and Re-emerging Issues

*2.2.6. Japanese encephalitis virus*

Rift Valley fever virus (RVFV) is classified within the genus *Phlebovirus* in the family *Bunyaviridae* and circulates in Central West, East and South Africa and in the Arabian Peninsula [8, 51]. Infection causes severe and often fatal illness in sheep, cattle, goats and camels, with occasional spillover to humans, in which the infection shows no symptoms or a mild illness associated with fever and liver abnormalities [1, 8]. However, during RVFV epizootics, up to 10% of affected humans may develop more severe disease, including encephalitis, retinitis, and hemorrhagic fever with case fatality rate approximately 10–20% [8, 52]. RVFV is maintained in an enzootic cycle among wildlife and a wide variety of mosquito species, including *Aedes*, *Culex*, *Anopheles*, and *Mansonia*. The virus is maintained by vertical transmission in eggs of *Aedes* species during dry season, with intermittent epizootic outbreaks occur during rainy season [1, 8]. Historically, RVFV was restricted to sub-Saharan eastern Africa, especially Rift Valley of the Kenya and Tanzania. Subsequent outbreaks with human involvement have been documented in South Africa, the Nile Valley, and the Saudi Arabian Peninsula. A large outbreak in Mauritania indicated dispersal of the virus in West Africa [53, 54], demonstrating the ability of RVFV to escape historical enzootic areas. Major irrigation projects and the El Nino effect are considered to be the important factors influencing the epidemiology of RVFV [4, 55] and the movement of viremic camels along trade routes that has been suspected to be the routes of dispersal. Moreover, before the onset of the disease, humans develop viremias suitable to infect susceptible mosquitoes; uncontrolled air travel therefore could introduce RVFV into North America or Europe where susceptible wild and domestic hosts and suitable vectors reside [1, 56]. RVFV is generally considered to be a candidate for emergence and global dispersion but, as the virus is transmissible by a wide variety of mosquitoes adapted to the local habitats in Africa and *Ae. Aegypti* is not a recognized primary vector, the likelihood of expansion outside Africa and Saudi Arabia appears to be low. However, RVFV could be inadvertently introduced via infected mosquitoes into a tropical region where competent domestic *Ae. aegypti* predominate in the urban environment [8]. Nevertheless, laboratory infection has highlighted the presence of competent *Cx. Pipiens* in Southern France and Tunisia with the potential for RVFV epizootics to occur in the virus, which was introduced into countries of the Mediterranean basin [57]. Several vaccines for RVFV have been developed and appear effective; however, their use is limited. Failure to contain these outbreaks provides a source of virus to seed outbreaks into other areas of Africa and the Middle East as well as the rest of the world. With a high potential impact on wildlife, domestic animal, and human health, failure to contain RVFV could seriously impact veterinary and human health in Asia, Europe, and the Americas [1, 51].

#### *2.3.2. Mayaro virus*

Mayaro virus (MAYV) is an emerging *alphavirus* with autochthonous transmission in central and south America with higher prevalence in amazon region; recently, it has been reported to circulate in the Caribbean [58, 59]. Infection produces indistinguishable symptoms to the closely related CHIKV; therefore, due to the high degree of co-circulation with CHIKV, DENV, and similar viruses, cases of MAYV infection are not reported frequently. An estimated 1% of all febrile dengue-like illness in northern South America is caused by MAYV, as evidenced by the high rates of detection during regional serosurveillance [6, 60, 61]. The transmission cycle of MAYV is similar to the sylvatic transmission of YFV, with nonhuman primates as main reservoirs. The primary vectors are likely mosquitoes from the genus *Haemagogus*; however, the virus has also been detected in other mosquitoes and mites [1]. A major concern is that MAYV has also been detected in two of the most abundant mosquito genera: *Culex* and *Aedes* [6, 62]. Experimental evidence suggests that the virus is highly infectious to *Ae. aegypti* [63] and can be transmitted at low rates by *Ae. albopictus*, making that species a potential secondary vector [6, 64]. Historically, MAYV outbreaks have been sporadic, however, spillover events have occurred following deforestation and urbanization in endemic areas, both of which bring the virus into closer proximity to larger human populations, and to their associated urban vectors [1, 6, 65]. Given the close genetic relationship with CHIKV, it is plausible that MAYV could also evolve to become more infectious to humans or anthropophilic mosquitoes, and experience similarly high levels of outbreaks.

Venezuela and Colombia in 1995 [71, 72]. In these areas, natural emergence will occur periodically, as long as equine herd immunity is not maintained at adequate levels by vaccination or natural acquisition of immunity from enzootic exposure. The risk of epidemic emergence may be increasing by the conversion of large areas of tropical forest to ranching and other forms of agriculture, increasing opportunities for infection of bridge vectors competent to the generation of an equine amplified cycle. Furthermore, urban peridomestic mosquito vectors such as *Ae. aegypti* [73] and *Ae. albopictus* [74] are capable of transmission after oral doses comparable to human viremia titers, making an *Ae. aegypti*-borne epidemic VEEV cycle possible [1]. Prevention and control of epizootic/epidemic VEEV depends on effective use of veterinary vaccines, but equine vaccination in many countries is not widespread. Therefore, during epizootic/epidemic transmission, mosquito control is an important adjunct to vaccination [7].

Emerging and Re-emerging Arboviral Diseases as a Global Health Problem

http://dx.doi.org/10.5772/intechopen.77382

35

Because they are not an essential part in the zoonotic arbovirus life cycle, arbovirus disease control based on humans and domestic animals cannot eradicate the arbovirus. Consequently, the reservoir in wild species places a limitation in the control disease emergence, and only understanding the interactions involved in the biology of the virus, hosts, and ecology will lead to effective control and prevention strategies [4, 5]. With effective vaccination and sustainable vector control programs, it is possible to control or even eliminate human transmission cycles. In fact, vaccination can increase herd immunity, making it easier to sustain reduced virus transmission with vector control. On the other hand, vector control can complement a vaccine by lowering the risk of infection, making vaccine delivery goals easier to achieve [75]. The YF vaccine has been used extensively in West Africa and has been instrumental in eliminating the urban transmission cycle in South America. However, despite its efficacy and low-cost production, epidemics continue to occur due to inadequate vaccination coverage, as demonstrated by the recent YF outbreak in Angola and Democratic Republic of Congo [76]. Adequate and continuous vaccination programs along with high levels of herd immunity are of paramount importance for the control of YF. In Africa, together with childhood immunization, mass preventive vaccination campaigns to protect elderly people need to be implemented [77]. Moreover, in South America, people of coastal areas are largely unvaccinated and therefore exposed to the risk of YFV coming from the near enzootic regions [75]. Finally, YF cases reported from travelers from Angola to China highlight the need to implement the WHO International Health Regulations in order to protect travelers and to avoid the introduction of YFV in naïve areas of Asia where the vector is widely present [76]. Japanese encephalitis was controlled in Japan, Taiwan, and Korea using inactivated vaccines, which also contributed to control infection in China [10, 78]. A live attenuated JEV vaccine was used to reduce the risk of infection in children in China, as well as being part of the large children immunization campaign in India [10]. At the end of 2015, the first dengue vaccine was licensed (CYD-TDV vaccine Dengvaxia). The results of a large phase III study in 10 endemic countries in Asia and South America showed a complex performance of the vaccine with efficacy dependent on serotype, as well as previous immunity and age of the subject [79, 80]. Two other live dengue virus vaccines are in phase III trials and many other dengue vaccines are in phase I and II trials [75]. Research on vaccines against CHIKV has been slow, as CHIKV causes

**3. Strategies for arbovirus control**

#### *2.3.3. Venezuelan equine encephalitis virus*

Venezuelan equine encephalitis virus (VEEV) is an alphavirus (*Togaviridae: Alphavirus*) widely distributed in tropical and subtropical regions of the Americas, where it circulates endemically between mosquitoes of the genus *Culex* and rodents. The VEEV complex can be subdivided into six different subtypes (I to IV) with type I further divided into other antigenic variants; only VEEV subtypes IAB and IC are considered epizootic variants and are pathogenic for horses [66, 67]. Also humans infected with epidemic VEEV strains develop high titers viremia and may therefore play a role as maintenance and amplification hosts [67–69]. Main epidemics occur when VEEV epidemic strains spill over into competent mosquitoes of the genera *Aedes* and *Psorophora*, which have a peridomestic behavior and may transmit VEEV to equids. An equine-mosquito amplification cycle may induce an extensive virus circulation that may spill over to humans and cause outbreaks of VEEV. Epidemic VEEV infection in humans is a highly disabling dengue-like febrile disease, which can lead to severe encephalitis with fatality rates of between 1 and 3%, especially in children [67, 70]. Moreover, if infection occurs during pregnancy, it may lead to severe neurological birth defects and anomalies [66]. The emergence of VEEV epidemics is based on a combination of ecological and viral genetic factors. Enzootic VEEV strains are not able to achieve a sufficient viremia for equine amplification. However, a single mutation in the viral genome can lead to changes in the viral envelope improving equine amplification. Because alphaviruses replicate with low genetic fidelity, it is likely that mutations competent for equine amplification occur regularly within sylvatic cycles. Then, the transport of mutants strains competent for the equine amplification in areas with susceptible equids and mosquito vectors allows the emergence of epidemics [1]. The last major VEE epidemic, which involved ca. 100,000 persons with an estimated 300 deaths, occurred in Venezuela and Colombia in 1995 [71, 72]. In these areas, natural emergence will occur periodically, as long as equine herd immunity is not maintained at adequate levels by vaccination or natural acquisition of immunity from enzootic exposure. The risk of epidemic emergence may be increasing by the conversion of large areas of tropical forest to ranching and other forms of agriculture, increasing opportunities for infection of bridge vectors competent to the generation of an equine amplified cycle. Furthermore, urban peridomestic mosquito vectors such as *Ae. aegypti* [73] and *Ae. albopictus* [74] are capable of transmission after oral doses comparable to human viremia titers, making an *Ae. aegypti*-borne epidemic VEEV cycle possible [1]. Prevention and control of epizootic/epidemic VEEV depends on effective use of veterinary vaccines, but equine vaccination in many countries is not widespread. Therefore, during epizootic/epidemic transmission, mosquito control is an important adjunct to vaccination [7].

## **3. Strategies for arbovirus control**

*2.3.2. Mayaro virus*

34 Public Health - Emerging and Re-emerging Issues

ence similarly high levels of outbreaks.

*2.3.3. Venezuelan equine encephalitis virus*

Mayaro virus (MAYV) is an emerging *alphavirus* with autochthonous transmission in central and south America with higher prevalence in amazon region; recently, it has been reported to circulate in the Caribbean [58, 59]. Infection produces indistinguishable symptoms to the closely related CHIKV; therefore, due to the high degree of co-circulation with CHIKV, DENV, and similar viruses, cases of MAYV infection are not reported frequently. An estimated 1% of all febrile dengue-like illness in northern South America is caused by MAYV, as evidenced by the high rates of detection during regional serosurveillance [6, 60, 61]. The transmission cycle of MAYV is similar to the sylvatic transmission of YFV, with nonhuman primates as main reservoirs. The primary vectors are likely mosquitoes from the genus *Haemagogus*; however, the virus has also been detected in other mosquitoes and mites [1]. A major concern is that MAYV has also been detected in two of the most abundant mosquito genera: *Culex* and *Aedes* [6, 62]. Experimental evidence suggests that the virus is highly infectious to *Ae. aegypti* [63] and can be transmitted at low rates by *Ae. albopictus*, making that species a potential secondary vector [6, 64]. Historically, MAYV outbreaks have been sporadic, however, spillover events have occurred following deforestation and urbanization in endemic areas, both of which bring the virus into closer proximity to larger human populations, and to their associated urban vectors [1, 6, 65]. Given the close genetic relationship with CHIKV, it is plausible that MAYV could also evolve to become more infectious to humans or anthropophilic mosquitoes, and experi-

Venezuelan equine encephalitis virus (VEEV) is an alphavirus (*Togaviridae: Alphavirus*) widely distributed in tropical and subtropical regions of the Americas, where it circulates endemically between mosquitoes of the genus *Culex* and rodents. The VEEV complex can be subdivided into six different subtypes (I to IV) with type I further divided into other antigenic variants; only VEEV subtypes IAB and IC are considered epizootic variants and are pathogenic for horses [66, 67]. Also humans infected with epidemic VEEV strains develop high titers viremia and may therefore play a role as maintenance and amplification hosts [67–69]. Main epidemics occur when VEEV epidemic strains spill over into competent mosquitoes of the genera *Aedes* and *Psorophora*, which have a peridomestic behavior and may transmit VEEV to equids. An equine-mosquito amplification cycle may induce an extensive virus circulation that may spill over to humans and cause outbreaks of VEEV. Epidemic VEEV infection in humans is a highly disabling dengue-like febrile disease, which can lead to severe encephalitis with fatality rates of between 1 and 3%, especially in children [67, 70]. Moreover, if infection occurs during pregnancy, it may lead to severe neurological birth defects and anomalies [66]. The emergence of VEEV epidemics is based on a combination of ecological and viral genetic factors. Enzootic VEEV strains are not able to achieve a sufficient viremia for equine amplification. However, a single mutation in the viral genome can lead to changes in the viral envelope improving equine amplification. Because alphaviruses replicate with low genetic fidelity, it is likely that mutations competent for equine amplification occur regularly within sylvatic cycles. Then, the transport of mutants strains competent for the equine amplification in areas with susceptible equids and mosquito vectors allows the emergence of epidemics [1]. The last major VEE epidemic, which involved ca. 100,000 persons with an estimated 300 deaths, occurred in Because they are not an essential part in the zoonotic arbovirus life cycle, arbovirus disease control based on humans and domestic animals cannot eradicate the arbovirus. Consequently, the reservoir in wild species places a limitation in the control disease emergence, and only understanding the interactions involved in the biology of the virus, hosts, and ecology will lead to effective control and prevention strategies [4, 5]. With effective vaccination and sustainable vector control programs, it is possible to control or even eliminate human transmission cycles. In fact, vaccination can increase herd immunity, making it easier to sustain reduced virus transmission with vector control. On the other hand, vector control can complement a vaccine by lowering the risk of infection, making vaccine delivery goals easier to achieve [75].

The YF vaccine has been used extensively in West Africa and has been instrumental in eliminating the urban transmission cycle in South America. However, despite its efficacy and low-cost production, epidemics continue to occur due to inadequate vaccination coverage, as demonstrated by the recent YF outbreak in Angola and Democratic Republic of Congo [76]. Adequate and continuous vaccination programs along with high levels of herd immunity are of paramount importance for the control of YF. In Africa, together with childhood immunization, mass preventive vaccination campaigns to protect elderly people need to be implemented [77]. Moreover, in South America, people of coastal areas are largely unvaccinated and therefore exposed to the risk of YFV coming from the near enzootic regions [75]. Finally, YF cases reported from travelers from Angola to China highlight the need to implement the WHO International Health Regulations in order to protect travelers and to avoid the introduction of YFV in naïve areas of Asia where the vector is widely present [76]. Japanese encephalitis was controlled in Japan, Taiwan, and Korea using inactivated vaccines, which also contributed to control infection in China [10, 78]. A live attenuated JEV vaccine was used to reduce the risk of infection in children in China, as well as being part of the large children immunization campaign in India [10]. At the end of 2015, the first dengue vaccine was licensed (CYD-TDV vaccine Dengvaxia). The results of a large phase III study in 10 endemic countries in Asia and South America showed a complex performance of the vaccine with efficacy dependent on serotype, as well as previous immunity and age of the subject [79, 80]. Two other live dengue virus vaccines are in phase III trials and many other dengue vaccines are in phase I and II trials [75]. Research on vaccines against CHIKV has been slow, as CHIKV causes major epidemics only every 10–30 years, limiting the interest of the pharmaceutical industry for a financial return [75]. However, two vaccines against CHIKV have recently completed phase I clinical trials, both are strongly immunogenic after 2–3 doses and are currently in phase II trials [81, 82]. Among more than 40 Zika vaccines developed, DNA, RNA, and inactivated virus [83–85] versions started clinical trials and the first live-attenuated vaccine has been demonstrated to be safe and efficacious after a single dose in mice [86]. However, there are some concerns about potential interactions with immunity generated by other flavivirus natural infections or vaccines leading to more severe manifestations of the disease, as well as the immune trigger in the development of Guillain-Barre syndrome [87]. Currently, there is no specific licensed anti-arbovirus agent, and patient management is therefore mainly supportive. Passive immunotherapy is a promising approach for the management of newborns exposed to CHIKV. The anti-CHIKV human immunoglobulins purified from convalescent donors exhibit strong anti-CHIKV effects in vitro and animal models [88], and are now evaluated in the prevention of mother-to-child CHIKV transmission in newborns born to viremic mothers [87]. Novel antiviral therapies are also being investigated. Drug repurposing strategies have identified potential inhibitors of *Flaviviridae* replication. Ivermectin strongly inhibits the replication of YFV, DENV, and WNV [89], while azithromycin inhibits the cytopathic effects induced by ZIKV in glial lines and in human astrocytes and is also considered safe for use during pregnancy [90]. Further new approaches aim to identify host factors and pathways that are critical for viral replication and to identify the putative inhibitors of these pathways as host-targeting antivirals [87].

preventing successful reproduction between infected and uninfected males and between infected males and females harboring different strains of *Wolbachia*, similar in method and effect to SIT [91, 96]. *Wolbachia* can also be used as a population replacement strategy, which consists in the release of female mosquitoes infected by *Wolbachia*, relying on high levels of maternal transmission [97]. The introduction of *Wolbachia* in the naturally uninfected field *Ae. aegypti* populations is currently used to confer resistance to viral infection, making infected mosquitoes poor vectors of pathogens of medical importance including DENV and CHIKV [98, 99]

Emerging and Re-emerging Arboviral Diseases as a Global Health Problem

http://dx.doi.org/10.5772/intechopen.77382

37

The implementation of localized arthropod control measures during epidemics, for example, in high-density urbanized areas, can play an important but transient role in reducing the impact on humans and animals of emerging arboviruses if these are supported from surveillance systems, which differ at regional level and in many areas are completely absent [4]. Furthermore, it is essential to characterize and understand viral genetics, antigenic properties, virulence patterns, vector associations, and maintenance mechanisms to identify and control future arboviral outbreaks. The next public health needs include communication to the population and physicians of vector-borne diseases, the guarantee of vector control programs, and the maintenance of adequate surveillance systems with trained personnel, together with the

Arboviruses already have a well-known history of emergence and will undoubtedly continue to emerge in the future. There are many unidentified arboviruses that, due to their high mutation rates, may emerge as pathogens even if they are not yet present as epidemic strains in the wild environment. Recent progress in sequencing offers new opportunities to identify them during surveillance activities, especially in the tropics, where viral diversity is higher [3]. The greatest risk for humans derives from the ability of some arboviruses to adopt urban transmission cycles involving highly efficient and anthropophilic vectors, such as *Ae. aegypti* and *Ae. albopictus*, or enzootic peridomestic cycles involving *Culex* urban populations [1]. The ability to urbanize and cause an epidemic, exemplified by DENV, CHIKV, and YFV, could be acquired by many other viruses, including VEEV and MAYV, which have the potential to infect these urban vectors and whose exposure to urban populations in the tropics is already known. A more complete understanding of the molecular interactions associated with the emergence will be particularly useful in predicting the likelihood of this happening [3]. The public health emergency of ZIKV, the threat of the YF, and the re-emergence of DENV and CHIKV should serve as a wake-up call for governments, academics, and WHO to strengthen the control and research programs on arboviral infections [75]. A continuous international and interdisciplinary response is needed to improve the ability to anticipate, control, and mitigate the risk of emerging and re-emerging arboviruses. Research priorities should focus on surveillance systems, knowledge of factors responsible for adaptation to other vectors, and other determinants of infection and transmission, as well as on the development of antiviral molecules or candidate vaccine. The shared characteristics of these viruses could stimulate common research themes for the development of antiviral therapies and vaccines, while the co-circulation of these viruses requires the development of differential diagnostic systems,

with similar effects characterized recently against ZIKV [100, 101].

availability of drugs, vaccines, and rapid diagnostic testing [5].

**4. Conclusions**

The continued outbreaks of YFV and JEV demonstrate that even with a widely available and effective vaccine, it is difficult to control a vector-borne disease using only vaccination [6]. Overall, the best current perspectives for controlling the majority of vector-borne diseases rely on reducing the contact between the vector and susceptible humans and the most effective approach for this goal remains the elimination or reduction of mosquito populations [87]. Nowadays, many of the insecticides used in the mid-twentieth century eradication campaign are considered environmentally unacceptable, as well as being economically prohibitive and at risk of developing resistance in mosquito populations [87, 91]. Several alternative approaches are focused on reducing the abundance of mosquitoes or preventing the transmission of pathogens by the mosquito. Environmental management includes modification of the natural breeding habitat of mosquitoes and the adoption of human behaviors that reduce the incidence of the bite, such as the elimination of domestic oviposition and larval sites, the indoor residual spraying and fumigation, the use of insecticide-treated bed nets and screening windows together with lethal traps, which have been found to be effective in reducing *Ae. aegypti* populations and transmission of CHIKV and DENV [87, 91, 92]. Another approach involves genetic modification of vectors and the release of genetically modified male mosquitoes expressing a dominant lethal gene, determining the death of all progeny from mating with wild females (sterile insect technique, SIT) [87, 91, 93]. Moreover, also the vector competence can be reduced by limiting viral infection or transmission through the introduction of transgenic mosquito lines in the field [94, 95]. Biological control represents another possible intervention and includes the use of natural predators or pathogens against mosquitoes. The strategy that involves the release of mosquitoes infected by *Wolbachia pipientis*, an endosymbiont bacterium that is transmitted vertically, allows to suppress the viral transmission by interfering with the reproduction of the mosquitoes [6, 87, 91]. *Wolbachia* infection affects sperm preventing successful reproduction between infected and uninfected males and between infected males and females harboring different strains of *Wolbachia*, similar in method and effect to SIT [91, 96]. *Wolbachia* can also be used as a population replacement strategy, which consists in the release of female mosquitoes infected by *Wolbachia*, relying on high levels of maternal transmission [97]. The introduction of *Wolbachia* in the naturally uninfected field *Ae. aegypti* populations is currently used to confer resistance to viral infection, making infected mosquitoes poor vectors of pathogens of medical importance including DENV and CHIKV [98, 99] with similar effects characterized recently against ZIKV [100, 101].

The implementation of localized arthropod control measures during epidemics, for example, in high-density urbanized areas, can play an important but transient role in reducing the impact on humans and animals of emerging arboviruses if these are supported from surveillance systems, which differ at regional level and in many areas are completely absent [4]. Furthermore, it is essential to characterize and understand viral genetics, antigenic properties, virulence patterns, vector associations, and maintenance mechanisms to identify and control future arboviral outbreaks. The next public health needs include communication to the population and physicians of vector-borne diseases, the guarantee of vector control programs, and the maintenance of adequate surveillance systems with trained personnel, together with the availability of drugs, vaccines, and rapid diagnostic testing [5].

## **4. Conclusions**

major epidemics only every 10–30 years, limiting the interest of the pharmaceutical industry for a financial return [75]. However, two vaccines against CHIKV have recently completed phase I clinical trials, both are strongly immunogenic after 2–3 doses and are currently in phase II trials [81, 82]. Among more than 40 Zika vaccines developed, DNA, RNA, and inactivated virus [83–85] versions started clinical trials and the first live-attenuated vaccine has been demonstrated to be safe and efficacious after a single dose in mice [86]. However, there are some concerns about potential interactions with immunity generated by other flavivirus natural infections or vaccines leading to more severe manifestations of the disease, as well as the immune trigger in the development of Guillain-Barre syndrome [87]. Currently, there is no specific licensed anti-arbovirus agent, and patient management is therefore mainly supportive. Passive immunotherapy is a promising approach for the management of newborns exposed to CHIKV. The anti-CHIKV human immunoglobulins purified from convalescent donors exhibit strong anti-CHIKV effects in vitro and animal models [88], and are now evaluated in the prevention of mother-to-child CHIKV transmission in newborns born to viremic mothers [87]. Novel antiviral therapies are also being investigated. Drug repurposing strategies have identified potential inhibitors of *Flaviviridae* replication. Ivermectin strongly inhibits the replication of YFV, DENV, and WNV [89], while azithromycin inhibits the cytopathic effects induced by ZIKV in glial lines and in human astrocytes and is also considered safe for use during pregnancy [90]. Further new approaches aim to identify host factors and pathways that are critical for viral replication and to identify the putative inhibitors of these pathways

The continued outbreaks of YFV and JEV demonstrate that even with a widely available and effective vaccine, it is difficult to control a vector-borne disease using only vaccination [6]. Overall, the best current perspectives for controlling the majority of vector-borne diseases rely on reducing the contact between the vector and susceptible humans and the most effective approach for this goal remains the elimination or reduction of mosquito populations [87]. Nowadays, many of the insecticides used in the mid-twentieth century eradication campaign are considered environmentally unacceptable, as well as being economically prohibitive and at risk of developing resistance in mosquito populations [87, 91]. Several alternative approaches are focused on reducing the abundance of mosquitoes or preventing the transmission of pathogens by the mosquito. Environmental management includes modification of the natural breeding habitat of mosquitoes and the adoption of human behaviors that reduce the incidence of the bite, such as the elimination of domestic oviposition and larval sites, the indoor residual spraying and fumigation, the use of insecticide-treated bed nets and screening windows together with lethal traps, which have been found to be effective in reducing *Ae. aegypti* populations and transmission of CHIKV and DENV [87, 91, 92]. Another approach involves genetic modification of vectors and the release of genetically modified male mosquitoes expressing a dominant lethal gene, determining the death of all progeny from mating with wild females (sterile insect technique, SIT) [87, 91, 93]. Moreover, also the vector competence can be reduced by limiting viral infection or transmission through the introduction of transgenic mosquito lines in the field [94, 95]. Biological control represents another possible intervention and includes the use of natural predators or pathogens against mosquitoes. The strategy that involves the release of mosquitoes infected by *Wolbachia pipientis*, an endosymbiont bacterium that is transmitted vertically, allows to suppress the viral transmission by interfering with the reproduction of the mosquitoes [6, 87, 91]. *Wolbachia* infection affects sperm

as host-targeting antivirals [87].

36 Public Health - Emerging and Re-emerging Issues

Arboviruses already have a well-known history of emergence and will undoubtedly continue to emerge in the future. There are many unidentified arboviruses that, due to their high mutation rates, may emerge as pathogens even if they are not yet present as epidemic strains in the wild environment. Recent progress in sequencing offers new opportunities to identify them during surveillance activities, especially in the tropics, where viral diversity is higher [3]. The greatest risk for humans derives from the ability of some arboviruses to adopt urban transmission cycles involving highly efficient and anthropophilic vectors, such as *Ae. aegypti* and *Ae. albopictus*, or enzootic peridomestic cycles involving *Culex* urban populations [1]. The ability to urbanize and cause an epidemic, exemplified by DENV, CHIKV, and YFV, could be acquired by many other viruses, including VEEV and MAYV, which have the potential to infect these urban vectors and whose exposure to urban populations in the tropics is already known. A more complete understanding of the molecular interactions associated with the emergence will be particularly useful in predicting the likelihood of this happening [3]. The public health emergency of ZIKV, the threat of the YF, and the re-emergence of DENV and CHIKV should serve as a wake-up call for governments, academics, and WHO to strengthen the control and research programs on arboviral infections [75]. A continuous international and interdisciplinary response is needed to improve the ability to anticipate, control, and mitigate the risk of emerging and re-emerging arboviruses. Research priorities should focus on surveillance systems, knowledge of factors responsible for adaptation to other vectors, and other determinants of infection and transmission, as well as on the development of antiviral molecules or candidate vaccine. The shared characteristics of these viruses could stimulate common research themes for the development of antiviral therapies and vaccines, while the co-circulation of these viruses requires the development of differential diagnostic systems, including more specific serological tests for seroprevalence studies. The socioeconomic and environmental factors driving the proliferation of vectors, particularly in cities of low-income countries, must be mitigated. An assessment of the available and developing vector control tools is needed to identify the most effective techniques and their combination with vaccination. Finally, new global alliances are needed, such as the global Dengue and the *Aedes*-related disease consortium, to enable the combination of the most effective and timely solutions against arboviral diseases [75].

[8] Gould E, Pettersson J, Higgs S, Charrel R, de Lamballerie X. Emerging arboviruses: Why

Emerging and Re-emerging Arboviral Diseases as a Global Health Problem

http://dx.doi.org/10.5772/intechopen.77382

39

[9] Gaunt MW, Sall AA, de Lamballerie X, Falconar AK, Dzhivanian TI, Gould EA. Phylogenetic relationships of flaviviruses correlate with their epidemiology, disease association and biogeography. The Journal of General Virology. 2001;**82**(Pt 8):1867-1876

[11] Powell JR, Tabachnick WJ. History of domestication and spread of Aedes aegypti--a

[12] Garcia-Rejon J, Lorono-Pino MA, Farfan-Ale JA, Flores-Flores L, Del Pilar Rosado-Paredes E, Rivero-Cardenas N, Najera-Vazquez R, Gomez-Carro S, Lira-Zumbardo V, Gonzalez-Martinez P, Lozano-Fuentes S, Elizondo-Quiroga D, Beaty BJ, Eisen L. Dengue virus-infected Aedes aegypti in the home environment. The American Journal of Tropical

[13] Gratz NG. Critical review of the vector status of Aedes albopictus. Medical and Veterinary

[14] Brady OJ, Gething PW, Bhatt S, Messina JP, Brownstein JS, Hoen AG, Moyes CL, Farlow AW, Scott TW, Hay SI. Refining the global spatial limits of dengue virus transmission by

[15] Stanaway JD, Shepard DS, Undurraga EA, Halasa YA, Coffeng LE, Brady OJ, Hay SI, Bedi N, Bensenor IM, Castaneda-Orjuela CA, Chuang TW, Gibney KB, Memish ZA, Rafay A, Ukwaja KN, Yonemoto N, Murray CJL. The global burden of dengue: An analysis from the global burden of disease study 2013. The Lancet Infectious Diseases.

[16] Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, Drake JM, Brownstein JS, Hoen AG, Sankoh O, Myers MF, George DB, Jaenisch T, Wint GR, Simmons CP, Scott TW, Farrar JJ, Hay SI. The global distribution and burden of dengue. Nature.

[17] Gubler DJ. Dengue, urbanization and globalization: The unholy trinity of the 21(st) cen-

[18] Wilder-Smith A, Gubler DJ. Geographic expansion of dengue: The impact of interna-

[19] Alves MJ, Fernandes PL, Amaro F, Osorio H, Luz T, Parreira P, Andrade G, Ze-Ze L, Zeller H. Clinical presentation and laboratory findings for the first autochthonous cases of dengue fever in Madeira island, Portugal. Euro Surveillance, 2013. October 2012:**18**(6)

[20] Succo T, Leparc-Goffart I, Ferre JB, Roiz D, Broche B, Maquart M, Noel H, Catelinois O, Entezam F, Caire D, Jourdain F, Esteve-Moussion I, Cochet A, Paupy C, Rousseau C, Paty MC, Golliot F. Autochthonous dengue outbreak in Nimes, south of France, July to

tional travel. The Medical Clinics of North America. 2008;**92**(6):1377-1390 x

tury. Tropical Medical Health. 2011;**39**(Suppl 4):3-11

September 2015. Euro Surveillance. 2016;**21**(21)

evidence-based consensus. PLoS Neglected Tropical Diseases. 2012;**6**(8):e1760

[10] Gould EA, Solomon T. Pathogenic flaviviruses. Lancet. 2008;**371**(9611):500-509

review. Memórias do Instituto Oswaldo Cruz. 2013;**108**(Suppl 1):11-17

today? One Health. 2017;**4**:1-13

Medicine and Hygiene. 2008;**79**(6):940-950

Entomology. 2004;**18**(3):215-227

2016;**16**(6):712-723

2013;**496**(7446):504-507

## **Conflict of interest**

The authors declare no conflict of interest.

## **Author details**

Serena Marchi<sup>1</sup> \*, Claudia Maria Trombetta<sup>1</sup> and Emanuele Montomoli1,2

\*Address all correspondence to: serena.marchi2@unisi.it

1 Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy

2 VisMederi Srl, Siena, Italy

## **References**


including more specific serological tests for seroprevalence studies. The socioeconomic and environmental factors driving the proliferation of vectors, particularly in cities of low-income countries, must be mitigated. An assessment of the available and developing vector control tools is needed to identify the most effective techniques and their combination with vaccination. Finally, new global alliances are needed, such as the global Dengue and the *Aedes*-related disease consortium, to enable the combination of the most effective and timely solutions

1 Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy

[1] Weaver SC, Reisen WK. Present and future arboviral threats. Antiviral Research.

[2] Agarwal A, Parida M, Dash PK. Impact of transmission cycles and vector competence on global expansion and emergence of arboviruses. Reviews in Medical Virology. 2017

[3] Coffey LL, Forrester N, Tsetsarkin K, Vasilakis N, Weaver SC. Factors shaping the adaptive landscape for arboviruses: Implications for the emergence of disease. Future Micro-

[4] Liang G, Gao X, Gould EA. Factors responsible for the emergence of arboviruses; strategies, challenges and limitations for their control. Emerging Microbes and Infections.

[5] Powers AM. Overview of emerging Arboviruses. Future Virology. 2009;**4**(4):391-401

[6] Dutra HL, Caragata EP, Moreira LA. The re-emerging arboviral threat: Hidden enemies: The emergence of obscure arboviral diseases, and the potential use of Wolbachia in their

[7] Gubler DJ. The global emergence/resurgence of arboviral diseases as public health prob-

and Emanuele Montomoli1,2

against arboviral diseases [75].

38 Public Health - Emerging and Re-emerging Issues

The authors declare no conflict of interest.

\*, Claudia Maria Trombetta<sup>1</sup>

\*Address all correspondence to: serena.marchi2@unisi.it

**Conflict of interest**

**Author details**

2 VisMederi Srl, Siena, Italy

2010;**85**(2):328-345

2015;**4**(3):e18

biology. 2013;**8**(2):155-176

control. BioEssays. 2017;**39**(2)

lems. Archives of Medical Research. 2002;**33**(4):330-342

Serena Marchi<sup>1</sup>

**References**


[21] Tomasello D, Schlagenhauf P. Chikungunya and dengue autochthonous cases in Europe, 2007-2012. Travel Medicine and Infectious Disease. 2013;**11**(5):274-284

[35] Esposito DLA, de Moraes JB, Antonio B. Lopes da Fonseca, Current priorities in the Zika

Emerging and Re-emerging Arboviral Diseases as a Global Health Problem

http://dx.doi.org/10.5772/intechopen.77382

41

[36] Mlakar J, Korva M, Tul N, Popovic M, Poljsak-Prijatelj M, Mraz J, Kolenc M, Resman Rus K, Vesnaver Vipotnik T, Fabjan Vodusek V, Vizjak A, Pizem J, Petrovec M, Avsic Zupanc T. Zika virus associated with microcephaly. The New England Journal of Medicine.

[37] Duffy MR, Chen TH, Hancock WT, Powers AM, Kool JL, Lanciotti RS, Pretrick M, Marfel M, Holzbauer S, Dubray C, Guillaumot L, Griggs A, Bel M, Lambert AJ, Laven J, Kosoy O, Panella A, Biggerstaff BJ, Fischer M, Hayes EB. Zika virus outbreak on Yap Island, Federated States of Micronesia. The New England Journal of Medicine.

[38] Lanciotti RS, Kosoy OL, Laven JJ, Velez JO, Lambert AJ, Johnson AJ, Stanfield SM, Duffy MR. Genetic and serologic properties of Zika virus associated with an epidemic, yap

[39] Cao-Lormeau VM, Roche C, Teissier A, Robin E, Berry AL, Mallet HP, Sall AA, Musso D. Zika virus, French polynesia, south pacific, 2013. Emerging Infectious Diseases.

[40] Monath TP, Vasconcelos PF. Yellow fever. Journal of Clinical Virology. 2015;**64**:160-173

[41] Wasserman S, Tambyah PA, Lim PL. Yellow fever cases in Asia: Primed for an epidemic.

[42] Tuboi SH, Costa ZG, da Costa Vasconcelos PF, Hatch D. Clinical and epidemiological characteristics of yellow fever in Brazil: Analysis of reported cases 1998-2002. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2007;**101**(2):169-175

[43] de Souza RP, Foster PG, Sallum MA, Coimbra TL, Maeda AY, Silveira VR, Moreno ES, da Silva FG, Rocco IM, Ferreira IB, Suzuki A, Oshiro FM, Petrella SM, Pereira LE, Katz G, Tengan CH, Siciliano MM, Dos Santos CL. Detection of a new yellow fever virus lineage within the south American genotype I in Brazil. Journal of Medical Virology. 2010;**82**(1):

[44] Gubler DJ. The changing epidemiology of yellow fever and dengue, 1900 to 2003: Full circle? Comparative Immunology, Microbiology and Infectious Diseases. 2004;**27**(5):319-330

[45] Kramer LD, Styer LM, Ebel GD. A global perspective on the epidemiology of West Nile

[46] Erlanger TE, Weiss S, Keiser J, Utzinger J, Wiedenmayer K. Past, present, and future of

[47] Cao L, Fu S, Gao X, Li M, Cui S, Li X, Cao Y, Lei W, Lu Z, He Y, Wang H, Yan J, Gao GF, Liang G. Low protective efficacy of the current Japanese encephalitis vaccine against the emerging genotype 5 Japanese encephalitis virus. PLoS Neglected Tropical Diseases.

Japanese encephalitis. Emerging Infectious Diseases. 2009;**15**(1):1-7

International Journal of Infectious Diseases. 2016;**48**:98-103

virus. Annual Review of Entomology. 2008;**53**:61-81

state, Micronesia, 2007. Emerging Infectious Diseases. 2008;**14**(8):1232-1239

response. Immunology; 2017

2016;**374**(10):951-958

2009;**360**(24):2536-2543

2014;**20**(6):1085-1086

175-185

2016;**10**(5):e0004686


[35] Esposito DLA, de Moraes JB, Antonio B. Lopes da Fonseca, Current priorities in the Zika response. Immunology; 2017

[21] Tomasello D, Schlagenhauf P. Chikungunya and dengue autochthonous cases in Europe,

[22] Effler PV, Pang L, Kitsutani P, Vorndam V, Nakata M, Ayers T, Elm J, Tom T, Reiter P, Rigau-Perez JG, Hayes JM, Mills K, Napier M, Clark GG, Gubler DJ, Hawaii T. Dengue Outbreak Investigation. Dengue fever, Hawaii, 2001-2002. Emerging Infectious Diseases.

[23] Centers for Disease, C. and Prevention. Dengue hemorrhagic fever--U.S.-Mexico border,

[24] Centers for Disease, C. and Prevention, Locally acquired Dengue--Key West. Florida, 2009-2010. MMWR. Morbidity and Mortality Weekly Report. 2010;**59**(19):577-581

[25] Higgs S, Vanlandingham D. Chikungunya virus and its mosquito vectors. Vector Borne

[26] Dash AP, Bhatia R, Sunyoto T, Mourya DT. Emerging and re-emerging arboviral dis-

[27] de Lamballerie X, Leroy E, Charrel RN, Ttsetsarkin K, Higgs S, Gould EA. Chikun-gunya virus adapts to tiger mosquito via evolutionary convergence: A sign of things to come?

[28] Tsetsarkin KA, Weaver SC. Sequential adaptive mutations enhance efficient vector switching by Chikungunya virus and its epidemic emergence. PLoS Pathogens.

[29] Weaver SC, Forrester NL. Chikungunya: Evolutionary history and recent epidemic

[30] Rezza G, Nicoletti L, Angelini R, Romi R, Finarelli AC, Panning M, Cordioli P, Fortuna C, Boros S, Magurano F, Silvi G, Angelini P, Dottori M, Ciufolini MG, Majori GC, Cassone A, C.s. group. Infection with chikungunya virus in Italy: An outbreak in a temperate

[31] Grandadam M, Caro V, Plumet S, Thiberge JM, Souares Y, Failloux AB, Tolou HJ, Budelot M, Cosserat D, Leparc-Goffart I, Despres P. Chikungunya virus, southeastern

[32] Leparc-Goffart, I., A. Nougairede, S. Cassadou, C. Prat, and X. de Lamballerie, Chikun-

[33] Nunes MR, Faria NR, de Vasconcelos JM, Golding N, Kraemer MU, de Oliveira LF, Azevedo Rdo S, da Silva DE, da Silva EV, da Silva SP, Carvalho VL, Coelho GE, Cruz AC, Rodrigues SG, Vianez JL Jr, Nunes BT, Cardoso JF, Tesh RB, Hay SI, Pybus OG, Vasconcelos PF. Emergence and potential for spread of Chikungunya virus in Brazil.

[34] Weaver SC, Lecuit M. Chikungunya virus and the global spread of a mosquito-borne

disease. The New England Journal of Medicine. 2015;**372**(13):1231-1239

eases in Southeast Asia. Journal of Vector Borne Diseases. 2013;**50**(2):77-84

2005. MMWR. Morbidity and Mortality Weekly Report. 2007;**56**(31):785-789

2007-2012. Travel Medicine and Infectious Disease. 2013;**11**(5):274-284

2005;**11**(5):742-749

40 Public Health - Emerging and Re-emerging Issues

and Zoonotic Diseases. 2015;**15**(4):231-240

spread. Antiviral Research. 2015;**120**:32-39

region. Lancet. 2007;**370**(9602):1840-1846

BMC Medicine. 2015;**13**:102

France. Emerging Infectious Diseases. 2011;**17**(5):910-913

gunya in the Americas. Lancet. 2014;**383**(9916):514

Virology Journal. 2008;**5**:33

2011;**7**(12):e1002412


[48] Patsoula E, Beleri S, Vakali A, Pervanidou D, Tegos N, Nearchou A, Daskalakis D, Mourelatos S, Hadjichristodoulou C. Records of Aedes albopictus (Skuse, 1894) (Diptera; Culicidae) and Culex tritaeniorhynchus (Diptera; Culicidae) expansion in areas in mainland Greece and islands. Vector Borne and Zoonotic Diseases. 2017;**17**(3):217-223

[60] Abad-Franch F, Grimmer GH, de Paula VS, Figueiredo LT, Braga WS, Luz SL. Mayaro virus infection in Amazonia: A multimodel inference approach to risk factor assessment.

Emerging and Re-emerging Arboviral Diseases as a Global Health Problem

http://dx.doi.org/10.5772/intechopen.77382

43

[61] Forshey BM, Guevara C, Laguna-Torres VA, Cespedes M, Vargas J, Gianella A, Vallejo E, Madrid C, Aguayo N, Gotuzzo E, Suarez V, Morales AM, Beingolea L, Reyes N, Perez J, Negrete M, Rocha C, Morrison AC, Russell KL, Blair PJ, Olson JG, Kochel TJ, N.F.S.W. Group. Arboviral etiologies of acute febrile illnesses in western South America,

[62] Serra OP, Cardoso BF, Ribeiro AL, Santos FA, Slhessarenko RD. Mayaro virus and dengue virus 1 and 4 natural infection in culicids from Cuiaba, state of Mato Grosso, Brazil.

[63] Long KC, Ziegler SA, Thangamani S, Hausser NL, Kochel TJ, Higgs S, Tesh RB. Experimental transmission of Mayaro virus by Aedes aegypti. The American Journal of Tropical

[64] Smith GC, Francy DB. Laboratory studies of a Brazilian strain of Aedes albopictus as a potential vector of Mayaro and Oropouche viruses. Journal of the American Mosquito

[65] Auguste AJ, Liria J, Forrester NL, Giambalvo D, Moncada M, Long KC, Moron D, de Manzione N, Tesh RB, Halsey ES, Kochel TJ, Hernandez R, Navarro JC, Weaver SC. Evolutionary and ecological characterization of Mayaro virus strains isolated during an

outbreak, Venezuela, 2010. Emerging Infectious Diseases. 2015;**21**(10):1742-1750 [66] Paniz-Mondolfi AE, Blohm G, Pinero R, Rondon-Cadenas C, Rodriguez-Morales AJ. Venezuelan equine encephalitis: How likely are we to see the next epidemic? Travel

[67] Pfeffer M, Dobler G. Emergence of zoonotic arboviruses by animal trade and migration.

[68] Aguilar PV, Greene IP, Coffey LL, Medina G, Moncayo AC, Anishchenko M, Ludwig GV, Turell MJ, O'Guinn ML, Lee J, Tesh RB, Watts DM, Russell KL, Hice C, Yanoviak S, Morrison AC, Klein TA, Dohm DJ, Guzman H, Travassos da Rosa AP, Guevara C, Kochel T, Olson J, Cabezas C, Weaver SC. Endemic Venezuelan equine encephalitis in

[69] Quiroz E, Aguilar PV, Cisneros J, Tesh RB, Weaver SC. Venezuelan equine encephalitis in Panama: Fatal endemic disease and genetic diversity of etiologic viral strains. PLoS

[70] Paessler S, Weaver SC. Vaccines for Venezuelan equine encephalitis. Vaccine. 2009;**27**

[71] Rivas F, Diaz LA, Cardenas VM, Daza E, Bruzon L, Alcala A, De la Hoz O, Caceres FM, Aristizabal G, Martinez JW, Revelo D, De la Hoz F, Boshell J, Camacho T, Calderon L, Olano VA, Villarreal LI, Roselli D, Alvarez G, Ludwig G, Tsai T. Epidemic Venezuelan equine encephalitis in La Guajira, Colombia, 1995. The Journal of Infectious Diseases.

northern Peru. Emerging Infectious Diseases. 2004;**10**(5):880-888

PLoS Neglected Tropical Diseases. 2012;**6**(10):e1846

2000-2007. PLoS Neglected Tropical Diseases. 2010;**4**(8):e787

Memórias do Instituto Oswaldo Cruz. 2016;**111**(1):20-29

Medicine and Hygiene. 2011;**85**(4):750-757

Medicine and Infectious Disease. 2017;**17**:67-68

Neglected Tropical Diseases. 2009;**3**(6):e472

Control Association. 1991;**7**(1):89-93

Parasites & Vectors. 2010;**3**(1):35

(Suppl 4):D80-D85

1997;**175**(4):828-832


[60] Abad-Franch F, Grimmer GH, de Paula VS, Figueiredo LT, Braga WS, Luz SL. Mayaro virus infection in Amazonia: A multimodel inference approach to risk factor assessment. PLoS Neglected Tropical Diseases. 2012;**6**(10):e1846

[48] Patsoula E, Beleri S, Vakali A, Pervanidou D, Tegos N, Nearchou A, Daskalakis D, Mourelatos S, Hadjichristodoulou C. Records of Aedes albopictus (Skuse, 1894) (Diptera; Culicidae) and Culex tritaeniorhynchus (Diptera; Culicidae) expansion in areas in mainland Greece and islands. Vector Borne and Zoonotic Diseases. 2017;**17**(3):217-223

[49] Ravanini P, Huhtamo E, Ilaria V, Crobu MG, Nicosia AM, Servino L, Rivasi F, Allegrini S, Miglio U, Magri A, Minisini R, Vapalahti O, Boldorini R. Japanese encephalitis virus RNA detected in Culex pipiens mosquitoes in Italy. Euro Surveillance. 2012;**17**(28) [50] Simon-Loriere E, Faye O, Prot M, Casademont I, Fall G, Fernandez-Garcia MD, Diagne MM, Kipela JM, Fall IS, Holmes EC, Sakuntabhai A, Sall AA. Autochthonous Japanese encephalitis with yellow fever Coinfection in Africa. The New England

[51] Bird BH, Ksiazek TG, Nichol ST, Maclachlan NJ. Rift Valley fever virus. Journal of the

[52] Madani TA, Al-Mazrou YY, Al-Jeffri MH, Mishkhas AA, Al-Rabeah AM, Turkistani AM, Al-Sayed MO, Abodahish AA, Khan AS, Ksiazek TG, Shobokshi O. Rift Valley fever epidemic in Saudi Arabia: Epidemiological, clinical, and laboratory characteristics. Clinical

[53] Bird BH, Githinji JW, Macharia JM, Kasiiti JL, Muriithi RM, Gacheru SG, Musaa JO, Towner JS, Reeder SA, Oliver JB, Stevens TL, Erickson BR, Morgan LT, Khristova ML, Hartman AL, Comer JA, Rollin PE, Ksiazek TG, Nichol ST. Multiple virus lineages sharing recent common ancestry were associated with a large Rift Valley fever outbreak among livestock in Kenya during 2006-2007. Journal of Virology. 2008;**82**(22):11152-11166

[54] Faye O, Diallo M, Diop D, Bezeid OE, Ba H, Niang M, Dia I, Mohamed SA, Ndiaye K, Diallo D, Ly PO, Diallo B, Nabeth P, Simon F, Lo B, Diop OM. Rift Valley fever outbreak with east-central African virus lineage in Mauritania, 2003. Emerging Infectious

[55] Gould EA, Higgs S. Impact of climate change and other factors on emerging arbovirus diseases. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2009;

[56] Turell MJ, Dohm DJ, Mores CN, Terracina L, Wallette DL Jr, Hribar LJ, Pecor JE, Blow JA. Potential for north American mosquitoes to transmit Rift Valley fever virus. Journal

[57] Moutailler S, Krida G, Schaffner F, Vazeille M, Failloux AB. Potential vectors of Rift Valley fever virus in the Mediterranean region. Vector Borne and Zoonotic Diseases.

[58] Figueiredo ML, Figueiredo LT. Emerging alphaviruses in the Americas: Chikungunya and Mayaro. Revista da Sociedade Brasileira de Medicina Tropical. 2014;**47**(6):677-683

[59] Rodriguez-Morales AJ, Paniz-Mondolfi AE, Villamil-Gomez WE, Navarro JC. Mayaro, Oropouche and Venezuelan equine encephalitis viruses: Following in the footsteps of

of the American Mosquito Control Association. 2008;**24**(4):502-507

Zika? Travel Medicine and Infectious Disease. 2017;**15**:72-73

Journal of Medicine. 2017;**376**(15):1483-1485

42 Public Health - Emerging and Re-emerging Issues

Infectious Diseases. 2003;**37**(8):1084-1092

Diseases. 2007;**13**(7):1016-1023

**103**(2):109-121

2008;**8**(6):749-753

American Veterinary Medical Association. 2009;**234**(7):883-893


[72] Weaver SC, Salas R, Rico-Hesse R, Ludwig GV, Oberste MS, Boshell J, Tesh RB. Reemergence of epidemic Venezuelan equine encephalomyelitis in South America. VEE Study Group. Lancet. 1996;**348**(9025):436-440

Agarwal A, Brinkman AL, Cabral C, Chandrashekar A, Giglio PB, Jetton D, Jimenez J, Lee BC, Mojta S, Molloy K, Shetty M, Neubauer GH, Stephenson KE, Peron JP, Zanotto PM, Misamore J, Finneyfrock B, Lewis MG, Alter G, Modjarrad K, Jarman RG, Eckels KH, Michael NL, Thomas SJ, Barouch DH. Protective efficacy of multiple vaccine platforms against Zika virus challenge in rhesus monkeys. Science. 2016;**353**(6304):

Emerging and Re-emerging Arboviral Diseases as a Global Health Problem

http://dx.doi.org/10.5772/intechopen.77382

45

[84] Dowd KA, Ko SY, Morabito KM, Yang ES, Pelc RS, DeMaso CR, Castilho LR, Abbink P, Boyd M, Nityanandam R, Gordon DN, Gallagher JR, Chen X, Todd JP, Tsybovsky Y, Harris A, Huang YS, Higgs S, Vanlandingham DL, Andersen H, Lewis MG, De La Barrera R, Eckels KH, Jarman RG, Nason MC, Barouch DH, Roederer M, Kong WP, Mascola JR, Pierson TC, Graham BS. Rapid development of a DNA vaccine for Zika

[85] Richner JM, Himansu S, Dowd KA, Butler SL, Salazar V, Fox JM, Julander JG, Tang WW, Shresta S, Pierson TC, Ciaramella G, Diamond MS. Modified mRNA vaccines protect

[86] Shan C, Muruato AE, Nunes BTD, Luo H, Xie X, Medeiros DBA, Wakamiya M, Tesh RB, Barrett AD, Wang T, Weaver SC, Vasconcelos PFC, Rossi SL, Shi PY. A live-attenuated Zika virus vaccine candidate induces sterilizing immunity in mouse models. Nature

[87] Weaver SC, Charlier C, Vasilakis N, Lecuit M. Zika, Chikungunya, and other emerging

[88] Couderc T, Khandoudi N, Grandadam M, Visse C, Gangneux N, Bagot S, Prost JF, Lecuit M. Prophylaxis and therapy for Chikungunya virus infection. The Journal of Infectious

[89] Mastrangelo E, Pezzullo M, De Burghgraeve T, Kaptein S, Pastorino B, Dallmeier K, de Lamballerie X, Neyts J, Hanson AM, Frick DN, Bolognesi M, Milani M. Ivermectin is a potent inhibitor of flavivirus replication specifically targeting NS3 helicase activity: New prospects for an old drug. The Journal of Antimicrobial Chemotherapy. 2012;**67**(8):

[90] Retallack H, Di Lullo E, Arias C, Knopp KA, Laurie MT, Sandoval-Espinosa C, Mancia Leon WR, Krencik R, Ullian EM, Spatazza J, Pollen AA, Mandel-Brehm C, Nowakowski TJ, Kriegstein AR, DeRisi JL. Zika virus cell tropism in the developing human brain and inhibition by azithromycin. Proceedings of the National Academy of Sciences of the

[91] McGraw EA, O'Neill SL. Beyond insecticides: New thinking on an ancient problem.

[92] Barrera R, Acevedo V, Felix GE, Hemme RR, Vazquez J, Munoz JL, Amador M. Impact of Autocidal gravid Ovitraps on Chikungunya virus incidence in Aedes aegypti (Diptera: Culicidae) in areas with and without traps. Journal of Medical Entomology.

vector-borne viral diseases. Annual Review of Medicine. 2018;**69**:395-408

1129-1132

virus. Science. 2016;**354**(6309):237-240

Medicine. 2017;**23**(6):763-767

Diseases. 2009;**200**(4):516-523

1884-1894

2017;**54**(2):387-395

against Zika virus infection. Cell. 2017;**169**(1):176

United States of America. 2016;**113**(50):14408-14413

Nature Reviews. Microbiology. 2013;**11**(3):181-193


Agarwal A, Brinkman AL, Cabral C, Chandrashekar A, Giglio PB, Jetton D, Jimenez J, Lee BC, Mojta S, Molloy K, Shetty M, Neubauer GH, Stephenson KE, Peron JP, Zanotto PM, Misamore J, Finneyfrock B, Lewis MG, Alter G, Modjarrad K, Jarman RG, Eckels KH, Michael NL, Thomas SJ, Barouch DH. Protective efficacy of multiple vaccine platforms against Zika virus challenge in rhesus monkeys. Science. 2016;**353**(6304): 1129-1132

[72] Weaver SC, Salas R, Rico-Hesse R, Ludwig GV, Oberste MS, Boshell J, Tesh RB. Reemergence of epidemic Venezuelan equine encephalomyelitis in South America. VEE

[73] Ortiz DI, Kang W, Weaver SC. Susceptibility of Ae. Aegypti (Diptera: Culicidae) to infection with epidemic (subtype IC) and enzootic (subtypes ID, IIIC, IIID) Venezuelan equine encephalitis complex alphaviruses. Journal of Medical Entomology. 2008;**45**(6):1117-1125

[74] Fernandez Z, Moncayo AC, Carrara AS, Forattini OP, Weaver SC. Vector competence of rural and urban strains of Aedes (Stegomyia) albopictus (Diptera: Culicidae) from Sao Paulo state, Brazil for IC, ID, and IF subtypes of Venezuelan equine encephalitis virus.

[75] Wilder-Smith A, Gubler DJ, Weaver SC, Monath TP, Heymann DL, Scott TW. Epidemic arboviral diseases: Priorities for research and public health. The Lancet Infectious

[76] Barrett ADT. Yellow fever live attenuated vaccine: A very successful live attenuated vaccine but still we have problems controlling the disease. Vaccine. 2017;**35**(44):5951-5955 [77] Wilder-Smith A, Monath TP. Responding to the threat of urban yellow fever outbreaks.

[78] Solomon T. Control of Japanese encephalitis--within our grasp? The New England

[79] Capeding MR, Tran NH, Hadinegoro SR, Ismail HI, Chotpitayasunondh T, ChuaMN, Luong CQ, Rusmil K, Wirawan DN, Nallusamy R, Pitisuttithum P, Thisyakorn U, Yoon IK, van der Vliet D, Langevin E, Laot T, Hutagalung Y, Frago C, Boaz M, Wartel TA, Tornieporth NG, Saville M, Bouckenooghe A, Group CYDS. Clinical efficacy and safety of a novel tetravalent dengue vaccine in healthy children in Asia: A phase 3, randomised, observer-masked,

[80] Villar L, Dayan GH, Arredondo-Garcia JL, Rivera DM, Cunha R, Deseda C, Reynales H, Costa MS, Morales-Ramirez JO, Carrasquilla G, Rey LC, Dietze R, Luz K, Rivas E, Miranda Montoya MC, Cortes Supelano M, Zambrano B, Langevin E, Boaz M, Tornieporth N, Saville M, Noriega F, C.Y.D.S. Group. Efficacy of a tetravalent dengue vaccine in children in Latin America. The New England Journal of Medicine. 2015;**372**(2):113-123 [81] Chang LJ, Dowd KA, Mendoza FH, Saunders JG, Sitar S, Plummer SH, Yamshchikov G, Sarwar UN, Hu Z, Enama ME, Bailer RT, Koup RA, Schwartz RM, Akahata W, Nabel GJ, Mascola JR, Pierson TC, Graham BS, Ledgerwood JE, Team VRCS. Safety and tolerability of chikungunya virus-like particle vaccine in healthy adults: A phase 1 dose-escalation

[82] Ramsauer K, Schwameis M, Firbas C, Mullner M, Putnak RJ, Thomas SJ, Despres P, Tauber E, Jilma B, Tangy F. Immunogenicity, safety, and tolerability of a recombinant measlesvirus-based chikungunya vaccine: A randomised, double-blind, placebo-controlled, active-comparator, first-in-man trial. The Lancet Infectious Diseases. 2015;**15**(5):519-527

[83] Abbink P, Larocca RA, De La Barrera RA, Bricault CA, Moseley ET, Boyd M, Kirilova M, Li Z, Ng'ang'a D, Nanayakkara O, Nityanandam R, Mercado NB, Borducchi EN,

Study Group. Lancet. 1996;**348**(9025):436-440

Journal of Medical Entomology. 2003;**40**(4):522-527

The Lancet Infectious Diseases. 2017;**17**(3):248-250

placebo-controlled trial. Lancet. 2014;**384**(9951):1358-1365

Journal of Medicine. 2006;**355**(9):869-871

trial. Lancet. 2014;**384**(9959):2046-2052

Diseases. 2017;**17**(3):e101-e106

44 Public Health - Emerging and Re-emerging Issues


[93] Wise de Valdez MR, Nimmo D, Betz J, Gong HF, James AA, Alphey L, Black WCt. Genetic elimination of dengue vector mosquitoes. Proceedings of the National Academy of Sciences of the United States of America. 2011;**108**(12):4772-4775

**Chapter 3**

**Provisional chapter**

**The Evolution of Entomological Research with Focus**

**The Evolution of Entomological Research with Focus** 

This paper presented previous and current research efforts for medically important mosquitoes that serve as vectors of emerging and re-emerging diseases in the Philippines, in light of identifying the research gap that exists in the field of public health entomology in the country. This extensive review of the past and current research studies with regard to medical entomology and vector control also attempted to provide proper direction and insights for effective implementation of the country's vector control programs. All research studies conducted in the Philippines from 1958 up to the present that are related to the paper's interest and are available on Philippines' Department of Science and Technology and RITM databases were tracked. Results from this analysis imply that studies on public health entomology in the Philippines have evolved and have gone through various stages of development over time. However, the magnitude of research on medically important mosquitoes in the country is still insufficient for it to contribute comprehensively to integrated methods of vector management and totally eliminate mosquito-borne infections in the Philippines. It is recommended for researchers to work on the continuity of vector researches and explore further the diversity of the entomological aspects of the control of vector-borne diseases.

**Keywords:** *Aedes* mosquitoes, medical entomology research, Zika, chikungunya,

Mosquito-transmitted diseases continue to cause great problem to the public health situation of tropical countries like the Philippines. Dengue, the world's fastest-spreading mosquito-borne

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.78686

**on Emerging and Re-emerging Mosquito-Borne**

**on Emerging and Re-emerging Mosquito-Borne** 

**Infections in the Philippines**

**Infections in the Philippines**

http://dx.doi.org/10.5772/intechopen.78686

**Abstract**

Japanese encephalitis

**1. Introduction**

Ferdinand V. Salazar and Kaymart A. Gimutao

Ferdinand V. Salazar and Kaymart A. Gimutao

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter


#### **The Evolution of Entomological Research with Focus on Emerging and Re-emerging Mosquito-Borne Infections in the Philippines The Evolution of Entomological Research with Focus on Emerging and Re-emerging Mosquito-Borne Infections in the Philippines**

DOI: 10.5772/intechopen.78686

Ferdinand V. Salazar and Kaymart A. Gimutao Ferdinand V. Salazar and Kaymart A. Gimutao

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.78686

#### **Abstract**

[93] Wise de Valdez MR, Nimmo D, Betz J, Gong HF, James AA, Alphey L, Black WCt. Genetic elimination of dengue vector mosquitoes. Proceedings of the National Academy

[94] Carvalho DO, Costa-da-Silva AL, Lees RS, Capurro ML. Two step male release strategy using transgenic mosquito lines to control transmission of vector-borne diseases. Acta

[95] Olson KE, Adelman ZN, Travanty EA, Sanchez-Vargas I, Beaty BJ, Blair CD. Developing arbovirus resistance in mosquitoes. Insect Biochemistry and Molecular Biology.

[96] Bourtzis K, Dobson SL, Xi Z, Rasgon JL, Calvitti M, Moreira LA, Bossin HC, Moretti R, Baton LA, Hughes GL, Mavingui P, Gilles JR. Harnessing mosquito-Wolbachia symbio-

[97] Hoffmann AA, Iturbe-Ormaetxe I, Callahan AG, Phillips BL, Billington K, Axford JK, Montgomery B, Turley AP, O'Neill SL. Stability of the wMel Wolbachia infection following invasion into Aedes aegypti populations. PLoS Neglected Tropical Diseases.

[98] Hoffmann AA, Montgomery BL, Popovici J, Iturbe-Ormaetxe I, Johnson PH, Muzzi F, Greenfield M, Durkan M, Leong YS, Dong Y, Cook H, Axford J, Callahan AG, Kenny N, Omodei C, McGraw EA, Ryan PA, Ritchie SA, Turelli M, O'Neill SL. Successful establishment of Wolbachia in Aedes populations to suppress dengue transmission. Nature.

[99] Moreira LA, Iturbe-Ormaetxe I, Jeffery JA, Lu G, Pyke AT, Hedges LM, Rocha BC, Hall-Mendelin S, Day A, Riegler M, Hugo LE, Johnson KN, Kay BH, McGraw EA, van den Hurk AF, Ryan PA, O'Neill SL. A Wolbachia symbiont in Aedes aegypti limits infection

[100] Aliota MT, Walker EC, Uribe Yepes A, Velez ID, Christensen BM, Osorio JE. The wMel strain of Wolbachia reduces transmission of Chikungunya virus in Aedes aegypti. PLoS

[101] Dutra HL, Rocha MN, Dias FB, Mansur SB, Caragata EP, Moreira LA. Wolbachia blocks currently circulating Zika virus isolates in Brazilian Aedes aegypti mosquitoes. Cell

with dengue, Chikungunya, and plasmodium. Cell. 2009;**139**(7):1268-1278

Neglected Tropical Diseases. 2016;**10**(4):e0004677

Host & Microbe. 2016;**19**(6):771-774

sis for vector and disease control. Acta Tropica. 2014;**132**(Suppl):S150-S163

of Sciences of the United States of America. 2011;**108**(12):4772-4775

Tropica. 2014;**132**(Suppl):S170-S177

2002;**32**(10):1333-1343

46 Public Health - Emerging and Re-emerging Issues

2014;**8**(9):e3115

2011;**476**(7361):454-457

This paper presented previous and current research efforts for medically important mosquitoes that serve as vectors of emerging and re-emerging diseases in the Philippines, in light of identifying the research gap that exists in the field of public health entomology in the country. This extensive review of the past and current research studies with regard to medical entomology and vector control also attempted to provide proper direction and insights for effective implementation of the country's vector control programs. All research studies conducted in the Philippines from 1958 up to the present that are related to the paper's interest and are available on Philippines' Department of Science and Technology and RITM databases were tracked. Results from this analysis imply that studies on public health entomology in the Philippines have evolved and have gone through various stages of development over time. However, the magnitude of research on medically important mosquitoes in the country is still insufficient for it to contribute comprehensively to integrated methods of vector management and totally eliminate mosquito-borne infections in the Philippines. It is recommended for researchers to work on the continuity of vector researches and explore further the diversity of the entomological aspects of the control of vector-borne diseases.

**Keywords:** *Aedes* mosquitoes, medical entomology research, Zika, chikungunya, Japanese encephalitis

## **1. Introduction**

Mosquito-transmitted diseases continue to cause great problem to the public health situation of tropical countries like the Philippines. Dengue, the world's fastest-spreading mosquito-borne

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

disease, brought burden to a total of 131,827 Filipinos in 2017 [1]. As climate change and global warming (which worsens every year) increase the likelihood and spread of many vector-borne diseases [2], the Philippines' public health has started to increase focus on other emerging and re-emerging mosquito-borne diseases such as the Zika virus, Japanese encephalitis, and chikungunya.

biological characteristics and behavior of disease vectors; and on how ecological and environmental factors affect their density and transmission for more holistic and integrated

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

http://dx.doi.org/10.5772/intechopen.78686

49

In the Philippines, current projects and researches on the entomological aspects of mosquitoborne diseases—from biological study of the vectors to their surveillance and control—are mainly conducted by the Department of Medical Entomology under the Research Institute for Tropical Medicine (RITM), the research arm on infectious and tropical diseases of the Philippines' Department of Health. Several private and public institutions in the country also conduct or support research with regard to public health entomology. These include the Philippine Council for Health Research and Development (PCHRD) of the Department of Science and Technology (DOST), the National Institute of Molecular Biology and Biotechnology, University of the Philippines Los Baños (BIOTECH-UPLB), the College of Public Health of the

This chapter attempts to present the previous and current research efforts for medically important mosquito vectors in the country in light of identifying the research gap that exists in the field of public health entomology in the Philippines; and to look for possible ways to come up with a continuous, sustainable, and integrated approach to vector research and their actual applications to reduce the burden of different vector-borne diseases in the country. This extensive review of the past and current projects or research in the country with regard to medical entomology and vector control is also critical to provide proper direction and

To do the review, all relevant research studies conducted in the Philippines that are related to primary vectors of emerging and re-emerging mosquito-borne diseases in the country from 1958 up to the present were tracked (including unpublished university dissertations, as well as the recently concluded research projects conducted by RITM that are yet to be published). This chapter particularly paid attention to vectors of dengue, chikungunya, Zika virus, and Japanese encephalitis. Researches were divided into three main categories: vector biology,

All RITM-participated studies that are related to the subject of interest were included in the analysis. Details of the research studies that were not conducted or participated by researchers from RITM were obtained through the help of the online database Health Research and Development Information Network (HERDIN: http://www.herdin.ph/), the national health research repository of the Philippines which is managed by DOST's PCHRD. The research studies were acquired by using helpful keywords related to the subjects of interest of this chapter. A total of 153 studies from HERDIN and RITM list have qualified for inclusion in

The flowchart below explains further details on the selection criteria of the studies that were

University of the Philippines Manila, and the University of San Carlos in Cebu.

insights for effective implementation of the country's vector control programs.

approach to vector control.

**2. Methodology**

this chapter.

vector surveillance, and vector control.

included in this chapter (**Figure 1**).

Zika virus (ZIKV) was mainly confined to the African continent until it was detected in Southeast Asia in the 1980s, then in the Micronesia in 2007, and, more recently, in the Americas in 2014, where it has displayed an explosive spread, as confirmed by the World Health Organization [3]. In the Philippines, the virus has been recorded as early as 1953 when a serological study detected 19 Zika-positive sera out of 153 samples tested [4]. In May 2012, amid the threat of ZIKV's global spread, a 15-year-old boy in Cebu City reported a subjective fever. By using real-time reverse transcription PCR targeting the gene that encodes the precursor of membrane protein, ZIKV RNA in the patient's serum sample was detected [5].

Meanwhile, two other neglected mosquito-borne diseases—chikungunya and Japanese encephalitis—recently made headlines in the Philippines because of unusual morbidity or mortality rates caused by the said viruses in the past few years.

In 2013, in the aftermath of Typhoon Haiyan, Region VI of the Philippines experienced two outbreaks of chikungunya fever in the provinces of Antique and Negros Occidental [6]. This was followed by another outbreak in Cavite in 2016 with more than 450 suspect cases. In the same year, a total of 6351 suspect chikungunya cases were reported throughout the country [7].

Japanese encephalitis (JE), on the other hand, caused nine deaths in the Philippines in September, 2017. This prompted the Department of Health to call on local executives and the public to intensify mosquito prevention and control measures at home and in the community, and to protect themselves from being bitten by mosquitoes, particularly in high-risk areas. The agency also started firming up plans to introduce JE vaccination among young children in 2018 [8].

The common epidemiological feature of these emerging and re-emerging diseases is that they are vectored by mosquitoes. Some mosquito vectors are specific to certain disease, while some are responsible for multiple diseases; and some control combinations are specific, while others are effective on several of them [9–11]. *Aedes* genus, for instance, are known vectors for numerous viral infections with *Aedes aegypti* and *Aedes albopictus* being the main vectors of the three diseases of interest in this chapter—dengue, chikungunya, and Zika virus.

In the absence of vaccine for many mosquito-borne diseases (except for Japanese B encephalitis and for dengue with limited reported efficacy and questions on its safety for those who have not contracted dengue), integrated vector management (IVM) remains the sole method to prevent transmission. IVM is the first line of defense against mosquito and other vector-borne diseases especially with the worsening effect of climate change, given that many vector-borne and zoonotic diseases (diseases involving vectors such as blood-feeding insects or animal hosts) exhibit some degree of sensitivity to climate [12].

The public health authorities in the country, including scientists and researchers must therefore pay attention as well on the aspect of medical entomology to look closely at the biological characteristics and behavior of disease vectors; and on how ecological and environmental factors affect their density and transmission for more holistic and integrated approach to vector control.

In the Philippines, current projects and researches on the entomological aspects of mosquitoborne diseases—from biological study of the vectors to their surveillance and control—are mainly conducted by the Department of Medical Entomology under the Research Institute for Tropical Medicine (RITM), the research arm on infectious and tropical diseases of the Philippines' Department of Health. Several private and public institutions in the country also conduct or support research with regard to public health entomology. These include the Philippine Council for Health Research and Development (PCHRD) of the Department of Science and Technology (DOST), the National Institute of Molecular Biology and Biotechnology, University of the Philippines Los Baños (BIOTECH-UPLB), the College of Public Health of the University of the Philippines Manila, and the University of San Carlos in Cebu.

This chapter attempts to present the previous and current research efforts for medically important mosquito vectors in the country in light of identifying the research gap that exists in the field of public health entomology in the Philippines; and to look for possible ways to come up with a continuous, sustainable, and integrated approach to vector research and their actual applications to reduce the burden of different vector-borne diseases in the country. This extensive review of the past and current projects or research in the country with regard to medical entomology and vector control is also critical to provide proper direction and insights for effective implementation of the country's vector control programs.

## **2. Methodology**

disease, brought burden to a total of 131,827 Filipinos in 2017 [1]. As climate change and global warming (which worsens every year) increase the likelihood and spread of many vector-borne diseases [2], the Philippines' public health has started to increase focus on other emerging and re-emerging mosquito-borne diseases such as the Zika virus, Japanese encephalitis, and

Zika virus (ZIKV) was mainly confined to the African continent until it was detected in Southeast Asia in the 1980s, then in the Micronesia in 2007, and, more recently, in the Americas in 2014, where it has displayed an explosive spread, as confirmed by the World Health Organization [3]. In the Philippines, the virus has been recorded as early as 1953 when a serological study detected 19 Zika-positive sera out of 153 samples tested [4]. In May 2012, amid the threat of ZIKV's global spread, a 15-year-old boy in Cebu City reported a subjective fever. By using real-time reverse transcription PCR targeting the gene that encodes the precur-

Meanwhile, two other neglected mosquito-borne diseases—chikungunya and Japanese encephalitis—recently made headlines in the Philippines because of unusual morbidity or

In 2013, in the aftermath of Typhoon Haiyan, Region VI of the Philippines experienced two outbreaks of chikungunya fever in the provinces of Antique and Negros Occidental [6]. This was followed by another outbreak in Cavite in 2016 with more than 450 suspect cases. In the same year, a total of 6351 suspect chikungunya cases were reported throughout the country [7]. Japanese encephalitis (JE), on the other hand, caused nine deaths in the Philippines in September, 2017. This prompted the Department of Health to call on local executives and the public to intensify mosquito prevention and control measures at home and in the community, and to protect themselves from being bitten by mosquitoes, particularly in high-risk areas. The agency also started firming up plans to introduce JE vaccination among young children

The common epidemiological feature of these emerging and re-emerging diseases is that they are vectored by mosquitoes. Some mosquito vectors are specific to certain disease, while some are responsible for multiple diseases; and some control combinations are specific, while others are effective on several of them [9–11]. *Aedes* genus, for instance, are known vectors for numerous viral infections with *Aedes aegypti* and *Aedes albopictus* being the main vectors of the

In the absence of vaccine for many mosquito-borne diseases (except for Japanese B encephalitis and for dengue with limited reported efficacy and questions on its safety for those who have not contracted dengue), integrated vector management (IVM) remains the sole method to prevent transmission. IVM is the first line of defense against mosquito and other vector-borne diseases especially with the worsening effect of climate change, given that many vector-borne and zoonotic diseases (diseases involving vectors such as blood-feeding insects or animal

The public health authorities in the country, including scientists and researchers must therefore pay attention as well on the aspect of medical entomology to look closely at the

three diseases of interest in this chapter—dengue, chikungunya, and Zika virus.

hosts) exhibit some degree of sensitivity to climate [12].

sor of membrane protein, ZIKV RNA in the patient's serum sample was detected [5].

mortality rates caused by the said viruses in the past few years.

chikungunya.

48 Public Health - Emerging and Re-emerging Issues

in 2018 [8].

To do the review, all relevant research studies conducted in the Philippines that are related to primary vectors of emerging and re-emerging mosquito-borne diseases in the country from 1958 up to the present were tracked (including unpublished university dissertations, as well as the recently concluded research projects conducted by RITM that are yet to be published). This chapter particularly paid attention to vectors of dengue, chikungunya, Zika virus, and Japanese encephalitis. Researches were divided into three main categories: vector biology, vector surveillance, and vector control.

All RITM-participated studies that are related to the subject of interest were included in the analysis. Details of the research studies that were not conducted or participated by researchers from RITM were obtained through the help of the online database Health Research and Development Information Network (HERDIN: http://www.herdin.ph/), the national health research repository of the Philippines which is managed by DOST's PCHRD. The research studies were acquired by using helpful keywords related to the subjects of interest of this chapter. A total of 153 studies from HERDIN and RITM list have qualified for inclusion in this chapter.

The flowchart below explains further details on the selection criteria of the studies that were included in this chapter (**Figure 1**).

Meanwhile, Siler et al. [15] described in 1926 the definite dengue season in Manila and Lowland Luzon. The study suggested that conditions are favorable for mass reproduction of *Ae. aegypti* during dry season (March to May, inclusive) if a few heavy rains occur at intervals

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

http://dx.doi.org/10.5772/intechopen.78686

51

In the late 1950s to 1960s, notable studies on mosquito vector surveillance and control were performed in the Philippines and its neighboring countries (**Table 1**) following a large epidemic of serious and often fatal cases of hemorrhagic febrile disease caused by mosquito bite in Manila in 1956 (with over 1200 cases and about 75 fatalities) and in Bangkok, Thailand

The disease was described as a new disease and was referred to as the Philippine hemorrhagic fever but was later renamed dengue hemorrhagic fever (DHF) as more cases were reported in both Thailand and the Philippines [17]. However, according to Halstead [18], the association of dengue and chikungunya viruses in time and place with severe hemorrhagic disease has

Vector surveillance studies in response to hemorrhagic fever pandemic in Southeast Asia included the distribution of *Aedes* mosquitoes in Manila and Bangkok in 1960; observations of vectors of dengue hemorrhagic fever in the Philippines, Bangkok, and Singapore from 1956 to 1961; and epidemiological-entomological observations on Philippine hemorrhagic fever in

Studies on vector control in the Philippines during this period mainly focused on potential larvicidal and adulticidal agents against mosquito vectors such as ordinary salt, benzyl iso-

Further studies on distribution of medically important mosquitoes in the Philippine islands were conducted the following decade (**Table 2**). In 1970, Baisas et al. [24] identified the distribution and abundance of medically important mosquito species in the Philippines for each

**Research title Year released**

1966

Newly recognized *Aedes aegypti* problems in Manila and Bangkok 1960 Entomological aspects of hemorrhagic fever epidemics in Bangkok, the Philippines, and Singapore 1961 Use of ordinary table salt against breeding of mosquitoes in artificial containers 1963 Control of the vector mosquitoes of hemorrhagic fever 1965

A possible larvicidal Agent among the bis-benzyl isoquinoline alkaloids 1968 Epidemiological-entomological observations on Philippine hemorrhagic fever 1968 Distribution and seasonal abundance of mosquitoes in the University of the Philippines campus 1969

Susceptibility of common household pest mosquitoes to experimental infection with *Brugia malayi*

**Table 1.** List of vector control and surveillance studies in the Philippines, 1960–1969.

microfilariae as compared to the principal vector

of 15–20 days; and during wet season (June to September).

(with nearly 2500 cases and about 250 fatalities) in 1958 [16].

1968 [16, 19, 20].

led many authors to assume that both viruses caused hemorrhagic fever.

quinoline alkaloids, and dichlorodiphenyltrichloroethane (DDT) [21–23].

**Figure 1.** Flowchart for the selection of studies included in this chapter.

## **3. Results**

#### **3.1. Vector surveillance and control studies**

The earliest recorded surveillance of mosquito vectors of public health importance in the Philippines was conducted by Ludlow [13] for her PhD dissertation which tackled the distribution of mosquito species in the Philippine Islands and the relation of their occurrence to the incidence of certain diseases in the country. Ludlow's studies of disease-bearing mosquitoes contributed greatly to the well-being of U.S. Army soldiers in the Philippines around the world during the time [14].

Meanwhile, Siler et al. [15] described in 1926 the definite dengue season in Manila and Lowland Luzon. The study suggested that conditions are favorable for mass reproduction of *Ae. aegypti* during dry season (March to May, inclusive) if a few heavy rains occur at intervals of 15–20 days; and during wet season (June to September).

In the late 1950s to 1960s, notable studies on mosquito vector surveillance and control were performed in the Philippines and its neighboring countries (**Table 1**) following a large epidemic of serious and often fatal cases of hemorrhagic febrile disease caused by mosquito bite in Manila in 1956 (with over 1200 cases and about 75 fatalities) and in Bangkok, Thailand (with nearly 2500 cases and about 250 fatalities) in 1958 [16].

The disease was described as a new disease and was referred to as the Philippine hemorrhagic fever but was later renamed dengue hemorrhagic fever (DHF) as more cases were reported in both Thailand and the Philippines [17]. However, according to Halstead [18], the association of dengue and chikungunya viruses in time and place with severe hemorrhagic disease has led many authors to assume that both viruses caused hemorrhagic fever.

Vector surveillance studies in response to hemorrhagic fever pandemic in Southeast Asia included the distribution of *Aedes* mosquitoes in Manila and Bangkok in 1960; observations of vectors of dengue hemorrhagic fever in the Philippines, Bangkok, and Singapore from 1956 to 1961; and epidemiological-entomological observations on Philippine hemorrhagic fever in 1968 [16, 19, 20].

Studies on vector control in the Philippines during this period mainly focused on potential larvicidal and adulticidal agents against mosquito vectors such as ordinary salt, benzyl isoquinoline alkaloids, and dichlorodiphenyltrichloroethane (DDT) [21–23].

Further studies on distribution of medically important mosquitoes in the Philippine islands were conducted the following decade (**Table 2**). In 1970, Baisas et al. [24] identified the distribution and abundance of medically important mosquito species in the Philippines for each


**Table 1.** List of vector control and surveillance studies in the Philippines, 1960–1969.

**3. Results**

**3.1. Vector surveillance and control studies**

50 Public Health - Emerging and Re-emerging Issues

**Figure 1.** Flowchart for the selection of studies included in this chapter.

world during the time [14].

The earliest recorded surveillance of mosquito vectors of public health importance in the Philippines was conducted by Ludlow [13] for her PhD dissertation which tackled the distribution of mosquito species in the Philippine Islands and the relation of their occurrence to the incidence of certain diseases in the country. Ludlow's studies of disease-bearing mosquitoes contributed greatly to the well-being of U.S. Army soldiers in the Philippines around the


Among these studies is a comprehensive vector surveillance study conducted by Salazar et al. [31] from 1978 to 1979, a survey of *Ae*. *aegypti* mosquitoes that used standard entomological procedures and calculations for adult and larval mosquito indices aside from obtaining information on the distribution and density of the species in the city of Manila. Salazar also investigated the entomological aspects of both dengue and malaria

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

http://dx.doi.org/10.5772/intechopen.78686

53

In terms of vector control, additional aspects of mosquito reduction were explored in this period aside from utilizing insecticides, particularly in terms of generating insights on participatory approach of mosquito reduction in the community and modifying health-risk behaviors of the people living in the vicinities which are vulnerable to outbreak of mosquito-borne diseases. For instance, Cruz conducted a study on the effectiveness of community-based

A study on *Bacillus thuringiensis* (Bt), a bacterial microbe derived from soil, was also explored in search of safe and effective mosquito larvicide. In 1984, Jueco et al. [34] performed bioassay of *Bacillus thuringiensis (Bt) Israelensis* serotype H-14 against Philippine strains of *Aedes aegypti*, *Anopheles litoralis,* and *Culex quinquefasciatus* in some drainage canals in the city of Manila to

Padua et al. [35, 36] on the other hand, studied the *Bt* subspecies *morrisoni* [serotype H 8a: 8b] (PG-14) from 1982 to 1984 which was obtained from a soil sample in Cebu City. This isolate produced a spherical or irregular parasporal crystal, highly toxic to mosquito larvae but not to the silkworm, *Bombyx mori*, and adults of a daphnid. It was also negative for 13-exotoxin. All this is in contrast to the type strain. This isolate, being the first discovered from the tropics, is

Meanwhile, a study on Japanese encephalitis mosquito vectors in the Philippines rice fields by Llagas et al. [38] in 1989 presented information that are relevant to the understanding of the Philippine rice agro-ecosystem and its characteristics in relation to vector

Overall in 1980s (**Table 3**), the number of studies investigating the effectiveness of different interventions to reduce or eliminate the density of mosquito vectors or combination of vector surveillance and control studies is higher than studies on mere surveillance of mosquito vectors—the first time since research studies on medically important mosquito vectors in the

This trend continued to increase in the following decades (**Table 4**). In 1990s, researchers explored further on different aspects of mosquito control which include the use of different Philippine plants such as tubli (*Derris elliptica* Benth), guyabano (*Annona muricata*), and selected seaweed species as potential larvicide or insecticide against medically important mosquitoes [39–41]; the use of N,N-diethyl-meta-toluamide (DEET) formulations as mosquito repellents [42]; utilization of permethrin-treated curtains for control of *Aedes aegypti* in the Philippines [43]; further studies on different *Bacillus thuringiensis* strains as potential larvicide [44, 45]; and observations on the effectiveness of different community-based approaches on mosquito reduction including modifying the knowledge, attitude, behaviors, and practices of the people in the communities which

in 1984 [32].

breeding.

country were implemented.

health program in *Aedes aegypti* control in 1982 [33].

test the susceptibility of the three species to the potential larvicide.

serologically different from Bt subsp. Israelensis, serotype H-14 [37].

are vulnerable to mosquito-borne disease outbreaks [46–48].

**Table 2.** List of vector control and surveillance studies in the Philippines, 1970–1979.

month and designated zone in a span of 12 months. During the 12-month period surveillance, eight species implicated in the transmission of various diseases (malaria, filaria, dengue, hemorrhagic fever, Japanese B encephalitis, and chikungunya) were obtained. The study further implied that Japanese B encephalitis was most likely to occur in epidemic form at that time because of *Culex tritaeniorhynchus* and *Culex gelidus*.

Meanwhile, Schoenig [25] conducted an ecological survey of mosquito vectors in Cebu City and its adjacent areas in 1971 which found *Aedes aegypti* Linnaeus to be the primary species present in the area. He also came up with a taxonomic key on determining the species collected in the field.

From 1972 to 1974, Basio et al. [26–30] implemented a series of mosquito vector surveillance and control studies in the Philippines. These are composed of surveillance on mosquitoes in relation to public health in the Philippines with reference to the principal vector, species, and the diseases they transmit; a research on the distribution of *Aedes aegypti* Linn in the country and its relationship to the spread of dengue hemorrhagic fever; ecological notes on two medically important mosquito species, *Aedes aegypti* and *Aedes albopictus*, in a selected geographic area of the UP College of Agriculture Campus in UP Los Baños, Laguna Province; mosquito control program at the Manila International Airport (now Ninoy Aquino International Airport) and vicinity with comments on problems encountered on the aerial transportation of mosquitoes; and an inland survey of the distribution and relative prevalence of *Aedes aegypti* (Diptera: Culicidae) with reference to mosquito-borne hemorrhagic fever.

Toward the latter part of 1970s and earlier part of 1980s, further studies on entomological aspects of emerging mosquito-borne diseases in the Philippines and on control of their major vectors were carried out by local scientists.

Among these studies is a comprehensive vector surveillance study conducted by Salazar et al. [31] from 1978 to 1979, a survey of *Ae*. *aegypti* mosquitoes that used standard entomological procedures and calculations for adult and larval mosquito indices aside from obtaining information on the distribution and density of the species in the city of Manila. Salazar also investigated the entomological aspects of both dengue and malaria in 1984 [32].

In terms of vector control, additional aspects of mosquito reduction were explored in this period aside from utilizing insecticides, particularly in terms of generating insights on participatory approach of mosquito reduction in the community and modifying health-risk behaviors of the people living in the vicinities which are vulnerable to outbreak of mosquito-borne diseases. For instance, Cruz conducted a study on the effectiveness of community-based health program in *Aedes aegypti* control in 1982 [33].

A study on *Bacillus thuringiensis* (Bt), a bacterial microbe derived from soil, was also explored in search of safe and effective mosquito larvicide. In 1984, Jueco et al. [34] performed bioassay of *Bacillus thuringiensis (Bt) Israelensis* serotype H-14 against Philippine strains of *Aedes aegypti*, *Anopheles litoralis,* and *Culex quinquefasciatus* in some drainage canals in the city of Manila to test the susceptibility of the three species to the potential larvicide.

Padua et al. [35, 36] on the other hand, studied the *Bt* subspecies *morrisoni* [serotype H 8a: 8b] (PG-14) from 1982 to 1984 which was obtained from a soil sample in Cebu City. This isolate produced a spherical or irregular parasporal crystal, highly toxic to mosquito larvae but not to the silkworm, *Bombyx mori*, and adults of a daphnid. It was also negative for 13-exotoxin. All this is in contrast to the type strain. This isolate, being the first discovered from the tropics, is serologically different from Bt subsp. Israelensis, serotype H-14 [37].

month and designated zone in a span of 12 months. During the 12-month period surveillance, eight species implicated in the transmission of various diseases (malaria, filaria, dengue, hemorrhagic fever, Japanese B encephalitis, and chikungunya) were obtained. The study further implied that Japanese B encephalitis was most likely to occur in epidemic form at that time

**Research title Year** 

Determination of the distribution and abundance of mosquitoes in selected geographic areas 1970 Mosquitoes in Cebu City and adjacent area: an ecological survey 1971

On Philippine mosquitoes, VIII. The distribution of *Aedes aegypti* Linn. (Diptera: Culicidae) and its

Mosquitoes in relation to public health in the Philippines with reference to the principal vector, species,

On Philippine mosquitoes, XII—Some ecological notes on two medically important mosquito species, *Aedes aegypti* and *Aedes albopictus*, in a selected geographic area of the UP College of Agriculture

The mosquito control program at the Manila International Airport and vicinity (Philippines) with

On Philippine mosquitoes XIII—An inland survey of the distribution and relative prevalence of *Aedes* 

Epidemiological, virological, and entomological studies on dengue in the city of Manila 1979

**released**

1972

1972

1973

1973

1974

Meanwhile, Schoenig [25] conducted an ecological survey of mosquito vectors in Cebu City and its adjacent areas in 1971 which found *Aedes aegypti* Linnaeus to be the primary species present in the area. He also came up with a taxonomic key on determining the species col-

From 1972 to 1974, Basio et al. [26–30] implemented a series of mosquito vector surveillance and control studies in the Philippines. These are composed of surveillance on mosquitoes in relation to public health in the Philippines with reference to the principal vector, species, and the diseases they transmit; a research on the distribution of *Aedes aegypti* Linn in the country and its relationship to the spread of dengue hemorrhagic fever; ecological notes on two medically important mosquito species, *Aedes aegypti* and *Aedes albopictus*, in a selected geographic area of the UP College of Agriculture Campus in UP Los Baños, Laguna Province; mosquito control program at the Manila International Airport (now Ninoy Aquino International Airport) and vicinity with comments on problems encountered on the aerial transportation of mosquitoes; and an inland survey of the distribution and relative prevalence of *Aedes aegypti* (Diptera:

Toward the latter part of 1970s and earlier part of 1980s, further studies on entomological aspects of emerging mosquito-borne diseases in the Philippines and on control of their major

because of *Culex tritaeniorhynchus* and *Culex gelidus*.

relationship to the spread of dengue hemorrhagic fever

52 Public Health - Emerging and Re-emerging Issues

Campus in UP Los Baños, Laguna Province (Diptera: Culicidae)

comments on problems encountered on the aerial transportation of mosquitoes

*aegypti* (Diptera: Culicidae) with reference to mosquito-borne hemorrhagic fever

**Table 2.** List of vector control and surveillance studies in the Philippines, 1970–1979.

and the diseases they transmit

Culicidae) with reference to mosquito-borne hemorrhagic fever.

vectors were carried out by local scientists.

lected in the field.

Meanwhile, a study on Japanese encephalitis mosquito vectors in the Philippines rice fields by Llagas et al. [38] in 1989 presented information that are relevant to the understanding of the Philippine rice agro-ecosystem and its characteristics in relation to vector breeding.

Overall in 1980s (**Table 3**), the number of studies investigating the effectiveness of different interventions to reduce or eliminate the density of mosquito vectors or combination of vector surveillance and control studies is higher than studies on mere surveillance of mosquito vectors—the first time since research studies on medically important mosquito vectors in the country were implemented.

This trend continued to increase in the following decades (**Table 4**). In 1990s, researchers explored further on different aspects of mosquito control which include the use of different Philippine plants such as tubli (*Derris elliptica* Benth), guyabano (*Annona muricata*), and selected seaweed species as potential larvicide or insecticide against medically important mosquitoes [39–41]; the use of N,N-diethyl-meta-toluamide (DEET) formulations as mosquito repellents [42]; utilization of permethrin-treated curtains for control of *Aedes aegypti* in the Philippines [43]; further studies on different *Bacillus thuringiensis* strains as potential larvicide [44, 45]; and observations on the effectiveness of different community-based approaches on mosquito reduction including modifying the knowledge, attitude, behaviors, and practices of the people in the communities which are vulnerable to mosquito-borne disease outbreaks [46–48].


The advent of the new millennium brought along major ecological and environmental issues globally such as overpopulation, urbanization, and climate change which affected the public health situation of the world, including the proliferation of mosquito-borne diseases. In response to these phenomena, new approaches on vector surveillance studies were employed by researchers on public health entomology in the Philippines, especially in the latter part of the 2000s when scientists all over the world have started to form a consensus and agreed that

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

http://dx.doi.org/10.5772/intechopen.78686

55

Aside from conducting an integrated research on the aspects of both vector surveillance and control, research studies in the Philippines also started to identify and analyze factors which are deemed critical on multiplication of mosquito vectors and on increase in incidences of vector-borne diseases in tropical setting such as rainfall, humidity, and temperature. This is to contribute to a proactive vector management efforts amid the abnormal climatic patterns and extreme weathers that happen across the globe because of climate change, which the climate

Among the studies of this kind include the analytical study on the relationship between rainfall, temperature, and humidity and the number of dengue fever cases in admitted patients in Northern Mindanao Medical Center from 1998 to 2007 by Seeto et al. [49] in 2008; correlation of climatic factors and dengue incidence in Metro Manila, Philippines by Sia Su [50] in 2008; and Reyes's study on rainfall, temperature, relative humidity, and dengue cases in Metro

Studies on biological methods for vector control were also explored in this period. Reyes et al. [52, 53] conducted two studies on the efficacy of Philippine species of *Mesocyclops* (Crustacea: Copepoda) as a biological control agent of *Aedes aegypti* in 2004 and 2005.

According to WHO, biological control is based on the introduction of organisms that prey upon, parasitize, compete with, or otherwise reduce populations of the target species. Against *Aedes*, a selection of larvivorous fish species and predatory copepods (small freshwater crus-

Research studies using the earlier approaches for vector control were further explored during this period such as screening of Philippine plants and trees for larvicidal activity or repellant against *Aedes aegypti* and other medically important mosquitoes; and observations on the behavioral change of the communities vulnerable to outbreaks of mosquito-borne diseases

With regard to Japanese encephalitis vectors, Bertuso et al. [55] conducted a study observing the ecology of *Culex tritaeniorhynchus, Cx. Gelidus,* and *Cx. bitaeniorhynchus* in the province of

The trend on integrated approaches to the conduct of research on vector surveillance and control continued in 2010s (**Table 6**). Researchers utilized modeling and simulation techniques to understand in a more holistic way the implications of climate change and other environmental factors on the density of medically important mosquitoes and dengue incidences in different areas of the country. For instance, the recently concluded research project of RITM

taceans) are effective against the immature larval stages of vector mosquitoes [54].

human-induced climate change is really happening (**Table 5**).

scientists claim as the "current normal."

through information dissemination.

Bulacan in 2006 with special reference to their aquatic habitat.

Manila in 2009 [51].

**Table 3.** List of vector control and surveillance studies in the Philippines, 1980–1989.


**Table 4.** List of vector control and surveillance studies in the Philippines, 1991–1999.

The advent of the new millennium brought along major ecological and environmental issues globally such as overpopulation, urbanization, and climate change which affected the public health situation of the world, including the proliferation of mosquito-borne diseases. In response to these phenomena, new approaches on vector surveillance studies were employed by researchers on public health entomology in the Philippines, especially in the latter part of the 2000s when scientists all over the world have started to form a consensus and agreed that human-induced climate change is really happening (**Table 5**).

Aside from conducting an integrated research on the aspects of both vector surveillance and control, research studies in the Philippines also started to identify and analyze factors which are deemed critical on multiplication of mosquito vectors and on increase in incidences of vector-borne diseases in tropical setting such as rainfall, humidity, and temperature. This is to contribute to a proactive vector management efforts amid the abnormal climatic patterns and extreme weathers that happen across the globe because of climate change, which the climate scientists claim as the "current normal."

Among the studies of this kind include the analytical study on the relationship between rainfall, temperature, and humidity and the number of dengue fever cases in admitted patients in Northern Mindanao Medical Center from 1998 to 2007 by Seeto et al. [49] in 2008; correlation of climatic factors and dengue incidence in Metro Manila, Philippines by Sia Su [50] in 2008; and Reyes's study on rainfall, temperature, relative humidity, and dengue cases in Metro Manila in 2009 [51].

**Research title Year released**

**Research title Year released**

Studies on dengue hemorrhagic fever in the Philippines II. Entomological aspects 1980 A study on the effectiveness of community-based health program in *Aedes aegypti* control 1982 *Bacillus thuringiensis* isolated in the Philippines 1982 Isolation of a *Bacillus thuringiensis* (serotype 8a:8b) highly and selectively toxic against mosquito larvae 1984 Malaria and dengue hemorrhagic fever in the Philippines: entomological aspects 1984

Bioassay of *Bacillus thuringiensis* Israelensis serotype H-14 against Philippine strains of *Aedes aegypti*,

Strategies for control of Japanese encephalitis mosquito vectors in the Philippines rice fields 1989 Cemetery vase breeding of dengue vectors in Manila, Republic of the Philippines 1989

1991

1984

1992

1993

1996

1997

1999

Ultrastructure study of *Bacillus thuringiensis*-treated *Aedes aegypti* larvae 1991 Comparison of the effectiveness of two DEET formulations against *Aedes albopictus* in the Philippines 1991

Seasonal abundance of dengue vectors in Manila, Republic of the Philippines 1993

Antibacterial, antifungal and larvicidal properties of selected seaweeds in Bolinao, Pangasinan 1994 Biology and control of *Aedes* mosquito vectors of dengue/dengue hemorrhagic fever in the Philippines 1995

Distribution of *Aedes albopictus* mosquitoes in one urban and sub-urban communities in the

**Table 3.** List of vector control and surveillance studies in the Philippines, 1980–1989.

Distribution of *Aedes Aegypti* and *Aedes albopictus* in one urban and sub-urban communities in the

Knowledge, attitudes, and practices of Filipino Mothers regarding the dengue fever syndrome:

Community-based control of dengue hemorrhagic fever: a 5-year prospective intervention program

Toxicity effect of effluents from selected food-processing industries along Butuanon River on larvae of

A community field practice report in Sitio Bagong Pook, Tanza, Cavite: control and prevention of

**Table 4.** List of vector control and surveillance studies in the Philippines, 1991–1999.

Update: Japanese encephalitis virus Activity in the Philippines 1999 The insecticidal effect of tubli (*Derris* sp.) root crude extract on *Aedes* mosquito larvae 1999 Use of permethrin-treated curtains for control of *Aedes aegypti* in the Philippines 1999

The larvicidal effect of guyabano (*Annona muricata*) leaf extract on *Aedes aegypti* mosquito 1999 Effects of mutants of *Bacillus thuringiensis* subsp. Israelensis on mosquito larvae (*Aedes aegypti*) 1999

Philippines; an ovitrap and larval survey

*Anopheles litoralis* and *Culex quinquefasciatus*

54 Public Health - Emerging and Re-emerging Issues

Philippines—an ovitrap and larval survey

implications toward preventive interventions

(1991–1995)

*Aedes* spp.

dengue fever

Studies on biological methods for vector control were also explored in this period. Reyes et al. [52, 53] conducted two studies on the efficacy of Philippine species of *Mesocyclops* (Crustacea: Copepoda) as a biological control agent of *Aedes aegypti* in 2004 and 2005.

According to WHO, biological control is based on the introduction of organisms that prey upon, parasitize, compete with, or otherwise reduce populations of the target species. Against *Aedes*, a selection of larvivorous fish species and predatory copepods (small freshwater crustaceans) are effective against the immature larval stages of vector mosquitoes [54].

Research studies using the earlier approaches for vector control were further explored during this period such as screening of Philippine plants and trees for larvicidal activity or repellant against *Aedes aegypti* and other medically important mosquitoes; and observations on the behavioral change of the communities vulnerable to outbreaks of mosquito-borne diseases through information dissemination.

With regard to Japanese encephalitis vectors, Bertuso et al. [55] conducted a study observing the ecology of *Culex tritaeniorhynchus, Cx. Gelidus,* and *Cx. bitaeniorhynchus* in the province of Bulacan in 2006 with special reference to their aquatic habitat.

The trend on integrated approaches to the conduct of research on vector surveillance and control continued in 2010s (**Table 6**). Researchers utilized modeling and simulation techniques to understand in a more holistic way the implications of climate change and other environmental factors on the density of medically important mosquitoes and dengue incidences in different areas of the country. For instance, the recently concluded research project of RITM


on the effect of weather patterns in predicting mosquito density and count of dengue cases in different locations in the Philippines used multiple regression analysis to come up with models containing predictor variables that contribute to the density of mosquitoes in the selected site. The study then came up with the best model on predicting mosquito density and count

**Research title Year** 

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

Dengue mosquito ovitrapping and preventive fogging trials in the Philippines 2007

Dengue vector surveillance in barangay Gumatdang, Itogon, Benguet 2007 *Aedes* survey of selected public hospitals admitting dengue patients in Metro Manila, Philippines 2008

The effect of interventional program on the larval indices of *Aedes Aegypti* in selected Barangays Isabela

Perceived self-efficacy to plan and execute an environmental action plan for dengue control among

Entomological survey of dengue vectors as basis for developing vector control measures in Barangay

Larvicidal effect of *Lansium domesticum* Correa (Sapindales: Meliaceae) exocarps and seeds on 3-day old

An evaluation on the impact of the dengue control program on the knowledge, attitudes and practices

An analytical study on the relationship between rainfall, temperature and humidity and the number of dengue fever cases in admitted patients at the Northern Mindanao Medical Center from 1998–2007

Enhanced development of dengue mosquito vector (*Aedes aegypti* Linnaeus) larvae feeding on maize

Correlation of climatic factors and dengue incidence in Metro Manila, Philippines 2008 Mosquito vectors and dengue cases in Manila 2009 Rainfall, temperature, relative humidity and dengue cases in Metro Manila, Philippines 2009

Larvicidal activity of coconut fatty alcohol sulfate (CFAS) o *Aedes (stegomyia) aegypti* (Linnaeus 762) 2009

of the residents of barangays Macasandig and Indahag, Cagayan de Oro City, 2007

**released**

57

2006

http://dx.doi.org/10.5772/intechopen.78686

2007

2008

2008

2008

2008

2009

Buczak et al. [56], on the other hand, built prediction models in 2014 for future dengue incidence in the Philippines that is capable of being modified for use in different situations; for diseases other than dengue; and for regions beyond the Philippines. This model predicted high or low incidence of dengue in the Philippines 4 weeks in advance of an outbreak with high accuracy, as measured by positive predictive value (PPV), negative predictive value

In Cebu City, Miksch et al. [57], used modeling and simulation techniques to understand how dengue spread in a community in 2015. The research team developed an agent-based model for simulating dengue epidemics which modeled human and mosquito agents with detailed agent's behavior, mosquito biting rules, and transmissions. Featuring a modular approach,

of dengue cases for particular locations using statistical computations.

**Table 5.** List of vector control and surveillance studies in the Philippines, 2000–2009.

(NPV), sensitivity, and specificity.

City, Basilan

Filipino University students

Poblacion, Muntinlupa City, Philippines

*Aedes aegypti* Linnaeus (Diptera: Culicidae) mosquito larvae

(*Zea mays* Linnaeus) pollen under laboratory conditions


**Table 5.** List of vector control and surveillance studies in the Philippines, 2000–2009.

**Research title Year** 

The larvicidal potential of extract from the leaves of lagnob (*Ficus septica* Burm.f.) on *Aedes* mosquito 2000 Identification of dengue larvae via larvitraps at Manila Central University (a preliminary study) 2000

The efficacy of abate 1 sg and culinex plus s in controlling *Aedes albopictus* larvae 2002

Screening of Philippine plants for larvicidal activity on *Aedes aegypti* 2003

The seasonal pattern of occurrence of *Aedes* mosquito dengue vector 2002

Establishment of sensitive vector indicator for dengue surveillance 2002

Students' perceptions about mosquito larval control in a dengue-endemic Philippine city 2004 Species of *Mesocyclops* (Crustacea: Copepoda) as a biological control agent of *Aedes aegypti* (Linnaeus) 2004

A preliminary study on the mosquito repellent effect of tea tree (*Melaleuca alternifolia*) oil 2005 Survey of freshwater Copepods (Crustacea) in selected areas of Luzon with dengue cases 2005 A comparison of an integrative learning method and problem-based learning method as dissemination tools about dengue hemorrhagic fever among public elementary school teachers in Zamboanga City

Survey of dengue vectors in Barangay 674 "Estero de Tanque", Paco, Manila 2005 The effect of interventional program on the larval indices of *Aedes Aegypti* in selected Barangays Isabela

*Aedes* sp. surveillance using ovitrap technique in Barangay Sta. Cruz, Makati City, Philippines 2006

The mosquito attracting power of powdered: *Ruellia tuberosa* (waterbomb) 2006

Ecology of mosquito vectors of Japanese encephalitis in Malawak, Bustos, Bulacan [Philippines] with

People's knowledge and practice and *Aedes aegypti* infestation in Cebu City, Philippines and

People's knowledge and practice and *Aedes aegypti* infestation in Cebu City, Philippines and

Knowledge, attitudes, and practices among residents of Brgy. Tinajeros, Malabon Metro Manila

An interventional study on the effectiveness of the basic training course on dengue prevention and

The association between local meteorological factors and hospital admissions of dengue hemorrhagic

The effectiveness of larval surveillance-integrative approach strategy in relation to prevalence and

The effect of puppetry as an educational intervention approach on the knowledge, attitude and practices regarding dengue hemorrhagic fever prevention and control among grade school children in

Evaluation of the present dengue situation and control strategies against *Aedes aegypti* in Cebu City,

Evaluation of the present dengue situation and control strategies against *Aedes aegypti* in Cebu City,

control among barangay health workers in Piñan, Zamboanga del Norte

implications for community-based dengue control

56 Public Health - Emerging and Re-emerging Issues

implications for community-based dengue control

regarding dengue prevention

fever in Iloilo Province, Philippines

Lawaan Elementary School, Banonong, Dapitan City

density of the *Aedes* larvae

Philippines

Philippines

City, Basilan

special reference to their aquatic habitat

**released**

2000

2000

2002

2003

2002

2003

2004

2005

2005

2005

2006

2006

on the effect of weather patterns in predicting mosquito density and count of dengue cases in different locations in the Philippines used multiple regression analysis to come up with models containing predictor variables that contribute to the density of mosquitoes in the selected site. The study then came up with the best model on predicting mosquito density and count of dengue cases for particular locations using statistical computations.

Buczak et al. [56], on the other hand, built prediction models in 2014 for future dengue incidence in the Philippines that is capable of being modified for use in different situations; for diseases other than dengue; and for regions beyond the Philippines. This model predicted high or low incidence of dengue in the Philippines 4 weeks in advance of an outbreak with high accuracy, as measured by positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity.

In Cebu City, Miksch et al. [57], used modeling and simulation techniques to understand how dengue spread in a community in 2015. The research team developed an agent-based model for simulating dengue epidemics which modeled human and mosquito agents with detailed agent's behavior, mosquito biting rules, and transmissions. Featuring a modular approach,


**Research title Year** 

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

Baseline and key container survey for *Aedes aegypti* and *Aedes albopictus* in Albay Province, Philippines 2012

Water quality and *Aedes* larval mosquito abundance in Caloocan city, Philippines 2012 The impact of climate change on the prevalence of dengue cases in the province of Albay 2013

Estimating dengue vector abundance in the wet and dry season: implications for targeted vector

A comparative study between hay infusion baited ovitrap with rain water baited ovitrap by counting

Medically important mosquitoes (Diptera: Culicidae) identified in rural barangay Binubusan, Lian,

Medically important mosquitoes (Diptera: Culicidae) identified in rural barangay Binubusan, Lian,

Entomological survey of artificial container breeding sites of dengue vectors in Batasan Hills, Quezon

Natural transovarial transmission of dengue viruses in *Aedes aegypti* (Diptera: Culicidae) in Cebu City,

Health promotive management interventions on the level of health care practices against dengue

The effectiveness of fragrant pandan plant (*Pandanus amaryllifolius* Roxb.) prop root extract as a

The larvicidal activity of brown algae *Padina minor* (Yamada 1925) and *Dictyota linearis* (Greville 1830)

The relationship between the level of awareness on the prevention of dengue fever and their practices of full-time mothers in Sitio Malibu, Barangay Subangdaku, Mandaue City: a basis for information

Socioeconomic status and level of knowledge on environmental measures on dengue hemorrhagic fever among residents in Sitio Sudtungan, Basak, Lapu-lapu City: proposed guidelines to enhance

Laboratory observations on the use of *Diplonychus rusticus* as a potential biological control agent on

Preliminary screening of Citrus microcarpa (calamansi) seed oil extract as a potential larvicide against

Knowledge, attitudes, perceptions and practices related to ovicidal-larvicidal traps for dengue control

Percent survival of dengue mosquito vector (*Aedes aegypti*) larvae feeding on rice (*Oryza sativa*) pollen

Prediction of high incidence of dengue in the Philippines 2014

Effect of *Aedes aegypti* exposure to spatial repellent chemicals on BG-Sentinel™ trap catches 2013 Larvicidal effect of ampalaya (*Momordica charantia*) fruit juice on *Aedes* mosquito larvae 2013 Dengue knowledge and preventive practices among rural residents in Samar Province, Philippines 2013 Knowledge and practices of mothers of Sitio Riverside barangay Sambag II Cebu City on dengue fever:

hemorrhagic fever among selected mothers in Barangay Guadalupe, Cebu City

against the dengue vector, *Aedes aegypti* (Linn 1762) (Diptera: Culicidae)

control in urban and peri-urban Asia

the numbers of mosquito eggs

Batangas Province, Philippines

Batangas Province, Philippines

mosquito (*Aedes aegypti*) larvicide

its disease transmission and prevention

dissemination on the prevention of dengue fever

awareness and prevention on dengue fever

*Aedes aegypti*: a dengue fever mosquito

among households in one barangay in Quezon city

Japanese encephalitis vector

under laboratory conditions

City

Philippines

**released**

59

2012

http://dx.doi.org/10.5772/intechopen.78686

2012

2012

2012

2013

2013

2013

2013

2013

2013

2013

2013

2013

2014

2014

2014


**Research title Year** 

Insecticidal activity of *Cucurbita maxima* Duch. var. suprema (squash) leaf blades and *Piper nigrum* Linn.

Best practices in dengue surveillance: a report from the Asia-Pacific and Americas Dengue Prevention

Antigen sandwich ELISA predicts RT-PCR detection of dengue virus genome in infected culture fluids

Climate change and incidence of dengue fever (DF) and dengue hemorrhagic fever (DHF) in Iligan

A study on the effect of utilizing school-based dengue education on the knowledge, attitude and practices of elementary students on dengue prevention and control in Tampilisan Central School,

The effectiveness of *Ocimum basilicum* (sweet basil) extract as a mosquito (female *Aedes aegypti*) repellant: basis for information dissemination as a potential alternative measure for preventing

The effectiveness of health teachings on the level of knowledge and degree of compliance on dengue awareness program as mandated by the department of health among selected residents in Barangay

Evaluation of a peridomestic mosquito trap for integration into an *Aedes aegypti* (Diptera: Culicidae)

Eco-bio-social research on dengue in Asia: a multicountry study on ecosystem and community-based

Effects of aqueous and pelletized admixture of *Piper nigrum* L on the oviposition behavior of *Aedes* 

Community-based dengue vector control: experiences in behavior change in Metropolitan Manila,

Operational efficiency and sustainability of vector control of malaria and dengue: descriptive case

Multi-functional controlled release system for fragrant and mosquito-repellent finishing in cotton

The key breeding sites by pupal survey for dengue mosquito vectors, *Aedes aegypti* (Linnaeus) and

Philippine water bug effective biological control for dengue 2012 Field evaluation of ovitraps with *Piper nigrum* to assess its larvicidal and oppositional effects on dengue

Rainfall, temperature and the incidence of dengue in Central Visayas, Philippines are not correlated 2012

The effect of climate change in the occurrence of dengue cases 2012 Review: geographical information systems for dengue surveillance 2012

approaches for the control of dengue vectors in urban and peri-urban Asia

Dengue vector surveillance methods in Muntinlupa City, Philippines 2011

Climatic factors affecting dengue fever and dengue hemorrhagic fever incidence in Makati City 2011

Development of natural-based mosquito repellent lotion against dengue fever 2011

(Black pepper) seeds against *Aedes aegypti* mosquitoes

58 Public Health - Emerging and Re-emerging Issues

barangay Poblacion Tampilisan, Zamboanga del Norte

*aegypti* mosquitoes and its larvicidal-ovicidal activity

*Aedes albopictus* (Skuse), in Guba, Cebu City, Philippines

Board

mosquito bites

Philippines

fabrics

mosquito vectors

Labangon, Cebu City

push-pull control strategy

studies from the Philippines

of *Aedes albopictus* C6/36 cells

City, Lanao del Norte, Philippines

**released**

2010

2010

2010

2011

2011

2011

2011

2012

2012

2012

2012

2012

2012

2012

2012


The use of more sophisticated biological and computational tools for vector control in the country such as molecular biology, nanotechnology, bioinformatics, or combination of these tools was also explored in the recent years. Among the studies that utilized these tools is the study by Contreras et al. [59] which fabricated a nanoparticle-based sensor using DNAzymefunctionalized dextrin-capped gold nanoparticles to detect the presence of dengue virus serotype-3 (DENV-3) in *Aedes aegypti*. In this research, the fabricated nanoparticle-based sensor can detect target concentration for as low as 0.1 μM using synthetic DENV-3 target and 5 × 102 PFU/mL using extracted RNA from *A. aegypti*. The nano-biosensor presented in this study provides a simple, faster, "greener," and portable way of detecting the DENV-3 in mosquitoes

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

http://dx.doi.org/10.5772/intechopen.78686

61

Cruz et al. [60], on the other hand, devised a CMOS RC oscillator in 2015 that operates at frequency based on the wing-beat frequency of male mosquitoes and dragonflies, in order to produce ultrasonic signal that repels biting female mosquitoes. According to the researchers, this microelectronic CMOS oscillator can be further developed into portable and wearable mosquitorepel circuits, and can help improve the nonoccurrence of malaria and dengue in the country.

Meanwhile in RITM, the Department of Medical Entomology established partnership with the *World Mosquito Program* of Monash University in Australia to pilot test the introduction of *Wolbachia* (a naturally occurring bacteria from other insects) into *Aedes aegypti* eggs. The said bacteria reduce the ability of mosquitoes to transmit harmful human viruses such as dengue,

One of the earliest peer-reviewed and comprehensive studies on biological characteristics of *Aedes Aegypti* in the Philippines is the study conducted by Del Rosario in 1961 which described some bionomic features of *Ae. aegypti* under laboratory conditions using an artificial colony. The study revealed that the development of *Ae. aegypti* from egg to adult takes about 2 weeks or more under ordinary room temperature (24–28°C). Oviposition follows in 4 or 5 days upon taking first blood meal (2 or 3 days after emergence). The female eats again 2 or 3 days later. Based on researcher's observations, *Ae. aegypti* species eat as many as eight times during its lifetime in the laboratory. The average interval between blood meals is 3.4 days. They laid eggs after almost every blood meal. However, there were instances where they had to take several blood meals before laying eggs. The number of eggs laid per oviposition ranges from 15 to 140 with an average of 57. The number of eggs by adults fed by chicken blood is signifi-

Another study on *Ae. aegypti* revealed that certain laboratory strains of *Ae. aegypti* differ significantly and consistently in their choice of oviposition substrate. Based on the experiment conducted by Schoenig in 1968, the strain differences are not essentially affected by environmental influences and the stability of this reaction indicates genetic control. The researcher further noted that oviposition on a solid surface (paper) is the wild-type character. There is evidence that this character may be largely controlled by a single gene with incomplete dominance which linked to sex on chromosome 1. The study also indicates that behavioral character in mosquitoes can be measured and the genetic basis of mosquito behavior can be

chikungunya, and Zika when optimum density is present in female adults.

cantly higher than those fed by human blood with an average of 76 [61].

for epidemiological purposes.

**3.2. Vector biology and life history studies**

further investigated [62].

**Table 6.** List of vector control and surveillance studies in the Philippines, 2010–2018.

this method provides flexibility and allows functionalities that are easy to manage and to communicate. The model was parameterized and calibrated to simulate the 2010 dengue epidemic in Cebu City, Philippines. The study provided insights into the spreading process of dengue. It revealed that the changing mosquito population during rainy season has a great impact on the epidemic. With this, the study showed how further research on that matter using models and extended biological studies might lead to a better understanding of the dengue spreading process, and eventually to more effective disease control.

Meanwhile, Duncombe et al. [58] suggested the use of geographical information systems (GIS) for dengue surveillance, citing the advancement of GIS technology and its potential to greatly assist dengue prevention and control, as it allows further investigation of surveillance data through spatial statistical analyses and visualization of patterns and relationships between disease and the environment. The paper added that open access applications enable all countries to use this technology, including those nations with limited resources and that the advances in open access GIS technologies should be viewed as a catalyst for increased global collaboration, where information sharing and public health planning are prioritized to achieve common goals.

The use of more sophisticated biological and computational tools for vector control in the country such as molecular biology, nanotechnology, bioinformatics, or combination of these tools was also explored in the recent years. Among the studies that utilized these tools is the study by Contreras et al. [59] which fabricated a nanoparticle-based sensor using DNAzymefunctionalized dextrin-capped gold nanoparticles to detect the presence of dengue virus serotype-3 (DENV-3) in *Aedes aegypti*. In this research, the fabricated nanoparticle-based sensor can detect target concentration for as low as 0.1 μM using synthetic DENV-3 target and 5 × 102 PFU/mL using extracted RNA from *A. aegypti*. The nano-biosensor presented in this study provides a simple, faster, "greener," and portable way of detecting the DENV-3 in mosquitoes for epidemiological purposes.

Cruz et al. [60], on the other hand, devised a CMOS RC oscillator in 2015 that operates at frequency based on the wing-beat frequency of male mosquitoes and dragonflies, in order to produce ultrasonic signal that repels biting female mosquitoes. According to the researchers, this microelectronic CMOS oscillator can be further developed into portable and wearable mosquitorepel circuits, and can help improve the nonoccurrence of malaria and dengue in the country.

Meanwhile in RITM, the Department of Medical Entomology established partnership with the *World Mosquito Program* of Monash University in Australia to pilot test the introduction of *Wolbachia* (a naturally occurring bacteria from other insects) into *Aedes aegypti* eggs. The said bacteria reduce the ability of mosquitoes to transmit harmful human viruses such as dengue, chikungunya, and Zika when optimum density is present in female adults.

## **3.2. Vector biology and life history studies**

this method provides flexibility and allows functionalities that are easy to manage and to communicate. The model was parameterized and calibrated to simulate the 2010 dengue epidemic in Cebu City, Philippines. The study provided insights into the spreading process of dengue. It revealed that the changing mosquito population during rainy season has a great impact on the epidemic. With this, the study showed how further research on that matter using models and extended biological studies might lead to a better understanding of the

**Research title Year** 

Transovarial transmission of dengue virus in *Aedes aegypti*: a case in Quezon City, Philippines 2014 Analysis of climate variability and dengue occurrence in social-ecological systems: the case of Bay, Los

The effectivity of Lanzones (*Lansium domesticum*) peelings' extract as mosquito repellant 2015

An agent-based epidemic model for dengue simulation in the Philippines 2015 Identification of mosquito species in brown sugar and yeast mosquito trap 2015 CMOS RC oscillator using 0.35 micron for portable mosquito-repel circuit 2015

Fabrication of a nanoparticle-based sensor for the detection of dengue virus-3 in *Aedes aegypti* 2016

The effect of cogon grass (*Imperata cylindrica*) and carabao grass (*Paspalum conjugatum*) leaf extract on

Isolation and identification of *Bacillus thuringiensis* from *Harpaphe haydeniana* and its entomotoxic

Effect of temperature, relative humidity and rainfall on dengue fever and leptospirosis infections in

Determinants of transmission risk and the role of vector pupal presence in the development of

BG-Sentinel™ trap efficacy as a component of proof-of concept for push-pull control strategy for

Evaluation of a spatial repellent push-pull strategy for the control of *Aedes aegypti* using experimental

Effect of weather patterns in predicting mosquito density and count of dengue cases in six locations in

integrated approaches to dengue control in Muntinlupa City, The Philippines

**Table 6.** List of vector control and surveillance studies in the Philippines, 2010–2018.

Baños and Calamba in Laguna, the Philippines

60 Public Health - Emerging and Re-emerging Issues

evaluation against *Aedes* and *Culex* larvae

mortality of *Aedes aegypti* larvae

Manila, the Philippines

dengue vector mosquitoes

huts in Western Thailand

the Philippines

**released**

2015

2015

2015

2016

2017

2017

2018

2018

Meanwhile, Duncombe et al. [58] suggested the use of geographical information systems (GIS) for dengue surveillance, citing the advancement of GIS technology and its potential to greatly assist dengue prevention and control, as it allows further investigation of surveillance data through spatial statistical analyses and visualization of patterns and relationships between disease and the environment. The paper added that open access applications enable all countries to use this technology, including those nations with limited resources and that the advances in open access GIS technologies should be viewed as a catalyst for increased global collaboration, where information sharing and public health planning are prioritized to

dengue spreading process, and eventually to more effective disease control.

achieve common goals.

One of the earliest peer-reviewed and comprehensive studies on biological characteristics of *Aedes Aegypti* in the Philippines is the study conducted by Del Rosario in 1961 which described some bionomic features of *Ae. aegypti* under laboratory conditions using an artificial colony. The study revealed that the development of *Ae. aegypti* from egg to adult takes about 2 weeks or more under ordinary room temperature (24–28°C). Oviposition follows in 4 or 5 days upon taking first blood meal (2 or 3 days after emergence). The female eats again 2 or 3 days later. Based on researcher's observations, *Ae. aegypti* species eat as many as eight times during its lifetime in the laboratory. The average interval between blood meals is 3.4 days. They laid eggs after almost every blood meal. However, there were instances where they had to take several blood meals before laying eggs. The number of eggs laid per oviposition ranges from 15 to 140 with an average of 57. The number of eggs by adults fed by chicken blood is significantly higher than those fed by human blood with an average of 76 [61].

Another study on *Ae. aegypti* revealed that certain laboratory strains of *Ae. aegypti* differ significantly and consistently in their choice of oviposition substrate. Based on the experiment conducted by Schoenig in 1968, the strain differences are not essentially affected by environmental influences and the stability of this reaction indicates genetic control. The researcher further noted that oviposition on a solid surface (paper) is the wild-type character. There is evidence that this character may be largely controlled by a single gene with incomplete dominance which linked to sex on chromosome 1. The study also indicates that behavioral character in mosquitoes can be measured and the genetic basis of mosquito behavior can be further investigated [62].

In 2012, a study on life history, fecundity, and blood feeding time of *Aedes albopictus*, another important vector of dengue viruses in the Philippines, was conducted by Aguila and Caoili under laboratory conditions (26.7±0.9°C and 83±5.7% RH). The controlled experiment revealed that the average development time of each life stages is as follows: eggs, 1.84 ± 0.8 days; larval stage: first instar, 2.31 ± 0.5 days; second instar, 1.11 ± 0.1 days; third instar, 1.12 ± 0.1 days; fourth instar 1.33 ± 0.2 days; pupal stage, 1.94 ± 0.1 days; and 3.91 ± 1.2 days for the adult longevity. The observed total developmental time from egg to adult was 13.55 ± 1.0 days. Female *Ae. albopictus* laid an average of 46.2 ± 32.3 eggs. Mortality factor from egg to pupal stage was K = 0.3808. Meanwhile, the researchers observed that the peak feeding time of *Ae. albopictus* regardless of age was at 07:00H, which is the first exposure period to the host. Additional peak biting time of 6- and 7-day-old females was at 10:00H, while that of 3-day-old females was at 21:00H and 03:00H. The study's results provide insights on effective mosquito management control strategy to prevent *Ae. albopictus* vectorial capacity anytime of the day [63].

Researchers also took advantage of bioinformatics and other innovative tools to gain further insights on the physiological features of vector mosquitoes. For instance, Sendaydiego et al. [64] identified the intraspecific divergence in wing shape and venation in *Aedes aegypti* using landmark-based geometric morphometrics. Results of the relative warp analysis showed some intraspecific variation in the wing outline of *Ae. aegypti*. The observed morphological disparity in wing shape suggests a possible morphological divergence among populations of *Ae. aegypti*.

In 2014, Alcantara constructed a homology model of *Ae. aegypti* chorion peroxidase enzyme and identified potential inhibitors of chorion peroxidase by computational method to predict the three-dimensional (3D) structure of *Ae. aegypti* chorion peroxidase. This study is significant on dengue vector control as development of ovicidal compounds targeting chorion peroxidase would complement existing larvicidal and adulticidal compounds for control of *Ae. aegypti* [65].

**Table 7** shows the list of vector biology and life history studies in the Philippines from 1961 to 2014.

### **3.3. Distribution of vector research per decade, category**

Studies on mosquito vectors of interest collected in this chapter were grouped according to decade they were released, ranging from 1958 up to the present. A total of 153 locally conducted studies were collected from RITM and HERDIN databases. The breakdown of number of studies conducted per decade is the following: 1 in 1950s, 11 in 1960s, 10 in 1970s, 9 in 1980s, 17 in 1990s, 39 in 2000s, and 66 in 2010s (**Figure 2**).

Except for 1970s and 1980s, there is an increasing trend on the number of studies conducted in the country over time. Decline on number of research in the 1970s and 1980s may be explained by the political turmoil and instability in the country during these decades which probably affected the funding of research in the Philippines. The country's political climate only stabilized in the latter part of the 1980s when transition in the Philippine government occurred, the first time in more than 20 years.

Research outputs following the decade of shift of administration in the country almost doubled from 9 in the 1980s to 17 in the 1990s. The increasing trend of research outputs on medical

**Research title Year released**

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

1963

63

http://dx.doi.org/10.5772/intechopen.78686

2010

2010

2012

Studies on the biology of Philippine mosquitoes, I—some bionomic features of *Aedes aegypti* 1961

Strain variation in *Aedes aegypti* 1968 Host-induced modification of dengue-2 virus surface antigens in *Aedes albopictus* cells 1973 Recapitulations on changes in dengue virus properties and the etiology of dengue hemorrhagic fever 1976 Notes on the karyotype of two Philippine Aedine mosquitoes 1989 Biology and control of *Aedes* mosquito vectors of dengue/dengue hemorrhagic fever in the Philippines 1995

Studies on the biology of Philippine mosquitoes, II—observations on the life and behavior of *Aedes* 

Production of viral antigens in culture fluid of C6/36 mosquito cell line infected with dengue type 4

Antigen sandwich ELISA predicts RT-PCR detection of dengue virus genome in infected culture fluids

Life history and blood feeding activity of a Philippine population of *Aedes albopictus* Skuse (Diptera:

**Table 7.** List of vector biology and life history studies in the Philippines, 1961–2014.

Describing wing geometry of *Aedes Aegypti* using landmark-based geometric morphometrics 2013 In silico identification of potential inhibitors of dengue mosquito, *Aedes Aegypti* chorion peroxidase 2014

virus strains isolated from patients with different clinical severities

*albopictus* (Skuse) in the laboratory

of *Aedes albopictus* C6/36 cells

Culicidae) under laboratory conditions

entomology further continued the following decades.

**Figure 2.** Distribution of mosquito vector studies per decade from 1950s to 2010s.


In 2012, a study on life history, fecundity, and blood feeding time of *Aedes albopictus*, another important vector of dengue viruses in the Philippines, was conducted by Aguila and Caoili under laboratory conditions (26.7±0.9°C and 83±5.7% RH). The controlled experiment revealed that the average development time of each life stages is as follows: eggs, 1.84 ± 0.8 days; larval stage: first instar, 2.31 ± 0.5 days; second instar, 1.11 ± 0.1 days; third instar, 1.12 ± 0.1 days; fourth instar 1.33 ± 0.2 days; pupal stage, 1.94 ± 0.1 days; and 3.91 ± 1.2 days for the adult longevity. The observed total developmental time from egg to adult was 13.55 ± 1.0 days. Female *Ae. albopictus* laid an average of 46.2 ± 32.3 eggs. Mortality factor from egg to pupal stage was K = 0.3808. Meanwhile, the researchers observed that the peak feeding time of *Ae. albopictus* regardless of age was at 07:00H, which is the first exposure period to the host. Additional peak biting time of 6- and 7-day-old females was at 10:00H, while that of 3-day-old females was at 21:00H and 03:00H. The study's results provide insights on effective mosquito management

control strategy to prevent *Ae. albopictus* vectorial capacity anytime of the day [63].

*Ae. aegypti*.

62 Public Health - Emerging and Re-emerging Issues

*Ae. aegypti* [65].

to 2014.

Researchers also took advantage of bioinformatics and other innovative tools to gain further insights on the physiological features of vector mosquitoes. For instance, Sendaydiego et al. [64] identified the intraspecific divergence in wing shape and venation in *Aedes aegypti* using landmark-based geometric morphometrics. Results of the relative warp analysis showed some intraspecific variation in the wing outline of *Ae. aegypti*. The observed morphological disparity in wing shape suggests a possible morphological divergence among populations of

In 2014, Alcantara constructed a homology model of *Ae. aegypti* chorion peroxidase enzyme and identified potential inhibitors of chorion peroxidase by computational method to predict the three-dimensional (3D) structure of *Ae. aegypti* chorion peroxidase. This study is significant on dengue vector control as development of ovicidal compounds targeting chorion peroxidase would complement existing larvicidal and adulticidal compounds for control of

**Table 7** shows the list of vector biology and life history studies in the Philippines from 1961

Studies on mosquito vectors of interest collected in this chapter were grouped according to decade they were released, ranging from 1958 up to the present. A total of 153 locally conducted studies were collected from RITM and HERDIN databases. The breakdown of number of studies conducted per decade is the following: 1 in 1950s, 11 in 1960s, 10 in 1970s, 9 in 1980s,

Except for 1970s and 1980s, there is an increasing trend on the number of studies conducted in the country over time. Decline on number of research in the 1970s and 1980s may be explained by the political turmoil and instability in the country during these decades which probably affected the funding of research in the Philippines. The country's political climate only stabilized in the latter part of the 1980s when transition in the Philippine government occurred, the

**3.3. Distribution of vector research per decade, category**

17 in 1990s, 39 in 2000s, and 66 in 2010s (**Figure 2**).

first time in more than 20 years.

**Figure 2.** Distribution of mosquito vector studies per decade from 1950s to 2010s.

Research outputs following the decade of shift of administration in the country almost doubled from 9 in the 1980s to 17 in the 1990s. The increasing trend of research outputs on medical entomology further continued the following decades.

period covered in this chapter. It also turns out that the research studies on public health entomology in the country, particularly on emerging and re-emerging mosquito-borne infections, are becoming more proactive and can serve as early warning for impact reduction, instead of merely responding during the period of outbreaks and epidemics. Specifically, public health entomology researches have looked at the broader point of view in terms of mass reproduction of mosquito vectors, taking into consideration different factors that affect their density

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

http://dx.doi.org/10.5772/intechopen.78686

65

However, it can also be implied from this analysis that the number of studies that concern this chapter's interest remains low but thematically, these studies follow universal trends. Newer aspects of vector control research were explored—from the use of ordinary salt as mosquito larvicide to the optimization of breakthrough technologies such as genetic modification, molecular biology, and bioinformatics to dramatically reduce mosquito-borne infec-

Nevertheless, the magnitude of research on medically important mosquitoes in the Philippines is still insufficient for it to contribute comprehensively to integrated methods of vector management and to totally eradicate mosquito-borne infections. Integrated vector management provides a sound conceptual framework for deployment of cost-effective and sustainable methods of vector control. This approach allows for full consideration of the complex determinants of disease transmission, including local disease ecology, the role of human activity in increasing risks of disease transmission, and the socioeconomic conditions of affected com-

Reasons for lack of merit of Philippine-conducted vector research include the absence of interests of the researchers to publish their studies; the discontinuation of research topics that need further validation due to lack of financial support; or lack of initiative from the researchers to further pursue their studies until empirical evidences are found, especially those who only conducted research to complete their university dissertations. On the other hand, some research studies identified in this chapter are practically a repeat of studies which were previously done and this could have been avoided if an online reference or database providing a rundown of all aspects of entomological research conducted in the country is available.

Researchers should work on the continuity of vector researches and explore further the diversity of the entomological aspects of the control of vector-borne diseases. The diversified approach to vector research offers the public health authorities some leeway and convenience of having a variety of choices for intervention to vector reduction in different mosquitoendemic areas since approaches to mosquito eradication are oftentimes location specific. Despite emergence of sophisticated tools for vector control research, studies on cheap but effective solution for vector control should still be explored since in many cases, approaches

It is thus recommended for the National Government to set up the country's Center of Excellence for Medical Entomology which will oversee the activities for public health entomology across the country, institutionalize a nationwide network of public health entomologists, spearhead the establishment of more satellite centers in different parts of the country to immediately address area-specific needs as they arise, and serve as the curator of medical

to mosquito source reduction in affected areas need not to be too expensive.

such as globalization, climate change, overpopulation, and urbanization.

tions in the country.

munities [66].

**Figure 3.** Distribution of mosquito vector studies according to category.

In terms of distribution of studies with regard to their respected categories, a total of 59 research studies (40%) fall under the Vector Surveillance Category, 79 studies (52%) fall under Vector Control Category, and 13 studies (8%) fall under Vector Biology Category (**Figure 3**).

The number of vector surveillance researches was prominent during the first decades covered in this study. By 1980s until the present, however, different aspects of mosquito vector control were explored by researchers either by means of chemical control, biological control, or environmental management, the third strategy includes modifying health-risk behaviors of the community which are vulnerable to mosquito-borne diseases outbreak.

Among the three categories of vector research, studies on the biological aspect of medically important mosquitoes seem to be lagging behind, comprising only about 9% of the total number of researches retrieved. By 2010s, however, more researchers have become interested on the biological characteristics of medically important mosquitoes in the country, with six research studies on this subject implemented in just a span of 6 years (2010–2015).

## **4. Conclusion and recommendation**

The entomological aspect of the control and prevention of mosquito-borne diseases in the Philippines is oftentimes neglected by the public health researchers and practitioners. In essence, however, the field of medical entomology and its underlying science should be the first line of defense on management and control of vector-borne diseases in the country. Overall, it is safe to say that the studies on public health entomology in the Philippines have evolved and have gone through various stages of development overtime, as presented in this chapter. If in the earlier years, scientists were more focused on surveillance of medically important mosquitoes, the research concentration has shifted to vector control halfway of the period covered in this chapter. It also turns out that the research studies on public health entomology in the country, particularly on emerging and re-emerging mosquito-borne infections, are becoming more proactive and can serve as early warning for impact reduction, instead of merely responding during the period of outbreaks and epidemics. Specifically, public health entomology researches have looked at the broader point of view in terms of mass reproduction of mosquito vectors, taking into consideration different factors that affect their density such as globalization, climate change, overpopulation, and urbanization.

However, it can also be implied from this analysis that the number of studies that concern this chapter's interest remains low but thematically, these studies follow universal trends. Newer aspects of vector control research were explored—from the use of ordinary salt as mosquito larvicide to the optimization of breakthrough technologies such as genetic modification, molecular biology, and bioinformatics to dramatically reduce mosquito-borne infections in the country.

Nevertheless, the magnitude of research on medically important mosquitoes in the Philippines is still insufficient for it to contribute comprehensively to integrated methods of vector management and to totally eradicate mosquito-borne infections. Integrated vector management provides a sound conceptual framework for deployment of cost-effective and sustainable methods of vector control. This approach allows for full consideration of the complex determinants of disease transmission, including local disease ecology, the role of human activity in increasing risks of disease transmission, and the socioeconomic conditions of affected communities [66].

**Figure 3.** Distribution of mosquito vector studies according to category.

64 Public Health - Emerging and Re-emerging Issues

**4. Conclusion and recommendation**

community which are vulnerable to mosquito-borne diseases outbreak.

In terms of distribution of studies with regard to their respected categories, a total of 59 research studies (40%) fall under the Vector Surveillance Category, 79 studies (52%) fall under Vector Control Category, and 13 studies (8%) fall under Vector Biology Category (**Figure 3**). The number of vector surveillance researches was prominent during the first decades covered in this study. By 1980s until the present, however, different aspects of mosquito vector control were explored by researchers either by means of chemical control, biological control, or environmental management, the third strategy includes modifying health-risk behaviors of the

Among the three categories of vector research, studies on the biological aspect of medically important mosquitoes seem to be lagging behind, comprising only about 9% of the total number of researches retrieved. By 2010s, however, more researchers have become interested on the biological characteristics of medically important mosquitoes in the country, with six

The entomological aspect of the control and prevention of mosquito-borne diseases in the Philippines is oftentimes neglected by the public health researchers and practitioners. In essence, however, the field of medical entomology and its underlying science should be the first line of defense on management and control of vector-borne diseases in the country. Overall, it is safe to say that the studies on public health entomology in the Philippines have evolved and have gone through various stages of development overtime, as presented in this chapter. If in the earlier years, scientists were more focused on surveillance of medically important mosquitoes, the research concentration has shifted to vector control halfway of the

research studies on this subject implemented in just a span of 6 years (2010–2015).

Reasons for lack of merit of Philippine-conducted vector research include the absence of interests of the researchers to publish their studies; the discontinuation of research topics that need further validation due to lack of financial support; or lack of initiative from the researchers to further pursue their studies until empirical evidences are found, especially those who only conducted research to complete their university dissertations. On the other hand, some research studies identified in this chapter are practically a repeat of studies which were previously done and this could have been avoided if an online reference or database providing a rundown of all aspects of entomological research conducted in the country is available.

Researchers should work on the continuity of vector researches and explore further the diversity of the entomological aspects of the control of vector-borne diseases. The diversified approach to vector research offers the public health authorities some leeway and convenience of having a variety of choices for intervention to vector reduction in different mosquitoendemic areas since approaches to mosquito eradication are oftentimes location specific. Despite emergence of sophisticated tools for vector control research, studies on cheap but effective solution for vector control should still be explored since in many cases, approaches to mosquito source reduction in affected areas need not to be too expensive.

It is thus recommended for the National Government to set up the country's Center of Excellence for Medical Entomology which will oversee the activities for public health entomology across the country, institutionalize a nationwide network of public health entomologists, spearhead the establishment of more satellite centers in different parts of the country to immediately address area-specific needs as they arise, and serve as the curator of medical entomology-related data and researches for a more organized manner of storage, retrieval, and application of these information on public health entomology and vector control.

But perhaps the most crucial part of public health entomology research is the communication and extension of these studies' potentials to the right people and concerned stakeholders. These include the public, policy-makers, mass media, local government units, and local health workers. After all, the end-goals of these researches are to be applied and utilized in the actual public health situations in the country, and in more fortunate scenarios, to serve as early warning to avoid the large-scale effect to public health of emerging and re-emerging mosquito-borne infections.

The stakeholders mentioned above need to be oriented on the importance of public health entomology and vector control so that they could support the conduct of further studies on the entomological aspects of mosquito-borne infections and even on the actual application of these researches through policy legislation and local government programs. As a science communication maxim says, "a research not communicated is like a research not done at all."

For instance, in a Dengue Vector Surveillance Workshop conducted by the Department of Health in 2014, insights were solicited among the regional health workers on why dengue vector surveillance (DVS) was not fully implemented in the country.

behaviors, physical, and biological characteristics or their density fluctuation as people from the community are already immersed with the ecology where these mosquitoes thrive.

**Figure 4.** Framework for dynamic communication/exchange of information among the major stakeholders of public health entomology for the conceptualization, implementation, and actual application of medical entomology research.

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

http://dx.doi.org/10.5772/intechopen.78686

67

It is therefore important to note that the scientists and researchers are not the lone sources of information in order to come up with an effective and integrated vector management plan. A smooth and dynamic flow of communication among the key actors mentioned above (who should be all treated equally as source of information, **Figure 4**) will lead to the development of collective insights and informed decisions for the conceptualization, implementation, and actual application of innovative but cost-effective medical entomology research for the benefit

of public health.

**Author details**

**References**

Ferdinand V. Salazar\* and Kaymart A. Gimutao

\*Address all correspondence to: rdsalazarvil@gmail.com

Tropical Medicine and Infectious Diseases. 2017;**2**:17

Filinvest City Alabang, Muntinlupa city, Philippines

Department of Medical Entomology, Research Institute for Tropical Medicine,

[1] Department of Health—Philippines (DOH). 2017. Dengue Cases: Morbidity Week 1-48 (Accessed 1-2-2017). Manila, Philippines. Retrieved January 2018 from the Worldwide Web: http://www.doh.gov.ph/sites/default/files/statistics/2017\_Dengue\_MW1-MW48.pdf

[2] Mitra K, Mawson A. Neglected tropical diseases: Epidemiology and global burden.

Inputs from the DVS workshop revealed that only 25% of the provinces and 6% of the municipalities/cities and barangays in the Philippines have completed the legislation to implement DVS in their localities. An alarming rate of 69% at the provincial level, 76% at the municipal/ city level, and 94% at the barangay level has no legislation at all to implement the said activity. In terms of budget allocation, there is actually no city/municipal local government unit (LGU) and barangay LGU which has fully designated budget for the conduct of DVS, while only 6.25% of the provincial LGUs have complete budget for the said activity [67].

The Philippine Local Government Code mandates local government units (LGUs) to implement activities and programs for vector control at provincial, city, and smaller municipal levels down to the barangay ("village" unit). Theoretically, this mandate is an ideal setup since local government units are more familiar with the demographics of their localities, (including the residents) than those from the National Government. But the lack of awareness of most LGUs on the importance of vector control does not translate to policy legislations and informed decisions to include vector surveillance as one of their priorities.

In the same manner, there is a need to review the national government policies in reference to factors that contribute largely to emerging and re-emerging mosquito-borne diseases. There is also a need to increase awareness of the public, especially the young aspiring scientists and researchers, that selected Philippine agencies have highly significant budget for the conduct of researches to encourage them to devote time toward the pursuit of scientific evidences, including those from the aspect of prevention of emerging and re-emerging mosquito-borne infections.

The public, on the other hand, especially those who reside in areas which are endemic to mosquito-borne infections may also provide insights on their communities' practices for vectors' source reduction, for the control of these vectors' mass reproduction, and even on the vectors' The Evolution of Entomological Research with Focus on Emerging and Re-emerging… http://dx.doi.org/10.5772/intechopen.78686 67

**Figure 4.** Framework for dynamic communication/exchange of information among the major stakeholders of public health entomology for the conceptualization, implementation, and actual application of medical entomology research.

behaviors, physical, and biological characteristics or their density fluctuation as people from the community are already immersed with the ecology where these mosquitoes thrive.

It is therefore important to note that the scientists and researchers are not the lone sources of information in order to come up with an effective and integrated vector management plan. A smooth and dynamic flow of communication among the key actors mentioned above (who should be all treated equally as source of information, **Figure 4**) will lead to the development of collective insights and informed decisions for the conceptualization, implementation, and actual application of innovative but cost-effective medical entomology research for the benefit of public health.

## **Author details**

entomology-related data and researches for a more organized manner of storage, retrieval,

But perhaps the most crucial part of public health entomology research is the communication and extension of these studies' potentials to the right people and concerned stakeholders. These include the public, policy-makers, mass media, local government units, and local health workers. After all, the end-goals of these researches are to be applied and utilized in the actual public health situations in the country, and in more fortunate scenarios, to serve as early warning to avoid the large-scale effect to public health of emerging and re-emerging

The stakeholders mentioned above need to be oriented on the importance of public health entomology and vector control so that they could support the conduct of further studies on the entomological aspects of mosquito-borne infections and even on the actual application of these researches through policy legislation and local government programs. As a science communication maxim says, "a research not communicated is like a research not done at all." For instance, in a Dengue Vector Surveillance Workshop conducted by the Department of Health in 2014, insights were solicited among the regional health workers on why dengue

Inputs from the DVS workshop revealed that only 25% of the provinces and 6% of the municipalities/cities and barangays in the Philippines have completed the legislation to implement DVS in their localities. An alarming rate of 69% at the provincial level, 76% at the municipal/ city level, and 94% at the barangay level has no legislation at all to implement the said activity. In terms of budget allocation, there is actually no city/municipal local government unit (LGU) and barangay LGU which has fully designated budget for the conduct of DVS, while only

The Philippine Local Government Code mandates local government units (LGUs) to implement activities and programs for vector control at provincial, city, and smaller municipal levels down to the barangay ("village" unit). Theoretically, this mandate is an ideal setup since local government units are more familiar with the demographics of their localities, (including the residents) than those from the National Government. But the lack of awareness of most LGUs on the importance of vector control does not translate to policy legislations and

In the same manner, there is a need to review the national government policies in reference to factors that contribute largely to emerging and re-emerging mosquito-borne diseases. There is also a need to increase awareness of the public, especially the young aspiring scientists and researchers, that selected Philippine agencies have highly significant budget for the conduct of researches to encourage them to devote time toward the pursuit of scientific evidences, including those from the aspect of prevention of emerging and re-emerging mosquito-borne

The public, on the other hand, especially those who reside in areas which are endemic to mosquito-borne infections may also provide insights on their communities' practices for vectors' source reduction, for the control of these vectors' mass reproduction, and even on the vectors'

vector surveillance (DVS) was not fully implemented in the country.

6.25% of the provincial LGUs have complete budget for the said activity [67].

informed decisions to include vector surveillance as one of their priorities.

and application of these information on public health entomology and vector control.

mosquito-borne infections.

66 Public Health - Emerging and Re-emerging Issues

infections.

Ferdinand V. Salazar\* and Kaymart A. Gimutao

\*Address all correspondence to: rdsalazarvil@gmail.com

Department of Medical Entomology, Research Institute for Tropical Medicine, Filinvest City Alabang, Muntinlupa city, Philippines

## **References**


[3] Saiz JC, Vasquez-Calvo A, Biazquez A, Merino-Ramos A, Escribano-Romero E, et al. Zika virus: The latest newcomer. Frontiers in Microbiology. 2016;**7**:496. DOI: org/10.3389/ fmicb.2016.00496

[15] Siler JF, Hall MW, Hitchens AP. Dengue: Its history, epidemiology, mechanism of transmission, etiology, clinical manifestations, immunity, and prevention. The Government of the Philippine Islands Department of Agriculture and Natural Resources Bureau of

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

http://dx.doi.org/10.5772/intechopen.78686

69

[16] Rudnick A, Hammon W. Newly recognized *Aedes aegypti* problems in Manila and

[17] Pettis M. *Aedes aegypti* and Dengue in the Philippines: Centering History and Critiquing Ecological and Public Health Approaches to Mosquito-Borne Disease in the Greater

[18] Halstead SB. Mosquito-borne haemorrhagic fevers of South and South-East Asia.

[19] Rudnick A, Hammon W. Entomological aspects of Thai hemorrhagic fever epidemics in Bangkok, Philippines, and Singapore, 1956 to 1961. SEAMED Monog. 1961;**2**:24-26 [20] Dizon J, Mendoza J, Gomez F. Epidemiological-entomological observations on Philippine hemorrhagic fever. Journal of the Philippine Medical Association. 1968;**44**(10):597-609

[21] Banez LL. Use of ordinary table salt against breeding of mosquitoes in artificial contain-

[22] Angeles LT, Fabella A, Gonzales A, Sotto AS. A possible larvicidal agent among the bis-

[23] Chow CY. Control of the vector mosquitoes of haemorrhagic fever. The Philippine

[24] Baisas FE, Cabrera BD, Santiago D. Determination of the distribution and abundance of mosquitoes in selected geographic areas. Acta Medica Philippine. 1970;**7**(2):40-81 [25] Schoenig E. Mosquitoes in Cebu City and adjacent area: An ecological survey. Philippine

[26] Basio RG. Mosquitoes in relation to public health in the Philippines with reference to the principal vector, species and the diseases they transmit. Philippine Journal of Public

[27] Basio RG, Azurin JC. On Philippine mosquitoes, VIII. The distribution of *Aedes aegypti* Linn. (Diptera: Culicidae) and its relationship to the spread of dengue hemorrhagic

[28] Basio RG, Alfonso PJ, Dario EJ, Navea M, Reyes M. On Philippine mosquitoes, XII— Some ecological notes on two medically important mosquito species, *Aedes aegypti* and *Aedes albopictus*, in a selected geographic area of the UP College of Agriculture Campus in UP Los Baños, Laguna Province. (Diptera: Culcidae). Philippine Journal of Public

benzyl isoquinoline alkaloids. Acta Medica Philippine. 1968;**5**(2):46-50

Science Manila. Manila Bureau of Printing; 1926. 21 p

Asian Pacific. Claremont, California: Pomona College; 2017

Bulletin of the World Health Organization. 1966;**35**(1):3-15

ers. The Philippine Journal of Science. 1963;**92**(4):447-481

Journal of Pediatrics. 1965;**14**(2):124-126

fever. Philippine Entomologist. 1972;**2**(3):183-194

Scientist. 1971;**8**:21-32

Health. 1972;**18**(2):141-157

Health. 1973;**18**:248-264

Bangkok. Mosquito News. 1961;**20**(3):257-249


[15] Siler JF, Hall MW, Hitchens AP. Dengue: Its history, epidemiology, mechanism of transmission, etiology, clinical manifestations, immunity, and prevention. The Government of the Philippine Islands Department of Agriculture and Natural Resources Bureau of Science Manila. Manila Bureau of Printing; 1926. 21 p

[3] Saiz JC, Vasquez-Calvo A, Biazquez A, Merino-Ramos A, Escribano-Romero E, et al. Zika virus: The latest newcomer. Frontiers in Microbiology. 2016;**7**:496. DOI: org/10.3389/

[4] Duong V, Dussart P, Buchy P. Zika virus in Asia. International Journal of Infectious

[5] Alera MT, Hermann L, Tac-An IA, Klungthong C, Rutvisuttinunt W, Manasatienkij W, et al. Zika virus infection, Philippines, 2012. Emerging Infectious Diseases. 2015;**21**(4)

[6] The World Health Organization in the Western Pacific Region (WHO-WPRO). Focus on Chikungunya. Early Warning Alert and Response Network Report, Manila, Philippines [internet]. 2014. Available from: http://www.wpro.who.int/philippines/typhoon\_hai-

[7] Department of Health—Philippines (DOH).. Chikungunya Cases: Morbidity Week 1-52 (Jan. 1-Dec. 31, 2016) [internet]. 2017. Available from: http://www.doh.gov.ph/sites/

[8] Department of Health—Philippines (DOH). DOH urges public to protect themselves from mosquito bites to prevent Japanese Encephalitis, [internet]. 2017. Available from:

[9] Beier JC, Keating J, Githure JI, Macdonald MB, Impoinvil DE, Novak RJ. Integrated vector management for malaria control. Malaria Journal. 2008;**7**(Suppl 1):S4. DOI: 10.1186/

[10] Chanda E, Masaninga F, Coleman M, Sikaala C, Katebe C, MacDonald M, et al. Integrated vector management: The Zambian experience. Malaria Journal. 2008;**7**:164. DOI:

[11] Chanda E, Coleman M, Kleinschmidt I, Hemingway J, Hamainza B, et al. Impact assessment of malaria vector control using routine surveillance data in Zambia: Implications for monitoring and evaluation. Malaria Journal. 2012;**11**:437. DOI: 10.1186/1475-2875-11-437

[12] The World Health Organization. Investing to Overcome the Global Impact of Neglected Tropical Diseases: Third WHO Report on Neglected Tropical Diseases. WHO Document

[13] Ludlow CS. The Mosquitoes of the Philippine Islands: The Distribution of Certain Species and Their Occurrence in Relation to the Incidence of Certain Diseases. Washington DC:

[14] Higgs S, Walker PF, Goraleski KA. Clara Southmayd Ludlow: Her thirst for knowledge was positively inspirational: Honoring a female giant in tropical medicine. The American Journal of Tropical Medicine and Hygiene. 2017;**97**(6):1638-1639. DOI: 10.4269/

default/files/statistics/2016\_ChikV\_MW1-MW52.pdf. [Accessed: 2017-12-08]

fmicb.2016.00496

68 Public Health - Emerging and Re-emerging Issues

1475-2875-7-S1- S4

ajtmh.17-ludlow

10.1186/1475-2875-7-164

Diseases. 2017;**54**. DOI: 10.1016/j.ijid.2016. 11.420

yan/media/Chikungunya.pdf. [Accessed: 2017-12-08]

http://www.doh.gov.ph/node/11110. [Accessed: 2017-12-08]

Production Services, Geneva, Switzerland; 2015. 191 p

George Washington University; 1908


[29] Basio RG. The mosquito control program at the Manila International Airport and vicinity (Philippines) with comments on problems encountered on the aerial transportation of mosquitoes. In: Chan YC, Chan KL, Ho BC, editors. Vector Control in South East Asia. Singapore: SEAMEO-TROPMED and Ministry of Health and University of Singapore. 1973. pp. 78-84

[41] Padla EP. Antibacterial, Antifungal and Larvicidal Properties of Selected Seaweeds in

The Evolution of Entomological Research with Focus on Emerging and Re-emerging…

http://dx.doi.org/10.5772/intechopen.78686

71

[42] Annis B. Comparison of the effectiveness of two DEET formulations against *Aedes albopictus* in the Philippines. Journal of the American Mosquito Control Association.

[43] Madarieta SK, Salarda A, Benabaye MRS, Bacus MB, Tagle JR. Use of permethrin-treated curtains for control of *Aedes aegypti* in the Philippines. Dengue Bulletin. 1999;**23**:51-54

[44] Flores JG, Lamorena MB. Ultrastructure study of *Bacillus thuringiensis*-treated *Aedes* 

[45] Alix BC, Montecillo RJ. Effects of Mutants of *Bacillus thuringiensis* subsp. *Israelensis* on Mosquito Larvae (*Aedes aegypti*). Cebu City, Philippines: University of San Carlos; 1999

[46] Galvez MC, Lecciones JA. Knowledge, attitudes and practices of Filipino mothers regarding the dengue fever syndrome implications towards preventive interventions.

[47] Tabuyan EP, Cristobal FL, Arciaga MR, Imlan-Marbella JC, Marbella MC, et al. Community-based control of dengue hemorrhagic fever: A 5-year prospective interven-

[48] Punzalan RS. A community field practice report in Sitio Bagong Pook, Tanza,Cavite: Control and prevention of dengue fever. Manila, Philippines: College of Public Health,

[49] Seeto CJ, Ricafort RM, Muti NM, Bartolome TF, Awing AG et al. An analytical study on the relationship between rainfall, temperature and humidity and the number of dengue fever cases in admitted patients at the Northern Mindanao Medical Center from 1998-

[50] Sia Su GL. Correlation of climatic factors and dengue incidence in Metro Manila,

[51] Panagodia-Reyes C. Rainfall, temperature, relative humidity and dengue cases in Metro Manila, Philippines. Emilio Aguinaldo College Research Bulletin. 2009;**8**(1). DOI:

[52] Reyes CP, Cruz I, Bautista SL. Philippine species of *Mesocyclops* (Crustacea: Copepoda) as a biological control agent of *Aedes aegypti* (Linnaeus). Dengue Bulletin. 2004;**28**:174-178

[53] Reyes CP, Bautista SL, Cruz EI. Survey of freshwater copepods (Crustacea) in selected

[54] The World Health Organization. Dengue control: Biological control [internet]. 2017. Geneva, Switzerland. Available from: http://www.who.int/denguecontrol/control\_strat-

areas of Luzon with dengue cases. EAC Research Bulletin. 2005;**4**(1):11-22

egies/ biological\_ control/en/. [Accessed: 2018-01-08]

2007. Cagayan de Oro City: Xavier University Student Working Series; 2008

Philippines. Royal Swedish Academy of Sciences. 2008;**37**(4):292-294

tion program (1991-1995). Philippine Journal of Pediatrics. 1996;**45**(4):228-232

Bolinao, Pangasinan. Manila, Philippines: University of St. Tomas; 1994

1991;**7**(4):543-546

*aegypti* larvae. Acta Manilana. 1991;**39**:25-29

Makati Medical Center Proceedings. 1993;**7**:45-50

University of the Philippines Manila; 1999

10.3860/eacrb.v8i1.1441


[41] Padla EP. Antibacterial, Antifungal and Larvicidal Properties of Selected Seaweeds in Bolinao, Pangasinan. Manila, Philippines: University of St. Tomas; 1994

[29] Basio RG. The mosquito control program at the Manila International Airport and vicinity (Philippines) with comments on problems encountered on the aerial transportation of mosquitoes. In: Chan YC, Chan KL, Ho BC, editors. Vector Control in South East Asia. Singapore: SEAMEO-TROPMED and Ministry of Health and University of Singapore.

[30] Basio RG, Azurin JC, Corcega AV, Madriaga ME. On Philippine mosquitoes XIII—An inland survey of the distribution and relative prevalence of *Aedes aegypti* (Diptera: Culicidae) with reference to mosquito-borne hemorrhagic fever. Phillipine Journal of

[31] Salazar NP, Esguerra R, Catangui F, Valeza F. Studies on dengue haemorrhagic fever in the Philippines ii. Entomological aspects. In: Proceedings of the 10th International Congress on Tropical Medicine and Malaria (ICTMM 1980); Manila, Philippines; 1980.

[32] Salazar NP. Malaria and dengue hemorrhagic fever in the Philippines: Entomological aspects. UP College of Public Health Alumni Society Journal. 1984;**2**(1):15-17

[33] Cruz GB. A Study on the Effectiveness of Community-Based Health Program in *Aedes* 

[34] Jueco NL,Monzon RB, de Leon W.Bioassay of *Bacillus thuringiensis* Israelensis serotype H-14 against Philippine strains of *Aedes aegypti*, *Anopheles litoralis* and *Culex quinquefas-*

[35] Padua LE, Gabriel BP, Aizawa K, Ohba M. *Bacillus thuringiensis* isolated in the Philippines.

[36] Padua LE, Ohba M, Aizawa K. Isolation of a *Bacillus thuringiensis* (serotype 8a: 8b) highly and selectively toxic against mosquito larvae. Journal of Invertebrate Pathology.

[37] Padua LE. Constraints on the use of *Bacillus thuringiensis* in the Philippines. In: Proceedings of International Workshop on the Biopesticide *Bacillus thuringiensis* and its Applications in Developing Countries; 4-6 November 1991; Cairo, Egypt. Qualiub,

[38] delas Llagas LA, Rigor EM, Reyes VC, Co BG. Strategies for control of Japanese encephalitis mosquito vectors in the Philippines rice fields. The Southeast Asian Journal of

[39] Santiago I, Mailed P, Jamir C, Jamora L. The insecticidal effect of tubli (*Derris* sp.) root

[40] Tangga-an HLA, Tulachan D, Stucki KC, Te MLT, Soco RT, et al. The larvicidal effect of guyabano (*Annona muricata*) leaf extract on *Aedes aegypti* mosquito. Cebu Doctors'

crude extract on *Aedes* mosquito larvae. SWU Research Digest. 1999;**6**:18-26

*aegypti* Control. Manila: Institute of Public Health; 1982

Cairo: Al-Ahram Commercial Press; 1993. pp. 179-188

Tropical Medicine and Public Health. 1989;**20**(4):629-633

*ciatus*. Acta Medica Philippine 1984;**20**(3):94-98

Philippine Entomologists. 1982;**5**:199-208

College Proceedings. 1999;**15**(1):137

1973. pp. 78-84

70 Public Health - Emerging and Re-emerging Issues

pp. 32-33

1984;**44**:12-17

Public Health. 1974;**19**:34-46


[55] Bertuso AG, Delas Llagas LA, Mistica MS, Samaniego JB. Ecology of mosquito vectors of Japanese encephalitis in Malawak, Bustos, Bulacan (Philippines) with special reference to their aquatic habitat (2006). Philippine Entomologist. 2006;**20**(1):43-55

**Section 2**

**Policies, Plans and Programs**


**Policies, Plans and Programs**

[55] Bertuso AG, Delas Llagas LA, Mistica MS, Samaniego JB. Ecology of mosquito vectors of Japanese encephalitis in Malawak, Bustos, Bulacan (Philippines) with special reference

[56] Buczak AL, Baugher B, Babin SM, Ramac-Thomas LC, Guven E, et al. Prediction of high incidence of dengue in the Philippines. PLoS Neglected Tropical Diseases. 2014;**8**(4):

[57] Miksch F, Pichler P, Espinosa KJP, Casera KS, Navarro A, et al. An agent-based epidemic model for dengue simulation in the Philippines. In: Proceedings of the 2015 Winter Simulation Conference (WSC '15); 06-09 December 2015: Huntington Beach, California.

[58] Duncombe J, Clements A, Hu W, Weinstein P, Ritchie S, Espino F. Review: Geographical information systems for dengue surveillance. The American Journal of Tropical Medicine

[59] Contreras J, Fernando F, Alocilja E, Salazar F, Bacay B. Fabrication of a nanoparticlebased sensor for the detection of dengue virus-3 in *Aedes aegypti*. International Journal of

[60] Cruz F, Latina M, Chung W. CMOS RC oscillator using 0.35 micron for portable mosquitorepel circuit. In: Proceedings of TENCON 2015-2015 IEEE Region 10 Conference; 01-04

[61] Del Rosario A. Studies on the biology of Philippine mosquitoes, I—Some bionomic fea-

[63] Aguila A. Life History and Blood Feeding Activity of a Philippine Population of *Aedes albopictus* Skuse (Diptera: Culicidae) under Laboratory Conditions. Los Baños,

[64] Sendaydiego MA, Torres J, Demayo CG. Wing geometry of *Aedes aegypti* using landmarkbased geometric morphometrics. International Journal of Bioscience, Biochemistry and

[65] Alcantara EP. *In silico* identification of potential inhibitors of dengue mosquito, *Aedes aegypti* chorion peroxidase. Journal of Computational Biology and Bioinformatics. 2014;

[66] TownsonI H, NathanII MB, Zaim M, Guillet P, Manga L, et al. Exploiting the potential of vector control for disease prevention. Bulletin of the World Health Organization.

[67] Department of Health. Workshop Documentation on the Development of Dengue Vector Surveillance (DVS) Plan Phase 1; 27-29 May 2014; Rizal, Philippines. Manila: National

Dengue Prevention and Control Program-Department of Health; 2014

November 2015; Macao, China. Singapore: IEEE Asia Pacific Limited; 2015

tures of *Aedes aegypti*. Philippine Journal of Science. 1961;**90**(3):361-370 [62] Schoenig E. Strain variation in *Aedes aegypti*. Philippine Scientists. 1968:29-39

and Hygiene. 2012;**86**(5):753-755. DOI: 10.4269/ajtmh.2012.11-0650

Sciences: Basic and Applied Research. 2016;**26**(3):138-157

Philippines: University of the Philippines Los Baños; 2012

Bioinformatics. 2013;**3**(4)

**2**(3):38-42

2005;**83**(12):942-947

to their aquatic habitat (2006). Philippine Entomologist. 2006;**20**(1):43-55

e2771. DOI: 10.1371/journal.pntd.0002771

72 Public Health - Emerging and Re-emerging Issues

New Jersey: IEEE; 2015. pp. 3202-3203

**Chapter 4**

**Provisional chapter**

**Mixed Methods Studies in Health Promotion: A Case-**

**Mixed Methods Studies in Health Promotion: A Case-**

DOI: 10.5772/intechopen.76711

**Study Based on the Life Situations of Young People of**

**Study Based on the Life Situations of Young People of** 

Mixed Methods Studies, which combine qualitative and quantitative research methods, are widely used across disciplines. However, in health promotion, quantitative methods dominate in most cases and qualitative methods are considered as an 'add on'. By means of a Mixed Methods Study about the living situation of young people from refugee backgrounds, aged between 11 and 21 years, in an administrative district in Germany, in which quantitative and qualitative research methods are considered coequal, the issue of Mixed Methods Studies potential in health promotion is discussed. In this study, the perspectives of the young people from refugee backgrounds, their social workers from youth welfare office and local providers have been gathered. The young people from refugee backgrounds and their social workers have been consulted with a qualitative interview, whereas the local providers have been consulted in a standardised manner. The combination of qualitative and quantitative research methods to analyse the living situation of young people from refugee backgrounds gives a holistic and comprehensive insight in social, cultural and structural frame conditions, social policy's challenges as well as individual requirements. Such Mixed Methods Studies prove suitable for health-related research, especially when it comes to quickly changing structural conditions, a difficultly accessible target group

**Keywords:** mixed methods study, young people from refugee backgrounds, qualitative

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

**Refugee Backgrounds in Germany**

**Refugee Backgrounds in Germany**

Marlen Niederberger and Meike Keller

Marlen Niederberger and Meike Keller

http://dx.doi.org/10.5772/intechopen.76711

and highly personal issues.

methods, quantitative methods, health promotion

**Abstract**

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

#### **Mixed Methods Studies in Health Promotion: A Case-Study Based on the Life Situations of Young People of Refugee Backgrounds in Germany Mixed Methods Studies in Health Promotion: A Case-Study Based on the Life Situations of Young People of Refugee Backgrounds in Germany**

DOI: 10.5772/intechopen.76711

Marlen Niederberger and Meike Keller Marlen Niederberger and Meike Keller

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76711

#### **Abstract**

Mixed Methods Studies, which combine qualitative and quantitative research methods, are widely used across disciplines. However, in health promotion, quantitative methods dominate in most cases and qualitative methods are considered as an 'add on'. By means of a Mixed Methods Study about the living situation of young people from refugee backgrounds, aged between 11 and 21 years, in an administrative district in Germany, in which quantitative and qualitative research methods are considered coequal, the issue of Mixed Methods Studies potential in health promotion is discussed. In this study, the perspectives of the young people from refugee backgrounds, their social workers from youth welfare office and local providers have been gathered. The young people from refugee backgrounds and their social workers have been consulted with a qualitative interview, whereas the local providers have been consulted in a standardised manner. The combination of qualitative and quantitative research methods to analyse the living situation of young people from refugee backgrounds gives a holistic and comprehensive insight in social, cultural and structural frame conditions, social policy's challenges as well as individual requirements. Such Mixed Methods Studies prove suitable for health-related research, especially when it comes to quickly changing structural conditions, a difficultly accessible target group and highly personal issues.

**Keywords:** mixed methods study, young people from refugee backgrounds, qualitative methods, quantitative methods, health promotion

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **1. Introduction**

Mixed Methods Studies—which combine qualitative and quantitative research methods—are now being utilised in many different disciplines [1, 6, 8, 18, 21, 26]. Standardised surveys are used in many cases, and qualitative interviews are then added as preliminary studies or for more in-depth research [40, 41]. The epistemological potential of Mixed Method Studies in which qualitative and quantitative research methods are combined with equal weighting is hardly ever considered or taken into account [25].

However, the fact that both qualitative and quantitative methods have their strengths yet also characteristic 'blind spots' is undisputed. These blind spots include, for example, replicability in the case of qualitative methods and the analysis of rarer or more extreme research groups in the case of quantitative methods. In order to also utilise the relevant strengths of quantitative and qualitative research methods and minimise any possible weaknesses, the use of so-called Mixed Methods Studies has become increasingly established over the last

Mixed Methods Studies in Health Promotion: A Case-Study Based on the Life Situations…

http://dx.doi.org/10.5772/intechopen.76711

77

Mixed Methods Studies are now a standard feature of empirical research [10]. This is demonstrated by various discussions and methodological work in the social sciences and education [11], social work [12] and nursing, rehabilitation and care sciences [1, 4, 13, 14]. In relevant textbooks on these subjects, chapters have been added on Mixed Methods Studies [15, 16] or dedicated textbooks on this subject have been published [17]. Its international relevance is demonstrated by the Journal of Mixed Methods which was published for the first time in 2007, books such as the 'Handbook of mixed methods in social and behavioural research' [18] or the 'Handbook of Multimethod and Mixed Methods Research' [19], as well as the 'Mixed

In general, mixed methods mean combining or integrating qualitative and quantitative

*'Mixed methods research is the type of research in which a researcher or team of researchers combines elements of qualitative and quantitative research approaches […] for the broad purposes of breadth and* 

At a methodological level, there are various different research designs that differ according to their chronological order, the weighting of the qualitative and quantitative elements and the sampling strategies [11]. Three basic designs are typically found in current methodological

• convergent or concurrent design: qualitative and quantitative substudies are carried out, at the same time where relevant, and their results are interpreted in relation to one another.

• exploratory sequential design: a qualitative preliminary study is carried out and evaluated in this case. The results are then used to develop a quantitative study. The methods are

• explanatory sequential design: The central aspect here is the completion and evaluation of a quantitative study, followed by a subsequent qualitative study for the purposes of more in-depth research or to clarify any unexpected findings. The substudies are also combined

A common argument for the use of mixed methods designs is the ability to use the strengths of one method to compensate for the weaknesses of another. Accordingly, the mixed methods

The research is combined at the results level (merging the data).

combined here when applying the methods (building the data).

in this case when applying the methods (explaining the data).

few years [6–9].

research.

**2.1. Definition of mixed methods studies**

Methods Research Association' (MMIRA).

*depth of understanding and corroboration'* [20].

discussions [9, 16, 21, 22] (see **Figure 1**):

This potential for knowledge will be examined in this chapter based on a specific example project. On behalf of the administrative district of Göppingen (Baden-Württemberg, Germany), a Mixed Methods Study was carried out in 2016/2017 into the life situations of young people from refugee backgrounds aged between 11 and 21 years old [5, 37]. This Mixed Methods Study looked into the views of young people from refugee backgrounds, their social workers from the youth welfare office and the providers of programmes and services in the administrative district. Qualitative interviews were used to survey the young people from refugee backgrounds and their social workers. The providers of programmes and services were surveyed using a standardised questionnaire. The combination of qualitative and quantitative research methods provides a holistic and comprehensive insight into the contextual and framework conditions, as well as the socio-political challenges and individual requirements. This study demonstrated that Mixed Methods Studies in which qualitative and quantitative studies are given equal weighting represent a suitable strategy for researching issues dealing with health promotion, especially with respect to sensitive subjects and difficulty to reach target groups.

An overview of the use and dissemination of Mixed Method Studies in health promotion will firstly be provided. An example study on the life situations of young people from refugee backgrounds will then be used to discuss the potential offered by Mixed Methods Studies for health promotion when the qualitative and quantitative methods are given equal weighting.

## **2. Methods in health promotion**

Health promotion utilises a very broad range of methods due to its interdisciplinary nature and the different approaches found in the fields of natural sciences, medicine, social sciences and psychology [6, 9, 18, 21]. The various disciplines each apply their own research methods depending on the research topic, the acquisition of epistemic knowledge and the available resources.

The terms qualitative and quantitative research methods are utilised across all disciplines [1, 4]. They are umbrella terms for a conglomerate of research methods, approaches and analyses. Quantitative research methods can be described as numeric, standardised, deductive and hypothesis testing methods that explain structures and processes from an external perspective [4]. Qualitative research methods can be described as inductive, interpretive and hypothesis generating methods that can be understood and reconstructed from an emic, internal perspective [1–5].

However, the fact that both qualitative and quantitative methods have their strengths yet also characteristic 'blind spots' is undisputed. These blind spots include, for example, replicability in the case of qualitative methods and the analysis of rarer or more extreme research groups in the case of quantitative methods. In order to also utilise the relevant strengths of quantitative and qualitative research methods and minimise any possible weaknesses, the use of so-called Mixed Methods Studies has become increasingly established over the last few years [6–9].

### **2.1. Definition of mixed methods studies**

**1. Introduction**

76 Public Health - Emerging and Re-emerging Issues

hardly ever considered or taken into account [25].

**2. Methods in health promotion**

resources.

perspective [1–5].

Mixed Methods Studies—which combine qualitative and quantitative research methods—are now being utilised in many different disciplines [1, 6, 8, 18, 21, 26]. Standardised surveys are used in many cases, and qualitative interviews are then added as preliminary studies or for more in-depth research [40, 41]. The epistemological potential of Mixed Method Studies in which qualitative and quantitative research methods are combined with equal weighting is

This potential for knowledge will be examined in this chapter based on a specific example project. On behalf of the administrative district of Göppingen (Baden-Württemberg, Germany), a Mixed Methods Study was carried out in 2016/2017 into the life situations of young people from refugee backgrounds aged between 11 and 21 years old [5, 37]. This Mixed Methods Study looked into the views of young people from refugee backgrounds, their social workers from the youth welfare office and the providers of programmes and services in the administrative district. Qualitative interviews were used to survey the young people from refugee backgrounds and their social workers. The providers of programmes and services were surveyed using a standardised questionnaire. The combination of qualitative and quantitative research methods provides a holistic and comprehensive insight into the contextual and framework conditions, as well as the socio-political challenges and individual requirements. This study demonstrated that Mixed Methods Studies in which qualitative and quantitative studies are given equal weighting represent a suitable strategy for researching issues dealing with health promotion, especially with respect to sensitive subjects and difficulty to reach target groups. An overview of the use and dissemination of Mixed Method Studies in health promotion will firstly be provided. An example study on the life situations of young people from refugee backgrounds will then be used to discuss the potential offered by Mixed Methods Studies for health promotion when the qualitative and quantitative methods are given equal weighting.

Health promotion utilises a very broad range of methods due to its interdisciplinary nature and the different approaches found in the fields of natural sciences, medicine, social sciences and psychology [6, 9, 18, 21]. The various disciplines each apply their own research methods depending on the research topic, the acquisition of epistemic knowledge and the available

The terms qualitative and quantitative research methods are utilised across all disciplines [1, 4]. They are umbrella terms for a conglomerate of research methods, approaches and analyses. Quantitative research methods can be described as numeric, standardised, deductive and hypothesis testing methods that explain structures and processes from an external perspective [4]. Qualitative research methods can be described as inductive, interpretive and hypothesis generating methods that can be understood and reconstructed from an emic, internal Mixed Methods Studies are now a standard feature of empirical research [10]. This is demonstrated by various discussions and methodological work in the social sciences and education [11], social work [12] and nursing, rehabilitation and care sciences [1, 4, 13, 14]. In relevant textbooks on these subjects, chapters have been added on Mixed Methods Studies [15, 16] or dedicated textbooks on this subject have been published [17]. Its international relevance is demonstrated by the Journal of Mixed Methods which was published for the first time in 2007, books such as the 'Handbook of mixed methods in social and behavioural research' [18] or the 'Handbook of Multimethod and Mixed Methods Research' [19], as well as the 'Mixed Methods Research Association' (MMIRA).

In general, mixed methods mean combining or integrating qualitative and quantitative research.

*'Mixed methods research is the type of research in which a researcher or team of researchers combines elements of qualitative and quantitative research approaches […] for the broad purposes of breadth and depth of understanding and corroboration'* [20].

At a methodological level, there are various different research designs that differ according to their chronological order, the weighting of the qualitative and quantitative elements and the sampling strategies [11]. Three basic designs are typically found in current methodological discussions [9, 16, 21, 22] (see **Figure 1**):


A common argument for the use of mixed methods designs is the ability to use the strengths of one method to compensate for the weaknesses of another. Accordingly, the mixed methods

**2.2. Mixed methods studies in health promotion**

to social, cultural, political and economic relationships.

changing conditions is a strength of Mixed Methods Studies [6].

found in Kelle and Krones [6] and Kelle et al. [1].

Methods Studies [27].

*2.3.1. Background*

The potential for knowledge and insight provided by Mixed Methods Studies offers a diverse range of highly promising opportunities for research work in health promotion [6, 9, 18, 21]. Since the Ottawa Charter was adopted by the World Health Organisation in 1986, health promotion has been viewed as a concept that can be applied when analysing the health resources and potential of an individual, as well as at all social levels. It is a complex social and health policy approach that influences an individual person's life skills and the capacity to take action, empowers people to improve their health and yet also deals with sustainable changes

Mixed Methods Studies in Health Promotion: A Case-Study Based on the Life Situations…

http://dx.doi.org/10.5772/intechopen.76711

79

Health promotion thus stands, on the one hand, for subject-related guidance focussing on, among other things, subjective perceptions, individual behaviour and personal skills, while on the other hand, it deals with social, political or economic relationships that provide the framework for a health-promoting lifestyle and are explicitly explained using the settingsbased approach. For a holistic, empirical analysis in the context of health promotion, it is thus important to focus on all levels (micro, meso and macro). Health promotion is also subject to constant change. Changes to ordinances and laws (e.g. the German Prevention Act in 2016), technical innovations (e.g. health apps, prosthetic devices), trends in nutrition and consumption (e.g. vegan diets) or also new target groups (such as, e.g. more than 1 million refugees that came to Germany in 2015 [23]) alter the framework conditions and efficiency levels of health promotion interventions. Gathering knowledge about these causal and sometimes

Mixed Methods Studies have been increasingly utilised in health promotion over the last few years [40, 41]. In the process, experimental designs have often been used [26]. Studies have been carried out using standardised questionnaires, diagnostic tests or instrument-based methods, always acknowledging the primacy of evidence-based practices [24]. In the context of this research, qualitative studies were mainly used in the form of preliminary studies or for more in-depth research into unexpected effects [25, 26]. The potential and possibilities offered by qualitative research methods were often not fully exploited in these Mixed

The following section presents a Mixed Methods Study about the life situations and wellbeing of young people from refugee backgrounds and the potential offered by Mixed Methods Studies in which the qualitative and quantitative methods are given equal weighting will then be discussed based on this example. Other examples to illustrate this type of research can be

Germany experienced an enormous increase in immigration due to asylum seekers in 2015. During this phase that was described as the 'refugee crisis', more than 1 million refugees and

**2.3. A mixed methods study on young people from refugee backgrounds**

**Figure 1.** Mixed-methods-basis-designs (based on [9] explanation: QUAN = quantitative component, QUAL = qualitative component, components represent the qualitative or quantitative component, depending on their sequence in the research design.

design developed by Udo Kelle has become the established model in Germany. He emphasises that the methodological weaknesses of one method can be compensated for through a combination of two or more methods [11]. In a similar way, other authors postulate, for example, that it is possible to use mixed methods to gain a better understanding of the research issue [13]. Creswell [22] summarises the research potential of combining qualitative and quantitative methods as follows:


However, it is also emphasised that Mixed Methods Studies do not represent a new gold standard but rather ONE alternative from all possible empirical approaches [12]. The role that Mixed Methods Studies play in health promotion is described in the following section.

## **2.2. Mixed methods studies in health promotion**

The potential for knowledge and insight provided by Mixed Methods Studies offers a diverse range of highly promising opportunities for research work in health promotion [6, 9, 18, 21]. Since the Ottawa Charter was adopted by the World Health Organisation in 1986, health promotion has been viewed as a concept that can be applied when analysing the health resources and potential of an individual, as well as at all social levels. It is a complex social and health policy approach that influences an individual person's life skills and the capacity to take action, empowers people to improve their health and yet also deals with sustainable changes to social, cultural, political and economic relationships.

Health promotion thus stands, on the one hand, for subject-related guidance focussing on, among other things, subjective perceptions, individual behaviour and personal skills, while on the other hand, it deals with social, political or economic relationships that provide the framework for a health-promoting lifestyle and are explicitly explained using the settingsbased approach. For a holistic, empirical analysis in the context of health promotion, it is thus important to focus on all levels (micro, meso and macro). Health promotion is also subject to constant change. Changes to ordinances and laws (e.g. the German Prevention Act in 2016), technical innovations (e.g. health apps, prosthetic devices), trends in nutrition and consumption (e.g. vegan diets) or also new target groups (such as, e.g. more than 1 million refugees that came to Germany in 2015 [23]) alter the framework conditions and efficiency levels of health promotion interventions. Gathering knowledge about these causal and sometimes changing conditions is a strength of Mixed Methods Studies [6].

Mixed Methods Studies have been increasingly utilised in health promotion over the last few years [40, 41]. In the process, experimental designs have often been used [26]. Studies have been carried out using standardised questionnaires, diagnostic tests or instrument-based methods, always acknowledging the primacy of evidence-based practices [24]. In the context of this research, qualitative studies were mainly used in the form of preliminary studies or for more in-depth research into unexpected effects [25, 26]. The potential and possibilities offered by qualitative research methods were often not fully exploited in these Mixed Methods Studies [27].

The following section presents a Mixed Methods Study about the life situations and wellbeing of young people from refugee backgrounds and the potential offered by Mixed Methods Studies in which the qualitative and quantitative methods are given equal weighting will then be discussed based on this example. Other examples to illustrate this type of research can be found in Kelle and Krones [6] and Kelle et al. [1].

### **2.3. A mixed methods study on young people from refugee backgrounds**

#### *2.3.1. Background*

design developed by Udo Kelle has become the established model in Germany. He emphasises that the methodological weaknesses of one method can be compensated for through a combination of two or more methods [11]. In a similar way, other authors postulate, for example, that it is possible to use mixed methods to gain a better understanding of the research issue [13]. Creswell [22] summarises the research potential of combining qualitative and quantita-

**Figure 1.** Mixed-methods-basis-designs (based on [9] explanation: QUAN = quantitative component, QUAL = qualitative component, components represent the qualitative or quantitative component, depending on their sequence in the

• obtain a more comprehensive view and more data about the problem than a single

• conduct preliminary exploration with individuals to make sure that interventions fit the

• add qualitative data to experimental trials by identifying participants to recruit and inter-

However, it is also emphasised that Mixed Methods Studies do not represent a new gold standard but rather ONE alternative from all possible empirical approaches [12]. The role that Mixed Methods Studies play in health promotion is described in the following section.

ventions to use and carrying out follow-up to further explain the outcomes.

tive methods as follows:

perspective;

research design.

• obtain two different perspectives;

78 Public Health - Emerging and Re-emerging Issues

participants and the site being studied;

• add to instrument data details about the setting and context;

Germany experienced an enormous increase in immigration due to asylum seekers in 2015. During this phase that was described as the 'refugee crisis', more than 1 million refugees and migrants travelled to Germany [23]. Germany is now faced with the political and social challenge of providing for and integrating these people from refugee backgrounds.

*2.3.2. Methodological challenges*

follows:

[33].

(e.g. leisure activities).

The central objective of this study was primarily to place the focus on the views of the young people from refugee backgrounds and gather information on their subjective points of view. Yet, this posed a challenge from a methodological perspective. Important reasons were as

Mixed Methods Studies in Health Promotion: A Case-Study Based on the Life Situations…

http://dx.doi.org/10.5772/intechopen.76711

81

**1. The young people spoke no or very little German at the time of the survey**: The target group for the study were young people from the 'refugee crisis' in 2015 shortly after their arrival in Germany or their host municipality. As these people had only lived in Germany

**2. The asylum procedures were still ongoing at the time of the study**, which meant that the young people were uncertain about whether they could remain in Germany and possibly felt a certain dependency on the German system. Other empirical studies have confirmed that, in view of the refugee's precarious life experiences during asylum that are controlled by outside forces, researchers tend to be perceived as powerful and presumably influential people by refugees [32]. People from refugee backgrounds are afraid that everything they say could have a potentially negative impact on the outcome of the asylum proceedings [32]. This highlights the ethical responsibility of the researchers to clearly explain the academic goals of the study, maintain academic and ethical standards and, where relevant,

**3. The young people's experiences in fleeing their native countries demonstrated, on the one hand, their resilience and survival skills yet, on the other hand, opened up the risk of traumatic experiences.** Addressing these possibly traumatic experiences cannot be the task of a researcher but it nevertheless needs to be taken into account in the design and implementation of a survey. The interviewers were usually asked in the qualitative interviews to show a respectful level of interest when traumatic experiences were mentioned and, if relevant, to sensitively ask about them but not to probe the interviewees further

**4. The young people from refugee backgrounds had only lived in the administrative district of Göppingen for a few months at the time of the survey.** Therefore, it was unclear how familiar they were with the administrative district or, for example, whether they were at all aware of any corresponding programmes or services for their specific target group

**5. The young people presumably have little or no experience with academia and research.** The basic prerequisite for an insightful interview is the trust of the interviewee [34, 35]. When dealing with interviewees of a young age, their friends were allowed to be present for this reason. Others recommend participatory observation in advance for the purpose of getting to know each other and building up trust [34, 35]. This option was not possible within the framework of this study (also for reasons of limited resources). Therefore, it was unclear to what extent the young refugees would be willing to provide a previously

unknown researcher with insights into their everyday lives during the interview.

for a short period of time, linguistic restrictions were a priori assumed.

not to fuel any false hope about the outcome of the asylum process.

A particularly vulnerable target group in this context is young people and minors (in some cases unaccompanied) from refugee backgrounds. More than 300,000 children and young people [28] travelled to Germany from abroad in 2015, of which around 45,000 were unaccompanied [29]. A larger number of the unaccompanied minors who travelled to Germany were male [30]. The majority of the minors were 16 or 17 years old when they entered the country. The main countries of origin were Afghanistan, Syria, Iraq, Eritrea and Somalia. Other countries of origin were Morocco, Iran, Gambia, Guinea, Pakistan and Bangladesh [31].

Young people from refugee backgrounds are an important target group for academic research and society. Research into their life situations, well-being and needs is an important basis for successful and sustainable integration. A comprehensive empirical analysis thus needs to take into account relationships at a meso- and macro-level, as well as the subject-based perspective at a micro-level. In this context, Mixed Methods Studies, where qualitative and quantitative research methods are given equal weighting, offer great potential for multifaceted and in-depth analysis.

This type of Mixed Methods Study was carried out in the administrative district of Göppingen (Baden-Württemberg, Germany) in 2016/2017 (see **Figure 2**). The background to this study was a youth welfare planning process for young people from refugee backgrounds between the ages of 11 and 21 years old. The central research questions were as follows:


**Figure 2.** Mixed methods study about the life situations of young people from refugee backgrounds [5].

#### *2.3.2. Methodological challenges*

migrants travelled to Germany [23]. Germany is now faced with the political and social chal-

A particularly vulnerable target group in this context is young people and minors (in some cases unaccompanied) from refugee backgrounds. More than 300,000 children and young people [28] travelled to Germany from abroad in 2015, of which around 45,000 were unaccompanied [29]. A larger number of the unaccompanied minors who travelled to Germany were male [30]. The majority of the minors were 16 or 17 years old when they entered the country. The main countries of origin were Afghanistan, Syria, Iraq, Eritrea and Somalia. Other coun-

Young people from refugee backgrounds are an important target group for academic research and society. Research into their life situations, well-being and needs is an important basis for successful and sustainable integration. A comprehensive empirical analysis thus needs to take into account relationships at a meso- and macro-level, as well as the subject-based perspective at a micro-level. In this context, Mixed Methods Studies, where qualitative and quantitative research methods are given equal weighting, offer great potential for multifaceted and in-depth analysis. This type of Mixed Methods Study was carried out in the administrative district of Göppingen (Baden-Württemberg, Germany) in 2016/2017 (see **Figure 2**). The background to this study was a youth welfare planning process for young people from refugee backgrounds between

• How do the young people from refugee backgrounds living in the administrative district

• What are their current life situations and, above all, what do the everyday lives and leisure time of young people from refugee backgrounds in the administrative district of Göppin-

• What do they need in order to feel at home in the administrative district of Göppingen?

**Figure 2.** Mixed methods study about the life situations of young people from refugee backgrounds [5].

lenge of providing for and integrating these people from refugee backgrounds.

tries of origin were Morocco, Iran, Gambia, Guinea, Pakistan and Bangladesh [31].

the ages of 11 and 21 years old. The central research questions were as follows:

of Göppingen feel?

80 Public Health - Emerging and Re-emerging Issues

gen look like?

The central objective of this study was primarily to place the focus on the views of the young people from refugee backgrounds and gather information on their subjective points of view. Yet, this posed a challenge from a methodological perspective. Important reasons were as follows:


These reasons explained the need to use a relatively open survey that promoted as much trust as possible. This is why a qualitative tool was used—a guideline-based, problem-centred interview, which enabled a certain level of comparability between the answers due to the use of key questions but also allowed space for reflexivity and the new and unexpected. It was not possible for the interviews to be conducted by multilingual interviewers in this study because it was not possible to find suitable people with the available resources at the time of the interviews. However, volunteer interpreters in the relevant native languages were available for the interviews. The interviews were conducted by Master's students in the field of health promotion, who were specifically selected due to their age and specialist background. They received intensive training in advance to develop their interviewing skills and remained in close contact with the research team and each other. The students documented their experiences in a postscriptum after each interview and discussed them within the group of interviewers. This primarily involved reflecting on their own role in the interview and giving their impression of the openness of the young people and their cooperation with the interpreter.

municipalities/cities, around 18 official asylum working groups, around 20 youth welfare providers and 20 schools with preparatory classes and six vocational colleges (as of October 2016). A total of 67 questionnaires were completed. Twenty-two questionnaires were received from the administrative district/municipalities, 18 from youth welfare providers, 11 from schools or educational institutions and 15 from 'other sources', which mainly comprised volunteer groups.

Mixed Methods Studies in Health Promotion: A Case-Study Based on the Life Situations…

http://dx.doi.org/10.5772/intechopen.76711

83

In order to supplement and consolidate the results of both analyses, **three qualitative guideline-based interviews with social workers from independent youth welfare agencies and the social welfare office** were conducted. Both groups of social workers are intensively involved with young people from refugee backgrounds and thus have a good overview of the current situation. However, the two groups of social workers have very different perspectives about the life situations of young people from refugee backgrounds. The social workers from the social welfare office are responsible for the accompanied young people from refugee backgrounds in community housing and those from the youth welfare office are responsible for the unaccompanied young people from refugee backgrounds who are cared for in children's homes provided by the youth welfare office. In order to ensure the maximum level of comparability, the guidelines and categories used for the analysis were strongly based on the

The study about young people from refugee backgrounds represented an explorative Mixed Methods Study in which the qualitative and quantitative methods were given equal weighting. The goal of the Mixed Methods Study was to gain a comprehensive, holistic and multiperspective insight for the purposes of analysing the life situations of young refugees. The different substudies were carried out in a coordinated but independent way. The two substudies involving the young people from refugee backgrounds and the providers of programmes and services were carried out in parallel, while the survey of the social workers was completed afterwards. The guidelines for the survey of the social workers were based on the findings of the previous studies. This meant there was a 'mixing' process on two levels: in the application methods because the guidelines for the survey of the social workers utilised the previous findings, and also in the analysis of the results in which the findings from the three surveys were considered in relation to one another and with equal weighting. Similarities, additions and differences were then identified with the aid of summary tables, the so-called joint displays (see **Figure 1** [37]).

The in-depth results of this study on young people from refugee backgrounds cannot be presented here in detail (further information can be found in [37]). However, it is possible to

• The young people from refugee backgrounds generally feel happy in the administrative

• They want to remain permanently in the administrative district and build a 'normal' life

interviews with the young people from refugee backgrounds.

**2.4. Results of the mixed methods study on young people from refugee** 

summarise the key results of all three substudies in five points:

with their own apartments, jobs and later their own families.

**backgrounds**

district of Göppingen.

Non-linguistic tools were explicitly integrated into the qualitative interviews. The young people brought personal possessions along to the interviews and were asked during them to draw the so-called mind maps comprising important objects or people in their everyday lives. One goal here was to casually ease the interviewee into the conversation. In addition, the objects that were drawn or brought along by the interviewee were used as a contextual anchor for the conversation.

#### *2.3.3. The survey process and random sampling*

A total of 10 **qualitative interviews with young people from refugee backgrounds** were conducted. The interviewees were between 15 and 19 years old; nine of them were male and one was female. They came from various different countries (including Afghanistan, Syria, Iraq and Gambia). Four of the young people lived with their families and other refugees in shared accommodation, while six of them were unaccompanied minors living in accommodation provided by the youth welfare office. All of the interviews were carried out on a voluntary basis, were digitally recorded after obtaining the person's permission and the German sections of the text were transcribed word for word. The interviews were analysed using a qualitative analysis of their content, in which the most important categories were inductively filtered out of the material and then collected together and analysed [36, 37]. In the course of this inductive analysis, the interviews were considered on a case-by-case basis and also in comparison to one another. The categories were primarily designed to reflect the everyday lives and leisure activities of the young people from refugee backgrounds.

In parallel to the interviews of the young people from refugee backgrounds, a **standardised online questionnaire of the providers of programmes and services in the administrative district** of Göppingen was carried out. The objective was to take stock of the existing and planned programmes and services for the target group of young people from refugee backgrounds aged between 11 and 21 years old. This enabled the framework conditions, that is, the structural and local conditions, to be systematically recorded. There are more than 100 providers of programmes and services in the administrative district of Göppingen, of which there are 38 municipalities/cities, around 18 official asylum working groups, around 20 youth welfare providers and 20 schools with preparatory classes and six vocational colleges (as of October 2016). A total of 67 questionnaires were completed. Twenty-two questionnaires were received from the administrative district/municipalities, 18 from youth welfare providers, 11 from schools or educational institutions and 15 from 'other sources', which mainly comprised volunteer groups.

These reasons explained the need to use a relatively open survey that promoted as much trust as possible. This is why a qualitative tool was used—a guideline-based, problem-centred interview, which enabled a certain level of comparability between the answers due to the use of key questions but also allowed space for reflexivity and the new and unexpected. It was not possible for the interviews to be conducted by multilingual interviewers in this study because it was not possible to find suitable people with the available resources at the time of the interviews. However, volunteer interpreters in the relevant native languages were available for the interviews. The interviews were conducted by Master's students in the field of health promotion, who were specifically selected due to their age and specialist background. They received intensive training in advance to develop their interviewing skills and remained in close contact with the research team and each other. The students documented their experiences in a postscriptum after each interview and discussed them within the group of interviewers. This primarily involved reflecting on their own role in the interview and giving their impression of

Non-linguistic tools were explicitly integrated into the qualitative interviews. The young people brought personal possessions along to the interviews and were asked during them to draw the so-called mind maps comprising important objects or people in their everyday lives. One goal here was to casually ease the interviewee into the conversation. In addition, the objects that were drawn or brought along by the interviewee were used as a contextual

A total of 10 **qualitative interviews with young people from refugee backgrounds** were conducted. The interviewees were between 15 and 19 years old; nine of them were male and one was female. They came from various different countries (including Afghanistan, Syria, Iraq and Gambia). Four of the young people lived with their families and other refugees in shared accommodation, while six of them were unaccompanied minors living in accommodation provided by the youth welfare office. All of the interviews were carried out on a voluntary basis, were digitally recorded after obtaining the person's permission and the German sections of the text were transcribed word for word. The interviews were analysed using a qualitative analysis of their content, in which the most important categories were inductively filtered out of the material and then collected together and analysed [36, 37]. In the course of this inductive analysis, the interviews were considered on a case-by-case basis and also in comparison to one another. The categories were primarily designed to reflect the everyday

In parallel to the interviews of the young people from refugee backgrounds, a **standardised online questionnaire of the providers of programmes and services in the administrative district** of Göppingen was carried out. The objective was to take stock of the existing and planned programmes and services for the target group of young people from refugee backgrounds aged between 11 and 21 years old. This enabled the framework conditions, that is, the structural and local conditions, to be systematically recorded. There are more than 100 providers of programmes and services in the administrative district of Göppingen, of which there are 38

the openness of the young people and their cooperation with the interpreter.

lives and leisure activities of the young people from refugee backgrounds.

anchor for the conversation.

82 Public Health - Emerging and Re-emerging Issues

*2.3.3. The survey process and random sampling*

In order to supplement and consolidate the results of both analyses, **three qualitative guideline-based interviews with social workers from independent youth welfare agencies and the social welfare office** were conducted. Both groups of social workers are intensively involved with young people from refugee backgrounds and thus have a good overview of the current situation. However, the two groups of social workers have very different perspectives about the life situations of young people from refugee backgrounds. The social workers from the social welfare office are responsible for the accompanied young people from refugee backgrounds in community housing and those from the youth welfare office are responsible for the unaccompanied young people from refugee backgrounds who are cared for in children's homes provided by the youth welfare office. In order to ensure the maximum level of comparability, the guidelines and categories used for the analysis were strongly based on the interviews with the young people from refugee backgrounds.

The study about young people from refugee backgrounds represented an explorative Mixed Methods Study in which the qualitative and quantitative methods were given equal weighting. The goal of the Mixed Methods Study was to gain a comprehensive, holistic and multiperspective insight for the purposes of analysing the life situations of young refugees. The different substudies were carried out in a coordinated but independent way. The two substudies involving the young people from refugee backgrounds and the providers of programmes and services were carried out in parallel, while the survey of the social workers was completed afterwards. The guidelines for the survey of the social workers were based on the findings of the previous studies. This meant there was a 'mixing' process on two levels: in the application methods because the guidelines for the survey of the social workers utilised the previous findings, and also in the analysis of the results in which the findings from the three surveys were considered in relation to one another and with equal weighting. Similarities, additions and differences were then identified with the aid of summary tables, the so-called joint displays (see **Figure 1** [37]).

## **2.4. Results of the mixed methods study on young people from refugee backgrounds**

The in-depth results of this study on young people from refugee backgrounds cannot be presented here in detail (further information can be found in [37]). However, it is possible to summarise the key results of all three substudies in five points:


• In order to guarantee the permanent integration of the young people from refugee backgrounds, it is necessary to make (further) adjustments to the framework conditions. The providers of programmes and services require, among other things, money, rooms, employees with the necessary intercultural skills and volunteer support to offer broad and low-threshold programmes and services.

not been aware of some of these illnesses in the past. This is particularly true of symptoms

Mixed Methods Studies in Health Promotion: A Case-Study Based on the Life Situations…

http://dx.doi.org/10.5772/intechopen.76711

85

**3.** The social workers believe that the young people are better housed in the countryside because the social structures, particularly the leisure activities, are better developed and it is thus easier for the young people to come into contact with the local population. However, the young people would prefer to live in the city where there is something to do, the distances are short, there are places with free Wi-Fi and there tend to be spaces to retreat and

In conclusion, the multiperspective analysis of the everyday lives and leisure activities of young people from refugee backgrounds delivered results that support and supplement one another. The identification of possible areas of tension during the planning and implementation of interventions and programmes/services for young people from refugee backgrounds appears to be particularly important so that they are met with an appropriate level of accep-

Mixed Methods Studies in which qualitative and quantitative methods have equal weighting offer great potential for health promotion. The prerequisite is that the choice of qualitative and quantitative research methods is appropriate to the subject matter, case-specific and based on epistemological principles. This does not 'only' mean qualitative preliminary studies in the form of standardised questionnaires. Even if the relevance of this design, especially for the development of questionnaires, is not disputed, it does not do justice to the possible insights that could be gained from Mixed Methods Studies in health promotion with a larger weighting toward qualitative studies. This potential exists at the following levels (also see

**1. For a holistic, comprehensive and multifaceted empirical analysis:** Mixed Methods Studies enable a holistic settings analysis by integrating micro-, meso- and macro-levels. At a meso- and macro-level, it is standardised processes above all that offer great potential because they take into account political regulations, structural conditions or demographic processes. The qualitative studies enable an analysis at a micro-level due to their greater

**2. Analysing marginalised target groups who are difficult to reach linguistically:** Health promotion often deals with marginalised and/or difficult to reach target groups, such as children and young people but also people with certain illnesses or disabilities. Studying these target groups is often a challenge because this research requires a certain level of mutual trust, and purely linguistic-based studies quickly reveal their limitations. Greater

**3. To find out why interventions have a different effect than anticipated:** For example, the frequency of use and motivation of the participants can be studied quantitatively but qualitative

weighting could be given to qualitative processes in these cases.

tance and willingness to implement them from all stakeholders involved.

**2.5. Gaining knowledge and insights from mixed methods studies in health** 

related to colds and flu, such as sniffles or coughing.

learn (such as the city library).

**promotion**

here [5, 6]):

focus on the subject.


Overall, the analysis of the current target-specific programmes and interventions identified the structures and processes at the meso-level of the providers of programmes and services. The evaluations of the interviews with the young people from refugee backgrounds and their social workers demonstrated the need for individual analysis on a case-by-case basis at a macro-level. They clearly demonstrated that a typical young refugee does not exist but rather it is necessary to reflect on individual life histories, relevancies and interpretative models. Specific differences in relation to gender and origin were particularly evident. In particular, accompanied young girls are difficult to reach with offers of potential leisure activities because they are already occupied with household and family duties. Young boys from Afghanistan and Syria appear to be comparatively active according to their social workers, while young boys from central African countries are more passive. The young people themselves often spoke in the interviews about anxiety disorders and concentration problems due to worries about their asylum application being rejected.

From a methodological perspective, the three substudies revealed convergent (=concordant) and complementary (=reciprocal) findings. However, the systematic comparison of the substudies also revealed different areas of tension (see [37]), the resolution of which is not part of the research assignment but rather the responsibility of the administrative district of Göppingen. Three areas of tension are presented here by way of example:


not been aware of some of these illnesses in the past. This is particularly true of symptoms related to colds and flu, such as sniffles or coughing.

• In order to guarantee the permanent integration of the young people from refugee backgrounds, it is necessary to make (further) adjustments to the framework conditions. The providers of programmes and services require, among other things, money, rooms, employees with the necessary intercultural skills and volunteer support to offer broad and

• The young people from refugee backgrounds require 'peaceful retreats', meaning places where they can withdraw and feel safe. These opportunities have not been available to

• In addition, they require young and capable counterparts who can support them on their

Overall, the analysis of the current target-specific programmes and interventions identified the structures and processes at the meso-level of the providers of programmes and services. The evaluations of the interviews with the young people from refugee backgrounds and their social workers demonstrated the need for individual analysis on a case-by-case basis at a macro-level. They clearly demonstrated that a typical young refugee does not exist but rather it is necessary to reflect on individual life histories, relevancies and interpretative models. Specific differences in relation to gender and origin were particularly evident. In particular, accompanied young girls are difficult to reach with offers of potential leisure activities because they are already occupied with household and family duties. Young boys from Afghanistan and Syria appear to be comparatively active according to their social workers, while young boys from central African countries are more passive. The young people themselves often spoke in the interviews about anxiety disorders and concentration problems due to worries

From a methodological perspective, the three substudies revealed convergent (=concordant) and complementary (=reciprocal) findings. However, the systematic comparison of the substudies also revealed different areas of tension (see [37]), the resolution of which is not part of the research assignment but rather the responsibility of the administrative district of

**1.** The standardised questionnaire for the providers of programmes and services demonstrated that a series of target group-specific measures have been delivered since the 'refugee crisis' and the majority of providers are also planning and implementing further measures. Yet, the young people from refugee backgrounds made it very clear in the interviews that they do not want any 'round-the-clock' care. Instead, they are looking for places to retreat

**2.** The interviews with the young people from refugee backgrounds indicated that they visit a doctor relatively frequently. However, the medical reasons and necessities were difficult to comprehend in the interviews. The interviews with the social workers were an additional opportunity for acquiring relevant knowledge in this area. They made it clear that these young people perceive some illnesses, which are considered normal for young people who grow up in Germany, as life-threatening. The reason for this is that they had

Göppingen. Three areas of tension are presented here by way of example:

that offer them the opportunity for calm and self-reflection.

path and who are ideally at a similar phase of life to the refugees themselves.

low-threshold programmes and services.

84 Public Health - Emerging and Re-emerging Issues

them to a sufficient degree up to now.

about their asylum application being rejected.

**3.** The social workers believe that the young people are better housed in the countryside because the social structures, particularly the leisure activities, are better developed and it is thus easier for the young people to come into contact with the local population. However, the young people would prefer to live in the city where there is something to do, the distances are short, there are places with free Wi-Fi and there tend to be spaces to retreat and learn (such as the city library).

In conclusion, the multiperspective analysis of the everyday lives and leisure activities of young people from refugee backgrounds delivered results that support and supplement one another. The identification of possible areas of tension during the planning and implementation of interventions and programmes/services for young people from refugee backgrounds appears to be particularly important so that they are met with an appropriate level of acceptance and willingness to implement them from all stakeholders involved.

## **2.5. Gaining knowledge and insights from mixed methods studies in health promotion**

Mixed Methods Studies in which qualitative and quantitative methods have equal weighting offer great potential for health promotion. The prerequisite is that the choice of qualitative and quantitative research methods is appropriate to the subject matter, case-specific and based on epistemological principles. This does not 'only' mean qualitative preliminary studies in the form of standardised questionnaires. Even if the relevance of this design, especially for the development of questionnaires, is not disputed, it does not do justice to the possible insights that could be gained from Mixed Methods Studies in health promotion with a larger weighting toward qualitative studies. This potential exists at the following levels (also see here [5, 6]):


methods are needed to find out why they are perhaps used in a different way than originally hoped. In addition, a combination of participatory processes can be used to include those affected and other citizens in the development, implementation and evaluation of measures for health promotion.

account the environment of those affected and capture the subjective sense behind actions or decisions. Depending on the survey method used, they also enable the participation of the target group and take into account a holistic settings-based approach in which a bottom-up-

Mixed Methods Studies in Health Promotion: A Case-Study Based on the Life Situations…

http://dx.doi.org/10.5772/intechopen.76711

87

Mixed Methods Studies with a priori equal weighting of qualitative and quantitative research methods offer great potential not only for status and needs assessments but also for intervention and evaluation studies in health promotion. The associated multiperspective analysis enables the subject-oriented development of interventions that take into account contextual and framework conditions, social and technical innovations, and individual causal attributions. Therefore, the results of the Mixed Methods Study about the living situation of young people from refugee backgrounds can be used to develop and distinguish interventions for health promoting and integration. In addition, these types of studies allow for the participation of difficult to reach or marginalised target groups, such as refugees, people with disabilities and sick people. This makes the implementation of effective and more sustainable

M. Niederberger and M. Keller declare that no conflicts of interest exist. All interviews were completed voluntary, made anonymous and the interviewees were informed about the further use of the data for academic research. The study was carried out in accordance with the

[1] Kelle U, Metje B, Newerla A. Methodentriangulation und Mixed-Methods in der Pflegeund Versorgungsforschung – konzeptuelle Überlegungen und empirische Erfahrungen.

[2] Knoblauch H: Qualitative Forschung am Scheideweg. Jüngere Entwicklungen der interpretativen Sozialforschung. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research. 2013;**14**(1):30 Absätze. Art 12. Available from: http://nbn-resolving.de/

Pflege und Gesellschaft: Zeitschrift für Pflegewissenschaft. 2014;**19**(4):317-329

or top-down-oriented process is possible.

interventions more likely.

**Conflict of interest**

principles of ethical research.

Marlen Niederberger\* and Meike Keller

urn:nbn:de:0114-fqs1303128

\*Address all correspondence to: marlen.niederberger@ph-gmuend.de

University of Education Schwäbisch Gmünd, Germany

**Author details**

**References**


In general, this potential also exists in all areas of health promotion, for both status and need assessments and also for intervention and evaluation studies. This is because the effectiveness of health-promoting interventions is always also dependent on social and cultural aspects. These factors are associated with, for example, questions about the accessibility of the target groups or the lasting effects on attitudes, motivation and behaviour. In addition, purely satisfaction-based surveys using standardised questionnaires often paint a too positive picture because those surveyed tend to give socially desirable answers [1].

Mixed Methods Studies can generally call on the whole repertoire of qualitative and quantitative methods. Previous experience demonstrates that, in the case of marginalised groups in particular, the integration of qualitative observation methods is sensible because it allows for initial contact between the researcher and the research subjects [1]. In addition, participatory processes such as photovoice or community mapping appear very promising because they enable collective reflection processes in everyday life and the world of work to be studied [38]. Focus groups—an example of a qualitative group process—enable the social environment to be analysed by integrating representatives from the relevant groups [39].

## **3. Conclusions**

Mixed Methods Studies in which qualitative and quantitative research methods are combined with equal weighting have proved themselves to be a suitable research strategy especially for subject-oriented, environment-based health promotion but also for specific settings-based questions. In the study about the living situation of young people from refugee background, the qualitative interviews enable the subjective perspective, and the standardised online questionnaire of the providers of programmes and services shows the institutional and structural conditions for a living in Göppingen. Mixed Methods Studies enable a holistic and multifaceted empirical understanding, can be used to explain the causes of certain actions, take into account the environment of those affected and capture the subjective sense behind actions or decisions. Depending on the survey method used, they also enable the participation of the target group and take into account a holistic settings-based approach in which a bottom-upor top-down-oriented process is possible.

Mixed Methods Studies with a priori equal weighting of qualitative and quantitative research methods offer great potential not only for status and needs assessments but also for intervention and evaluation studies in health promotion. The associated multiperspective analysis enables the subject-oriented development of interventions that take into account contextual and framework conditions, social and technical innovations, and individual causal attributions. Therefore, the results of the Mixed Methods Study about the living situation of young people from refugee backgrounds can be used to develop and distinguish interventions for health promoting and integration. In addition, these types of studies allow for the participation of difficult to reach or marginalised target groups, such as refugees, people with disabilities and sick people. This makes the implementation of effective and more sustainable interventions more likely.

## **Conflict of interest**

methods are needed to find out why they are perhaps used in a different way than originally hoped. In addition, a combination of participatory processes can be used to include those affected and other citizens in the development, implementation and evaluation of

**4. To identify complex and changing causal conditions:** Complex causal conditions can be studied using quantitative experimental settings. However, these processes reveal their limitations when structures change, new target groups appear or social change occurs. Qualitative methods offer great potential in this area because they are more open and place

**5. To analyse sensitive and personal subjects:** Especially in the health sector, the focus is often placed on intimate and personal issues, which generates problems related to social or cultural desirability when studied using standardised questionnaires. Qualitative interviews and group discussions (e.g. focus groups) which bring together social groups or

In general, this potential also exists in all areas of health promotion, for both status and need assessments and also for intervention and evaluation studies. This is because the effectiveness of health-promoting interventions is always also dependent on social and cultural aspects. These factors are associated with, for example, questions about the accessibility of the target groups or the lasting effects on attitudes, motivation and behaviour. In addition, purely satisfaction-based surveys using standardised questionnaires often paint a too positive picture

Mixed Methods Studies can generally call on the whole repertoire of qualitative and quantitative methods. Previous experience demonstrates that, in the case of marginalised groups in particular, the integration of qualitative observation methods is sensible because it allows for initial contact between the researcher and the research subjects [1]. In addition, participatory processes such as photovoice or community mapping appear very promising because they enable collective reflection processes in everyday life and the world of work to be studied [38]. Focus groups—an example of a qualitative group process—enable the social environment to

Mixed Methods Studies in which qualitative and quantitative research methods are combined with equal weighting have proved themselves to be a suitable research strategy especially for subject-oriented, environment-based health promotion but also for specific settings-based questions. In the study about the living situation of young people from refugee background, the qualitative interviews enable the subjective perspective, and the standardised online questionnaire of the providers of programmes and services shows the institutional and structural conditions for a living in Göppingen. Mixed Methods Studies enable a holistic and multifaceted empirical understanding, can be used to explain the causes of certain actions, take into

persons from similar backgrounds can provide support in this area.

because those surveyed tend to give socially desirable answers [1].

be analysed by integrating representatives from the relevant groups [39].

measures for health promotion.

86 Public Health - Emerging and Re-emerging Issues

a greater focus on the subject.

**3. Conclusions**

M. Niederberger and M. Keller declare that no conflicts of interest exist. All interviews were completed voluntary, made anonymous and the interviewees were informed about the further use of the data for academic research. The study was carried out in accordance with the principles of ethical research.

## **Author details**

Marlen Niederberger\* and Meike Keller

\*Address all correspondence to: marlen.niederberger@ph-gmuend.de

University of Education Schwäbisch Gmünd, Germany

## **References**


[3] Pike KL. Language in Relation to a Unified Theory of the Structure of Human Behavior. Dallas: Summer Institute of Linguistics; 1954

[17] Kuckartz U. Mixed Methods: Methodologie, Forschungsdesigns und Analyseverfahren.

Mixed Methods Studies in Health Promotion: A Case-Study Based on the Life Situations…

http://dx.doi.org/10.5772/intechopen.76711

89

[18] Tashakkori A, Teddlie C, editors. Handbook of Mixed Methods in Social and Behavioral

[19] Hesse-Biber S, Johnson B, editors. The Oxford Handbook of Multi- and Mixed-Methods

[20] Johnson RB, Onwuegbuzie AJ, Turner LA. Toward a definition of mixed methods

[21] Tashakkori A, Teddlie C. Handbook of Mixed-Methods in Social & Behavioral Research,

[22] Creswell JW. A Concise Introduction to Mixed Methods Research. Los Angeles, London,

[23] Statistisches Bundesamt. 2015: Höchststände bei Zuwanderung und Wanderungsüberschuss in Deutschland. Pressemitteilung Nr. 246 vom 14.07.2016 [Internet]. 2016. Available from: https://www.destatis.de/DE/PresseService/Presse/Pressemitteilungen/

[24] Kliche T, Koch U, Lehmann H, Töppich J. Evidenzbasierte Prävention und Gesundheitsförderung. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz.

[25] O'Cathain EM, Nicholl J. The quality of mixed methods studies in health services

[26] Palinkas LA, Horwitz SM, Chamberlain P, Hurlburt MS, Landsverk J. Mixed-methods designs in mental health services research: A review. Psychiatric Services. 2011;**62**:255-263

[27] Mayer H. Das methodologische Schweigen? – Ein Blick in die Forschungslandschaft der

[28] Deutsches Komitee für UNICEF. UNICEF-Lagebericht zur Situation der Flüchtlingskinder in Deutschland. Unter Verwendung von Recherchen des Bundesfachverband

[29] Statistisches Bundesamt. Unbegleitete minderjährige Flüchtlinge. Available from: https:// mediendienst-integration.de/migration/flucht-asyl/minderjaehrige.html [Accessed: Dec

[30] Statistisches Bundesamt. Unbegleitete Einreisen Minderjähriger aus dem Ausland lassen Inobhutnahmen 2014 stark ansteigen. Pressemitteilung Nr. 340 vom 16.09.2015. [Internet]. 2015. Available from: https://www.destatis.de/DE/PresseService/Presse/

[31] Bundestagsdrucksache 18/9273. Unbegleitete minderjährige Flüchtlinge im Asylverfahren. Berlin: Deutscher Bundestag [Internet]. 2016. Available from: http://dip21.bundestag.de/

Pressemitteilungen/2015/09/PD15\_340\_225.html [Accessed: Mar 19, 2017]

research. Journal of Health Services Research & Policy. 2008;**13**:92-98

Wiesbaden: Springer; 2014

2006;**49**(2):141-150

16, 2017]

Research. 2nd ed. Thousand Oaks, CA: Sage; 2010

New Delhi, Singapore, Washington, DC: Sage; 2015

2016/07/PD16\_246\_12421.html [Accessed: Mar 9, 2017]

Mixed Methods Studies. Pflege. 2013;**26**:200-302

Unbegleitete Minderjährige Flüchtlinge e.V. Köln. 2016

dip21/btd/18/092/1809273.pdf [Accessed: Nov 29, 2017]

Thousand Oaks: Sage; 2003. pp. 457-488

Research Inquiry. Oxford University Press: Oxford; 2015

research. Journal of Mixed Methods Research. 2007;**1**:112-133


[17] Kuckartz U. Mixed Methods: Methodologie, Forschungsdesigns und Analyseverfahren. Wiesbaden: Springer; 2014

[3] Pike KL. Language in Relation to a Unified Theory of the Structure of Human Behavior.

[4] Wirtz MA, Stohmer J. Anwendung und Integration qualitativer und quantitativer Forschungsmethoden in der rehabilitationswissenschaftlichen Interventionsforschung.

[5] Niederberger M. Mixed-Methods-Studien in der Gesundheitsförderung. Am Beispiel einer Studie über junge Menschen mit Fluchterfahrung. Präv Gesundheitsf. 2017. DOI:

[6] Kelle U, Krones T. "Evidence based Medicine" und "Mixed Methods" – wie methodologische Diskussionen in der Medizin und den Sozialwissenschaften voneinander profitieren könnten. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen

[7] Kelle U. Die Integration Qualitativer und Quantitativer Methoden in der Empirischen

[8] Creswell J, Plano CV. Designing and Conducting Mixed Methods Research. Los Angeles,

[9] Curry L, Nunez-Smith M. Mixed Methods in Health Sciences Research. A Practical Primer. Los Angeles, London, New Delhi, Singapore, Washington DC: Sage; 2015 [10] Schreier M. Qualitative und Quantitative Methoden in der Sozialforschung: Vielfalt statt Einheit! In: Symposium: Qualitative und quantitative Methoden in der Sozialforschung: Differenz und/oder Einheit? 1. Berliner Methodentreffen Qualitative Forschung. Jun 24-25, 2005. [Internet]. 2005. Available from: http://www.berliner-methodentreffen.de/

[11] Kelle U. Mixed methods. In: Baur N, Blasius J, editors. Handbuch der Empirischen

[12] Schneider A. Triangulation und Integration von qualitativer und quantitativer Forschung in der Sozialen Arbeit. In: Mührel E, Birgmeier B, editors. Persektiven sozialpädagogischer Forschung. Soziale Arbeite in Theorie und Wissenschaft. Wiesbaden: Springer;

[13] Mayer H. Qualitative Forschung in der Konjunktur – (k)ein Anlass zur Freude? Pflege &

[14] Plano Clark L, Anderson N, Wertz JA, Zhou Y, Schumacher K, Miaskowski C. Conceptualizing longitudinal mixed methods designs: A methodological review of health

[15] Baur N, Blasius J, editors. Handbuch der Empirischen Sozialforschung. Wiesbaden:

[16] Leavy P. Research Design. Quantitative, Qualitative, Mixed Methods, Arts-Based, and Community-Based Participatory Research Approaches. New York, London: The

sciences research. Journal of Mixed Methods Research. 2016;**9**(4):297-319

Dallas: Summer Institute of Linguistics; 1954

Sozialforschung. Wiesbaden: Springer VS; 2007

material/2005/schreier.pdf [Accessed: May 17, 2017]

Sozialforschung. Springer: Wiesbaden; 2014. pp. 153-166

Gesellschaft: Zeitschrift für Pflegewissenschaft. 2016;**21**(1):5-19

London, New Delhi, Singapore, Washington DC: Sage; 2011

Rehabilitation. 2016;**55**:191-199

10.1007/s11553-017-0602-5

88 Public Health - Emerging and Re-emerging Issues

2010;**104**:630-635

2014. pp. 15-30

Springer; 2014

Guilford Press; 2017


[32] Fritsche A. Kultur(en) und Sprache(n) der Asylwirklichkeit – Herausforderungen empirischer Forschung im Kontext von Unsicherheit, Verrechtlichung, Interkulturalität und Mehrsprachigkeit. Österreich Z Soziol. 2016;**41**(2):165-190

**Chapter 5**

**Provisional chapter**

**Developing Community Health and Cohesion Through**

*Aim*: This chapter examines the relationship of increasing sociodemographic and organisational diversity to community health development. The particular focus is the contribution of faith-oriented agencies to the processes of community cohesion required to

*Context*: The background is of rapid growth in the number of economic migrants and political refugees, their mobility and the impact on formal healthcare services seeking to constrain demand. Globally, a need to extend informal and non-statutory interventions,

*Methodology*: A narrative evidence synthesis was undertaken drawing on research literature and policy documents. Themes emerging were then applied as criteria to elicit key messages from a series of local case studies and service evaluations. The synthesis was undertaken in response to the following two research questions: '(How) can spiritual actors and agencies promote relational integration in both new communities and those with rapidly increasing cultural and demographic diversity?'; 'Which models of wellbeing practice are most appropriate for faith-based contributions to community health development in settings with such (increasing cultural and demographic) diversity?'. *Findings*: The evidence synthesis confirms the potential benefits of and for spiritual agencies especially, in respect of creating communities with identities built on more open com-

*Conclusion*: The topic summary is used to scope a future research agenda in which the profiling of different relationship networks and their development processes is indicated

**Keywords:** diversity, community health, cohesion, faith, social enterprise, Winchester

**Developing Community Health and Cohesion through** 

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.77974

**Diversity: An Evidence Synthesis for Faith-Based**

**Diversity: An Evidence Synthesis for Faith-Based** 

**Agencies**

**Abstract**

as a priority.

**Agencies**

Geoffrey Meads and Amanda Lees

Geoffrey Meads and Amanda Lees

http://dx.doi.org/10.5772/intechopen.77974

underpin public health improvements.

which promote public health, has been recognised.

munication systems and socially interactive networks.

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter


#### **Developing Community Health and Cohesion Through Diversity: An Evidence Synthesis for Faith-Based Agencies Developing Community Health and Cohesion through Diversity: An Evidence Synthesis for Faith-Based Agencies**

DOI: 10.5772/intechopen.77974

#### Geoffrey Meads and Amanda Lees Geoffrey Meads and Amanda Lees

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.77974

#### **Abstract**

[32] Fritsche A. Kultur(en) und Sprache(n) der Asylwirklichkeit – Herausforderungen empirischer Forschung im Kontext von Unsicherheit, Verrechtlichung, Interkulturalität

[33] Enzenhofer E, Braakmann D, Kein C, Spicker I. SALOMON Next Step. Bedrohungswahrnehmung von MigrantInnen. Eine Studie im Rahmen der osterreichischen Sicherheitsforschung. Projektendbericht, Forschungsinstitut des Roten Kreuzes, Wien. 2009. Available from: http://www.roteskreuz.at/fileadmin/user\_upload/LV/ Wien/Metanavigation/Forschungsinstitut/MitarbeiterInnen%20+%20Projektberichte/ SALOMON%20Next%20Step%20Projektendbericht.pdf [Accessed: Dec 13, 2017]

[34] Reinders H. Qualitative Interviews mit Jugendlichen führen. Ein Leitfaden: De Gruyter

[35] Oetting-Roß C, Ullrich C, Schnepp W, Büscher A. Qualitative Forschung mit lebenslimitierend erkrankten Kindern und Jugendlichen: Hören wir richtig hin? [46Absätze]. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research. 2016;**17**(2). Art.

[36] Mayring P. Qualitative Inhaltsanalyse. Grundlagen und Techniken, 12. überarb. Aufl.

[37] Niederberger M, Keller M. Lebenssituation junger Menschen mit Fluchterfahrung im

[38] Von Unger H. Partizipative Forschung. Einführung in die Forschungspraxis. Wiesbaden:

[39] Schulz M, Mack B, Renn O, editors. Fokusgruppen in der empirischen Sozialwissenschaft. Von der Konzeption bis zur Auswertung. Wiesbaden: Verlag für Sozialwissenschaften;

[40] Carayon P, Kianfar S, Li Y, Xie A, Alyousef B, Wooldridge A. A systematic review of mixed methods research on human factors and ergonomics in health care. Applied

[41] Islam F, Oremus M. Mixed methods immigrant mental health research in Canada: A systematic review. Journal of Immigrant and Minority Health. 2014;**16**(6):1284-1289

24. Available from: http://nbn-resolving.de/urn:nbn:de:0114-fqs1602241

Landkreis Göppingen. Journal Gesundheitsförderung. 2017;**5**(1):66-69

und Mehrsprachigkeit. Österreich Z Soziol. 2016;**41**(2):165-190

Oldenbourg; 2016

90 Public Health - Emerging and Re-emerging Issues

Springer; 2014

2012

Beltz: Weinheim und Basel; 2015

Ergonomics. 2015;**51**:291-321

*Aim*: This chapter examines the relationship of increasing sociodemographic and organisational diversity to community health development. The particular focus is the contribution of faith-oriented agencies to the processes of community cohesion required to underpin public health improvements.

*Context*: The background is of rapid growth in the number of economic migrants and political refugees, their mobility and the impact on formal healthcare services seeking to constrain demand. Globally, a need to extend informal and non-statutory interventions, which promote public health, has been recognised.

*Methodology*: A narrative evidence synthesis was undertaken drawing on research literature and policy documents. Themes emerging were then applied as criteria to elicit key messages from a series of local case studies and service evaluations. The synthesis was undertaken in response to the following two research questions: '(How) can spiritual actors and agencies promote relational integration in both new communities and those with rapidly increasing cultural and demographic diversity?'; 'Which models of wellbeing practice are most appropriate for faith-based contributions to community health development in settings with such (increasing cultural and demographic) diversity?'.

*Findings*: The evidence synthesis confirms the potential benefits of and for spiritual agencies especially, in respect of creating communities with identities built on more open communication systems and socially interactive networks.

*Conclusion*: The topic summary is used to scope a future research agenda in which the profiling of different relationship networks and their development processes is indicated as a priority.

**Keywords:** diversity, community health, cohesion, faith, social enterprise, Winchester

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **1. Introduction**

In this chapter, we will explore some of the issues for public health that arise as a result of the rapid expansion in frontline well-being practices. This recent growth is a modern global phenomenon, associated with the common requirements of formal healthcare institutions for alternative sources of demand management and the equally urgent need to accommodate new migrants effectively into domestic economies. For public health the Marmot Reviews, and their endorsement by the World Health Organization in 2008 [1, 2], effectively legitimised the modern shift towards more pluralistic approaches. The independent sector, in a myriad of different formats, is recognised as an essential participant. Globally, it has now become a key partner for statutory public authorities through its contributions to health improvement and reductions in health inequalities. While recognising this international context, not least for the purposes of comparative evaluation and transferable learning, the following pages will, however, largely rely on research undertaken specifically for local agencies within the UK.

evaluations and evidence syntheses have been undertaken, particularly for Christian charities and senior clergy. This chapter itself follows on from a request from two diocesan leaders in the Winchester area for guidance in relation to the research evidence and its possible applications in two types of locality where new diversities are apparent: major new housing settlements and neighbourhoods with long established cultures confined to those with white middle-class backgrounds. Both the two research commissioners are keen to discover 'new opportunities for community cohesion from diversity' and thence for enhanced public health.

Developing Community Health and Cohesion Through Diversity: An Evidence Synthesis…

http://dx.doi.org/10.5772/intechopen.77974

93

This interest in new topics from those looking to augment divine revelation with empirical research findings is matched by our own professional researchers' interest in identifying new ways of data capture and analysis that will support the increasingly pluralistic approaches to public health practice. How, for example, can research help identify which profiles of wellbeing practices effectively enhance community cohesion and public health in different types of suburb? Do more diverse neighbourhoods develop distinctive and different relational net-

Given our personal study interests, this last question is of particular significance to us as a subject in respect of those in the first and last years of life: those 'growing up' and those 'growing down'. As health science students, we have been very aware that, even in public health research programmes, it is trial-based methodologies that still hold sway, notwithstanding the shift to cluster and cohort studies and natural experiments. Such methodologies do seem to struggle with issues of context and communication. Trials do not identify the emergent and sometimes implicit values of newly diverse localities. Their fixed intervals for data collection are not well suited to an informed understanding over time of the very old and very young, who often simply cannot comply with standard written or oral scientific research requirements. Yet, it is such groupings as these which constitute the litmus test for verifiable

This leads us to the purpose of this chapter. In the UK we hear quite a lot of talk to the effect that the changes in the health system amount to 'a return to the Victorian days' of the nineteenth century, in effect a 're-emerging' public health issue. The implied negative message is one of the clocks being turned back to times when state welfare policy was not universal and churches were the last resort safety nets for the poor and disadvantaged. This perspective points now to a new paternalism, ultimately designed to sustain established elites. But this is not where we are coming from. Our aim here is firmly within the policy framework espoused by the British NHS, which invariably emphasises 'equality and diversity', as demonstrated in the policy document extracts and references provided later in this chapter. These two principles are presented not just as inseparable but interdependent. Accordingly, our aim here is to present research findings which offer the potential to promote public health in communities characterised by diversity. Behind this aim is the aspiration that equivalent positive co-contributions in these communities from their different and distinct members become seen as standard habitual behaviour and normative as a result. For institutions such as the Church of England with its deeply embedded hierarchies, this can be especially challenging. This can be true for those in leadership positions within the Winchester Diocese,

works and informal resources to support wellbeing?

developments of community cohesion through diversity.

Of these local agencies, faith-based organisational initiatives have been most significant. These have been especially apparent in the county of Hampshire and the Winchester Diocese of the Church of England, where our Health and Wellbeing Research Group is located. The growth in the range and scale of wellbeing practices is inextricably linked to a policy of the Anglican Communion which seeks to take advantage of novel organisational options for 'missional social action'. At the heart of such 'action' is the expression of Christian values to promote community wellbeing in locations where social need is seen as most acute. In line with this policy, every one of the 127 parishes in the diocese, since 2014, has been required to identify a shortfall in community health and to bring forwards a social enterprise development in response. The result has been an unprecedented growth in voluntary services dedicated to community wellbeing [3].

While 100 plus Good Neighbour befriending schemes and up to 40 food banks are the most obvious examples in the diocese of the new faith-based social enterprises, the latter have also been characterised by a new diversity, including such as a young persons' beach night club and a rural property mediation service. This creative organisational diversity has developed in parallel with the increased sociodemographic diversity of the local communities themselves. This diversity, derived principally from the growth in economic migrants, has itself produced new wellbeing practices, with the expansion in modes of pilates, personal training and massage services the most obvious illustrations of this trend. The overall effect is captured in the changing profile of the High Street, where the concept of wellbeing now rivals that of hospitality in its practical expressions. Together, it is not uncommon for them to provide well over half of the service outlets and shops, with international exemplars in cities such as Melbourne pointing to the future scope for further growth through psychologically oriented interventions that include slumber, stress relief and a variety of counselling clinics and remedial muscular support services, such as myotherapy and naturopathy [4].

These two formative structural influences of both increased social enterprise and social mobility have helped to shape our research agenda over the past 3 years. A series of local evaluations and evidence syntheses have been undertaken, particularly for Christian charities and senior clergy. This chapter itself follows on from a request from two diocesan leaders in the Winchester area for guidance in relation to the research evidence and its possible applications in two types of locality where new diversities are apparent: major new housing settlements and neighbourhoods with long established cultures confined to those with white middle-class backgrounds. Both the two research commissioners are keen to discover 'new opportunities for community cohesion from diversity' and thence for enhanced public health.

**1. Introduction**

92 Public Health - Emerging and Re-emerging Issues

community wellbeing [3].

In this chapter, we will explore some of the issues for public health that arise as a result of the rapid expansion in frontline well-being practices. This recent growth is a modern global phenomenon, associated with the common requirements of formal healthcare institutions for alternative sources of demand management and the equally urgent need to accommodate new migrants effectively into domestic economies. For public health the Marmot Reviews, and their endorsement by the World Health Organization in 2008 [1, 2], effectively legitimised the modern shift towards more pluralistic approaches. The independent sector, in a myriad of different formats, is recognised as an essential participant. Globally, it has now become a key partner for statutory public authorities through its contributions to health improvement and reductions in health inequalities. While recognising this international context, not least for the purposes of comparative evaluation and transferable learning, the following pages will, however, largely rely on research undertaken specifically for local agencies within the UK.

Of these local agencies, faith-based organisational initiatives have been most significant. These have been especially apparent in the county of Hampshire and the Winchester Diocese of the Church of England, where our Health and Wellbeing Research Group is located. The growth in the range and scale of wellbeing practices is inextricably linked to a policy of the Anglican Communion which seeks to take advantage of novel organisational options for 'missional social action'. At the heart of such 'action' is the expression of Christian values to promote community wellbeing in locations where social need is seen as most acute. In line with this policy, every one of the 127 parishes in the diocese, since 2014, has been required to identify a shortfall in community health and to bring forwards a social enterprise development in response. The result has been an unprecedented growth in voluntary services dedicated to

While 100 plus Good Neighbour befriending schemes and up to 40 food banks are the most obvious examples in the diocese of the new faith-based social enterprises, the latter have also been characterised by a new diversity, including such as a young persons' beach night club and a rural property mediation service. This creative organisational diversity has developed in parallel with the increased sociodemographic diversity of the local communities themselves. This diversity, derived principally from the growth in economic migrants, has itself produced new wellbeing practices, with the expansion in modes of pilates, personal training and massage services the most obvious illustrations of this trend. The overall effect is captured in the changing profile of the High Street, where the concept of wellbeing now rivals that of hospitality in its practical expressions. Together, it is not uncommon for them to provide well over half of the service outlets and shops, with international exemplars in cities such as Melbourne pointing to the future scope for further growth through psychologically oriented interventions that include slumber, stress relief and a variety of counselling clinics

and remedial muscular support services, such as myotherapy and naturopathy [4].

These two formative structural influences of both increased social enterprise and social mobility have helped to shape our research agenda over the past 3 years. A series of local This interest in new topics from those looking to augment divine revelation with empirical research findings is matched by our own professional researchers' interest in identifying new ways of data capture and analysis that will support the increasingly pluralistic approaches to public health practice. How, for example, can research help identify which profiles of wellbeing practices effectively enhance community cohesion and public health in different types of suburb? Do more diverse neighbourhoods develop distinctive and different relational networks and informal resources to support wellbeing?

Given our personal study interests, this last question is of particular significance to us as a subject in respect of those in the first and last years of life: those 'growing up' and those 'growing down'. As health science students, we have been very aware that, even in public health research programmes, it is trial-based methodologies that still hold sway, notwithstanding the shift to cluster and cohort studies and natural experiments. Such methodologies do seem to struggle with issues of context and communication. Trials do not identify the emergent and sometimes implicit values of newly diverse localities. Their fixed intervals for data collection are not well suited to an informed understanding over time of the very old and very young, who often simply cannot comply with standard written or oral scientific research requirements. Yet, it is such groupings as these which constitute the litmus test for verifiable developments of community cohesion through diversity.

This leads us to the purpose of this chapter. In the UK we hear quite a lot of talk to the effect that the changes in the health system amount to 'a return to the Victorian days' of the nineteenth century, in effect a 're-emerging' public health issue. The implied negative message is one of the clocks being turned back to times when state welfare policy was not universal and churches were the last resort safety nets for the poor and disadvantaged. This perspective points now to a new paternalism, ultimately designed to sustain established elites. But this is not where we are coming from. Our aim here is firmly within the policy framework espoused by the British NHS, which invariably emphasises 'equality and diversity', as demonstrated in the policy document extracts and references provided later in this chapter. These two principles are presented not just as inseparable but interdependent. Accordingly, our aim here is to present research findings which offer the potential to promote public health in communities characterised by diversity. Behind this aim is the aspiration that equivalent positive co-contributions in these communities from their different and distinct members become seen as standard habitual behaviour and normative as a result. For institutions such as the Church of England with its deeply embedded hierarchies, this can be especially challenging. This can be true for those in leadership positions within the Winchester Diocese, particularly given its strong pastoral care traditions across Hampshire. And, this can be true for their counterparts elsewhere.

## **2. Methodology**

Through the detailed discussions with the diocesan leaders referred to above, the following research question was defined for the initial literature review:

'(How) can spiritual actors and agencies promote relational integration in both new communities and those with rapidly increasing cultural and demographic diversity?'

The discussions revealed an awareness that there could be risks as well as benefits in such a promotional role. Christian leadership and community health were certainly not taken to be synonymous. Notwithstanding this understanding, the assumption that the review would produce some positive findings led to a second supplementary research question. This is as follows:

'Which models of wellbeing practice are most appropriate for faith-based contributions to community health development in settings with such (increasing cultural and demographic) diversity?'

The findings in this chapter are from two sources. First, we detail those from a structured background literature review undertaken as a response to the enquiries from the diocesan leaders described above. To reflect our own personal subject interests and to provide a defined starting point, this begun by concentrating on the needs of those 'growing up and down' at the early and later stages of life in the context of increasing and increasingly diverse communities and then moved on to a synthesis of recent relevant policy documents. This shift of focus was a response to the relative paucity of research data available because of the novelty of public health-oriented social enterprises and the richness of the recent policy developments.

and social cohesion', were identified as the benchmark policy statements for this review [5, 6]. Accordingly, a post-2001 time frame was used for the UK literature search, with some tolerance in respect of international sources to reflect the impetus given to relevant research by the World Health Organization's Jakarta Declaration of the next century's public health needs in 1997 [7].

Developing Community Health and Cohesion Through Diversity: An Evidence Synthesis…

http://dx.doi.org/10.5772/intechopen.77974

95

Finally, in terms of search criteria, selection was also framed by our particular focus on the early and later years of life. Initial searches on Embase, Medline, PubMed and the NIHR found very few research publications from recent medical research. Through expert advice from the university librarian, ESBO and SCOPUS were then employed as integrated databases which combine health and social care research and practice sources. At this stage it became apparent that the most prominent feature of recent publications was not a particular research project but the detailed policy documentation in respect of diversity and community health. This documentation has an international profile and includes both policy formulation and implementation papers. As a body of work, it was also largely unknown to those, such as our diocesan leaders, who are engaged in addressing the issues of a new diversity in housing

Accordingly, adopting a pragmatic approach to the review, the effect of our early findings at this stage was to redirect our focus to the material that could be of most utility: the wider policy sources and our own local evaluations of wellbeing sites. Our aim became a narrative

settlements.

**Figure 1.** Scoping review process.

As our second source, we then summarise the applied learning now available in the various projects undertaken by members of the University of Winchester's Health and Wellbeing Research Group, with both local NHS and faith-oriented partners, in relation to community health and wellbeing. Mostly local case studies and service evaluations these often augment and illustrate in practice the policy developments referred to in the previous paragraph. The chapter concludes with a short topic summary and the scoping of a future research agenda. The review process is set out in **Figure 1**.

A systematic literature review/meta-analysis was not viable given the lack of empirical papers. An inclusive approach to judging the quality of papers was employed, whereby the two criteria for inclusion were subject relevance and potential for local application rather than the rating of research quality. The literature review employed a cascade approach structured by combinations of overarching terms as keywords: diversity, community health, cohesion, faith, spiritual, social enterprise and network. The Marmot Reviews referenced in this article, and the London government's explicit watershed acknowledgement that 'faith-based organisations in multi-ethnic communities are key factors 'in developing confident, active communities Developing Community Health and Cohesion Through Diversity: An Evidence Synthesis… http://dx.doi.org/10.5772/intechopen.77974 95

**Figure 1.** Scoping review process.

particularly given its strong pastoral care traditions across Hampshire. And, this can be true

Through the detailed discussions with the diocesan leaders referred to above, the following

'(How) can spiritual actors and agencies promote relational integration in both new commu-

The discussions revealed an awareness that there could be risks as well as benefits in such a promotional role. Christian leadership and community health were certainly not taken to be synonymous. Notwithstanding this understanding, the assumption that the review would produce some positive findings led to a second supplementary research question. This is as follows:

'Which models of wellbeing practice are most appropriate for faith-based contributions to community health development in settings with such (increasing cultural and demographic)

The findings in this chapter are from two sources. First, we detail those from a structured background literature review undertaken as a response to the enquiries from the diocesan leaders described above. To reflect our own personal subject interests and to provide a defined starting point, this begun by concentrating on the needs of those 'growing up and down' at the early and later stages of life in the context of increasing and increasingly diverse communities and then moved on to a synthesis of recent relevant policy documents. This shift of focus was a response to the relative paucity of research data available because of the novelty of public

health-oriented social enterprises and the richness of the recent policy developments.

As our second source, we then summarise the applied learning now available in the various projects undertaken by members of the University of Winchester's Health and Wellbeing Research Group, with both local NHS and faith-oriented partners, in relation to community health and wellbeing. Mostly local case studies and service evaluations these often augment and illustrate in practice the policy developments referred to in the previous paragraph. The chapter concludes with a short topic summary and the scoping of a future research agenda.

A systematic literature review/meta-analysis was not viable given the lack of empirical papers. An inclusive approach to judging the quality of papers was employed, whereby the two criteria for inclusion were subject relevance and potential for local application rather than the rating of research quality. The literature review employed a cascade approach structured by combinations of overarching terms as keywords: diversity, community health, cohesion, faith, spiritual, social enterprise and network. The Marmot Reviews referenced in this article, and the London government's explicit watershed acknowledgement that 'faith-based organisations in multi-ethnic communities are key factors 'in developing confident, active communities

nities and those with rapidly increasing cultural and demographic diversity?'

research question was defined for the initial literature review:

for their counterparts elsewhere.

94 Public Health - Emerging and Re-emerging Issues

The review process is set out in **Figure 1**.

**2. Methodology**

diversity?'

and social cohesion', were identified as the benchmark policy statements for this review [5, 6]. Accordingly, a post-2001 time frame was used for the UK literature search, with some tolerance in respect of international sources to reflect the impetus given to relevant research by the World Health Organization's Jakarta Declaration of the next century's public health needs in 1997 [7].

Finally, in terms of search criteria, selection was also framed by our particular focus on the early and later years of life. Initial searches on Embase, Medline, PubMed and the NIHR found very few research publications from recent medical research. Through expert advice from the university librarian, ESBO and SCOPUS were then employed as integrated databases which combine health and social care research and practice sources. At this stage it became apparent that the most prominent feature of recent publications was not a particular research project but the detailed policy documentation in respect of diversity and community health. This documentation has an international profile and includes both policy formulation and implementation papers. As a body of work, it was also largely unknown to those, such as our diocesan leaders, who are engaged in addressing the issues of a new diversity in housing settlements.

Accordingly, adopting a pragmatic approach to the review, the effect of our early findings at this stage was to redirect our focus to the material that could be of most utility: the wider policy sources and our own local evaluations of wellbeing sites. Our aim became a narrative synthesis of these informed by the initial literature review, with the topic summary set out at the conclusion of this chapter as the end product.

challenges to physical, mental and social health. Through its case studies, the UK's Community Development Foundation identifies the celebration across newly diverse communities by faith agencies of religious occasions and festivals as a 'baseline' for empowerment and participation [14]. American counterpart bodies to the Foundation similarly record such religious approaches rooted in 'respect, empathy and active listening' as critical to the sense of 'mastery' and 'social

Developing Community Health and Cohesion Through Diversity: An Evidence Synthesis…

http://dx.doi.org/10.5772/intechopen.77974

97

Because of their values, faith-based agencies can be particularly adept at helping to redefine and extend the meaning of 'kinship' in diverse communities to a range of newcomers [17]. The older demographic profile of many church memberships can also be a 'community asset' as a means of face-to-face relationship building for informal networks, simply because older people are more likely to be experienced and comfortable in direct personal contact rather than digital communications [18]. They are also incentivised in emerging communities by the

In informal network developments which promote open communication such contacts are a source of identity for new communities and those facing cultural challenges. Shared stories and their associated experiences are vital, so that studies consistently point to the need for modern internally diverse communities to develop socially through 'events' rather than structurally through 'monuments' [20]. At Winchester our recent evidence synthesis for the local diocese found much to support the view that faith-based agencies and individuals are particularly well placed to supply the required 'creational narratives'. Their doctrines, backed

A note of caution, however, is required. We have noticed that while in practice we know of many examples of faith-based organisations (FBOs) hosting such as toddler groups, 'messy church', seniors' befriending schemes and the like, the academic literature focuses predominantly on developments in the formal as opposed to the informal wellbeing system. For example, this is particularly evident in state-sponsored early years' provision. Over recent years in the UK, a series of policy and practice reforms have aimed to improve outcomes and healthcare services for children and young people. There has been a joint focus on safeguarding children and reducing health inequalities via initiatives such as Sure Start, Children's Trusts, Childcare Partnerships and pre-school education [22]. This bias towards expressed

policy as opposed to policy espoused by behaviour points to a future research need.

Within recent years, two main drivers have emerged for increased engagement with communities as a vehicle to improving health and wellbeing. These are overdemand and systemic strain on traditional NHS-based health services and a growing recognition of the importance of the social determinants of health, which cannot be addressed within the confines of a hospital or GP surgery [1]. These drivers for engagement with communities and citizens are laid out in the NHS 'Five Year Forward View' [23], Public Health England's (PHE) strategy and 'From Evidence into Action' [24]. To promote healthy lifestyles and positive health behaviours, the latter calls for 'place-based approaches and community development, harnessing the collective assets and resources available locally to address local needs'. Similarly, the Marmot Strategic

connectedness' required for flourishing community health developments [15, 16].

basic need for such contact to combat the risks of social isolation and loneliness [19].

by conviction, are full of appropriate language and imagery [21].

**3.2. Policy sources**

## **3. Findings**

Our findings fall into three categories. First, the structured literature review pointed to significant changes in the life cycles of modern community development. In particular, it highlighted the importance and growth of informal relational networks and their alternative emphases on different modes of wellbeing. Secondly, the formative influence of detailed and often quite prescriptive policy documents has been confirmed as drivers of collaborative change for increasingly diverse communities through the creation of increasingly diverse agencies. And, finally, as our third finding, a miscellany of local lessons for operational practice have been identified in respect of critical cross generational roles in community cohesion and the specific role of those on the early and later years of life to these. The evidence suggests that, for all the three findings, those coming from faith backgrounds can make positive and distinctive contributions.

## **3.1. Life cycle**

Communities like individuals have their own life cycles. Historically, the concept of 'life cycle' has been central to an understanding of what constitutes wellbeing. Accordingly, influential writers in the last century still identified the family and the neighbourhood (or local 'clan') as the basic building blocks for both individuals [8, 9]. This applied to what was largely understood as physical and psychological wellbeing in respect of both individuals' recovery from periods of illness and communities in their successive stages of ongoing and largely architectural regeneration. The research literature in this period on wellbeing interventions is characterised by studies of both relational networks and clinical conditions that possess welldefined boundaries, with the health status of (usually lonely) older people especially linked to relationships of geographic proximity [10, 11].

Our review of the research literature indicated, above all else, how increased diversity has helped to change the previously conventional understanding of both wellbeing and then its supportive relational networks. Crucially, as a result the life cycle for both forming and reforming communities is changing, and essentially this fundamental change is characterised by shifts from often quite closed to much more open patterns of communication and by less structural and more socially interactive modes of identity development. For each of these shifts, the contribution of those at the initial 'growing up' and final 'growing down' stages of the individual life cycle appears to be crucial, through, for instance, hosting early years' parental clubs and classes and recruiting to seniors' befriending schemes.

Moreover, equally crucially, it is often the spiritually oriented organisations which are the key agencies in enabling these contributions to be effective in terms of the more recent holistic definitions of wellbeing. As multidimensional post-Millennium 'dynamic equilibrium' theories of wellbeing have gained traction [12, 13] so has the notion that relational networks must expand, in order that individual persons and the public at large can effectively meet accelerating challenges to physical, mental and social health. Through its case studies, the UK's Community Development Foundation identifies the celebration across newly diverse communities by faith agencies of religious occasions and festivals as a 'baseline' for empowerment and participation [14]. American counterpart bodies to the Foundation similarly record such religious approaches rooted in 'respect, empathy and active listening' as critical to the sense of 'mastery' and 'social connectedness' required for flourishing community health developments [15, 16].

Because of their values, faith-based agencies can be particularly adept at helping to redefine and extend the meaning of 'kinship' in diverse communities to a range of newcomers [17]. The older demographic profile of many church memberships can also be a 'community asset' as a means of face-to-face relationship building for informal networks, simply because older people are more likely to be experienced and comfortable in direct personal contact rather than digital communications [18]. They are also incentivised in emerging communities by the basic need for such contact to combat the risks of social isolation and loneliness [19].

In informal network developments which promote open communication such contacts are a source of identity for new communities and those facing cultural challenges. Shared stories and their associated experiences are vital, so that studies consistently point to the need for modern internally diverse communities to develop socially through 'events' rather than structurally through 'monuments' [20]. At Winchester our recent evidence synthesis for the local diocese found much to support the view that faith-based agencies and individuals are particularly well placed to supply the required 'creational narratives'. Their doctrines, backed by conviction, are full of appropriate language and imagery [21].

A note of caution, however, is required. We have noticed that while in practice we know of many examples of faith-based organisations (FBOs) hosting such as toddler groups, 'messy church', seniors' befriending schemes and the like, the academic literature focuses predominantly on developments in the formal as opposed to the informal wellbeing system. For example, this is particularly evident in state-sponsored early years' provision. Over recent years in the UK, a series of policy and practice reforms have aimed to improve outcomes and healthcare services for children and young people. There has been a joint focus on safeguarding children and reducing health inequalities via initiatives such as Sure Start, Children's Trusts, Childcare Partnerships and pre-school education [22]. This bias towards expressed policy as opposed to policy espoused by behaviour points to a future research need.

### **3.2. Policy sources**

synthesis of these informed by the initial literature review, with the topic summary set out at

Our findings fall into three categories. First, the structured literature review pointed to significant changes in the life cycles of modern community development. In particular, it highlighted the importance and growth of informal relational networks and their alternative emphases on different modes of wellbeing. Secondly, the formative influence of detailed and often quite prescriptive policy documents has been confirmed as drivers of collaborative change for increasingly diverse communities through the creation of increasingly diverse agencies. And, finally, as our third finding, a miscellany of local lessons for operational practice have been identified in respect of critical cross generational roles in community cohesion and the specific role of those on the early and later years of life to these. The evidence suggests that, for all the three findings,

those coming from faith backgrounds can make positive and distinctive contributions.

Communities like individuals have their own life cycles. Historically, the concept of 'life cycle' has been central to an understanding of what constitutes wellbeing. Accordingly, influential writers in the last century still identified the family and the neighbourhood (or local 'clan') as the basic building blocks for both individuals [8, 9]. This applied to what was largely understood as physical and psychological wellbeing in respect of both individuals' recovery from periods of illness and communities in their successive stages of ongoing and largely architectural regeneration. The research literature in this period on wellbeing interventions is characterised by studies of both relational networks and clinical conditions that possess welldefined boundaries, with the health status of (usually lonely) older people especially linked

Our review of the research literature indicated, above all else, how increased diversity has helped to change the previously conventional understanding of both wellbeing and then its supportive relational networks. Crucially, as a result the life cycle for both forming and reforming communities is changing, and essentially this fundamental change is characterised by shifts from often quite closed to much more open patterns of communication and by less structural and more socially interactive modes of identity development. For each of these shifts, the contribution of those at the initial 'growing up' and final 'growing down' stages of the individual life cycle appears to be crucial, through, for instance, hosting early years'

Moreover, equally crucially, it is often the spiritually oriented organisations which are the key agencies in enabling these contributions to be effective in terms of the more recent holistic definitions of wellbeing. As multidimensional post-Millennium 'dynamic equilibrium' theories of wellbeing have gained traction [12, 13] so has the notion that relational networks must expand, in order that individual persons and the public at large can effectively meet accelerating

parental clubs and classes and recruiting to seniors' befriending schemes.

the conclusion of this chapter as the end product.

96 Public Health - Emerging and Re-emerging Issues

to relationships of geographic proximity [10, 11].

**3. Findings**

**3.1. Life cycle**

Within recent years, two main drivers have emerged for increased engagement with communities as a vehicle to improving health and wellbeing. These are overdemand and systemic strain on traditional NHS-based health services and a growing recognition of the importance of the social determinants of health, which cannot be addressed within the confines of a hospital or GP surgery [1]. These drivers for engagement with communities and citizens are laid out in the NHS 'Five Year Forward View' [23], Public Health England's (PHE) strategy and 'From Evidence into Action' [24]. To promote healthy lifestyles and positive health behaviours, the latter calls for 'place-based approaches and community development, harnessing the collective assets and resources available locally to address local needs'. Similarly, the Marmot Strategic Review of Health Inequalities in England [25] called for the creation and development of healthy and sustainable places and communities. Like several of its international counterparts, the NHS Five Year Forward View recognises the unique contribution of charities and voluntary organisations with their opportunity to reach underserved groups and respond to local need.

FaithAction [28] has itself produced a report highlighting the particular role that faith-based organisations (FBOs) can play in the promotion of community health and wellbeing. One particular strength of FBOs relates to their access to communities at risk of marginalisation and/or specific disease profiles. In cases where language and other barriers exist amongst particular communities, members often do not engage with primary health services and miss out on preventative services such as health screening or advice. FBOs, through their engagement with these communities have valuable access and understanding of their needs and are valuable partners to health providers in working with these populations. This is of particular use where certain ethnic groups have a higher risk for certain diseases. Most of the evidence in this regard is situated in US-based Black American churches. A well-developed body of research shows the role that churches can play in promoting behaviour change for prevention/management of diabetes and cardiovascular disease, as well as encouraging the uptake of screening programmes. The literature in the UK is mainly situated with the South Asian community for similar reasons but is less developed than the evidence base in the United States. An example of one UK study is the development of an antismoking educational intervention for Bangladeshi and Pakistani communities—developed in conjunction with Muslim faith leaders for delivery in mosques, faith schools, women's groups and madrassas. The programme aimed to discourage smoking in homes was based on Koranic teaching about not

Developing Community Health and Cohesion Through Diversity: An Evidence Synthesis…

http://dx.doi.org/10.5772/intechopen.77974

99

There is a further body of research that shows positive benefits to mental health, wellbeing and social capital in being regularly involved in religious activities. These benefits appear to be linked to increased social support and sense of meaning. FBOs also have a number of assets and resources suitable for health promotion, including established presence and networks

The authors do, however, note that there are examples of some negative FBO contributions relating to fundamentalism and exclusivity. Similar challenges are highlighted in a smallscale study of antipoverty projects in one city in the South of England. This found 'virtuous yet simultaneously exclusionary cycles' stemming from social action by faith groups. This related specifically to the preference by Christian organisations (who in this city were the predominant faith group) to partner only with other Christian projects—meaning that minority faith groups were excluded from ecumenical networks for social action. In this study, Hindu and Muslim faith groups struggled to mobilise resources to support local community projects—focusing rather on supporting the wider community of believers overseas

In this section of the chapter, we simply summarise some of the transferable learning available—but not necessarily published—from eight local research and consultancy projects either initiated or commissioned by local faith-oriented agencies. Three of these concerned services for families with young children, while each of the rest involved leading contributions from seniors either as clients or service providers. All the agency names have been withheld for reasons of confidentiality. The projects have been undertaken by members of the Health and

harming oneself and others [29].

in disaster relief efforts [30].

**3.3. Local lessons**

within communities, buildings and culture of volunteering.

Wellbeing Research Group at the University of Winchester.

As the responsible national agency, Public Health England [26] has identified a set of local health assets that support the positive health and wellbeing of the community. Shown below, these emphasise the importance of informal networks for social (and intergenerational) interaction, such as babysitting circles, alongside formal provision by the public, private or third sectors:


Community-centred approaches to health and wellbeing recognise and seek to mobilise assets that already exist within communities.

Explicating this, South [27] identified a 'family of community-centred approaches for health and wellbeing', which are listed below. While the PHE report does not specifically mention FBOs, the FaithAction charity (a national network supporting faith- and community-based organisations involved in social action) highlights the 'very strong resonance' between the approaches recommended by a range of policy documents in respect of enhancing health and wellbeing through better engagement with communities and 'the activities of faith groups' [28].

Family of community-centred approaches:


FaithAction [28] has itself produced a report highlighting the particular role that faith-based organisations (FBOs) can play in the promotion of community health and wellbeing. One particular strength of FBOs relates to their access to communities at risk of marginalisation and/or specific disease profiles. In cases where language and other barriers exist amongst particular communities, members often do not engage with primary health services and miss out on preventative services such as health screening or advice. FBOs, through their engagement with these communities have valuable access and understanding of their needs and are valuable partners to health providers in working with these populations. This is of particular use where certain ethnic groups have a higher risk for certain diseases. Most of the evidence in this regard is situated in US-based Black American churches. A well-developed body of research shows the role that churches can play in promoting behaviour change for prevention/management of diabetes and cardiovascular disease, as well as encouraging the uptake of screening programmes. The literature in the UK is mainly situated with the South Asian community for similar reasons but is less developed than the evidence base in the United States. An example of one UK study is the development of an antismoking educational intervention for Bangladeshi and Pakistani communities—developed in conjunction with Muslim faith leaders for delivery in mosques, faith schools, women's groups and madrassas. The programme aimed to discourage smoking in homes was based on Koranic teaching about not harming oneself and others [29].

There is a further body of research that shows positive benefits to mental health, wellbeing and social capital in being regularly involved in religious activities. These benefits appear to be linked to increased social support and sense of meaning. FBOs also have a number of assets and resources suitable for health promotion, including established presence and networks within communities, buildings and culture of volunteering.

The authors do, however, note that there are examples of some negative FBO contributions relating to fundamentalism and exclusivity. Similar challenges are highlighted in a smallscale study of antipoverty projects in one city in the South of England. This found 'virtuous yet simultaneously exclusionary cycles' stemming from social action by faith groups. This related specifically to the preference by Christian organisations (who in this city were the predominant faith group) to partner only with other Christian projects—meaning that minority faith groups were excluded from ecumenical networks for social action. In this study, Hindu and Muslim faith groups struggled to mobilise resources to support local community projects—focusing rather on supporting the wider community of believers overseas in disaster relief efforts [30].

#### **3.3. Local lessons**

Review of Health Inequalities in England [25] called for the creation and development of healthy and sustainable places and communities. Like several of its international counterparts, the NHS Five Year Forward View recognises the unique contribution of charities and voluntary organisations with their opportunity to reach underserved groups and respond to local need. As the responsible national agency, Public Health England [26] has identified a set of local health assets that support the positive health and wellbeing of the community. Shown below, these emphasise the importance of informal networks for social (and intergenerational) interaction, such as babysitting circles, alongside formal provision by the public, private or third sectors:

• The skills, knowledge, social competence and commitment of individual community

• Friendships, intergenerational solidarity, community and neighbourliness within a

• Local groups and community and voluntary associations, ranging from formal organisa-

Community-centred approaches to health and wellbeing recognise and seek to mobilise assets

Explicating this, South [27] identified a 'family of community-centred approaches for health and wellbeing', which are listed below. While the PHE report does not specifically mention FBOs, the FaithAction charity (a national network supporting faith- and community-based organisations involved in social action) highlights the 'very strong resonance' between the approaches recommended by a range of policy documents in respect of enhancing health and wellbeing through better engagement with communities and 'the activities of faith groups' [28].

**1.** Strengthening communities—this includes a range of approaches such as creating networks to enhance the wellbeing of those involved. An example given is the Men's Shed network, which is aimed at reducing the social isolation of men. These approaches work

**2.** Volunteer and peer roles—these approaches train individuals to provide information, support and advice and organise activities related to health and wellbeing within their (or other) communities. These can include volunteer health roles and health trainers/health champions. **3.** Collaborations and partnerships refer to approaches in which partnerships are built with communities to improve planning and decision-making. These may involve participatory

**4.** Access to community resources—this involves the connection of people to resources in their communities such as information, advice, help and group activities. Such approaches

research, co-production projects and community engagement in planning.

tions to informal, mutual aid networks such as babysitting circles. • Physical, environmental and economic resources within a community. • Assets brought by external agencies—public, private and third sector.

by building social cohesion, awareness and collective action.

may include social prescribing or community hubs.

members.

community.

that already exist within communities.

98 Public Health - Emerging and Re-emerging Issues

Family of community-centred approaches:

In this section of the chapter, we simply summarise some of the transferable learning available—but not necessarily published—from eight local research and consultancy projects either initiated or commissioned by local faith-oriented agencies. Three of these concerned services for families with young children, while each of the rest involved leading contributions from seniors either as clients or service providers. All the agency names have been withheld for reasons of confidentiality. The projects have been undertaken by members of the Health and Wellbeing Research Group at the University of Winchester.

Cross generational communications have long been promulgated as a potentially rich but underutilised resource for sapiential learning [31]. The findings in two of our projects supported this view. In the first active and trained older men served (with consent) as befrienders for families at risk of breakdown across a range of new and older housing estates. In these families the father was absent for reasons of custodial incarceration or partner separation. Perhaps, surprisingly, it was the fathers who scored this service the highest in terms of positive satisfaction, with some highlighting the prospective benefits of being able to draw on older mens' experience and contacts for future employment and training opportunities. A second project for families which have suffered parental loss is similarly highlighting the contribution of older persons as both sponsors and carers on a citywide basis.

a clear summary that describes well-defined elements of the topic's subject areas, as the start-

Developing Community Health and Cohesion Through Diversity: An Evidence Synthesis…

http://dx.doi.org/10.5772/intechopen.77974

101

In responding to this challenge, we return to what became our main aim of identifying the potential for public health of increasingly diverse communities. In pulling together our literature review findings with local practice examples, we are in the position to provide a narrative

What we can assert with confidence, in a topic summary, from the evidence so far is that diverse communities can be cohesive and that this cohesion can be a source for health promotion. Two key factors have been identified as positive factors in achieving this cohesion. The first key factor is the development of more open communication systems in and across communities, and the second key factor is the expansion of more socially interactive means of identity development within them. These two determinants possess corresponding factors which have been dominant but are now required to be less influential if diversity and cohesion are to be enhanced: the focus on internal communications and physical structures for

We can also postulate that while many agencies are able to contribute to local health improvements, the two core positive features of diverse but cohesive communities do provide particular opportunities for those with a faith orientation. The research so far supports this assertion, which aligns for example with some recent studies from the United States [38, 39]. Faith-oriented agencies are particularly well placed in terms of values and vocational commitment to facilitate and integrate the growing range of informal networks and wellbeing service outlets which posited the policies that we have noted for place-based public health. Above all their spiritual orientation means that there are no boundaries to the reach of their relationships with people located across all sociodemographic categories, political affiliations

Geared to alleviating health inequalities, evaluations of the effects of all community-based health and wellbeing interventions must pay particular attention to accessing with sensitivity the views of those most at risk of being disadvantaged. For the significance of spiritual actors and agency researchers must be prepared to learn from faith-based and other organisations already working in these domains. The two-way exchange between faith and empiricism can only help to address inherent and novel cultural, language and practical issues arising in new communities. A number of scholars have begun to address these issues in other areas of research (e.g. [40]). Those seeking to enhance community health and cohesion through new forms of diversity can be encouraged by the findings of past studies while recognising the

While there is a growing body of research in respect of relational network developments which can effectively support older people, there does appear to be a particular gap in terms of early years' studies. Whether more charity or business-oriented, FBOS are clearly now a fact of life and further research is needed across all age ranges, 'growing up' and 'growing down'

ing point for the commissioning of future research, is a difficult challenge.

synthesis of this potential. This now follows.

community development.

and economic classes.

**4.2. Implications for research**

pressing need now for further supportive research.

Two further projects locate older people in pastoral roles. The findings here seem to confirm those of comparable previous past service evaluations and organisational analyses in terms of identifying the peculiar benefits of seniors' 'brief interventions' and 'moderating influences' [32, 33], because such young street partygoers or busy and stressed commuters perceive them as safe, non-threatening sources of wisdom and authoritative guidance. For these older people too, there is the perceived advantage of having spiritual vocation with prayerful peer support. The term 'moderating influences' also applies to our studies of governance in faith-based social enterprises. These specific contributions by 'experienced elders' have been important in the process of evolution through which exclusively faith-based trustees 'bridge' between their missional aims and the needs and demands of the wider community [34].

Our recent work focusing on the evaluation of health literacy resources for parents of children under 5 [35] highlighted the barriers faced by parents (white British and those for whom English is not the first language), with low literacy/health literacy. This represents a paradox that those who are most in need of health literacy resources are least likely to access them [36]. Vulnerable groups have the need of additional support to access, understand and apply resources, but identifying these needs is challenging as these communities are reticent to engage with research [37]. Researchers who are serious about engaging with minority groups will need to address any cultural, language and practical barriers that exist. As outlined above, FBOs and community groups already engaging with these groups are likely to possess useful insights. The current work within our Health and Wellbeing Research Group is focused on identifying how to effectively engage vulnerable parents/children in research, by learning from the existing good practice of community and faith-based organisations already working in these domains.

## **4. Discussion**

### **4.1. Topic summary**

We now need to draw together the learning acquired from our data capture and analysis. This has to begin by acknowledging that policy development has outstripped research when it comes to setting the agenda for communities affected by modern trends in diversity. Empirical studies are in short supply. The pace of change is such that the process of producing a clear summary that describes well-defined elements of the topic's subject areas, as the starting point for the commissioning of future research, is a difficult challenge.

In responding to this challenge, we return to what became our main aim of identifying the potential for public health of increasingly diverse communities. In pulling together our literature review findings with local practice examples, we are in the position to provide a narrative synthesis of this potential. This now follows.

What we can assert with confidence, in a topic summary, from the evidence so far is that diverse communities can be cohesive and that this cohesion can be a source for health promotion. Two key factors have been identified as positive factors in achieving this cohesion. The first key factor is the development of more open communication systems in and across communities, and the second key factor is the expansion of more socially interactive means of identity development within them. These two determinants possess corresponding factors which have been dominant but are now required to be less influential if diversity and cohesion are to be enhanced: the focus on internal communications and physical structures for community development.

We can also postulate that while many agencies are able to contribute to local health improvements, the two core positive features of diverse but cohesive communities do provide particular opportunities for those with a faith orientation. The research so far supports this assertion, which aligns for example with some recent studies from the United States [38, 39]. Faith-oriented agencies are particularly well placed in terms of values and vocational commitment to facilitate and integrate the growing range of informal networks and wellbeing service outlets which posited the policies that we have noted for place-based public health. Above all their spiritual orientation means that there are no boundaries to the reach of their relationships with people located across all sociodemographic categories, political affiliations and economic classes.

### **4.2. Implications for research**

Cross generational communications have long been promulgated as a potentially rich but underutilised resource for sapiential learning [31]. The findings in two of our projects supported this view. In the first active and trained older men served (with consent) as befrienders for families at risk of breakdown across a range of new and older housing estates. In these families the father was absent for reasons of custodial incarceration or partner separation. Perhaps, surprisingly, it was the fathers who scored this service the highest in terms of positive satisfaction, with some highlighting the prospective benefits of being able to draw on older mens' experience and contacts for future employment and training opportunities. A second project for families which have suffered parental loss is similarly highlighting the

Two further projects locate older people in pastoral roles. The findings here seem to confirm those of comparable previous past service evaluations and organisational analyses in terms of identifying the peculiar benefits of seniors' 'brief interventions' and 'moderating influences' [32, 33], because such young street partygoers or busy and stressed commuters perceive them as safe, non-threatening sources of wisdom and authoritative guidance. For these older people too, there is the perceived advantage of having spiritual vocation with prayerful peer support. The term 'moderating influences' also applies to our studies of governance in faith-based social enterprises. These specific contributions by 'experienced elders' have been important in the process of evolution through which exclusively faith-based trustees 'bridge' between their

Our recent work focusing on the evaluation of health literacy resources for parents of children under 5 [35] highlighted the barriers faced by parents (white British and those for whom English is not the first language), with low literacy/health literacy. This represents a paradox that those who are most in need of health literacy resources are least likely to access them [36]. Vulnerable groups have the need of additional support to access, understand and apply resources, but identifying these needs is challenging as these communities are reticent to engage with research [37]. Researchers who are serious about engaging with minority groups will need to address any cultural, language and practical barriers that exist. As outlined above, FBOs and community groups already engaging with these groups are likely to possess useful insights. The current work within our Health and Wellbeing Research Group is focused on identifying how to effectively engage vulnerable parents/children in research, by learning from the existing good practice of community and faith-based organisations already working

We now need to draw together the learning acquired from our data capture and analysis. This has to begin by acknowledging that policy development has outstripped research when it comes to setting the agenda for communities affected by modern trends in diversity. Empirical studies are in short supply. The pace of change is such that the process of producing

contribution of older persons as both sponsors and carers on a citywide basis.

100 Public Health - Emerging and Re-emerging Issues

missional aims and the needs and demands of the wider community [34].

in these domains.

**4. Discussion**

**4.1. Topic summary**

Geared to alleviating health inequalities, evaluations of the effects of all community-based health and wellbeing interventions must pay particular attention to accessing with sensitivity the views of those most at risk of being disadvantaged. For the significance of spiritual actors and agency researchers must be prepared to learn from faith-based and other organisations already working in these domains. The two-way exchange between faith and empiricism can only help to address inherent and novel cultural, language and practical issues arising in new communities. A number of scholars have begun to address these issues in other areas of research (e.g. [40]). Those seeking to enhance community health and cohesion through new forms of diversity can be encouraged by the findings of past studies while recognising the pressing need now for further supportive research.

While there is a growing body of research in respect of relational network developments which can effectively support older people, there does appear to be a particular gap in terms of early years' studies. Whether more charity or business-oriented, FBOS are clearly now a fact of life and further research is needed across all age ranges, 'growing up' and 'growing down' are included. There are methodological challenges here for researchers. Traditional 'closed system' experimental approaches will not suit community interventions that take place within the complex systems of social relationships that increasingly characterise more diverse communities. The cohesion of these depends on a better understanding of what they are and how they can grow. The opportunities for ethnographic and realist research approaches [41, 42] are abundant, and it would be the prudent leader of a faith-oriented social enterprise who incorporates action research or participant observation into his or her toolkit.

[3] Diocese of Winchester, Sharing God's Life. Winchester: Brand Creative; 2016

University Press Oxford; 2006. ISBN: 0198565895, 9780198565895

sions of network building. The Gerontologist. 1981;**21**(6):600-609

Personality and Social Psychology. 1983;**45**:943-953

national Journal of Wellbeing. 2012;**23**:222-235

Community Development Foundation; 2000

[6] Denham J. Building Cohesive Communities. London: Home Office; 2001

Open Public Health Journal. 2016;**9**:31-37

London: Bedford Square Press; 1982

Measures. Newport, USA: ONS; 2001

Learning: Belmont, USA; 2008

Oxford: Butterworth-Heinemann; 2009

synthesis. Housing, Care and Support. 2016;**19**(3/4):1-9

WHO; 1997

1991;**5**(2):147-162

[4] Meads G. Wellbeing agencies in the high street: The rebirth of primary health care? The

Developing Community Health and Cohesion Through Diversity: An Evidence Synthesis…

http://dx.doi.org/10.5772/intechopen.77974

103

[5] Wilkinson RG, Marmot MG. Social Determinants of Health. 2nd ed. Oxford: Oxford

[7] World Health Assembly. Health Promotion into the 21st Century. Declaration. Jakarta:

[8] Barclay P. Social Workers, their Role and Tasks. Neighbourhood Social Work Report.

[9] Wenger GC. A network typology: From theory to practice. Journal of Ageing Studies.

[10] Wentowski GJ. Reciprocity and the coping strategies of older people. Cultural dimen-

[11] Wheeler L, Reis H, Neziek J. Loneliness, social interaction and sex roles. Journal of

[12] Beaumont J. Measuring National Wellbeing – Discussion Paper on Domains and

[13] Dodge R, Daly A, Heyton J, Sanders LD. The challenge of defining wellbeing. Inter-

[14] Barr A, Hashagen S. Achieving Better Community Development. Handbook. London:

[15] Goodman L, Fels Smyth K. The Full Frame Approach. On the Rise: Cambridge, MASS; 2006 [16] Homan M. Promoting Community Change: Making it Happen in the Real World. Cengage

[17] Phillipson C. The Family and Community Life of Older People: Social Networks and

[18] Gardner P. Natural neighbourhood networks—Important social networks in the lives of

[19] Golden J, Conroy I, Bruce I. Loneliness, social support networks, mood and wellbeing in community dwelling elderly. Journal of Geriatric Pscyhiatry. 2009;**24**(7):694-700

[20] Richards G, Palmer RD. Eventful Cities: Cultural Management and Urban Revitalisation.

[21] Meads G, Lees A, Tapson C. Creational narratives for new housing communities: Evidence

older adults aging in place. Journal of Aging Studies. 2011;**25**(3):263-267

Social Support in three Urban Areas. London: Routledge; 2001

It is a limitation of this chapter that it has only scratched the surface of such qualitative enquiry methods in its exploration of the new profile of wellbeing interventions. Our research process for this process has been essentially iterative, responding both to the particular agendas of our partners and the sometimes unexpected direction provided by the sources accessed. Local case studies from arbitrarily selected locations can only ever be, at best, indicative and generalisable findings in respect of our two initial questions regarding the contribution of faithbased agencies are still out of reach. But the topic summary above does provide a platform on which more in-depth studies can now be formulated.

## **5. Conclusion**

We have described the unique role that faith-based agencies can play through their existing presence and infrastructure within communities and their associated social (or religious and spiritual) capital. Relevant policy and practice guidance have been identified which iterates a range of models to maximise engagement of existing health services with faith-based and third sector organisations, and evidence for some of these models has been presented. As has been stated earlier, policy has outstripped research in this area, and there is much scope for further research and evaluation in the area of faith-based contributions to health and wellbeing.

## **Author details**

Geoffrey Meads\* and Amanda Lees

\*Address all correspondence to: geoffrey.meads@winchester.ac.uk

Health and Wellbeing Research Group, University of Winchester, Winchester, UK

## **References**


[3] Diocese of Winchester, Sharing God's Life. Winchester: Brand Creative; 2016

are included. There are methodological challenges here for researchers. Traditional 'closed system' experimental approaches will not suit community interventions that take place within the complex systems of social relationships that increasingly characterise more diverse communities. The cohesion of these depends on a better understanding of what they are and how they can grow. The opportunities for ethnographic and realist research approaches [41, 42] are abundant, and it would be the prudent leader of a faith-oriented social enterprise

It is a limitation of this chapter that it has only scratched the surface of such qualitative enquiry methods in its exploration of the new profile of wellbeing interventions. Our research process for this process has been essentially iterative, responding both to the particular agendas of our partners and the sometimes unexpected direction provided by the sources accessed. Local case studies from arbitrarily selected locations can only ever be, at best, indicative and generalisable findings in respect of our two initial questions regarding the contribution of faithbased agencies are still out of reach. But the topic summary above does provide a platform on

We have described the unique role that faith-based agencies can play through their existing presence and infrastructure within communities and their associated social (or religious and spiritual) capital. Relevant policy and practice guidance have been identified which iterates a range of models to maximise engagement of existing health services with faith-based and third sector organisations, and evidence for some of these models has been presented. As has been stated earlier, policy has outstripped research in this area, and there is much scope for further research and evaluation in the area of faith-based contributions to health and wellbeing.

who incorporates action research or participant observation into his or her toolkit.

which more in-depth studies can now be formulated.

**5. Conclusion**

102 Public Health - Emerging and Re-emerging Issues

**Author details**

**References**

WHO; 2003

Geoffrey Meads\* and Amanda Lees

\*Address all correspondence to: geoffrey.meads@winchester.ac.uk

Social Determinants of Health. Geneva: WHO; 2008

Health and Wellbeing Research Group, University of Winchester, Winchester, UK

[1] Marmot M. Wilkinson R, Social Determinants of Health. The Solid Facts. Copenhagen:

[2] Marmot M. Closing the Gap in a Generation: Health Equity Through Action on the


[22] Peckover S. From "public health" to "safeguarding children": British health visiting in policy, practice and research. Children & Society. 2013;**27**:116-126. DOI: 10.1111/ j.1099-0860.2011.00370.x

[36] Patient Information Forum. Making the Case for Information [Internet]. 2013. Available from: http://www.selfcareforum.org/wp-content/uploads/2013/07/PiF-Case-for-

Developing Community Health and Cohesion Through Diversity: An Evidence Synthesis…

http://dx.doi.org/10.5772/intechopen.77974

105

[37] Dixon Woods M, Cavers D, Agarwal S, Annandale E, Arthur A, Harvey J, Hsu R, Katbamna S, Olsen R, Smith L, Riley R, Sutton AJ. Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Medical

[38] Popay J, Whitehead M, Carr-hill R. The impact on health inequalities of approaches to community engagement in the new deal for communities regeneration initiative: A

[39] Zahner S, Corrado S. Local health department partnerships with faith based organisations. Journal of Public Health Management and Practice. 2004;**10**(3):258-265

[40] Swinton J, Mowat H. Practical Theology and Qualitative Research. London: SCM Press;

[41] Draper B. Soulfness: Deepening the Mindful Life. London: Hodder & Stoughton; 2016

Information-Exec-Summ-FINAL-May13.pdf [Accessed: 2017-10-08]

Research Methodology. 2006;**6**:35. DOI: 10.1186/1471-2288-6-35

[42] Pawson R, Tilley N. Realistic Evaluation. London: Sage; 1997

2006

mixed methods evaluation. Public Health Research. 2015;**3**(12):111-134


[22] Peckover S. From "public health" to "safeguarding children": British health visiting in policy, practice and research. Children & Society. 2013;**27**:116-126. DOI: 10.1111/

[23] UK Department of Health. Five Year Forward View [Internet]. 2014. Available from: https://www.england.nhs.uk/five-year-forward-view/ [Accessed: 2018-02-21]

[24] Public Health England. From Evidence into action: Opportunities to Protect and Improve the Nation's Health [Internet]. 2014. Available from: https://www.gov.uk/government/ publications/from-evidence-into-action-opportunities-to-protect-and-improve-the-

[25] Marmot, M. Fair Society, Healthy Lives. The Marmot Review [Internet]. 2010. Available

[26] Public Health England. A Guide to Community-centred Approaches for Health and Wellbeing [Internet]. 2015. Available from: www.gov.uk/phe [Accessed: 2017-12-19] [27] South, J. The Family of Community-Centred Approaches for Health and Wellbeing [Internet]. 2014. Available from: https://www.nice.org.uk/guidance/ng44/evidence/

[28] FaithAction. The Impact of Faith-Based Organisations on Public Health and Social Capital [Internet]. 2014. Available from: http://www.faithaction.net/resources/ [Accessed:

[29] Ainsworth H, Shah S, Ahmed F, Amos A, Cameron I, Fairhurst C, King R, Mir G, Parrott S, Sheikh A, Torgerson D, Thomson H, Siddiqi K. Muslim communities learning about second-hand smoke (MCLASS): Study protocol for a pilot cluster randomised controlled

[30] Pathak P, McGhee D. "I thought this was a Christian thing?" Exploring virtuous and exclusionary cycles in faith-based social action. Community Development Journal.

[31] Schweitzer P. Age Exchanges. An Inter-Generational Approach. London: The Remini-

[32] Seanor J. Learning from failure, ambiguity and trust in a social enterprise. Social Enter-

[33] Flint J. Faith and housing in England: Promoting community cohesion or contributing to urban segregation? Journal of Ethnic and Migration Studies. 2010;**36**(2):257-274

[34] Meads G. From pastoral care to public health: An ethnographic case study of collaborative governance in a local food Bank. The Open Public Health Journal. 2017;**10**:3-13. DOI:

[35] Lees A, Tapson K, Patel S. A qualitative evaluation of parents' experiences of health literacy information about common childhood conditions. Self Care. 2018;**9**(1):1-15

from: www.ucl.ac.uk/marmotreview [Accessed: 2018-02-22]

expert-paper-1-jane-south-2368404973 [Accessed 2017-12-19]

trial. Trials. 2013;**14**:295. DOI: 10.1186/1745-6215-14-295

2015;**2015, 50**(1):40-54. DOI: 10.1093/cdj/bst089

j.1099-0860.2011.00370.x

104 Public Health - Emerging and Re-emerging Issues

2018-01-19]

scence Centre; 2003

prise Journal. 2008;**4**(1):24-40

10.2174/187494450171001

nations-health [Accessed: 2018-02-21]

**Chapter 6**

**Provisional chapter**

**Combating Cancer Through Public Health Practice in**

**Combating Cancer Through Public Health Practice in** 

DOI: 10.5772/intechopen.78582

**the United States: An In-Depth Look at the National**

**the United States: An In-Depth Look at the National** 

Cancer is the second leading cause of the death in the United States (U.S.). The National Comprehensive Cancer Control Program (NCCCP) is a national, public health practice program funded by the U.S. Centers for Disease Control and Prevention. The NCCCP has been planning and implementing interventions to reduce the burden of cancer since 1998. Interventions are implemented across three areas primary prevention, early detection, and survivorship using health systems and environmental changes to promote sustainable cancer control. The aim of this chapter is to provide a summary of the NCCCP, and highlight specific examples of interventions and successes to aid cancer planning in other countries. Cancer plan analyses show that all NCCCP participant cancer plans address reducing tobacco use for cancer prevention and 98% contain activities to increase colorectal cancer screening. The vast majority implement activities to improve the quality of life following a cancer diagnosis (94%). Relatively fewer cancer plans contain activities to reduce radon exposure (42%), promote human papilloma virus vaccination (62%), and incorporate the use of genomics in cancer control (56%). The examples of NCCCP activities demonstrate success in controlling cancer and other non-communicable diseases

**Keywords:** comprehensive cancer control, cancer plan, primary prevention,

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

**Comprehensive Cancer Control Program**

**Comprehensive Cancer Control Program**

Sherri L. Stewart, Nikki S. Hayes, Angela R. Moore,

Sherri L. Stewart, Nikki S. Hayes, Angela R. Moore,

Robert Bailey II, Phaeydra M. Brown and

Robert Bailey II, Phaeydra M. Brown and

http://dx.doi.org/10.5772/intechopen.78582

through public health practice.

cancer screening, cancer survivorship

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Ena Wanliss

**Abstract**

Ena Wanliss

#### **Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the National Comprehensive Cancer Control Program Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the National Comprehensive Cancer Control Program**

DOI: 10.5772/intechopen.78582

Sherri L. Stewart, Nikki S. Hayes, Angela R. Moore, Robert Bailey II, Phaeydra M. Brown and Ena Wanliss Sherri L. Stewart, Nikki S. Hayes, Angela R. Moore, Robert Bailey II, Phaeydra M. Brown and Ena Wanliss

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.78582

#### **Abstract**

Cancer is the second leading cause of the death in the United States (U.S.). The National Comprehensive Cancer Control Program (NCCCP) is a national, public health practice program funded by the U.S. Centers for Disease Control and Prevention. The NCCCP has been planning and implementing interventions to reduce the burden of cancer since 1998. Interventions are implemented across three areas primary prevention, early detection, and survivorship using health systems and environmental changes to promote sustainable cancer control. The aim of this chapter is to provide a summary of the NCCCP, and highlight specific examples of interventions and successes to aid cancer planning in other countries. Cancer plan analyses show that all NCCCP participant cancer plans address reducing tobacco use for cancer prevention and 98% contain activities to increase colorectal cancer screening. The vast majority implement activities to improve the quality of life following a cancer diagnosis (94%). Relatively fewer cancer plans contain activities to reduce radon exposure (42%), promote human papilloma virus vaccination (62%), and incorporate the use of genomics in cancer control (56%). The examples of NCCCP activities demonstrate success in controlling cancer and other non-communicable diseases through public health practice.

**Keywords:** comprehensive cancer control, cancer plan, primary prevention, cancer screening, cancer survivorship

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **1. Introduction**

#### **1.1. Cancer and public health in the United States**

Cancer is a major public health concern in the United States (U.S.); it is currently the second leading cause of death among U.S. men and women after heart disease [1]. Cancer has long been a commonly diagnosed disease in the U.S. with over a million new cases diagnosed each year [2]. While age-adjusted rates of cancer have for the most part decreased in recent years, the actual number of cases diagnosed has increased and is projected to continue to increase in future years, mostly due to the aging of the U.S. population [2, 3]. Projections also suggest that cancer will soon surpass heart disease to become the overall leading cause of death in the U.S. [1]. The U.S. Centers for Disease Control and Prevention (CDC), the nation's health protection agency, administers several national programs to reduce the burden of cancer [4]. In 1992, the National Program of Cancer Registries (NPCR) was established to systematically collect information on all cancers diagnosed in the United States (NPCR registries cover 96% of the U.S. population). NPCR, in collaboration with other agencies, releases the official federal cancer statistics on an annual basis [2, 5]. In 1990, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was established to provide breast and cervical cancer screening and diagnostic services to low-income, under- and uninsured women who would otherwise have no access to these services [6]. From 1991 to 2012, the NBCCEDP has served more than 4.5 million women, and more than 65,000 breast and cervical cancer diagnoses occurred through the program during this time [6].

treatment. Conversely, cancer rates in many low and middle-income countries are increasing due to increases in preventable risk behaviors such as smoking, obesity, and physical inactivity [11]. The global movement for cancer control is gaining momentum. Since 2011, the World Health Organization (WHO) has called for improved agenda setting for cancer control among all member states (including low-income countries), to offset the large economic burden caused by cancer in all countries [12]. WHO cancer control strategies include planning, reduction of non-behavioral factors such as environmental and infectious risks in all countries, as well as progress in cancer treatment and effective health systems in more affluent countries [12]. **Figure 1** lists additional cancer control strategies for all countries by income level, suggested by the U.S. Institute of Medicine, the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, and the Union for International Cancer Control [13]. The NCCCP is a long-standing example of a successful national cancer control program that incorporates these strategies. The NCCCP brings together an extremely diverse set of U.S. state, tribal, and territorial participants under one national umbrella program. As such, it serves as a rich resource for the global incorporation of cancer control measures across myriad populations with different structures and challenges. This aim of this book chapter is to provide a summary of the NCCCP, and highlight specific examples of interventions implemented and successes achieved. Our intention is to provide a snapshot of activities that have been implemented at given times over the 20-year history of the program, in order to aid other countries in their cancer control activities. The examples discussed below may also aid

Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the…

http://dx.doi.org/10.5772/intechopen.78582

109

**Figure 1.** Global strategies for controlling cancer by income level of country. Reprinted with permission from authors

and the American Society of Clinical Oncology [13].

Because cancer is a group of diseases with various risk factors and outcomes, it was determined that a more broad-based and coordinated public health approach that incorporated risk reduction, early detection and post-diagnosis care may be necessary to address cancer in the U.S. As such, in 1998, CDC established the National Comprehensive Cancer Control Program (NCCCP), which provides funding to state and local health departments throughout the United States for the formation of a coalition of public health practitioners, clinicians, academicians, and other key stakeholders residing in or administering to that population [7]. This coalition uses their first-hand knowledge of the key factors and issues that their population faces with regard to cancer to develop a formal, written cancer plan which guides the cancer control activities within the area [7]. Cancer plans are updated at specified time intervals and are available along with a search tool for public use on CDC's website [8].

In addition to an increasing U.S. cancer burden, cancer is an emerging public health challenge in developing countries because of the aging and expansion of the population and increased prevalence of cancer risk factors such as smoking, obesity, and physical inactivity [9]. While global public health efforts in developing countries have traditionally centered on the prevention and treatment of communicable diseases, the global burden of disease has been changing, with approximately 70% of worldwide deaths in 2015 due to non-communicable diseases [10]. Cancer accounted for 22% of all non-communicable deaths globally in 2015, and over 75% of these deaths occurred in low and middle-income countries [10]. While the burden of cancer is substantial in all countries, high-income countries are increasingly addressing cancer rates through improvements in risk factor prevention, screening and early detection, and treatment. Conversely, cancer rates in many low and middle-income countries are increasing due to increases in preventable risk behaviors such as smoking, obesity, and physical inactivity [11]. The global movement for cancer control is gaining momentum. Since 2011, the World Health Organization (WHO) has called for improved agenda setting for cancer control among all member states (including low-income countries), to offset the large economic burden caused by cancer in all countries [12]. WHO cancer control strategies include planning, reduction of non-behavioral factors such as environmental and infectious risks in all countries, as well as progress in cancer treatment and effective health systems in more affluent countries [12]. **Figure 1** lists additional cancer control strategies for all countries by income level, suggested by the U.S. Institute of Medicine, the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, and the Union for International Cancer Control [13]. The NCCCP is a long-standing example of a successful national cancer control program that incorporates these strategies. The NCCCP brings together an extremely diverse set of U.S. state, tribal, and territorial participants under one national umbrella program. As such, it serves as a rich resource for the global incorporation of cancer control measures across myriad populations with different structures and challenges. This aim of this book chapter is to provide a summary of the NCCCP, and highlight specific examples of interventions implemented and successes achieved. Our intention is to provide a snapshot of activities that have been implemented at given times over the 20-year history of the program, in order to aid other countries in their cancer control activities. The examples discussed below may also aid

**1. Introduction**

108 Public Health - Emerging and Re-emerging Issues

**1.1. Cancer and public health in the United States**

occurred through the program during this time [6].

Cancer is a major public health concern in the United States (U.S.); it is currently the second leading cause of death among U.S. men and women after heart disease [1]. Cancer has long been a commonly diagnosed disease in the U.S. with over a million new cases diagnosed each year [2]. While age-adjusted rates of cancer have for the most part decreased in recent years, the actual number of cases diagnosed has increased and is projected to continue to increase in future years, mostly due to the aging of the U.S. population [2, 3]. Projections also suggest that cancer will soon surpass heart disease to become the overall leading cause of death in the U.S. [1]. The U.S. Centers for Disease Control and Prevention (CDC), the nation's health protection agency, administers several national programs to reduce the burden of cancer [4]. In 1992, the National Program of Cancer Registries (NPCR) was established to systematically collect information on all cancers diagnosed in the United States (NPCR registries cover 96% of the U.S. population). NPCR, in collaboration with other agencies, releases the official federal cancer statistics on an annual basis [2, 5]. In 1990, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was established to provide breast and cervical cancer screening and diagnostic services to low-income, under- and uninsured women who would otherwise have no access to these services [6]. From 1991 to 2012, the NBCCEDP has served more than 4.5 million women, and more than 65,000 breast and cervical cancer diagnoses

Because cancer is a group of diseases with various risk factors and outcomes, it was determined that a more broad-based and coordinated public health approach that incorporated risk reduction, early detection and post-diagnosis care may be necessary to address cancer in the U.S. As such, in 1998, CDC established the National Comprehensive Cancer Control Program (NCCCP), which provides funding to state and local health departments throughout the United States for the formation of a coalition of public health practitioners, clinicians, academicians, and other key stakeholders residing in or administering to that population [7]. This coalition uses their first-hand knowledge of the key factors and issues that their population faces with regard to cancer to develop a formal, written cancer plan which guides the cancer control activities within the area [7]. Cancer plans are updated at specified time intervals and are available along with a search tool for public use on CDC's website [8].

In addition to an increasing U.S. cancer burden, cancer is an emerging public health challenge in developing countries because of the aging and expansion of the population and increased prevalence of cancer risk factors such as smoking, obesity, and physical inactivity [9]. While global public health efforts in developing countries have traditionally centered on the prevention and treatment of communicable diseases, the global burden of disease has been changing, with approximately 70% of worldwide deaths in 2015 due to non-communicable diseases [10]. Cancer accounted for 22% of all non-communicable deaths globally in 2015, and over 75% of these deaths occurred in low and middle-income countries [10]. While the burden of cancer is substantial in all countries, high-income countries are increasingly addressing cancer rates through improvements in risk factor prevention, screening and early detection, and

**Figure 1.** Global strategies for controlling cancer by income level of country. Reprinted with permission from authors and the American Society of Clinical Oncology [13].

those doing non-communicable disease planning, as many risk factors for cancer are shared with other non-communicable diseases [12].

were receiving funding to implement specific cancer control activities [14]. Also in 2005, CDC began offering additional funding on a competitive basis to NCCCP participants to implement specific activities related to ovarian, prostate, skin, colorectal cancer. As of 2018, the NCCCP has 66 funded participants: all 50 states, the District of Columbia, Puerto Rico, eight AI/AN tribes or tribal organizations, and six USAPIJ. There is a great deal of diversity among each of these funded entities in terms of cancer burden, racial and ethnic structure, levels of income inequality and poverty, and access to cancer care and services. All these factors influ-

Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the…

http://dx.doi.org/10.5772/intechopen.78582

111

Evaluation efforts at the national level in the early years of the program, including the development and fielding of a performance measurement system and cancer plan assessment tool, provided valuable information regarding technical assistance needs and improvements that could be made across all participants [16–18]. Results from surveys in 2009 and 2010 showed that a majority of programs had successfully implemented at least one community- or organization-level change strategy; however, not all programs were using only evidence-based interventions, and there were few participants linking their activities to cancer impact [19]. Recognizing that participants needed assistance in these areas, as well as in communicating their efforts, CDC developed an overarching set of strategic priorities to guide the cancer public health practice of all NCCCP participants, regardless of their unique nature and cancer burden [20]. These priorities (**Table 1**) provide a roadmap for participants to follow, while still allowing for flexibility at the participant level for development of specific strategies that work in their area. At the national level, the priorities allow for provision of standardized technical assistance and tools, a more objective and consistent way to assess participant performance, and a more uniform and systematic way to disseminate information and successes regarding programmatic activities. The priorities span the cancer continuum (primary prevention, early detection, and survivorship), and place special emphasis on addressing health disparities and inequities in each of these continuum areas [20]. The priorities also define the methodology participants are encouraged to use to address these areas, specifically the implementation of systems and environmental change approaches, and emphasize participant-level evaluation as critical part of programmatic success [20]. The priorities were released in 2010 and were readily incorporated into planning by NCCCP participants. Soon after the release of the priorities, informal assessments showed programs tended to focus on implementation activities in one priority area (for example, some participants were implementing only primary

1. Place emphasis on the primary prevention of cancer during planning and implementation to reduce risk and

4. Reduce cancer disparities by planning and implementing interventions in line with priorities 1-3, but tailored for

2. Promote the early detection of cancers for which population-based screening is recommended.

5. Use systems and environmental change approaches resulting in sustainable cancer control.

environmental exposures.

3. Address the public health needs of cancer survivors.

specific underserved and/or in-need populations.

6. Measure all outcomes and impact through formal evaluation.

**Table 1.** The National Comprehensive Cancer Control Program Priorities.

ence the level of funding each participant receives from CDC.

## **1.2. Sources and methodology**

PubMed (https://www.ncbi.nlm.nih.gov/pubmed/) was searched for the key words "comprehensive cancer control" in order to retrieve published articles pertaining to the NCCCP. Articles were limited to those published from U.S. authors and those published since 1998, the year the NCCCP was established. Article abstracts were scanned in order to determine whether the content was related to the NCCCP specifically, or to other general or broad efforts not pertaining to this CDC-funded program. All articles found to be NCCCP-specific were read for content and those that contained analyses of cancer plans or activities implemented as part of cancer planning were chosen for inclusion as an example of activities in this book chapter (see Section 3 below). In addition, CDC's main cancer website https://www.cdc.gov/ cancer/ was searched for NCCCP-related content, and all content that contained activities implemented as part of cancer planning was also included in the examples section. Articles or website material retrieved that pertained solely to NCCCP development and/or evaluation were generally excluded from the examples section, but were used in some cases to describe the NCCCP (see Section 2 below). The examples provided in Section 3 do not represent a comprehensive environmental scan or systematic review of all initiatives undertaken by NCCCP participants, as only published literature found on PubMed or CDC's NCCCP website were used as sources. Many NCCCP participants have their own websites with further information that may be useful for cancer and non-communicable disease planners. NCCCP participant information is available on the CDC website [8].

## **2. The National Comprehensive Cancer Control Program**

In 1998, the NCCCP was established and provided funding to five U.S. states and one tribal health board–Colorado, Massachusetts, Michigan, North Carolina, Texas, and the Northwest Portland Area Indian Health Board [NPAIHB]. These areas already had existing cancer plans and were in different stages of implementation [14]. The new CDC funding allowed for expansion into certain areas such as survivorship, pediatric cancers, genomics, and blood cancers [15]. It also established an avenue for providing coordinated, technical assistance from the national perspective and exchange of ideas and practices among the participants. The program quickly grew over the next few years to include 63 participants in 2005 (all 50 U.S. states, the District of Columbia, Puerto Rico, six American Indian/Alaska Native (AI/AN) tribes and tribal organizations, and six U.S. Associated Pacific Islands Jurisdictions [USAPIJ]) [14]. CDC funding specifically allowed for NCCCP participants to establish or maintain diverse cancer coalitions made up of key cancer stakeholders in each participant's area, for the coalition to determine their area's individual priorities for cancer prevention and control in a formal cancer plan, and to establish an ongoing infrastructure to implement priorities contained within the cancer plan [10]. As of 2005, more than half of the 63 NCCCP participants were receiving funding solely to build capacity and infrastructure, while the more advanced participants were receiving funding to implement specific cancer control activities [14]. Also in 2005, CDC began offering additional funding on a competitive basis to NCCCP participants to implement specific activities related to ovarian, prostate, skin, colorectal cancer. As of 2018, the NCCCP has 66 funded participants: all 50 states, the District of Columbia, Puerto Rico, eight AI/AN tribes or tribal organizations, and six USAPIJ. There is a great deal of diversity among each of these funded entities in terms of cancer burden, racial and ethnic structure, levels of income inequality and poverty, and access to cancer care and services. All these factors influence the level of funding each participant receives from CDC.

Evaluation efforts at the national level in the early years of the program, including the development and fielding of a performance measurement system and cancer plan assessment tool, provided valuable information regarding technical assistance needs and improvements that could be made across all participants [16–18]. Results from surveys in 2009 and 2010 showed that a majority of programs had successfully implemented at least one community- or organization-level change strategy; however, not all programs were using only evidence-based interventions, and there were few participants linking their activities to cancer impact [19]. Recognizing that participants needed assistance in these areas, as well as in communicating their efforts, CDC developed an overarching set of strategic priorities to guide the cancer public health practice of all NCCCP participants, regardless of their unique nature and cancer burden [20]. These priorities (**Table 1**) provide a roadmap for participants to follow, while still allowing for flexibility at the participant level for development of specific strategies that work in their area. At the national level, the priorities allow for provision of standardized technical assistance and tools, a more objective and consistent way to assess participant performance, and a more uniform and systematic way to disseminate information and successes regarding programmatic activities. The priorities span the cancer continuum (primary prevention, early detection, and survivorship), and place special emphasis on addressing health disparities and inequities in each of these continuum areas [20]. The priorities also define the methodology participants are encouraged to use to address these areas, specifically the implementation of systems and environmental change approaches, and emphasize participant-level evaluation as critical part of programmatic success [20]. The priorities were released in 2010 and were readily incorporated into planning by NCCCP participants. Soon after the release of the priorities, informal assessments showed programs tended to focus on implementation activities in one priority area (for example, some participants were implementing only primary


those doing non-communicable disease planning, as many risk factors for cancer are shared

PubMed (https://www.ncbi.nlm.nih.gov/pubmed/) was searched for the key words "comprehensive cancer control" in order to retrieve published articles pertaining to the NCCCP. Articles were limited to those published from U.S. authors and those published since 1998, the year the NCCCP was established. Article abstracts were scanned in order to determine whether the content was related to the NCCCP specifically, or to other general or broad efforts not pertaining to this CDC-funded program. All articles found to be NCCCP-specific were read for content and those that contained analyses of cancer plans or activities implemented as part of cancer planning were chosen for inclusion as an example of activities in this book chapter (see Section 3 below). In addition, CDC's main cancer website https://www.cdc.gov/ cancer/ was searched for NCCCP-related content, and all content that contained activities implemented as part of cancer planning was also included in the examples section. Articles or website material retrieved that pertained solely to NCCCP development and/or evaluation were generally excluded from the examples section, but were used in some cases to describe the NCCCP (see Section 2 below). The examples provided in Section 3 do not represent a comprehensive environmental scan or systematic review of all initiatives undertaken by NCCCP participants, as only published literature found on PubMed or CDC's NCCCP website were used as sources. Many NCCCP participants have their own websites with further information that may be useful for cancer and non-communicable disease planners. NCCCP participant

with other non-communicable diseases [12].

information is available on the CDC website [8].

**2. The National Comprehensive Cancer Control Program**

In 1998, the NCCCP was established and provided funding to five U.S. states and one tribal health board–Colorado, Massachusetts, Michigan, North Carolina, Texas, and the Northwest Portland Area Indian Health Board [NPAIHB]. These areas already had existing cancer plans and were in different stages of implementation [14]. The new CDC funding allowed for expansion into certain areas such as survivorship, pediatric cancers, genomics, and blood cancers [15]. It also established an avenue for providing coordinated, technical assistance from the national perspective and exchange of ideas and practices among the participants. The program quickly grew over the next few years to include 63 participants in 2005 (all 50 U.S. states, the District of Columbia, Puerto Rico, six American Indian/Alaska Native (AI/AN) tribes and tribal organizations, and six U.S. Associated Pacific Islands Jurisdictions [USAPIJ]) [14]. CDC funding specifically allowed for NCCCP participants to establish or maintain diverse cancer coalitions made up of key cancer stakeholders in each participant's area, for the coalition to determine their area's individual priorities for cancer prevention and control in a formal cancer plan, and to establish an ongoing infrastructure to implement priorities contained within the cancer plan [10]. As of 2005, more than half of the 63 NCCCP participants were receiving funding solely to build capacity and infrastructure, while the more advanced participants

**1.2. Sources and methodology**

110 Public Health - Emerging and Re-emerging Issues


**Table 1.** The National Comprehensive Cancer Control Program Priorities.

<sup>1.</sup> Place emphasis on the primary prevention of cancer during planning and implementation to reduce risk and environmental exposures.

prevention strategies listed). As of 2018, all 66 NCCCP participants have demonstrated the capability to implement activities in all priority areas. Current funding agreements require that all NCCCP participants at least three interventions in each of the cancer continuum areas and at least one strategy in these areas has to be aimed at reducing cancer disparities [21]. Additionally, participants use a specific library of interventions and data indicators, compiled by CDC, as a tool to plan and implement their interventions [21].

Implementation of activities that address behavioral risk factors is a key approach most NCCCP plans address the primary prevention of cancer. Lung cancer is the leading cause of death in the U.S. [2], and tobacco use is responsible for about 90% of lung cancer diagnoses [27]. A 2013 assessment of NCCCP cancer plans showed that all plans incorporated at least one evidence-based tobacco control strategy [26]. On average, plans included five Community Guide recommendations related to tobacco, with activities focused on supporting smoking bans and restrictions (87%), mass media campaigns combined with other interventions (81%), provider reminders and provider education (19%), and promoting reduction of client costs for cessation therapies (49%) [26]. The Arkansas Cancer Coalition (ARCC) educated local legislators and the public about the benefits of raising taxes on tobacco products, including specific information regarding the expanded health programs that tobacco tax revenue could offset in Arkansas (estimated to be nearly \$180 million for Arkansas) [27]. The Cherokee Nation Comprehensive Cancer Control Program implemented the *Tobacco Tour*, which educated young members of their tribe about the dangers of tobacco use, using culturally appropriate story-telling methods [28]. The education program also included a presentation from a sixtime cancer survivor and former smokeless tobacco user, who shared intimate details about his experience with tobacco-associated cancer which strongly resonated with the students [28]. Over a four-year period, the *Tobacco Tour* reached more than 4400 children and adolescents in the Cherokee Nation's 14-county Tribal Jurisdictional Service Area in Oklahoma [28]. Radon is the second leading cause of lung cancer, and the leading cause of lung cancer among non-smokers [29]. Many NCCCP participants are increasingly incorporating activities to reduce exposure to radon, a radioactive gas ubiquitously present in the lower levels of U.S. homes and buildings [29]. A 2010 review of cancer plans identified radon-related activities in 27 (42%) plans [29]. An updated review in 2017, showed that the number of NCCCP participants addressing radon had increased; nearly two-thirds of all NCCCP cancer plans contained radon-related strategies [30]. Specific examples of radon activities implemented included increasing education, promoting radon testing and remediation of houses, partnering with other national agencies that address radon, and promoting adherence to existing local statewide radon policies [29, 30]. Iowa has the highest average radon concentrations in the U.S.; the Iowa Cancer Consortium led a collaboration to increase levels of awareness, testing, and (if necessary) mitigation, and to introduce a comprehensive radon control policy in Iowa by engaging partners and stakeholders across the states. Following their multi-pronged intervention, the number of radon tests increased by 20%, and the number of mitigations

Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the…

http://dx.doi.org/10.5772/intechopen.78582

113

completed by certified mitigators increased by 108% [31].

It was recently reported that approximately 631,000 persons per year in the United States receive a diagnosis of a cancer associated with overweight and obesity, representing 40% of all cancers diagnosed [32]. There are several evidence-based nutrition and physical activity strategies for reducing cancer risk due to obesity. A 2016 review of NCCCP cancer plans showed that nutrition and physical activity content was consistently included in all cancer plans, with 89% contained specific goals or strategies in these areas [33]. The most common strategies were related to education (71%), followed by school wellness (61%), worksite-wellness, (47%), and community physical activity (39%) [33]. Examples of strategies in plans included promoting the building of safe sidewalks and bike paths between community schools and residential

## **3. Examples of National Comprehensive Cancer Control Program implementation activities and success**

## **3.1. Evidence for initiatives and interventions**

As of 2017, all NCCCP participants were required to use 60% of their funding for implementation of interventions (with the other 40% being applied to personnel and staffing costs) [21]. All NCCCP participants, regardless of their unique cancer burden, are required to implement evidence-based initiatives and interventions (EBIs) to prevent and control cancer in their population [20]. Several U.S. organizations provide resources for these interventions. The United States Preventive Services Task Force (USPSTF), an independent, volunteer panel of national experts in disease prevention and evidence-based medicine [22], synthesizes all data in a given area (e.g., cervical cancer screening), and provides evidencebased recommendations about clinical preventive services that NCCCP participants follow. CDC's Guide to Community Preventive Services (The Community Guide), the National Cancer Institute's (NCI) Research-tested Intervention Programs (RTIPs) and Using What Works: Adapting Evidence-Based Programs to Fit Your Needs, and the Cancer Control P.L.A.N.E.T. (Plan, Link, Act, Network with Evidence-based tools, co-sponsored by CDC, NCI and others [23]), all provide EBI resources and tools for NCCCP participants [20]. A 2012 survey showed that 75% of NCCCP directors from states, tribes and/or USAPIJs reported using EBIs to address cancer plan objectives [24]. Most directors had used web sites for The Community Guide (95%) and Cancer Control P.L.A.N.E.T. (75%) [24]. Brief descriptions and specific examples of the types of activities are described below, categorized by each cancer continuum-related NCCCP priority area. These implementation examples are from a variety of NCCCP participants in different settings and with different resources. More detailed information on these implementation activities can be found in the cited reference or by contacting the individual NCCCP participant [8].

#### *3.1.1. Emphasizing the primary prevention of cancer*

Primary prevention for cancer includes reducing exposure to cancer-promoting environmental influences, reduction of genetic and behavioral risk factors, and vaccination against viruses that can cause cancer [25]. Many cancer risk factors and viruses also cause other diseases, and therefore emphasizing primary prevention in NCCCP plans has a broader impact on improving health [4]. Many of the strategies and interventions in these areas are specifically recommended to reduce the global burden of cancer [9, 12].

Implementation of activities that address behavioral risk factors is a key approach most NCCCP plans address the primary prevention of cancer. Lung cancer is the leading cause of death in the U.S. [2], and tobacco use is responsible for about 90% of lung cancer diagnoses [27]. A 2013 assessment of NCCCP cancer plans showed that all plans incorporated at least one evidence-based tobacco control strategy [26]. On average, plans included five Community Guide recommendations related to tobacco, with activities focused on supporting smoking bans and restrictions (87%), mass media campaigns combined with other interventions (81%), provider reminders and provider education (19%), and promoting reduction of client costs for cessation therapies (49%) [26]. The Arkansas Cancer Coalition (ARCC) educated local legislators and the public about the benefits of raising taxes on tobacco products, including specific information regarding the expanded health programs that tobacco tax revenue could offset in Arkansas (estimated to be nearly \$180 million for Arkansas) [27]. The Cherokee Nation Comprehensive Cancer Control Program implemented the *Tobacco Tour*, which educated young members of their tribe about the dangers of tobacco use, using culturally appropriate story-telling methods [28]. The education program also included a presentation from a sixtime cancer survivor and former smokeless tobacco user, who shared intimate details about his experience with tobacco-associated cancer which strongly resonated with the students [28]. Over a four-year period, the *Tobacco Tour* reached more than 4400 children and adolescents in the Cherokee Nation's 14-county Tribal Jurisdictional Service Area in Oklahoma [28].

prevention strategies listed). As of 2018, all 66 NCCCP participants have demonstrated the capability to implement activities in all priority areas. Current funding agreements require that all NCCCP participants at least three interventions in each of the cancer continuum areas and at least one strategy in these areas has to be aimed at reducing cancer disparities [21]. Additionally, participants use a specific library of interventions and data indicators, compiled

**3. Examples of National Comprehensive Cancer Control Program** 

As of 2017, all NCCCP participants were required to use 60% of their funding for implementation of interventions (with the other 40% being applied to personnel and staffing costs) [21]. All NCCCP participants, regardless of their unique cancer burden, are required to implement evidence-based initiatives and interventions (EBIs) to prevent and control cancer in their population [20]. Several U.S. organizations provide resources for these interventions. The United States Preventive Services Task Force (USPSTF), an independent, volunteer panel of national experts in disease prevention and evidence-based medicine [22], synthesizes all data in a given area (e.g., cervical cancer screening), and provides evidencebased recommendations about clinical preventive services that NCCCP participants follow. CDC's Guide to Community Preventive Services (The Community Guide), the National Cancer Institute's (NCI) Research-tested Intervention Programs (RTIPs) and Using What Works: Adapting Evidence-Based Programs to Fit Your Needs, and the Cancer Control P.L.A.N.E.T. (Plan, Link, Act, Network with Evidence-based tools, co-sponsored by CDC, NCI and others [23]), all provide EBI resources and tools for NCCCP participants [20]. A 2012 survey showed that 75% of NCCCP directors from states, tribes and/or USAPIJs reported using EBIs to address cancer plan objectives [24]. Most directors had used web sites for The Community Guide (95%) and Cancer Control P.L.A.N.E.T. (75%) [24]. Brief descriptions and specific examples of the types of activities are described below, categorized by each cancer continuum-related NCCCP priority area. These implementation examples are from a variety of NCCCP participants in different settings and with different resources. More detailed information on these implementation activities can be found in the cited reference

Primary prevention for cancer includes reducing exposure to cancer-promoting environmental influences, reduction of genetic and behavioral risk factors, and vaccination against viruses that can cause cancer [25]. Many cancer risk factors and viruses also cause other diseases, and therefore emphasizing primary prevention in NCCCP plans has a broader impact on improving health [4]. Many of the strategies and interventions in these areas are specifically

by CDC, as a tool to plan and implement their interventions [21].

**implementation activities and success**

112 Public Health - Emerging and Re-emerging Issues

**3.1. Evidence for initiatives and interventions**

or by contacting the individual NCCCP participant [8].

recommended to reduce the global burden of cancer [9, 12].

*3.1.1. Emphasizing the primary prevention of cancer*

Radon is the second leading cause of lung cancer, and the leading cause of lung cancer among non-smokers [29]. Many NCCCP participants are increasingly incorporating activities to reduce exposure to radon, a radioactive gas ubiquitously present in the lower levels of U.S. homes and buildings [29]. A 2010 review of cancer plans identified radon-related activities in 27 (42%) plans [29]. An updated review in 2017, showed that the number of NCCCP participants addressing radon had increased; nearly two-thirds of all NCCCP cancer plans contained radon-related strategies [30]. Specific examples of radon activities implemented included increasing education, promoting radon testing and remediation of houses, partnering with other national agencies that address radon, and promoting adherence to existing local statewide radon policies [29, 30]. Iowa has the highest average radon concentrations in the U.S.; the Iowa Cancer Consortium led a collaboration to increase levels of awareness, testing, and (if necessary) mitigation, and to introduce a comprehensive radon control policy in Iowa by engaging partners and stakeholders across the states. Following their multi-pronged intervention, the number of radon tests increased by 20%, and the number of mitigations completed by certified mitigators increased by 108% [31].

It was recently reported that approximately 631,000 persons per year in the United States receive a diagnosis of a cancer associated with overweight and obesity, representing 40% of all cancers diagnosed [32]. There are several evidence-based nutrition and physical activity strategies for reducing cancer risk due to obesity. A 2016 review of NCCCP cancer plans showed that nutrition and physical activity content was consistently included in all cancer plans, with 89% contained specific goals or strategies in these areas [33]. The most common strategies were related to education (71%), followed by school wellness (61%), worksite-wellness, (47%), and community physical activity (39%) [33]. Examples of strategies in plans included promoting the building of safe sidewalks and bike paths between community schools and residential areas, promoting increased time requirement for physical activity during physical education classes in school, increasing healthy food access (farmer's markets, community gardens, etc.), and encouraging children to decrease time spent with video games and TV and to substitute physical activity [33]. Indiana's Cancer Consortium implemented a "*Complete Streets"* initiative aimed at making city streets accessible and attractive to pedestrians and cyclists as well as automobile traffic. They provided coordinated education to the public and decision makers about the importance of planned environments, and partnered with the state transportation department, street design and engineering, pedestrian, and bicycle interest groups to facilitate its implementation. The intervention increased opportunities for Indiana residents to be physically active and reduce their cancer risk [34]. The Iowa Comprehensive Cancer Control Program designed a local initiative to reduce cancers that are disproportionately higher among African-Americans in Iowa [34]. The "*Body and Soul"* program was adapted from RTIPs [35], and tailored for the Iowa population, to increase awareness of healthier choices in nutrition and exercise [34]. In the first year, Iowa worked with 2 churches to support health awareness among its members [34]. More than 1,300 African-American residents across Iowa participated in the program in one year alone, and it is currently estimated that the program has now reached approximately 9700 African-American Iowans [34].

B virus (HBV), respectively [25]. Routine vaccination against HPV at age 11 or 12 years of age has been recommended in the United States since 2006 for females and since 2011 for males [37]. NCCCP participants have played a key role in increasing uptake of the HPV vaccine. A 2017 cancer plan review showed that 62% of plans incorporated at least one activity since 2013 to address low HPV vaccination coverage in their areas [38]. Most plans (86%) reported community education activities, while 65% reported activities associated with provider education [38]. Systems-based strategies such as client reminders or provider assessment and feedback were reported in about of quarter of plans [38]. The North Dakota Comprehensive Cancer Control Program (ND CCCP) partnered with local public health units to facilitate an in-school vaccination program [34]. Public health units in four North Dakota rural counties launched school clinics in 20 middle and high schools to provide HPV vaccinations to students during school hours [34]. Each of the counties involved met or exceeded a 10% increase in vaccination rates, with one county reporting an increase of 18% [34]. The South Dakota Comprehensive Cancer Control Program (SDCCCP) had similar success partnering with a major integrated healthcare system within the state to increase the state's HPV vaccination rates [34]. Over a one year period starting in 2015, SDCCCP partnered with the health system to send out client reminders and provider feedback in seven primary care clinics [34]. More than 41,500 reminders were sent out and more than 3000 doses of HPV vaccine were administered as a result [34]. Community-based activities including panel discussions with cancer survivors and providers and showings of the "Someone You Love: The HPV Epidemic" documentary [39] were also implemented to raise awareness. At the end of the one-year implementation time, the seven participating clinics reported a 14 percentage point increase in HPV doses given to those who

Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the…

http://dx.doi.org/10.5772/intechopen.78582

115

HBV vaccination is currently recommended for all infants, unvaccinated children aged <19 years, persons with diabetes aged 19–59 years, and all those who are at high risk for HBV infection [40]. A 2012 review of 66 cancer plans for liver cancer and HBV content revealed that 35% addressed liver cancer prevention through HBV-related strategies [41]. Specific strategies reported were to implement a culturally-appropriate campaign for high-risk Asian and Pacific Islander communities to increase their awareness about hepatitis B and preventive measures, and to liaise with the local sexually transmitted infections program to share data and incorporate cancer awareness in its activities [41]. Cherokee Nation and Idaho have actively engaged in promoting HBV vaccination by distributing over 2000 patient education resources, holding community meetings about risks associated with liver cancer, and developing and delivering

Genomics is becoming an increasingly important field in the U.S., particularly with regard to its usefulness in precision medicine [42]. CDC has held several workshops and meetings to promote incorporation of genomic and genetic testing awareness and uptake into public health practice [43, 44]. Particular focus areas have been increasing awareness of and surveillance for cancer-promoting genetic mutations such as BRCA1/BRCA2 and those associated with Lynch syndrome that predispose individuals to breast, ovarian, colorectal, uterine, and other cancers [44]. A 2005 review noted that 56% of state plans analyzed had begun to implement genomics components described in their plan [45]. Most states emphasized educating health care providers and the public about the role of genomics in cancer control, and many considered awareness of family history to be an important aspect of cancer planning [45].

had not previously been vaccinated [34].

provider education sessions on HBV vaccination.

Intense, intermittent exposure to ultraviolet (UV) light from the sun is strongly linked with melanoma, which is one of the deadliest forms of skin cancer in the U.S. [2, 36]. New Mexico, Florida, and Arizona used systems and environmental change strategies and the establishment of partnerships (adapted for their individual needs) within schools and educational community to control sun exposure among school children [36]. New Mexico provided two or more presentations per year in schools delivering specific messages to avoid the sun between 10 am and 4 pm, wear sun-protective clothing when exposed to sunlight, and use sunscreen with a sun-protection factor of 15 or higher [36]. More than 3600 students demonstrated positive behavior changes following educational presentations, including playing in the shade, wearing a hat, using sunscreen, and wearing sunglasses. [36]. Additionally, many teachers, who serve as important role models for school children, reported positive changes in their own behavior related to sun safety [36]. New Mexico also implemented 55 systems and environmental changes including modifying recess times to avoid peak UV exposure, allowing students to wear hats outside, and providing shade structures or planting trees [36]. It is estimated that a total of 56,000 school-age children, school staff and community members have been reached through these efforts in New Mexico [27]. South Dakota worked with two worksites who hired seasonal workers to work outdoors to limit UV exposure in the workplace [34]. These worksites adopted local policies to provide employees with sunscreen and lip balm, and employees were also encouraged to wear wide-brimmed hats, long sleeve shirts, lightweight full-length pants, and sunglasses, as well as work in shaded areas and avoiding peak sun hours when possible [34]. Workers (n = 450) reported an increase in their knowledge of sun safety and using some form of protective behavior; wearing wide-brimmed hats and sunglasses, and spending more time in shady areas when possible were the most commonly reported sun protection behaviors [34]. The largest positive behavioral changes were observed among white men younger than 24 or aged 45–54 [34].

Vaccination against certain viruses can prevent cancer [25]. Cervical cancer and hepatocellular (liver) cancer are strongly linked to infection with human papilloma virus (HPV) and hepatitis B virus (HBV), respectively [25]. Routine vaccination against HPV at age 11 or 12 years of age has been recommended in the United States since 2006 for females and since 2011 for males [37]. NCCCP participants have played a key role in increasing uptake of the HPV vaccine. A 2017 cancer plan review showed that 62% of plans incorporated at least one activity since 2013 to address low HPV vaccination coverage in their areas [38]. Most plans (86%) reported community education activities, while 65% reported activities associated with provider education [38]. Systems-based strategies such as client reminders or provider assessment and feedback were reported in about of quarter of plans [38]. The North Dakota Comprehensive Cancer Control Program (ND CCCP) partnered with local public health units to facilitate an in-school vaccination program [34]. Public health units in four North Dakota rural counties launched school clinics in 20 middle and high schools to provide HPV vaccinations to students during school hours [34]. Each of the counties involved met or exceeded a 10% increase in vaccination rates, with one county reporting an increase of 18% [34]. The South Dakota Comprehensive Cancer Control Program (SDCCCP) had similar success partnering with a major integrated healthcare system within the state to increase the state's HPV vaccination rates [34]. Over a one year period starting in 2015, SDCCCP partnered with the health system to send out client reminders and provider feedback in seven primary care clinics [34]. More than 41,500 reminders were sent out and more than 3000 doses of HPV vaccine were administered as a result [34]. Community-based activities including panel discussions with cancer survivors and providers and showings of the "Someone You Love: The HPV Epidemic" documentary [39] were also implemented to raise awareness. At the end of the one-year implementation time, the seven participating clinics reported a 14 percentage point increase in HPV doses given to those who had not previously been vaccinated [34].

areas, promoting increased time requirement for physical activity during physical education classes in school, increasing healthy food access (farmer's markets, community gardens, etc.), and encouraging children to decrease time spent with video games and TV and to substitute physical activity [33]. Indiana's Cancer Consortium implemented a "*Complete Streets"* initiative aimed at making city streets accessible and attractive to pedestrians and cyclists as well as automobile traffic. They provided coordinated education to the public and decision makers about the importance of planned environments, and partnered with the state transportation department, street design and engineering, pedestrian, and bicycle interest groups to facilitate its implementation. The intervention increased opportunities for Indiana residents to be physically active and reduce their cancer risk [34]. The Iowa Comprehensive Cancer Control Program designed a local initiative to reduce cancers that are disproportionately higher among African-Americans in Iowa [34]. The "*Body and Soul"* program was adapted from RTIPs [35], and tailored for the Iowa population, to increase awareness of healthier choices in nutrition and exercise [34]. In the first year, Iowa worked with 2 churches to support health awareness among its members [34]. More than 1,300 African-American residents across Iowa participated in the program in one year alone, and it is currently estimated that the program

Intense, intermittent exposure to ultraviolet (UV) light from the sun is strongly linked with melanoma, which is one of the deadliest forms of skin cancer in the U.S. [2, 36]. New Mexico, Florida, and Arizona used systems and environmental change strategies and the establishment of partnerships (adapted for their individual needs) within schools and educational community to control sun exposure among school children [36]. New Mexico provided two or more presentations per year in schools delivering specific messages to avoid the sun between 10 am and 4 pm, wear sun-protective clothing when exposed to sunlight, and use sunscreen with a sun-protection factor of 15 or higher [36]. More than 3600 students demonstrated positive behavior changes following educational presentations, including playing in the shade, wearing a hat, using sunscreen, and wearing sunglasses. [36]. Additionally, many teachers, who serve as important role models for school children, reported positive changes in their own behavior related to sun safety [36]. New Mexico also implemented 55 systems and environmental changes including modifying recess times to avoid peak UV exposure, allowing students to wear hats outside, and providing shade structures or planting trees [36]. It is estimated that a total of 56,000 school-age children, school staff and community members have been reached through these efforts in New Mexico [27]. South Dakota worked with two worksites who hired seasonal workers to work outdoors to limit UV exposure in the workplace [34]. These worksites adopted local policies to provide employees with sunscreen and lip balm, and employees were also encouraged to wear wide-brimmed hats, long sleeve shirts, lightweight full-length pants, and sunglasses, as well as work in shaded areas and avoiding peak sun hours when possible [34]. Workers (n = 450) reported an increase in their knowledge of sun safety and using some form of protective behavior; wearing wide-brimmed hats and sunglasses, and spending more time in shady areas when possible were the most commonly reported sun protection behaviors [34]. The largest positive behavioral changes

has now reached approximately 9700 African-American Iowans [34].

114 Public Health - Emerging and Re-emerging Issues

were observed among white men younger than 24 or aged 45–54 [34].

Vaccination against certain viruses can prevent cancer [25]. Cervical cancer and hepatocellular (liver) cancer are strongly linked to infection with human papilloma virus (HPV) and hepatitis HBV vaccination is currently recommended for all infants, unvaccinated children aged <19 years, persons with diabetes aged 19–59 years, and all those who are at high risk for HBV infection [40]. A 2012 review of 66 cancer plans for liver cancer and HBV content revealed that 35% addressed liver cancer prevention through HBV-related strategies [41]. Specific strategies reported were to implement a culturally-appropriate campaign for high-risk Asian and Pacific Islander communities to increase their awareness about hepatitis B and preventive measures, and to liaise with the local sexually transmitted infections program to share data and incorporate cancer awareness in its activities [41]. Cherokee Nation and Idaho have actively engaged in promoting HBV vaccination by distributing over 2000 patient education resources, holding community meetings about risks associated with liver cancer, and developing and delivering provider education sessions on HBV vaccination.

Genomics is becoming an increasingly important field in the U.S., particularly with regard to its usefulness in precision medicine [42]. CDC has held several workshops and meetings to promote incorporation of genomic and genetic testing awareness and uptake into public health practice [43, 44]. Particular focus areas have been increasing awareness of and surveillance for cancer-promoting genetic mutations such as BRCA1/BRCA2 and those associated with Lynch syndrome that predispose individuals to breast, ovarian, colorectal, uterine, and other cancers [44]. A 2005 review noted that 56% of state plans analyzed had begun to implement genomics components described in their plan [45]. Most states emphasized educating health care providers and the public about the role of genomics in cancer control, and many considered awareness of family history to be an important aspect of cancer planning [45]. Approximately 67% of states with family history components in their plans had begun to implement initiatives in this area [45]. Alaska, Michigan, New Jersey, Puerto Rico, Tennessee, Texas, West Virginia, and Wisconsin held a series of structured, educational workshops, using resource materials from CDC's *Inside Knowledge* gynecologic cancer awareness campaign [46] to teach women about ovarian cancer risk factors and symptoms [47]. Educational sessions were implemented over a one year period and were tailored to the particular population. Following the workshops, almost 80% of women correctly identified genetic mutations as a risk factor for ovarian cancer, and the number of women reporting being confident in speaking to their doctor about genetic testing increased 30% [47].

insurance agencies in their state to promote colorectal cancer screening through several educational articles sent out in routine communications by the insurers, and postcards sent individuals reminding them that their insurance coverage allowed them to get screened [27]. About 92,000 Montanans were reach through these efforts [27]. Similar interventions by the Idaho Comprehensive Cancer Alliance resulted in an 8% increase over a 4 year period in

Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the…

http://dx.doi.org/10.5772/intechopen.78582

117

Population-based lung cancer screening for long-term, heavy smokers is a relatively recent USPSTF recommendation compared to the other early detection recommendations discussed above [22]. As such, many NCCCP participants are beginning to collect baseline data in order to determine the interventions and types of interventions needed to increase adherence to this recommendation. Recently, the Maine Comprehensive Cancer Control Program conducted a survey to find out how many health facilities offered screening and the barriers to adopting screening [34]. While 1,131 lung cancer screenings were provided in results reported from their 2015 survey, most (84.4%) were performed in the two most populated counties included in the survey [34]. Barriers to screening identified included limited staffing, lack of patient and provider education, screening costs, and data reporting requirements of the Centers for Medicare & Medicaid Services (CMS) [34]. Armed with these data, Maine is preparing interventions to increase lung cancer screening across their state. They are developing appropriate interventions to lessen these barriers, and have adopted the lung cancer screening module of CDC's Behavioral Risk Factor Surveillance System (BRFSS) in 2017 to measure the results of their efforts [34].

Survival from commonly diagnosed cancers (such as breast and colorectal cancers) has increased steadily in most developed countries, and considerable increases in prostate cancer survival have occurred in many countries in South America, Asia, and Europe [52]. People living with cancer have several unique needs that can be addressed through public health practice [53]. Cancer survivors often face long-term adverse physical, psychosocial, and financial effects from their cancer diagnosis and treatment [53, 54], and have elevated risks for developing subsequent, new cancers as well as other chronic diseases compared to those who have never had cancer [54]. The number of cancer survivors in the U.S. has steadily increased over the last 3 decades [54]. A 2016 study indicated there were over 19 million current U.S. cancer survivors [55]. Many of the evidence-based interventions for primary prevention and early detection equally apply to survivors. NCCCP participants have adapted these interventions for their survivor populations, given the increased health risks present in this group compared to those who have not had cancer. Additional survivor-specific activities are also often implemented. A 2013 assessment of NCCCP cancer plans showed that 94% contained cancer survivorship content [56]. The most commonly incorporated survivorship activities were providing communication, education, and training (91%), followed by developing programs, policies, and infrastructure (90%), ensuring access to quality care and services (77%), and supporting surveillance and applied research (75%) [56]. Common examples of implementation in these areas included incorporation of CDC's cancer survivorship BRFSS module to characterize health behaviors (such as tobacco use and cancer screening among cancer survivors), development of fact sheets explaining individual cancer diagnoses, collaboration with community resources

persons reporting they received a colonoscopy [34].

*3.1.3. Addressing the public health needs of cancer survivors*

## *3.1.2. Promoting early detection of cancer*

Early detection for cancer involves screening for early malignancies or premalignancies and often treatment or removal of these lesions before they can spread to other parts of the body [25]. This area of addressing cancer is perhaps the most recognized by U.S. cancer specialists and the general public [25]. Early detection requires a solid clinical infrastructure to perform screenings and assess clinical and pathologic results of testing, so it can be more difficult to achieve in low-resource areas. CDC provides mammography and Pap smear screening services through its NBCCEDP [6], and the majority of providers in NBCCEDP-funded jurisdictions reported adequate technological resources for screening women [38]. As a community-driven implementation program, the NCCCP assists with promoting early detection by increasing knowledge and awareness of cancers that can be screened for, and implementing health systems changes to deliver screening among those who are eligible. NCCCP practitioners are required to partner and collaborate in a formal leadership team with NBCCEDP practitioners at the state and local levels as a requirement of CDC funding [21]. This helps ensure streamlining of screening activities between the programs.

Population-based early detection or screening is currently recommended by USPSTF for only a few types of cancer: mammography for breast cancer, pap smear for cervical cancer, colonoscopy (and other tests) for colorectal cancer, and the use of low-dose computed tomography for lung cancer screening [22]. Cancer plan reviews have shown that the vast majority contain cervical cancer content with 80.4% containing educational activities with a focus on individual behavior change [48]. Clinician behavior change was included in 41.2% of plans, and 11.7% identifying specific systems or environmental changes to bring about this change in clinicians [48]. This work does extend to NCCCP-funded areas of relatively low resources, such as the USAPIJs. In Yap USAPIJ, comprehensive cancer control practitioners held educational workshops to increase knowledge of cervical cancer screening and showed an approximate 25% increase in knowledge of Pap smear screening recommendations among the 326 women attending the workshops [44]. And a cross-sectional survey of 72 health care providers from five of the six USAPIJ funded by the NCCCP showed that most providers reported cervical cancer prevention as a priority in their clinical practices (90.3%) and used Pap smear screening (86.1%) [49].

Nearly all NCCCP cancer plans (98%) discuss interventions related to colorectal cancer screening [50]. Many (44%) included interventions to promote colorectal cancer screening in the workplace [51]. The Montana Cancer Control Program (MCCP) partnered with several insurance agencies in their state to promote colorectal cancer screening through several educational articles sent out in routine communications by the insurers, and postcards sent individuals reminding them that their insurance coverage allowed them to get screened [27]. About 92,000 Montanans were reach through these efforts [27]. Similar interventions by the Idaho Comprehensive Cancer Alliance resulted in an 8% increase over a 4 year period in persons reporting they received a colonoscopy [34].

Population-based lung cancer screening for long-term, heavy smokers is a relatively recent USPSTF recommendation compared to the other early detection recommendations discussed above [22]. As such, many NCCCP participants are beginning to collect baseline data in order to determine the interventions and types of interventions needed to increase adherence to this recommendation. Recently, the Maine Comprehensive Cancer Control Program conducted a survey to find out how many health facilities offered screening and the barriers to adopting screening [34]. While 1,131 lung cancer screenings were provided in results reported from their 2015 survey, most (84.4%) were performed in the two most populated counties included in the survey [34]. Barriers to screening identified included limited staffing, lack of patient and provider education, screening costs, and data reporting requirements of the Centers for Medicare & Medicaid Services (CMS) [34]. Armed with these data, Maine is preparing interventions to increase lung cancer screening across their state. They are developing appropriate interventions to lessen these barriers, and have adopted the lung cancer screening module of CDC's Behavioral Risk Factor Surveillance System (BRFSS) in 2017 to measure the results of their efforts [34].

#### *3.1.3. Addressing the public health needs of cancer survivors*

Approximately 67% of states with family history components in their plans had begun to implement initiatives in this area [45]. Alaska, Michigan, New Jersey, Puerto Rico, Tennessee, Texas, West Virginia, and Wisconsin held a series of structured, educational workshops, using resource materials from CDC's *Inside Knowledge* gynecologic cancer awareness campaign [46] to teach women about ovarian cancer risk factors and symptoms [47]. Educational sessions were implemented over a one year period and were tailored to the particular population. Following the workshops, almost 80% of women correctly identified genetic mutations as a risk factor for ovarian cancer, and the number of women reporting being confident in speak-

Early detection for cancer involves screening for early malignancies or premalignancies and often treatment or removal of these lesions before they can spread to other parts of the body [25]. This area of addressing cancer is perhaps the most recognized by U.S. cancer specialists and the general public [25]. Early detection requires a solid clinical infrastructure to perform screenings and assess clinical and pathologic results of testing, so it can be more difficult to achieve in low-resource areas. CDC provides mammography and Pap smear screening services through its NBCCEDP [6], and the majority of providers in NBCCEDP-funded jurisdictions reported adequate technological resources for screening women [38]. As a community-driven implementation program, the NCCCP assists with promoting early detection by increasing knowledge and awareness of cancers that can be screened for, and implementing health systems changes to deliver screening among those who are eligible. NCCCP practitioners are required to partner and collaborate in a formal leadership team with NBCCEDP practitioners at the state and local levels as a requirement of CDC funding [21]. This helps

Population-based early detection or screening is currently recommended by USPSTF for only a few types of cancer: mammography for breast cancer, pap smear for cervical cancer, colonoscopy (and other tests) for colorectal cancer, and the use of low-dose computed tomography for lung cancer screening [22]. Cancer plan reviews have shown that the vast majority contain cervical cancer content with 80.4% containing educational activities with a focus on individual behavior change [48]. Clinician behavior change was included in 41.2% of plans, and 11.7% identifying specific systems or environmental changes to bring about this change in clinicians [48]. This work does extend to NCCCP-funded areas of relatively low resources, such as the USAPIJs. In Yap USAPIJ, comprehensive cancer control practitioners held educational workshops to increase knowledge of cervical cancer screening and showed an approximate 25% increase in knowledge of Pap smear screening recommendations among the 326 women attending the workshops [44]. And a cross-sectional survey of 72 health care providers from five of the six USAPIJ funded by the NCCCP showed that most providers reported cervical cancer prevention as a priority in their clinical practices (90.3%) and used Pap smear screening (86.1%) [49].

Nearly all NCCCP cancer plans (98%) discuss interventions related to colorectal cancer screening [50]. Many (44%) included interventions to promote colorectal cancer screening in the workplace [51]. The Montana Cancer Control Program (MCCP) partnered with several

ing to their doctor about genetic testing increased 30% [47].

ensure streamlining of screening activities between the programs.

*3.1.2. Promoting early detection of cancer*

116 Public Health - Emerging and Re-emerging Issues

Survival from commonly diagnosed cancers (such as breast and colorectal cancers) has increased steadily in most developed countries, and considerable increases in prostate cancer survival have occurred in many countries in South America, Asia, and Europe [52]. People living with cancer have several unique needs that can be addressed through public health practice [53]. Cancer survivors often face long-term adverse physical, psychosocial, and financial effects from their cancer diagnosis and treatment [53, 54], and have elevated risks for developing subsequent, new cancers as well as other chronic diseases compared to those who have never had cancer [54]. The number of cancer survivors in the U.S. has steadily increased over the last 3 decades [54]. A 2016 study indicated there were over 19 million current U.S. cancer survivors [55]. Many of the evidence-based interventions for primary prevention and early detection equally apply to survivors. NCCCP participants have adapted these interventions for their survivor populations, given the increased health risks present in this group compared to those who have not had cancer. Additional survivor-specific activities are also often implemented. A 2013 assessment of NCCCP cancer plans showed that 94% contained cancer survivorship content [56]. The most commonly incorporated survivorship activities were providing communication, education, and training (91%), followed by developing programs, policies, and infrastructure (90%), ensuring access to quality care and services (77%), and supporting surveillance and applied research (75%) [56]. Common examples of implementation in these areas included incorporation of CDC's cancer survivorship BRFSS module to characterize health behaviors (such as tobacco use and cancer screening among cancer survivors), development of fact sheets explaining individual cancer diagnoses, collaboration with community resources such as the YMCA's Cancer Survivor Program [57] which encourages exercise among survivors, and the fielding of needs assessments to determine where to allocate resources to ensure access to quality care and services [56]. Specific examples of activities in New Mexico, South Carolina, Vermont, Washington state, and the Fond Du Lac Band of Lake Superior Chippewa tribe are: (1) promotion of doctor and patient use of survivor care plans to better understand care prescribed and received; (2) use of patient navigation programs to help survivors gain access to clinical services; (3) use of psychosocial distress screening among cancer survivors to identify and treat concurrent illnesses stemming from their cancer diagnosis; and (4) facilitation of communication among cancer survivors through peer support groups and workshops to help survivors feel less marginalized and better equipped to handle their diagnosis [58]. Recognizing that a cancer diagnosis affects not only the individual, but also those in close proximity to the survivor, NCCCP participants also provide support to families and caregivers as part of addressing the survivors' needs. In 2007, the Alaska Native Tribal Health Consortium (ANTHC) began a grief camp for Alaska Native children who lost a family member due to cancer. The ANTHC developed and implemented Camp Coho, a one-day camp that provided culturally appropriate messages of grief support to children, including using art therapy, healing circles, and assigning children a peer to provide one-on-one support. Post camp surveys indicated that 75% of children no longer felt alone in their cancer loss after attending the camp [27]. The Wyoming Comprehensive Cancer Control Consortium (WCCCC) created a similar camp experience to bring children who themselves were diagnosed with cancer and their parents and sibling caregivers together [34]. Camp Courage Wyoming was established as a yearly camp in 2012, to allow families to build a statewide, long-lasting survivorship support network [34]. During the weekend long camp, cancer counseling and support group services are available, and families can attend educational workshops taught by physicians specializing in childhood cancers [34]. Attendees reported that the opportunity to talk with others about the challenges associated with having a child diagnosed with cancer has been very valuable [34]. Building on the knowledge gained from participant survivor activities, and in an effort to accelerate survivorship activities across all NCCCP participants, CDC began providing additional funding on a competitive basis to a small number of participants in 2015 to enhance surveillance of survivors and their behaviors, implement community-clinical linkages that would promote receipt of quality care for cancer, and increase provider education about survivorship needs and assist providers with completing and distributing survivor care plans [59].

a series of guidelines for cancer survivor care, including colorectal cancer care [63], and George Washington Cancer Institute develops and disseminates social media messages about cancer

• Intercultural Cancer Council

• Leukemia and Lymphoma Society

• National Association of Chronic Disease Directors • National Association of County and City Health

http://dx.doi.org/10.5772/intechopen.78582

119

• North American Association of Central Cancer

• LIVESTRONG

Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the…

Officials

Registries

• Truth Initiative • YMCA of the USA

• National Cancer Institute • Susan G. Komen for the Cure

Cancer is an ongoing public health concern in developed countries and an emerging concern in developing countries [9, 12]. Many countries are beginning to recognize the importance of comprehensive cancer control and are beginning to design national cancer control programs to improve cancer survival and quality of life through evidence-based strategies [64, 65]. Early efforts have reported several challenges including the lack of access to care, contamination of the environment, and cancer fatalistic attitudes among individuals in China, lack of informed healthcare staff, and sociocultural barriers in India, and inadequate assessment of cancer burden, negative societal attitudes towards cancer prevention, and lack of partnerships and engagement in Russia [66]. Many countries (both developed and developing) have cited the need for better assessments of cancer burden, determination of risk and protective factors, early detection and screening, interventions in vaccination, tobacco cessation efforts and palliative care, coordination and measurement of impact [67, 68]. The U.S. NCCCP provides a successful model, addressing all these factors in a coordinated, impactful, and collaborative approach for these countries to learn from and adapt. The varied examples of successful implementation activities presented above provide a platform to assist other countries with cancer planning. As countries begin to design and implement their national cancer control programs, they may wish to adapt a similar design to the NCCCP, that is, a community-based implementation program, with guidance and assistance from national levels. This particular design has been most effective for the U.S. in addressing multiple populations with widely diverging attitudes and infrastructure, and has contributed to the NCCCP's success over the last 20 years. All countries involved in national cancer planning could learn from the

EBIs for NCCCP participants to distribute during particular cancer awareness months.

**4. Conclusion**

• American Cancer Society

• Cancer Support Community

Cancer

• American Cancer Society Cancer Action Network • American College of Surgeons Commission on

• Association of State and Territorial Health Officials

**Table 2.** Comprehensive Cancer Control National Partnership Members.

• **Centers for Disease Control and Prevention** • The George Washington University Cancer Center • Health Resources Services Administration

#### **3.2. Guidance of the National Comprehensive Cancer Control Program**

The NCCCP is guided at the U.S. federal government level by CDC's Division of Cancer Prevention and Control (DCPC) [60]. Formal collaborations across CDC ensure complementary programmatic efforts [61]. For example, a consortium of national networks to enhance the quality and performance of the NCCCP in specific populations who traditionally experience health disparities is jointly supported by DCPC and CDC's Office on Smoking and Health. CDC also maintains a formal partnership with several national organizations listed in **Table 2** [62], who provide specific resources to assist NCCCP with interventions. These comprehensive cancer control national partners have helped build and sustain coalition capacity through a variety of technical assistance activities [62]. For example, the American Cancer Society drafted and published • American Cancer Society

such as the YMCA's Cancer Survivor Program [57] which encourages exercise among survivors, and the fielding of needs assessments to determine where to allocate resources to ensure access to quality care and services [56]. Specific examples of activities in New Mexico, South Carolina, Vermont, Washington state, and the Fond Du Lac Band of Lake Superior Chippewa tribe are: (1) promotion of doctor and patient use of survivor care plans to better understand care prescribed and received; (2) use of patient navigation programs to help survivors gain access to clinical services; (3) use of psychosocial distress screening among cancer survivors to identify and treat concurrent illnesses stemming from their cancer diagnosis; and (4) facilitation of communication among cancer survivors through peer support groups and workshops to help survivors feel less marginalized and better equipped to handle their diagnosis [58]. Recognizing that a cancer diagnosis affects not only the individual, but also those in close proximity to the survivor, NCCCP participants also provide support to families and caregivers as part of addressing the survivors' needs. In 2007, the Alaska Native Tribal Health Consortium (ANTHC) began a grief camp for Alaska Native children who lost a family member due to cancer. The ANTHC developed and implemented Camp Coho, a one-day camp that provided culturally appropriate messages of grief support to children, including using art therapy, healing circles, and assigning children a peer to provide one-on-one support. Post camp surveys indicated that 75% of children no longer felt alone in their cancer loss after attending the camp [27]. The Wyoming Comprehensive Cancer Control Consortium (WCCCC) created a similar camp experience to bring children who themselves were diagnosed with cancer and their parents and sibling caregivers together [34]. Camp Courage Wyoming was established as a yearly camp in 2012, to allow families to build a statewide, long-lasting survivorship support network [34]. During the weekend long camp, cancer counseling and support group services are available, and families can attend educational workshops taught by physicians specializing in childhood cancers [34]. Attendees reported that the opportunity to talk with others about the challenges associated with having a child diagnosed with cancer has been very valuable [34]. Building on the knowledge gained from participant survivor activities, and in an effort to accelerate survivorship activities across all NCCCP participants, CDC began providing additional funding on a competitive basis to a small number of participants in 2015 to enhance surveillance of survivors and their behaviors, implement community-clinical linkages that would promote receipt of quality care for cancer, and increase provider education about survivorship

118 Public Health - Emerging and Re-emerging Issues

needs and assist providers with completing and distributing survivor care plans [59].

The NCCCP is guided at the U.S. federal government level by CDC's Division of Cancer Prevention and Control (DCPC) [60]. Formal collaborations across CDC ensure complementary programmatic efforts [61]. For example, a consortium of national networks to enhance the quality and performance of the NCCCP in specific populations who traditionally experience health disparities is jointly supported by DCPC and CDC's Office on Smoking and Health. CDC also maintains a formal partnership with several national organizations listed in **Table 2** [62], who provide specific resources to assist NCCCP with interventions. These comprehensive cancer control national partners have helped build and sustain coalition capacity through a variety of technical assistance activities [62]. For example, the American Cancer Society drafted and published

**3.2. Guidance of the National Comprehensive Cancer Control Program**


• Intercultural Cancer Council


**Table 2.** Comprehensive Cancer Control National Partnership Members.

a series of guidelines for cancer survivor care, including colorectal cancer care [63], and George Washington Cancer Institute develops and disseminates social media messages about cancer EBIs for NCCCP participants to distribute during particular cancer awareness months.

#### **4. Conclusion**

Cancer is an ongoing public health concern in developed countries and an emerging concern in developing countries [9, 12]. Many countries are beginning to recognize the importance of comprehensive cancer control and are beginning to design national cancer control programs to improve cancer survival and quality of life through evidence-based strategies [64, 65]. Early efforts have reported several challenges including the lack of access to care, contamination of the environment, and cancer fatalistic attitudes among individuals in China, lack of informed healthcare staff, and sociocultural barriers in India, and inadequate assessment of cancer burden, negative societal attitudes towards cancer prevention, and lack of partnerships and engagement in Russia [66]. Many countries (both developed and developing) have cited the need for better assessments of cancer burden, determination of risk and protective factors, early detection and screening, interventions in vaccination, tobacco cessation efforts and palliative care, coordination and measurement of impact [67, 68]. The U.S. NCCCP provides a successful model, addressing all these factors in a coordinated, impactful, and collaborative approach for these countries to learn from and adapt. The varied examples of successful implementation activities presented above provide a platform to assist other countries with cancer planning. As countries begin to design and implement their national cancer control programs, they may wish to adapt a similar design to the NCCCP, that is, a community-based implementation program, with guidance and assistance from national levels. This particular design has been most effective for the U.S. in addressing multiple populations with widely diverging attitudes and infrastructure, and has contributed to the NCCCP's success over the last 20 years. All countries involved in national cancer planning could learn from the NCCCP in their efforts to control cancer across diverse populations. Bringing key stakeholders together with first-hand knowledge of the cancer-related challenges in a given population is an essential first step. Allowing stakeholders themselves to write and implement a specific plan, based on their knowledge and all available data from the population, led to successful interventions in the NCCCP. Focusing on the implementation of similar cancer prevention and risk reduction strategies may be a good first option for many countries [13].

[3] Weir HK, White MC. Cancer incidence and mortality through 2020. Preventing Chronic

Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the…

http://dx.doi.org/10.5772/intechopen.78582

121

[4] Frieden TR. A framework for public health action: the health impact pyramid. American Journal of Public Health. 2010;**100**(4):590-595. DOI: 10.2105/AJPH.2009.185652

[5] Jemal A, Ward EM, Johnson CJ, Cronin KA, Ma J, Ryerson B, et al. Annual report to the nation on the status of cancer, 1975-2014, featuring survival. Journal of the National

[6] Miller JW, Royalty J, Henley J, White A, Richardson LC. Breast and cervical cancers diagnosed and stage at diagnosis among women served through the National Breast and Cervical Cancer Early Detection Program. Cancer Causes & Control. 2015;**26**(5):

[7] Major A, Stewart SL. Celebrating 10 years of the National Comprehensive Cancer

[8] CDC. About the National Comprehensive Cancer Control Program 2018. Available from:

[9] Braithwaite D, Boffetta P, Rebbeck TR, Meyskens F. Cancer prevention for global health: A report from the ASPO International Cancer Prevention Interest Group. Cancer Epidemiology, Biomarkers & Prevention. 2012;**21**(9):1606-1610. DOI: 10.1158/1055-9965.

[10] World Health Organization. Global Health Observatory (GHO) Data. NCD Mortality and Morbidity. Available from: http://www.who.int/gho/ncd/mortality\_morbidity/en/.

[11] Torre LA, Siegel RL, Ward EM, Jemal A. Global cancer incidence and mortality rates and trends–An update. Cancer Epidemiology, Biomarkers & Prevention. 2016;**25**(1):16-27.

[12] Ullrich A, Miller A. Global response to the burden of cancer: the WHO approach. American Society of Clinical Oncology educational book American Society of Clinical Oncology Meeting. 2014:e311-e315. DOI: 10.14694/EdBook\_AM.2014.34.e311. https://www.

[13] de Souza JA, Hunt B, Asirwa FC, Adebamowo C, Lopes G. Global health equity: cancer care outcome disparities in high-, middle-, and low-income countries. Journal of Clinical

[14] Given LS, Black B, Lowry G, Huang P, Kerner JF. Collaborating to conquer cancer: A comprehensive approach to cancer control. Cancer Causes & Control: CCC. 2005;**16**(Suppl 1):

[15] Miller SE, Hager P, Lopez K, Salinas J, Shepherd WL. The past, present, and future of comprehensive cancer control from the state and tribal perspective. Preventing Chronic

Control Program, 1998 to 2008. Preventing Chronic Disease. 2009;**6**(4):A133

https://www.cdc.gov/cancer/ncccp/about.htm [Accessed: March 22, 2018]

Disease. 2016;**13**:E48. DOI: 10.5888/pcd13.160024

Cancer Institute. 2017;**109**(9). DOI: 10.1093/jnci/djx030

741-747. DOI: 10.1007/s10552-015-0543-2

EPI-12-0848

[Accessed: March 22, 2018]

DOI: 10.1158/1055-9965.epi-15-0578

ncbi.nlm.nih.gov/pubmed/24857118

3-14. DOI: 10.1007/s10552-005-0499-8

Disease. 2009;**6**(4):A112

Oncology. 2016;**34**(1):6-13. DOI: 10.1200/jco.2015.62.2860

## **Acknowledgements**

The authors are grateful to Dr. Eric Tai, MD, MPH who provided invaluable advice and technical assistance, as well as critical review for this book chapter.

## **Conflict of interest**

The authors have no conflicts of interest.

## **Disclaimer**

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

## **Author details**

Sherri L. Stewart\*, Nikki S. Hayes, Angela R. Moore, Robert Bailey II, Phaeydra M. Brown and Ena Wanliss

\*Address all correspondence to: sstewart2@cdc.gov

Centers for Disease Control and Prevention, Atlanta, GA, USA

## **References**


[3] Weir HK, White MC. Cancer incidence and mortality through 2020. Preventing Chronic Disease. 2016;**13**:E48. DOI: 10.5888/pcd13.160024

NCCCP in their efforts to control cancer across diverse populations. Bringing key stakeholders together with first-hand knowledge of the cancer-related challenges in a given population is an essential first step. Allowing stakeholders themselves to write and implement a specific plan, based on their knowledge and all available data from the population, led to successful interventions in the NCCCP. Focusing on the implementation of similar cancer prevention

The authors are grateful to Dr. Eric Tai, MD, MPH who provided invaluable advice and tech-

The findings and conclusions in this report are those of the authors and do not necessarily

Sherri L. Stewart\*, Nikki S. Hayes, Angela R. Moore, Robert Bailey II, Phaeydra M. Brown

[1] Weir HK, Anderson RN, Coleman King SM, Soman A, Thompson TD, Hong Y, et al. Heart disease and cancer deaths–Trends and projections in the United States, 1969-2020.

[2] USCS Working Group. United States Cancer Statistics: 1999-2014 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2017. Available from:

Preventing Chronic Disease. 2016;**13**:E157. DOI: 10.5888/pcd13.160211

and risk reduction strategies may be a good first option for many countries [13].

nical assistance, as well as critical review for this book chapter.

represent the views of the Centers for Disease Control and Prevention.

**Acknowledgements**

120 Public Health - Emerging and Re-emerging Issues

**Conflict of interest**

**Disclaimer**

**Author details**

and Ena Wanliss

**References**

The authors have no conflicts of interest.

\*Address all correspondence to: sstewart2@cdc.gov

Centers for Disease Control and Prevention, Atlanta, GA, USA

www.cdc.gov/uscs [Accessed: March 22, 2018]


[16] Rochester P, Chapel T, Black B, Bucher J, Housemann R. The evaluation of comprehensive cancer control efforts: Useful techniques and unique requirements. Cancer Causes & Control: CCC. 2005;**16**(Suppl 1):69-78. DOI: 10.1007/s10552-005-0510-4

[28] CDC. Stories of Success: National Comprehensive Cancer Control Program: Comprehensive Cancer Control in Action. Atlanta Centers for Disease Control and Prevention,

Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the…

http://dx.doi.org/10.5772/intechopen.78582

123

[29] Neri A, Stewart SL, Angell W. Radon control activities for lung cancer prevention in national Comprehensive Cancer Control Program plans, 2005-2011. Preventing Chronic

[30] Acree P, Puckett M, Neri A. Evaluating progress in radon control activities for lung cancer prevention in national Comprehensive Cancer Control Program plans, 2011-2015. Journal of Community Health. 2017;**42**(5):962-967. DOI: 10.1007/s10900-017-0342-7 [31] Bain AA, Abbott AL, Miller LL. Successes and challenges in implementation of radon control activities in Iowa. Preventing Chronic Disease. 2016;**13**:2010, E50-2015. DOI:

[32] Steele CB, Thomas CC, Henley SJ, Massetti GM, Galuska DA, Agurs-Collins T, et al. Vital signs: Trends in incidence of cancers associated with overweight and obesity– United States, 2005-2014. MMWR Morbidity and Mortality Weekly Report. 2017;**66**(39):

[33] Puckett M, Neri A, Underwood JM, Stewart SL. Nutrition and physical activity strategies for cancer prevention in current national Comprehensive Cancer Control Program plans. Journal of Community Health. 2016;**41**(5):1013-1020. DOI: 10.1007/s10900-016-0184-8 [34] CDC. National Comprehensive Cancer Control Program (NCCCP): Success Stories From the Field 2018. Available from: https://www.cdc.gov/cancer/ncccp/state.htm. [Accessed:

[35] National Cancer Institute. RTIPs: Body and Soul 2018 Available from: https://rtips.cancer.gov/rtips/programDetails.do?programId=257161. [Accessed: March 22, 201E8] [36] Townsend JS, Pinkerton B, McKenna SA, Higgins SM, Tai E, Steele CB, et al. Targeting children through school-based education and policy strategies: Comprehensive cancer control activities in melanoma prevention. Journal of the American Academy of

[37] Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination–Updated recommendations of the advisory committee on immunization practices. MMWR Morbidity and Mortality Weekly Report. 2016;**65**(49):1405-1408. DOI:

[38] Townsend JS, Steele CB, Hayes N, Bhatt A, Moore AR. Human papillomavirus vaccine as an anticancer vaccine: Collaborative efforts to promote human papillomavirus vaccine in the national Comprehensive Cancer Control Program. Journal of Women's Health.

[39] Someone You Love: The HPV Epidemic 2018 Available from: https://www.hpvepidemic.

[40] Schillie SV, C; Reingold, A; Harris, A; Haber, P; Ward, JW; Nelson, NP Prevention of hepatitis b virus infection in the United States: Recommendations of the Advisory

Dermatology. 2011;**65**(5 Suppl 1):S104-S113. DOI: 10.1016/j.jaad.2011.05.036

National Comprehensive Cancer Control Program; 2012

Disease. 2013;**10**:E132. DOI: 10.5888/pcd10.120337

1052-1058. DOI: 10.15585/mmwr.mm6639e1

10.5888/pcd13.150596

March 22, 2018]

10.15585/mmwr.mm6549a5

com/. [Accessed: March 22, 2018]

2017;**26**(3):200-206. DOI: 10.1089/jwh.2017.6351


[28] CDC. Stories of Success: National Comprehensive Cancer Control Program: Comprehensive Cancer Control in Action. Atlanta Centers for Disease Control and Prevention, National Comprehensive Cancer Control Program; 2012

[16] Rochester P, Chapel T, Black B, Bucher J, Housemann R. The evaluation of comprehensive cancer control efforts: Useful techniques and unique requirements. Cancer Causes

[17] Rochester P, Adams E, Porterfield DS, Holden D, McAleer K, Steele CB. Cancer plan index: A measure for assessing the quality of cancer plans. Journal of Public Health Management and Practice. 2011;**17**(6):E12-E17. DOI: 10.1097/PHH.0b013e318215a603 [18] Rochester P, Porterfield DS, Richardson LC, McAleer K, Adams E, Holden D. Piloting performance measurement for Comprehensive Cancer Control programs. Journal of Public Health Management and Practice. 2011;**17**(3):275-282. DOI: 10.1097/PHH.

[19] Townsend JS, Moore AR, Mulder TN, Boyd M. What does a performance measurement system tell us about the national Comprehensive Cancer Control Program? Journal of Public Health Management and Practice. 2015;**21**(5):449-458. DOI: 10.1097/phh.

[20] Belle Isle L, Plescia M, La Porta M, Shepherd W. In conclusion: Looking to the future of comprehensive cancer control. Cancer Causes & Control. 2010;**21**(12):2049-2057. DOI: 10.1007/

[21] CDC. FOA DP17-1701 Cancer Prevention and Control Programs for State, Territorial, and Tribal Organizations. National Comprehensive Cancer Control Program At –A–Glance 2017 Available from: http://new.grantreviewinfo.net/sites/default/files/Reviewer%20

[22] USPSTF. US Preventive Services Task Force 2018. Available from: https://www.uspre-

[23] Agency for Healthcare Research and Quality ACS, Centers for Disease Control and Prevention, the Commission on Cancer, National Cancer Institute, and Substance Abuse and Mental Health Services Administration. Cancer Control P.L.A.N.E.T. 2018. Available

from: https://cancercontrolplanet.cancer.gov/planet/. [Accessed: March 22, 2018]

[24] Steele CB, Rose JM, Chovnick G, Townsend JS, Stockmyer CK, Fonseka J, et al. Use of evidence-based practices and resources among Comprehensive Cancer Control programs. Journal of Public Health Management and Practice. 2015;**21**(5):441-448. DOI:

[25] Frieden TR, Myers JE, Krauskopf MS, Farley TA. A public health approach to winning the war against cancer. The Oncologist. 2008;**13**(12):1306-1313. DOI: 10.1634/

[26] Dunne K, Henderson S, Stewart SL, Moore A, Hayes NS, Jordan J, et al. An update on tobacco control initiatives in Comprehensive Cancer Control plans. Preventing Chronic

[27] CDC. Stories of Success. National Comprehensive Cancer Control Program Comprehensive Cancer Control in Action 2010. Available from: https://www.cdc.gov/cancer/

ncccp/pdf/success/SuccessStories.pdf. [Accessed: March 22, 2018]

Tool%20-%20NCCCP.pdf. [Accessed: March 22, 2018]

Disease. 2013;**10**:E107. DOI: 10.5888/pcd10.120331

ventiveservicestaskforce.org/. [Accessed: March 22, 2018]

& Control: CCC. 2005;**16**(Suppl 1):69-78. DOI: 10.1007/s10552-005-0510-4

0b013e3181fd4d19

122 Public Health - Emerging and Re-emerging Issues

0000000000000124

s10552-010-9666-7

10.1097/phh.0000000000000053

theoncologist.2008-0157


Committee on immunization practices. MMWR Recomm Reports 2018;67(No. RR-1): 1-31. DOI: http://dx.doi.org/10.15585/mmwr.rr6701a1

from 279 population-based registries in 67 countries (CONCORD-2). Lancet. 2015;

Combating Cancer Through Public Health Practice in the United States: An In-Depth Look at the…

http://dx.doi.org/10.5772/intechopen.78582

125

[53] Fairley TL, Pollack LA, Moore AR, Smith JL. Addressing cancer survivorship through public health: an update from the Centers for Disease Control and Prevention. Journal of

[54] Underwood JM, Townsend JS, Stewart SL, Buchannan N, Ekwueme DU, Hawkins NA, et al. Surveillance of demographic characteristics and health behaviors among adult cancer survivors–Behavioral Risk Factor Surveillance System, United States, 2009.

Morbidity and Mortality Weekly Report Surveillance Summaries. 2012;**61**(1):1-23 [55] Kale HP, Carroll NV. Self-reported financial burden of cancer care and its effect on physical and mental health-related quality of life among US cancer survivors. Cancer.

[56] Underwood JM, Lakhani N, Rohan E, Moore A, Stewart SL. An evaluation of cancer survivorship activities across national Comprehensive Cancer Control Programs. Journal

[57] YMCA. YMCA Cancer Survivors. About the Program 2018 Available from: http://ymca-

[58] Underwood JM, Lakhani N, Finifrock D, Pinkerton B, Johnson KL, Mallory SH, et al. Evidence-based cancer survivorship activities for comprehensive cancer control. American Journal of Preventive Medicine. 2015;**49**(6, Suppl 5):S536-S542. DOI: 10.1016/j.

[59] CDC. Increasing the Implementation of Evidence-Based Cancer Survivorship Interventions to Increase Quality and Duration of Life Among Cancer Patients 2015. Available from: https://www.cdc.gov/cancer/ncccp/dp15-1501.htm. [Accessed: March 22, 2018] [60] CDC. Centers for Disease Control and Prevention. Cancer Prevention and Control. 2018

[61] Momin B, Neri A, Zhang L, Kahende J, Duke J, Green SG, et al. Mixed-methods for comparing tobacco cessation interventions. Journal of Smoking Cessation. 2017;**12**(1):15-21.

[62] CDC. The Comprehensive Cancer Control National Partnership 2018. Available from: https://www.cdc.gov/cancer/ncccp/partners.htm. [Accessed: March 22, 2018]

[63] El-Shami K, Oeffinger KC, Erb NL, Willis A, Bretsch JK, Pratt-Chapman ML, et al. American Cancer Society colorectal cancer survivorship care guidelines. CA: a Cancer

[64] Akaza H, Kawahara N, Masui T, Takeyama K, Nogimori M, Roh JK. Union for International Cancer Control International Session: healthcare economics: The significance of the UN Summit non-communicable diseases political declaration in Asia. Cancer

Available from: https://www.cdc.gov/cancer/. [Accessed: March 22, 2018]

Journal for Clinicians. 2015;**65**(6):428-455. DOI: 10.3322/caac.21286

Science. 2013;**104**(6):773-778. DOI: 10.1111/cas.12142

of Cancer Survivorship. 2015;**9**(3):554-559. DOI: 10.1007/s11764-015-0432-4

**385**(9972):977-1010. DOI: 10.1016/s0140-6736(14)62038-9

2016;**122**(8):283-289. DOI: 10.1002/cncr.29808

cancersurvivor.com/. [Accessed: March 22, 2018]

amepre.2015.08.011

DOI: 10.1017/jsc.2015.7

Women's Health. 2009;**18**(10):1525-1531. DOI: 10.1089/jwh.2009.1666


from 279 population-based registries in 67 countries (CONCORD-2). Lancet. 2015; **385**(9972):977-1010. DOI: 10.1016/s0140-6736(14)62038-9

[53] Fairley TL, Pollack LA, Moore AR, Smith JL. Addressing cancer survivorship through public health: an update from the Centers for Disease Control and Prevention. Journal of Women's Health. 2009;**18**(10):1525-1531. DOI: 10.1089/jwh.2009.1666

Committee on immunization practices. MMWR Recomm Reports 2018;67(No. RR-1):

[41] Momin B, Richardson L. An analysis of content in Comprehensive Cancer Control plans that address chronic hepatitis B and C virus infections as major risk factors for liver cancer. Journal of Community Health. 2012;**37**(4):912-916. DOI: 10.1007/s10900-011-9507-y

[42] Aronson SJ, Rehm HL. Building the foundation for genomics in precision medicine.

[43] Bellcross CA, Bedrosian SR, Daniels E, Duquette D, Hampel H, Jasperson K, et al. Implementing screening for Lynch syndrome among patients with newly diagnosed colorectal cancer: Summary of a public health/clinical collaborative meeting. Genetics in

[44] Rodriguez JL, Thomas CC, Massetti GM, Duquette D, Avner L, Iskander J, et al. CDC grand rounds: Family history and genomics as tools for cancer prevention and control. MMWR Morbidity and Mortality Weekly Report. 2016;**65**(46):1291-1294. DOI: 10.15585/

[45] Irwin DE, Zuiker ES, Rakhra-Burris T, Millikan RC. Review of state Comprehensive Cancer Control plans for genomics content. Preventing Chronic Disease. 2005;**2**(2):A08

[46] Rim SH, Polonec L, Stewart SL, Gelb CA. A national initiative for women and healthcare providers: CDC's inside knowledge: Get the facts about gynecologic cancer campaign.

[47] Puckett MC, Townsend JS, Gelb CA, Hager P, Conlon A, Stewart SL.Ovarian cancer knowledge in women and providers following education with inside knowledge campaign materials. Journal of Cancer Education. 2017. https://doi.org/10.1007/s13187-017-1245-0

[48] Meyerson BE, Zimet GD, Multani GS, Levell C, Lawrence CA, Smith JS. Increasing efforts to reduce cervical cancer through state-level Comprehensive Cancer Control Planning. Cancer Prevention Research. 2015;**8**(7):636-641. DOI: 10.1158/1940-6207.capr-15-0004 [49] Townsend JS, Stormo AR, Roland KB, Buenconsejo-Lum L, White S, Saraiya M. Current cervical cancer screening knowledge, awareness, and practices among U.S. affiliated pacific island providers: opportunities and challenges. The Oncologist. 2014;**19**(4):

[50] Townsend JS, Richardson LC, Steele CB, White DE. Evidence-based interventions and screening recommendations for colorectal cancer in Comprehensive Cancer Control

[51] Nahmias Z, Townsend JS, Neri A, Stewart SL. Worksite cancer prevention activities in the national Comprehensive Cancer Control Program. Journal of Community Health.

[52] Allemani C, Weir HK, Carreira H, Harewood R, Spika D, Wang XS, et al. Global surveillance of cancer survival 1995-2009: analysis of individual data for 25,676,887 patients

Plans: A content analysis. Preventing Chronic Disease. 2009;**6**(4):A127

Journal of Women's Health. 2011;**20**(11):1579-1585. DOI: 10.1089/jwh.2011.3202

1-31. DOI: http://dx.doi.org/10.15585/mmwr.rr6701a1

Nature. 2015;**526**(7573):336-342. DOI: 10.1038/nature15816

383-393. DOI: 10.1634/theoncologist.2013-0340

2016;**41**(4):838-844. DOI: 10.1007/s10900-016-0161-2

mmwr.mm6546a3

124 Public Health - Emerging and Re-emerging Issues

Medicine. 2012;**14**(1):152-162. DOI: 10.1038/gim.0b013e31823375ea


[65] Gospodarowicz M, Trypuc J, D'Cruz A, Khader J, Omar S, Knaul F. Cancer services and the comprehensive cancer center. In: Gelband H, Jha P, Sankaranarayanan R, Horton S, editors. Cancer: Disease Control Priorities. 3rd ed. Vol. 3. Washington (DC: International Bank for Reconstruction and Development / The World Bank; 2015. DOI: 10.1596/978-1-4648-0349-9\_ch11

**Chapter 7**

**Provisional chapter**

**Taking it to the Pulpit: Repositioning FBOs as Critical**

**Taking it to the Pulpit: Repositioning FBOs as Critical** 

In spite of significant gains achieved in the fight against HIV/AIDS, it remains a huge public health challenge in South Africa. Therefore, there is a need for continuous concerted efforts involving critical agencies like faith- based organizations (FBOs) that are already prominent in health care. The chapter examines how FBOs involved in HIV/AIDS response can be repositioned and further empowered. Though FBOs remain very critical and relevant to the national response in the country given their grassroots reach and influence; there is ambivalence on the value of such roles and how they relate to the national response. The main findings include: FBOs are not fully integrated into the national response framework; in spite of laudable strides, FBOs still embody a negative influence on the response especially in terms of the use of condoms; FBOs lack capacity in such crucial areas as networking and partnership; however, they are active in rural enclaves and in the prevention and care aspects of the response. There is a need to strengthen these FBOs, align their initiatives to both the national framework and orthodox knowledge regarding the pandemic. This chapter recommends programs to build the managerial and technical

**Keywords:** : HIV/AIDS, faith-based organizations, response framework, capacity,

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Despite considerable strides made in the fight against HIV/AIDS in Africa, it still remains a formidable challenge in the areas of public health and general development in the continent. This entails that there is no gainsaying the need for continued concerted efforts at addressing the menace of the pandemic. Without doubt, Faith-Based Organizations (FBOs)

DOI: 10.5772/intechopen.79660

**Agencies in the HIV/AIDS Response in South Africa**

**Agencies in the HIV/AIDS Response in South Africa**

Edlyne Eze Anugwom

Edlyne Eze Anugwom

**Abstract**

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79660

capacities of these FBOs

South Africa

**1. Introduction**


#### **Taking it to the Pulpit: Repositioning FBOs as Critical Agencies in the HIV/AIDS Response in South Africa Taking it to the Pulpit: Repositioning FBOs as Critical Agencies in the HIV/AIDS Response in South Africa**

DOI: 10.5772/intechopen.79660

#### Edlyne Eze Anugwom Edlyne Eze Anugwom

[65] Gospodarowicz M, Trypuc J, D'Cruz A, Khader J, Omar S, Knaul F. Cancer services and the comprehensive cancer center. In: Gelband H, Jha P, Sankaranarayanan R, Horton S, editors. Cancer: Disease Control Priorities. 3rd ed. Vol. 3. Washington (DC: International Bank for Reconstruction and Development / The World Bank; 2015. DOI:

[66] Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, Fan L, Li J, Chavarri-Guerra Y, et al. Challenges to effective cancer control in China, India, and Russia. The Lancet Oncology.

[67] Moore MA. Cancer control programs in East Asia: Evidence from the international literature. Journal of Preventive Medicine and Public Health. 2014;**47**(4):183-200. DOI:

[68] Rouhollahi MR, Mohagheghi MA, Mohammadrezai N, Ghiasvand R, Ghanbari Motlagh A, Harirchi I, et al. Situation analysis of the National Comprehensive Cancer Control Program (2013) in the I. R. of Iran; assessment and recommendations based on the IAEA imPACT mission. Archives of Iranian Medicine. 2014;**17**(4):222-231. DOI: 014174/aim.003

10.1596/978-1-4648-0349-9\_ch11

126 Public Health - Emerging and Re-emerging Issues

10.3961/jpmph.2014.47.4.183

2014;**15**(5):489-538. DOI: 10.1016/s1470-2045(14)70029-4

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79660

#### **Abstract**

In spite of significant gains achieved in the fight against HIV/AIDS, it remains a huge public health challenge in South Africa. Therefore, there is a need for continuous concerted efforts involving critical agencies like faith- based organizations (FBOs) that are already prominent in health care. The chapter examines how FBOs involved in HIV/AIDS response can be repositioned and further empowered. Though FBOs remain very critical and relevant to the national response in the country given their grassroots reach and influence; there is ambivalence on the value of such roles and how they relate to the national response. The main findings include: FBOs are not fully integrated into the national response framework; in spite of laudable strides, FBOs still embody a negative influence on the response especially in terms of the use of condoms; FBOs lack capacity in such crucial areas as networking and partnership; however, they are active in rural enclaves and in the prevention and care aspects of the response. There is a need to strengthen these FBOs, align their initiatives to both the national framework and orthodox knowledge regarding the pandemic. This chapter recommends programs to build the managerial and technical capacities of these FBOs

**Keywords:** : HIV/AIDS, faith-based organizations, response framework, capacity, South Africa

## **1. Introduction**

Despite considerable strides made in the fight against HIV/AIDS in Africa, it still remains a formidable challenge in the areas of public health and general development in the continent. This entails that there is no gainsaying the need for continued concerted efforts at addressing the menace of the pandemic. Without doubt, Faith-Based Organizations (FBOs)

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

have emerged as critical agencies of health provisioning in Africa especially with reference to HIV/AIDS. Thus, these FBOs appear as imperative avenues for fighting the pandemic in Africa. In view of the foregoing, the aim of this chapter is to assess the role of FBOs in South Africa in the response and more critically how such roles can be repositioned and enhanced to contribute more meaningfully to the overall national response. Thus, this chapter argues that while significant progress has been made in the fight against HIV/ AIDS in South Africa,<sup>1</sup>,<sup>2</sup> there is still a need for a much more concerted approach which should reposition and harness the value of Faith-Based Organizations (FBOs) as mediators in social life of citizens. In other words, its aims include to examine the roles of FBOs in the HIV/AIDS response, how such roles are integrated within the larger national response framework, the opportunities/niches which these FBOs embody, as well as the constraints or limitations suffered by these FBOs and how their undoubted visibility can be enhanced in improving the response.

In spite of the implicit recognition of the value of FBOs in the national response especially through the existence of faith-based sector in the South African National AIDS Council (SANAC), there remains to emerge a sustained and systematic thorough-going effort to fully integrate, deepen, and recalibrate the actions of the FBOs in the response. In other words, there is yet to really emerge a broad-based national and committed effort to locate these FBOs and their diverse actions squarely within the broad response framework as well as the obvious paucity in efforts to empower, strengthen, and effectively streamline the FBO contribution to the response.

Taking it to the Pulpit: Repositioning FBOs as Critical Agencies in the HIV/AIDS Response…

http://dx.doi.org/10.5772/intechopen.79660

129

The Christian AIDS Bureau for Southern Africa (CABSA) has arisen to inject the needed impetus and collaborative energy into the FBOs role in the HIV/AIDS response [8]. However, while re-emphasizing the important role of FBOs in the response, the CABSA's Executive Director, Lyn van Rooyen, argued that there is a need for FBOs to rethink their role in relation to the HIV/AIDS response [9]. But while the role of the FBOs in the response remains largely undoubted, what has remained mainly unknown is the connection between these roles and the largely national or state level response. In other words, how does the role played by these FBOs intertwine, feed in and integrate with the comprehensive response framework and whether such roles are defined and structured by the guiding rubrics of the national strategy especially in the rudiments of prevention usually captured in the ABC acronym (abstinence,

Even though a good number of studies [10–12] have been carried out on the health roles of FBOs in Africa, there is no doubt that there is still the need for more information and knowledge about the range of HIV/AIDS services provided by these organizations and more critically how and at what juncture these services interface with those from formal agencies. But even beyond the above is the need to understand the trajectories of the FBOs driven response and how these have been consistent or otherwise with the perceived dynamism of the general

Therefore, as has been argued, "generalizations about FBOs' HIV/AIDS prevention responses are unhelpful as they create an inaccurate picture of FBOs' HIV/AIDS response efforts" ([13], p. 314). In other words, there is a need for nuanced knowledge about the FBOs contribution which takes cognition of peculiarities, alignment and consistency with the broad national response framework and integration within such a broad framework. But in order to achieve the needed integration and consistency with the broader national response, there is a need for a better understanding of the peculiar predicaments these FBOs face and how these FBOs and their efforts can be better repositioned to squarely connect with the national response framework.

According to the Pew Research Center [14], the religious affiliations of South Africans range from preponderance of Protestantism to a significant (rapidly increasing) presence of Islam.

3 At a recent fora with FBOs, SANAC expressed concern that there is the substitution of ARV treatment with holy water and other faith-based commodities which are not scientifically proven to be effective against the pandemic [8].

**2. Profile of the FBOs engaged in the response**

be faithful, and condoms).<sup>3</sup>

state-driven response.

There is no gainsaying the fact that FBOs play critical roles in the health behaviour and health choices that people make in South Africa and the whole of the continent. This stems both from the remarkable level of religiosity among South Africans especially those who are largely marginal to the socioeconomic spheres of the society and the widespread prominence of these FBOs. As social indicators and even cursory observation would reveal, those who are most vulnerable to HIV/AIDS and also bear a high burden of the pandemic are people from the above category who are mainly poor, uneducated and more often than not excluded [3–5].

While South Africa has obviously weathered the storm of AIDS mainly through the global emphasis on ARVs and a much improved prevention program emphasizing safe sex, condom use, marital fidelity, knowledge of HIV/AIDS status, and reframing of AIDS as not a death penalty, there is still much work to be done not only to sustain the progress made but to ensure that the optimism expressed about overcoming the pandemic in the last few years is met. There is no doubt, as anyone familiar with the checkered history of South Africa with the AIDS pandemic would concede that FBOs were critical in the efforts of people to deal with the pandemic especially in terms of caregiving and provision of psychological and physical support to those afflicted and affected by AIDS; the role of FBOs in this regard seems both expected and in line with a consistent mediation in the health decisions of people in Africa [3, 6, 7].

Interestingly, while FBOs in Africa as a whole have responded to the pandemic, much of the response has been largely moralistic and often showing rejection of the core foundations of the campaign especially with regard to condom use and the issue of premarital sex [7]. The above calls attention to the need for AIDS policy planners and intervention agencies in South Africa to reflect on ways through which the FBOs can significantly benchmark their AIDS services and stance on the orthodoxy regarding the pandemic.

<sup>1</sup> Almost 20% of all HIV-positive people in the whole world live within South Africa's borders [1].

<sup>2</sup> While HIV prevalence among young South Africans is regarded as one of the highest in the world, there has been a significant decline from 10.3% in 2005 to 5.6% in 2016 (see, [2]). However, there is still a long way to go before Eureka.

In spite of the implicit recognition of the value of FBOs in the national response especially through the existence of faith-based sector in the South African National AIDS Council (SANAC), there remains to emerge a sustained and systematic thorough-going effort to fully integrate, deepen, and recalibrate the actions of the FBOs in the response. In other words, there is yet to really emerge a broad-based national and committed effort to locate these FBOs and their diverse actions squarely within the broad response framework as well as the obvious paucity in efforts to empower, strengthen, and effectively streamline the FBO contribution to the response.

have emerged as critical agencies of health provisioning in Africa especially with reference to HIV/AIDS. Thus, these FBOs appear as imperative avenues for fighting the pandemic in Africa. In view of the foregoing, the aim of this chapter is to assess the role of FBOs in South Africa in the response and more critically how such roles can be repositioned and enhanced to contribute more meaningfully to the overall national response. Thus, this chapter argues that while significant progress has been made in the fight against HIV/

should reposition and harness the value of Faith-Based Organizations (FBOs) as mediators in social life of citizens. In other words, its aims include to examine the roles of FBOs in the HIV/AIDS response, how such roles are integrated within the larger national response framework, the opportunities/niches which these FBOs embody, as well as the constraints or limitations suffered by these FBOs and how their undoubted visibility can be enhanced

There is no gainsaying the fact that FBOs play critical roles in the health behaviour and health choices that people make in South Africa and the whole of the continent. This stems both from the remarkable level of religiosity among South Africans especially those who are largely marginal to the socioeconomic spheres of the society and the widespread prominence of these FBOs. As social indicators and even cursory observation would reveal, those who are most vulnerable to HIV/AIDS and also bear a high burden of the pandemic are people from the above category who are mainly poor, uneducated and more often than not

While South Africa has obviously weathered the storm of AIDS mainly through the global emphasis on ARVs and a much improved prevention program emphasizing safe sex, condom use, marital fidelity, knowledge of HIV/AIDS status, and reframing of AIDS as not a death penalty, there is still much work to be done not only to sustain the progress made but to ensure that the optimism expressed about overcoming the pandemic in the last few years is met. There is no doubt, as anyone familiar with the checkered history of South Africa with the AIDS pandemic would concede that FBOs were critical in the efforts of people to deal with the pandemic especially in terms of caregiving and provision of psychological and physical support to those afflicted and affected by AIDS; the role of FBOs in this regard seems both expected and in line with a consistent mediation in the health decisions of people

Interestingly, while FBOs in Africa as a whole have responded to the pandemic, much of the response has been largely moralistic and often showing rejection of the core foundations of the campaign especially with regard to condom use and the issue of premarital sex [7]. The above calls attention to the need for AIDS policy planners and intervention agencies in South Africa to reflect on ways through which the FBOs can significantly benchmark their AIDS

2 While HIV prevalence among young South Africans is regarded as one of the highest in the world, there has been a significant decline from 10.3% in 2005 to 5.6% in 2016 (see, [2]). However, there is still a long way to go before Eureka.

services and stance on the orthodoxy regarding the pandemic.

1 Almost 20% of all HIV-positive people in the whole world live within South Africa's borders [1].

there is still a need for a much more concerted approach which

AIDS in South Africa,<sup>1</sup>,<sup>2</sup>

128 Public Health - Emerging and Re-emerging Issues

in improving the response.

excluded [3–5].

in Africa [3, 6, 7].

The Christian AIDS Bureau for Southern Africa (CABSA) has arisen to inject the needed impetus and collaborative energy into the FBOs role in the HIV/AIDS response [8]. However, while re-emphasizing the important role of FBOs in the response, the CABSA's Executive Director, Lyn van Rooyen, argued that there is a need for FBOs to rethink their role in relation to the HIV/AIDS response [9]. But while the role of the FBOs in the response remains largely undoubted, what has remained mainly unknown is the connection between these roles and the largely national or state level response. In other words, how does the role played by these FBOs intertwine, feed in and integrate with the comprehensive response framework and whether such roles are defined and structured by the guiding rubrics of the national strategy especially in the rudiments of prevention usually captured in the ABC acronym (abstinence, be faithful, and condoms).<sup>3</sup>

Even though a good number of studies [10–12] have been carried out on the health roles of FBOs in Africa, there is no doubt that there is still the need for more information and knowledge about the range of HIV/AIDS services provided by these organizations and more critically how and at what juncture these services interface with those from formal agencies. But even beyond the above is the need to understand the trajectories of the FBOs driven response and how these have been consistent or otherwise with the perceived dynamism of the general state-driven response.

Therefore, as has been argued, "generalizations about FBOs' HIV/AIDS prevention responses are unhelpful as they create an inaccurate picture of FBOs' HIV/AIDS response efforts" ([13], p. 314). In other words, there is a need for nuanced knowledge about the FBOs contribution which takes cognition of peculiarities, alignment and consistency with the broad national response framework and integration within such a broad framework. But in order to achieve the needed integration and consistency with the broader national response, there is a need for a better understanding of the peculiar predicaments these FBOs face and how these FBOs and their efforts can be better repositioned to squarely connect with the national response framework.

## **2. Profile of the FBOs engaged in the response**

According to the Pew Research Center [14], the religious affiliations of South Africans range from preponderance of Protestantism to a significant (rapidly increasing) presence of Islam.

<sup>3</sup> At a recent fora with FBOs, SANAC expressed concern that there is the substitution of ARV treatment with holy water and other faith-based commodities which are not scientifically proven to be effective against the pandemic [8].

In its estimation, the religious affiliations or spread of South African population (i.e., those who profess any form of religion) are protestant (41%), African Independent Churches (AICs) (27%), Catholics (11%), and Islam somewhere between 1.6 and 3% [14]. Be that as it may, Faith-Based Organizations in reality in South Africa represent a plethora of entities ranging from places of worship to even quasi-development or social organization with a mission of faith. These entail that FBOs are of various types and share a broad commonality in the faith nature or centeredness of the organization concerned or its parent body.

**3. Overview of the history and roles of the FBOs in the general** 

The role of FBOs in Southern Africa in providing care and support to those infected and affected by HIV/AIDS has been globally acknowledged [15–17]. In other words, there is a recognition, even where self-referent, that African FBOs are critical or important role players in the HIV/AIDS response especially in care giving (see, [18–21]) and also in the areas of prevention and awareness creation. At the same time, even while recognizing the roles of these FBOs, some authors have equally indicated these organizations as acting in ways that often undermine the overall response [21–23]. In other words, while there is no doubt that these FBOs do certain things in terms of the pandemic, there is ambivalence in terms of the net effect of such contributions and how the various roles of the different FBOs conflate with the overall

Taking it to the Pulpit: Repositioning FBOs as Critical Agencies in the HIV/AIDS Response…

http://dx.doi.org/10.5772/intechopen.79660

131

The role of the FBOs in the response in South Africa is equally underpinned by the realization that the real push for a systematic and state-wide recognition of the pandemic and needed response came from civil society groups and leaders who had to confront the unyielding denialism of the government regarding the pandemic between 1998 and 2008. In fact, this denialism under the then government of Thabo Mbeki gave rise to the non-acceptance and disavowal of the link between HIV and AIDS. A good survey of the history and politics of AIDS in South Africa between 1994 when democratic governance commenced and 2008 would certainly highlight the undaunted fight of civil society groups including FBOs for the mainstreaming of HIV/AIDS in national health framework and provisioning [1, 18, 24].

Apart from using the media and strategic awareness creation and coalitions, there was even utilization of legal means including the popular court case on the need of the state to provide nevirapine for PMTCT, the abdication of which these groups argued was really unconstitutional [1, 25]. In that historic case, the High Court in Pretoria found in favor of civil society arguing that a countrywide PMTCT program is in reality an ineluctable obligation of the South African State [24]. Incidentally, the then Health Minister, Tshabalala-Msimang appealed the court decision but lost in a historic case that generated great criticism and public opprobrium for the state. Going forward from the change in 2002, the government eventually signed off on a new National Strategic Plan (NSP) on HIV and AIDS and STIs (2007–2011) produced by SANAC. Given an onslaught of internal dissension, international condemnation, and even ridiculing of the government, it was a matter of time before the state made a volte-face. The change came in 2002 when a cabinet statement offered acceptance of the link between HIV and AIDS, the rolling out of PMTCT in the nine regions of the country, and the launching of the Strategic STI (including AIDS) Plan (2002–2005) among other measures [1, 24]. Following that was the approval eventually by the cabinet in November 2003 of an Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa as a whole [1, 24]. However, the first broad-based National Strategic Plan (2007–2011) that was led by SANAC but which involved dialog and consultation with stakeholders and the political class finally emerged in 2006 [1, 24].

Currently, there is a new National Strategic Plan for HIV, TB, and STIs (2017–2022) which is the fourth plan in this regard and embodies the aspiration to build on the progress that has been achieved in the national response so far [26]. The fact that the present plan aims

**response**

national strategy and broad efforts.

However, this chapter adopts a very generous definition of FBOs involved in the HIV/AIDS response. This definition is robust and involves different sizes and types of FBOs operating at local, provincial, and national levels. Therefore, FBOs in this case refer to a broad set of faith-based organizations or institutions including national religious structures like the South African Bishops Conference, faith-based non-governmental organizations like Youth for Christ, community-based or local parishes and congregations, church-based or aligned social service agencies, and other social service agencies and projects tied to faith-based organizations or churches (see also [5]). In spite of the above general conceptualization, it is necessary to mention that the real work of intervention whether in terms of care or prevention or even access to treatment is more readily crystallized at the community or local level. For instance, while the national FBO body or coalition like the Bishops Conference may issue proclamations and provide general guidelines, the nitty-gritty of dealing with those affected and infected usually lies with the different parishes, congregations, and similar spatially delimited church groups or organizations. While both levels of efforts are complementary and important, the response patterns and interactions play out mostly at the local and community levels.

As cursory observation would reveal, there is a preponderance of these FBOs in the urban areas of the country. This entails that accessing of HIV/AIDS services would be particularly challenging for rural dwellers especially when one takes cognizance of the fact that the formal response structures are equally not well entrenched in the rural enclaves. Further characterization of FBOs here depends essentially on the material available in the South African National AIDS Database [3]. The database shows 162 FBOs involved in the response of which 96% are Christian and 40% are Muslim. Among the Christian FBOs, the distribution was Catholic 14%, Dutch Reformed Churches 11%, Pentecostal/Charismatic 11%, Anglican 7%, Methodist 6%, and others 8%. Apart from the above denominational and demographic characteristics, these FBOs can equally be characterized as networks and coalitions (4%), faith-based NGOs (16%), and projects/special initiatives (47%). Incidentally, these categories are hardly mutually exclusive and overlaps occur. In spite of these, the highest number of FBOs engaged in the response is in the project-oriented categories (47%), followed by faith-based NGOs (16%) and social service outlets (13%), while the lowest of less than 5% is found among networks and coalitions which suggest glaring capacity and integration challenges generally.

In spite of the above, the FBOs are usually concentrated in the area of prevention rather than treatment and management. In other words, the bulk of the activities of the FBOs are awareness, counseling, and to an extent testing. But they usually shun from the provision of core medical care and hardly focus on condom seen largely as inconsistent with the scripture and liturgy of these organizations. In a curious sense, the FBOs seem to have replaced condom promotion with abstinence. Hence, they are much more comfortable with preaching and privileging abstinence rather than focusing on condoms.

## **3. Overview of the history and roles of the FBOs in the general response**

In its estimation, the religious affiliations or spread of South African population (i.e., those who profess any form of religion) are protestant (41%), African Independent Churches (AICs) (27%), Catholics (11%), and Islam somewhere between 1.6 and 3% [14]. Be that as it may, Faith-Based Organizations in reality in South Africa represent a plethora of entities ranging from places of worship to even quasi-development or social organization with a mission of faith. These entail that FBOs are of various types and share a broad commonality in the faith

However, this chapter adopts a very generous definition of FBOs involved in the HIV/AIDS response. This definition is robust and involves different sizes and types of FBOs operating at local, provincial, and national levels. Therefore, FBOs in this case refer to a broad set of faith-based organizations or institutions including national religious structures like the South African Bishops Conference, faith-based non-governmental organizations like Youth for Christ, community-based or local parishes and congregations, church-based or aligned social service agencies, and other social service agencies and projects tied to faith-based organizations or churches (see also [5]). In spite of the above general conceptualization, it is necessary to mention that the real work of intervention whether in terms of care or prevention or even access to treatment is more readily crystallized at the community or local level. For instance, while the national FBO body or coalition like the Bishops Conference may issue proclamations and provide general guidelines, the nitty-gritty of dealing with those affected and infected usually lies with the different parishes, congregations, and similar spatially delimited church groups or organizations. While both levels of efforts are complementary and important, the

response patterns and interactions play out mostly at the local and community levels.

coalitions which suggest glaring capacity and integration challenges generally.

privileging abstinence rather than focusing on condoms.

In spite of the above, the FBOs are usually concentrated in the area of prevention rather than treatment and management. In other words, the bulk of the activities of the FBOs are awareness, counseling, and to an extent testing. But they usually shun from the provision of core medical care and hardly focus on condom seen largely as inconsistent with the scripture and liturgy of these organizations. In a curious sense, the FBOs seem to have replaced condom promotion with abstinence. Hence, they are much more comfortable with preaching and

As cursory observation would reveal, there is a preponderance of these FBOs in the urban areas of the country. This entails that accessing of HIV/AIDS services would be particularly challenging for rural dwellers especially when one takes cognizance of the fact that the formal response structures are equally not well entrenched in the rural enclaves. Further characterization of FBOs here depends essentially on the material available in the South African National AIDS Database [3]. The database shows 162 FBOs involved in the response of which 96% are Christian and 40% are Muslim. Among the Christian FBOs, the distribution was Catholic 14%, Dutch Reformed Churches 11%, Pentecostal/Charismatic 11%, Anglican 7%, Methodist 6%, and others 8%. Apart from the above denominational and demographic characteristics, these FBOs can equally be characterized as networks and coalitions (4%), faith-based NGOs (16%), and projects/special initiatives (47%). Incidentally, these categories are hardly mutually exclusive and overlaps occur. In spite of these, the highest number of FBOs engaged in the response is in the project-oriented categories (47%), followed by faith-based NGOs (16%) and social service outlets (13%), while the lowest of less than 5% is found among networks and

nature or centeredness of the organization concerned or its parent body.

130 Public Health - Emerging and Re-emerging Issues

The role of FBOs in Southern Africa in providing care and support to those infected and affected by HIV/AIDS has been globally acknowledged [15–17]. In other words, there is a recognition, even where self-referent, that African FBOs are critical or important role players in the HIV/AIDS response especially in care giving (see, [18–21]) and also in the areas of prevention and awareness creation. At the same time, even while recognizing the roles of these FBOs, some authors have equally indicated these organizations as acting in ways that often undermine the overall response [21–23]. In other words, while there is no doubt that these FBOs do certain things in terms of the pandemic, there is ambivalence in terms of the net effect of such contributions and how the various roles of the different FBOs conflate with the overall national strategy and broad efforts.

The role of the FBOs in the response in South Africa is equally underpinned by the realization that the real push for a systematic and state-wide recognition of the pandemic and needed response came from civil society groups and leaders who had to confront the unyielding denialism of the government regarding the pandemic between 1998 and 2008. In fact, this denialism under the then government of Thabo Mbeki gave rise to the non-acceptance and disavowal of the link between HIV and AIDS. A good survey of the history and politics of AIDS in South Africa between 1994 when democratic governance commenced and 2008 would certainly highlight the undaunted fight of civil society groups including FBOs for the mainstreaming of HIV/AIDS in national health framework and provisioning [1, 18, 24].

Apart from using the media and strategic awareness creation and coalitions, there was even utilization of legal means including the popular court case on the need of the state to provide nevirapine for PMTCT, the abdication of which these groups argued was really unconstitutional [1, 25]. In that historic case, the High Court in Pretoria found in favor of civil society arguing that a countrywide PMTCT program is in reality an ineluctable obligation of the South African State [24]. Incidentally, the then Health Minister, Tshabalala-Msimang appealed the court decision but lost in a historic case that generated great criticism and public opprobrium for the state. Going forward from the change in 2002, the government eventually signed off on a new National Strategic Plan (NSP) on HIV and AIDS and STIs (2007–2011) produced by SANAC. Given an onslaught of internal dissension, international condemnation, and even ridiculing of the government, it was a matter of time before the state made a volte-face. The change came in 2002 when a cabinet statement offered acceptance of the link between HIV and AIDS, the rolling out of PMTCT in the nine regions of the country, and the launching of the Strategic STI (including AIDS) Plan (2002–2005) among other measures [1, 24]. Following that was the approval eventually by the cabinet in November 2003 of an Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa as a whole [1, 24]. However, the first broad-based National Strategic Plan (2007–2011) that was led by SANAC but which involved dialog and consultation with stakeholders and the political class finally emerged in 2006 [1, 24].

Currently, there is a new National Strategic Plan for HIV, TB, and STIs (2017–2022) which is the fourth plan in this regard and embodies the aspiration to build on the progress that has been achieved in the national response so far [26]. The fact that the present plan aims at "saturation of high-impact prevention and treatment services and strengthened efforts to address the social and structural factors that increase vulnerability to infection" ([20], p. xiii) means an increased opportunity for non-governmental groups including FBOs to find credible niche and relevance in the response. Interestingly, goal 6 of the Plan which is, "promote leadership and shared accountability for a sustainable response to HIV, TB and STIs" embody the desire to capture, strengthen, and create spaces for role performance by the private sector, labor and civil society organizations in the national response.

**5. Results and discussion**

impediments to the FBOs response.

Some of these are examined subsequently.

neled along the broader state level response framework.

*5.1.2. FBOs and understanding of sexuality and sexual behaviour*

*5.1.1. Grassroots/community reach*

The results and discussion in this chapter would be organized under two main headings, namely opportunities and niches of FBOs in the HIV/AIDS response and the constraints/

Taking it to the Pulpit: Repositioning FBOs as Critical Agencies in the HIV/AIDS Response…

http://dx.doi.org/10.5772/intechopen.79660

133

As obvious from the foregoing discussions, FBOs in South Africa and even the continent at large play critical roles in the health-seeking behaviour of people including HIV/AIDS. However, the role of the church in the above capacity often raises concerns regarding the nature of such involvement and its consistency with biomedical standards and procedures. In spite of this, the FBOs in South Africa offer opportunities and/or possess niches relevant to the response.

Perhaps, the greatest niche of the FBOs is captured in their grassroots or community reach and engagement capacity. In this case, the FBOs usually mobilize and engage with people and communities at the grassroots and have utilized this capacity to render services and support to those affected by the pandemic [7, 13, 15]. Specifically, the FBOs have been largely prominent at this level in the areas of care and support, counseling, and providing psycho-moral support of various types. The believability of the FBOs from the point of view of the people and the high faith imbued in these organizations give them the ability not only to intercede but mediate the response in ways that can be really effective if properly managed and chan-

As has been argued, "FBOs are at the centre of community life in much of South Africa and have extensive reach into the most remote and isolated parts of the country. These organizations hold positions of trust, which give their actions and words considerable potency. They have frequent opportunities to interact with their congregations and communities and have the ability to influence social norms and behaviours through moral teachings" [27]. Therefore, the relevance and value of the FBOs are further enhanced by the realization that these organizations have very robust community level roots and presence. These position them as critical agencies at the community level in addressing and mediating health challenges of members and others at that level. In other words, both their visibility and acceptance at the community level far outweigh those of the formal health system or state-driven HIV/AIDS agencies. Hence, they remain important agencies for influencing and impacting both health-seeking decisions and access to health care of people especially at community and rural enclaves.

There is without doubt a need to seriously nuance our understanding of the role of FBOs and religiosity as a whole on sexuality and sexual behaviour in African societies. This is especially the case in view of the fact that evidence from studies in developing countries of the world

**5.1. Opportunities and niches of FBOs in the HIV/AIDS response**

## **4. Methodology**

This chapter derived its information from documentary sources of data and the extant literature. The review of literature for this chapter was based on the following general criteria:

**Database:** The literature search focused essentially on databases known for housing information and journals on social sciences and health, public health, HIV/AIDS, and religion and health in Africa. Thus, the following databases were utilized: South Africa Database on HIV/ AIDS, Google Scholar, ProQuest, Medline Plus, UWC Online Library, and Cochrane Library.

**Data type:** Primary and secondary data, that is, papers that were derived through field work studies or surveys and those that were generated through documentary data or literature review.

**Terms/concepts used:** Terms and concepts use for the literature search included HIV/AIDS, Africa, South Africa, religion, Health; Faith-Based Organizations in Africa response to HIV/ AIDS in Africa, and UNAIDS.

**Geographical focus:** Africa, Southern Africa, and South Africa.

**Inclusion criteria:** Papers and articles utilized for the review were selected on the basis of the following criteria: focus on HIV/AIDS and religion; HIV/AIDS and FBOs in Africa; published between 2000 and 2017; social science articles on FBOs and health-seeking behaviour in Africa; role of FBOs in HIV/AIDS and health provision in Africa.

**Exclusion criteria:** The following criteria were used in excluding material in the review process: papers dealing with HIV/AIDS in other regions of the world; extreme-dated papers, that is, papers published before 2000; gray literature and opinion articles; papers focusing only on biomedical aspects of HIV/AIDS in Africa.

The above guided the literature review for this chapter and provided information and insight for a thorough-going overview of the FBOs response to the HIV/AIDS pandemic and the teasing out of both the structural impediments to the optimal utilization of these FBOs and the unique opportunities they still portend, especially in reaching the teeming number of those either vulnerable or marginal to the socio-economic spheres of the society. Therefore, while there is undoubtedly a good volume of published materials in the above regard, this chapter prioritized those focusing on the role and involvement of FBOs in the response to HIV/AIDS, the state of the response in South Africa, as well as the nature of FBOs involved in the response.

## **5. Results and discussion**

at "saturation of high-impact prevention and treatment services and strengthened efforts to address the social and structural factors that increase vulnerability to infection" ([20], p. xiii) means an increased opportunity for non-governmental groups including FBOs to find credible niche and relevance in the response. Interestingly, goal 6 of the Plan which is, "promote leadership and shared accountability for a sustainable response to HIV, TB and STIs" embody the desire to capture, strengthen, and create spaces for role performance by the private sector,

This chapter derived its information from documentary sources of data and the extant literature. The review of literature for this chapter was based on the following general criteria: **Database:** The literature search focused essentially on databases known for housing information and journals on social sciences and health, public health, HIV/AIDS, and religion and health in Africa. Thus, the following databases were utilized: South Africa Database on HIV/ AIDS, Google Scholar, ProQuest, Medline Plus, UWC Online Library, and Cochrane Library. **Data type:** Primary and secondary data, that is, papers that were derived through field work studies or surveys and those that were generated through documentary data or literature

**Terms/concepts used:** Terms and concepts use for the literature search included HIV/AIDS, Africa, South Africa, religion, Health; Faith-Based Organizations in Africa response to HIV/

**Inclusion criteria:** Papers and articles utilized for the review were selected on the basis of the following criteria: focus on HIV/AIDS and religion; HIV/AIDS and FBOs in Africa; published between 2000 and 2017; social science articles on FBOs and health-seeking behaviour in

**Exclusion criteria:** The following criteria were used in excluding material in the review process: papers dealing with HIV/AIDS in other regions of the world; extreme-dated papers, that is, papers published before 2000; gray literature and opinion articles; papers focusing only on

The above guided the literature review for this chapter and provided information and insight for a thorough-going overview of the FBOs response to the HIV/AIDS pandemic and the teasing out of both the structural impediments to the optimal utilization of these FBOs and the unique opportunities they still portend, especially in reaching the teeming number of those either vulnerable or marginal to the socio-economic spheres of the society. Therefore, while there is undoubtedly a good volume of published materials in the above regard, this chapter prioritized those focusing on the role and involvement of FBOs in the response to HIV/AIDS, the state of the response in South Africa, as well as the nature of FBOs involved in the response.

labor and civil society organizations in the national response.

**Geographical focus:** Africa, Southern Africa, and South Africa.

Africa; role of FBOs in HIV/AIDS and health provision in Africa.

**4. Methodology**

132 Public Health - Emerging and Re-emerging Issues

review.

AIDS in Africa, and UNAIDS.

biomedical aspects of HIV/AIDS in Africa.

The results and discussion in this chapter would be organized under two main headings, namely opportunities and niches of FBOs in the HIV/AIDS response and the constraints/ impediments to the FBOs response.

#### **5.1. Opportunities and niches of FBOs in the HIV/AIDS response**

As obvious from the foregoing discussions, FBOs in South Africa and even the continent at large play critical roles in the health-seeking behaviour of people including HIV/AIDS. However, the role of the church in the above capacity often raises concerns regarding the nature of such involvement and its consistency with biomedical standards and procedures. In spite of this, the FBOs in South Africa offer opportunities and/or possess niches relevant to the response. Some of these are examined subsequently.

#### *5.1.1. Grassroots/community reach*

Perhaps, the greatest niche of the FBOs is captured in their grassroots or community reach and engagement capacity. In this case, the FBOs usually mobilize and engage with people and communities at the grassroots and have utilized this capacity to render services and support to those affected by the pandemic [7, 13, 15]. Specifically, the FBOs have been largely prominent at this level in the areas of care and support, counseling, and providing psycho-moral support of various types. The believability of the FBOs from the point of view of the people and the high faith imbued in these organizations give them the ability not only to intercede but mediate the response in ways that can be really effective if properly managed and channeled along the broader state level response framework.

As has been argued, "FBOs are at the centre of community life in much of South Africa and have extensive reach into the most remote and isolated parts of the country. These organizations hold positions of trust, which give their actions and words considerable potency. They have frequent opportunities to interact with their congregations and communities and have the ability to influence social norms and behaviours through moral teachings" [27]. Therefore, the relevance and value of the FBOs are further enhanced by the realization that these organizations have very robust community level roots and presence. These position them as critical agencies at the community level in addressing and mediating health challenges of members and others at that level. In other words, both their visibility and acceptance at the community level far outweigh those of the formal health system or state-driven HIV/AIDS agencies. Hence, they remain important agencies for influencing and impacting both health-seeking decisions and access to health care of people especially at community and rural enclaves.

#### *5.1.2. FBOs and understanding of sexuality and sexual behaviour*

There is without doubt a need to seriously nuance our understanding of the role of FBOs and religiosity as a whole on sexuality and sexual behaviour in African societies. This is especially the case in view of the fact that evidence from studies in developing countries of the world places religiosity and religious organizations in an ambivalent position in relation to sexuality and sexual behaviour [28–32]. Therefore, these studies reveal that while people especially youth who profess religion or are religious are less likely to have sexual partners and be initiated into sexual activities, they are also prone to be less sensitive to the need for protection when they become sexually active. However, studies from Africa would tend to neutralize the influence of religion on sexual activity by young people who are religious in relation to the other members of the society [6, 33–35]. But these studies did not dispute the undoubted influence of the church in personal life and social behaviour of Africans.

the latter are usually dependent on donations and goodwill from church members and thus

Taking it to the Pulpit: Repositioning FBOs as Critical Agencies in the HIV/AIDS Response…

http://dx.doi.org/10.5772/intechopen.79660

135

Even where funding exists especially in terms of programs of international multi-lateral development agencies, FBOs have not been very successful in accessing these funds. In other words, while some of the FBOs have accessed such funds, many have been unable due to capacity challenges to make optimum use of this channel of funding. The FBOs often lack the technical capacity to develop project proposals and even position papers often necessary to attract or compete for such funding. Poor networking and partnership also hinder these groups. Incidentally, fundamentalist and isolationist (seen here as resistance to external influ-

Therefore, scarcity of fund is generally seen as militating against the effectiveness of the FBOs. Many of the FBOs involved in different aspects of the response experience funding challenges followed by lack of equipment or infrastructure [5]. The above challenges can be easily appreciated against the background of the nature and primary goals of FBOs which cast them as non-profit and not engaged in business or economic ventures for making money. FBOs largely depend on free-will donations and offertory of church members. In many cases, even the specialized or dedicated HIV/AIDS units of churches or denominations are equally dependent on the goodwill donations of members and whatever money allocated from the general church pool. In spite of the assistance of government and international agencies, HIV/ AIDS response in light of the heavy burden from it remains more or less resource guzzling. Therefore, the extent and depth of coverage or response effectiveness depends on the availability of funding and the necessary equipment and infrastructure without which actions

There is also the nagging issue of conflation and sin-oriented definition of the pandemic by a good number of the FBOs. This orientation hinders the effectiveness of FBOs in the response. In such a situation, there arises conflation of sexuality and morality and the treatment or perception of AIDS as the fruit of sin [27]. In other words, there is often the tendency among the FBOs to indirectly and in some few cases directly blame the victims. AIDS is thus seen as an issue which underlines both immorality and sinful

A crucial bulwark in the FBO response to the pandemic lies especially in the adoption of a moral kaleidoscope in the perception of the pandemic. In almost all instances, the church sees HIV/AIDS as more a reflection of individual moral laxity and irresponsibility than just the occurrence of disease. Often times, the emphasis is placed on ascertaining how the individual became infected rather than on prioritizing service. Therefore, even though the Catholic church or most of the Pentecostal churches are berated for unshifting and loud stance on condoms, the FBOs generally suffer from the above moralization of the pandemic and are also encumbered by patriarchal and hierarchical structures that while preserving the church as a consistent and fixed embodiment of spirituality reproduces gender inequality that enhances

vulnerability and the inability of women to access HIV/AIDS services [7].

ence and values) leanings of FBOs also come in the way of their ability to reach out.

always in acute need of funding in order to function effectively [7].

toward addressing the pandemic are severely encumbered.

*5.2.2. Conflation and sin-oriented approach*

predilection of those affected [4, 21].

#### *5.1.3. Protection from early sexual activity and promiscuity*

Also, religious organizations and churches spend energy on moral principles and the denouncement of promiscuity. The undeniable fact is that religion plays a role in protecting young people from early sexual activity, sex adventurism, and general promiscuity, all of which may be positive to the HIV/AIDS elimination drive. But the way and manner the church goes about performing the above roles with specific reference to HIV/AIDS would seem really important. In other words, the church can function as both the linchpin of the response in communities and at the same time ironically perpetrate practices and values that ultimately seem antithetical to the response especially in terms of dealing with those who are affected and infected and also in decreasing vulnerability and eliminating risky behaviour by young people [6, 7, 27].

Even though efforts have been made starting from 2003 to understand and document the activities of these FBOs in the response as part of a general view of community level activities around the pandemic, it is ambivalent whether the outcomes of such evaluations and assessments have become effectively utilized in strengthening the national response to HIV/ AIDS. Perhaps, concrete attempts at doing the above would have entailed the enhancement of the capacity of the FBOs.

### **5.2. Constraints/impediments to the FBOs response**

Definitely, the concern in this chapter apart from the main focus of proffering measures for strengthening the FBOs contribution to the response is also the need to overcome some of the inadequacies and actions or mis-actions of these organizations which ultimately portend negative consequences for the response. These may include subjecting the HIV/AIDS core messages to wrongful and slanted biblical interpretations, over-utilization of religious doctrines in evaluating HIV/AIDS prevention messages and overtly moralizing tendencies which interfere with what the church can and cannot do within the response. Some of these issues are addressed subsequently.

### *5.2.1. Funding limitations and technical incapacity*

While the South African government and its agencies often fund FBOs run or owned social service agencies and projects involved in the response, they hardly commit to the churches or congregations or response initiatives embedded in them. The end product is that while the former do not have adequate funding in spite of what comes from statutory agencies, the latter are usually dependent on donations and goodwill from church members and thus always in acute need of funding in order to function effectively [7].

Even where funding exists especially in terms of programs of international multi-lateral development agencies, FBOs have not been very successful in accessing these funds. In other words, while some of the FBOs have accessed such funds, many have been unable due to capacity challenges to make optimum use of this channel of funding. The FBOs often lack the technical capacity to develop project proposals and even position papers often necessary to attract or compete for such funding. Poor networking and partnership also hinder these groups. Incidentally, fundamentalist and isolationist (seen here as resistance to external influence and values) leanings of FBOs also come in the way of their ability to reach out.

Therefore, scarcity of fund is generally seen as militating against the effectiveness of the FBOs. Many of the FBOs involved in different aspects of the response experience funding challenges followed by lack of equipment or infrastructure [5]. The above challenges can be easily appreciated against the background of the nature and primary goals of FBOs which cast them as non-profit and not engaged in business or economic ventures for making money. FBOs largely depend on free-will donations and offertory of church members. In many cases, even the specialized or dedicated HIV/AIDS units of churches or denominations are equally dependent on the goodwill donations of members and whatever money allocated from the general church pool. In spite of the assistance of government and international agencies, HIV/ AIDS response in light of the heavy burden from it remains more or less resource guzzling. Therefore, the extent and depth of coverage or response effectiveness depends on the availability of funding and the necessary equipment and infrastructure without which actions toward addressing the pandemic are severely encumbered.

#### *5.2.2. Conflation and sin-oriented approach*

places religiosity and religious organizations in an ambivalent position in relation to sexuality and sexual behaviour [28–32]. Therefore, these studies reveal that while people especially youth who profess religion or are religious are less likely to have sexual partners and be initiated into sexual activities, they are also prone to be less sensitive to the need for protection when they become sexually active. However, studies from Africa would tend to neutralize the influence of religion on sexual activity by young people who are religious in relation to the other members of the society [6, 33–35]. But these studies did not dispute the undoubted

Also, religious organizations and churches spend energy on moral principles and the denouncement of promiscuity. The undeniable fact is that religion plays a role in protecting young people from early sexual activity, sex adventurism, and general promiscuity, all of which may be positive to the HIV/AIDS elimination drive. But the way and manner the church goes about performing the above roles with specific reference to HIV/AIDS would seem really important. In other words, the church can function as both the linchpin of the response in communities and at the same time ironically perpetrate practices and values that ultimately seem antithetical to the response especially in terms of dealing with those who are affected and infected and also

in decreasing vulnerability and eliminating risky behaviour by young people [6, 7, 27].

Even though efforts have been made starting from 2003 to understand and document the activities of these FBOs in the response as part of a general view of community level activities around the pandemic, it is ambivalent whether the outcomes of such evaluations and assessments have become effectively utilized in strengthening the national response to HIV/ AIDS. Perhaps, concrete attempts at doing the above would have entailed the enhancement

Definitely, the concern in this chapter apart from the main focus of proffering measures for strengthening the FBOs contribution to the response is also the need to overcome some of the inadequacies and actions or mis-actions of these organizations which ultimately portend negative consequences for the response. These may include subjecting the HIV/AIDS core messages to wrongful and slanted biblical interpretations, over-utilization of religious doctrines in evaluating HIV/AIDS prevention messages and overtly moralizing tendencies which interfere with what the church can and cannot do within the response. Some of these issues

While the South African government and its agencies often fund FBOs run or owned social service agencies and projects involved in the response, they hardly commit to the churches or congregations or response initiatives embedded in them. The end product is that while the former do not have adequate funding in spite of what comes from statutory agencies,

influence of the church in personal life and social behaviour of Africans.

*5.1.3. Protection from early sexual activity and promiscuity*

134 Public Health - Emerging and Re-emerging Issues

**5.2. Constraints/impediments to the FBOs response**

*5.2.1. Funding limitations and technical incapacity*

of the capacity of the FBOs.

are addressed subsequently.

There is also the nagging issue of conflation and sin-oriented definition of the pandemic by a good number of the FBOs. This orientation hinders the effectiveness of FBOs in the response. In such a situation, there arises conflation of sexuality and morality and the treatment or perception of AIDS as the fruit of sin [27]. In other words, there is often the tendency among the FBOs to indirectly and in some few cases directly blame the victims. AIDS is thus seen as an issue which underlines both immorality and sinful predilection of those affected [4, 21].

A crucial bulwark in the FBO response to the pandemic lies especially in the adoption of a moral kaleidoscope in the perception of the pandemic. In almost all instances, the church sees HIV/AIDS as more a reflection of individual moral laxity and irresponsibility than just the occurrence of disease. Often times, the emphasis is placed on ascertaining how the individual became infected rather than on prioritizing service. Therefore, even though the Catholic church or most of the Pentecostal churches are berated for unshifting and loud stance on condoms, the FBOs generally suffer from the above moralization of the pandemic and are also encumbered by patriarchal and hierarchical structures that while preserving the church as a consistent and fixed embodiment of spirituality reproduces gender inequality that enhances vulnerability and the inability of women to access HIV/AIDS services [7].

#### *5.2.3. Traditional conservatism*

Perhaps, equally constraining, the role of the FBOs in the challenge of the pandemic is the nature of the church as a largely conservative and very slow-changing entity. There is no doubt that the response in South Africa like in so many other countries in the continent calls for dynamism and working in concert and collaboration with other stakeholders. The noted conservatism of the church and the abhorrence of "outside" interference may actually make it difficult to integrate FBO response activities into a broad systematic response framework [13, 15, 36].

citizens see the church as more or less the mainstay of their existence. Thus, FBOs are fulcrums of their economic, political, and health decisions and crucially condition their beliefs about diseases including HIV/AIDS and the desired cum approved (scripturally or denominationally) response. Incidentally, the citizens who belong to this category are also those mainly at risk and highly vulnerable to HIV/AIDS. It stands to reason therefore that re-aligning these FBOs to the orthodox response framework and improving their capacities as health mediators would in the medium run greatly improve the HIV/AIDS response in the country as a whole. It was in recognition of the role of the FBOs that the SANAC encourages regular dialog between the FBOs and Civil Society Forum (CSF) of the SANAC. But such dialog should be deepened and made regular in order to address some of the noted predilection of the FBOs in responding to the pandemic including using holy water in place of ARV [8]. In fact, as cursory observation would show, FBOs in the continent (not only South Africa) have often promoted the use of such commodities as holy water, holy oil, holy sand, and anointed spiritual items in perceived treatment of the pandemic. These items are usually seen as general spiritual agencies of miracle cure. Before enumerating ways through which the FBOs can be repositioned and strengthened in terms of further contributing to the HIV/AIDS response, there is a need to point out that the beginning of effective mainstreaming and integration of the FBOs into the national response framework should be against the appreciation of the variety of FBOs operating in the country. In other words, there is a need to take cognizance of the peculiarities, denominational/religious bends, and defining characteristics of these groups. Thus, a one-size-fits-all approach would not suffice. Therefore, there is a need for tailored engagements that aim at creatively harnessing the strengths of these FBOs as mass organizations. Strategies to be considered

Taking it to the Pulpit: Repositioning FBOs as Critical Agencies in the HIV/AIDS Response…

http://dx.doi.org/10.5772/intechopen.79660

137

**1.** Facilitating the FBOs to reconcile liturgical stands with the reality of the pandemic. Specifically, in this regard, efforts would include the acceptance of condom and the una-

**2.** Improving the awareness creation of the FBOs—while huge success has been achieved on awareness in general in the country as a whole, the FBOs lag behind, and often a good number of them avoid the topic of AIDS altogether and adopt a more or less ostrich approach. Therefore, there is a need to take awareness to the church and the pulpit. But even more critical is to ensure that awareness messages whether captured in main liturgical modes or in the communication outlets of the church need to be informed by a good knowledge of

**3.** Empowering the churches to establish formal organs within the church hierarchy dedicated to the HIV/AIDS pandemic response. Such organs should be manned by members who have good knowledge of the pandemic and have the time to dedicate to the response. Members of such church organs would need to be empowered through capacity training

**4.** Partnership and networking: The partnership and networking envisaged here should be between the FBOs and state agencies on one hand and a form of triple network involving the FBOs, state agencies, and NGOs/CSOs engaged in intervention programs at various

voidable reality of premarital sex and marital infidelity.

the pandemic and location of South Africa within the global response.

by the agencies of the state in charge of the response to the pandemic.

include the following:

levels of the response.

#### *5.2.4. Non-integration into larger service delivery networks*

An important evaluation of the roles and activities of FBOs in the HIV/AIDS response in South Africa has been carried out by CADRE [31]. The evaluation profiled these FBOs and outlined such technical issues as funding, capacity, and networking in the FBOs and underlined the significant roles of these FBOs especially in the areas of care and prevention. However, the report located a couple of challenges confronting these organizations, ranging from the scope or extent of reach and funding but more critical is the finding of the evaluation that the activities of these FBOs do not appear to be integrated into the larger service delivery networks [5]. In other words, these FBOs while performing critical functions are not systematically connected to the larger response framework and are dogged by funding and technical challenges. Thus, while these FBOs remain undoubtedly imperative to the response, their effectiveness has not been maximized or systematically harnessed. Therefore, the picture of the mid-2000s painted in the evaluation remains largely the same till now. In fact, there is the feeling that these FBOs in the euphoria of the remarkable strides achieved in the response in the country have become almost lethargic and have not advanced much in terms of improved capacity.

#### *5.2.5. Other constraints*

The capacity of FBOs to perform in the response is also limited by the fact that what apparently appears like FBO agencies involved in the response are in reality a case of these agencies taking on the added responsibility of dealing with HIV/AIDS. In other words, HIV/AIDS responses are often embedded in organizations that predated the pandemic with clear mandates beyond HIV/AIDS. These militate against the development of a clear-cut HIV/AIDSfocused capacity even in the long run in these FBOs [5, 7]. Even more perturbing is that often times, one perceives the FBOs in the response in the form of tiny islands cut off from each other and from the big sea. In this sense, there is a dearth of effective networking and coalition across FBOs in the response. This really militates against capacity development as each FBO's effort becomes disparate from the others, and there is hardly meaningful integration, sharing of resources, sharing of lessons learnt, and interdependence even on delimited scope.

## **6. Conclusion: Strengthening and mainstreaming FBOs response to HIV/AIDS in South Africa**

The FBOs are usually very important components of the social life of a large number of South African citizens who are really marginal to the socio-economic spheres of the society. These citizens see the church as more or less the mainstay of their existence. Thus, FBOs are fulcrums of their economic, political, and health decisions and crucially condition their beliefs about diseases including HIV/AIDS and the desired cum approved (scripturally or denominationally) response. Incidentally, the citizens who belong to this category are also those mainly at risk and highly vulnerable to HIV/AIDS. It stands to reason therefore that re-aligning these FBOs to the orthodox response framework and improving their capacities as health mediators would in the medium run greatly improve the HIV/AIDS response in the country as a whole.

*5.2.3. Traditional conservatism*

136 Public Health - Emerging and Re-emerging Issues

*5.2.5. Other constraints*

**HIV/AIDS in South Africa**

*5.2.4. Non-integration into larger service delivery networks*

Perhaps, equally constraining, the role of the FBOs in the challenge of the pandemic is the nature of the church as a largely conservative and very slow-changing entity. There is no doubt that the response in South Africa like in so many other countries in the continent calls for dynamism and working in concert and collaboration with other stakeholders. The noted conservatism of the church and the abhorrence of "outside" interference may actually make it difficult to integrate FBO response activities into a broad systematic response framework [13, 15, 36].

An important evaluation of the roles and activities of FBOs in the HIV/AIDS response in South Africa has been carried out by CADRE [31]. The evaluation profiled these FBOs and outlined such technical issues as funding, capacity, and networking in the FBOs and underlined the significant roles of these FBOs especially in the areas of care and prevention. However, the report located a couple of challenges confronting these organizations, ranging from the scope or extent of reach and funding but more critical is the finding of the evaluation that the activities of these FBOs do not appear to be integrated into the larger service delivery networks [5]. In other words, these FBOs while performing critical functions are not systematically connected to the larger response framework and are dogged by funding and technical challenges. Thus, while these FBOs remain undoubtedly imperative to the response, their effectiveness has not been maximized or systematically harnessed. Therefore, the picture of the mid-2000s painted in the evaluation remains largely the same till now. In fact, there is the feeling that these FBOs in the euphoria of the remarkable strides achieved in the response in the country have become almost lethargic and have not advanced much in terms of improved capacity.

The capacity of FBOs to perform in the response is also limited by the fact that what apparently appears like FBO agencies involved in the response are in reality a case of these agencies taking on the added responsibility of dealing with HIV/AIDS. In other words, HIV/AIDS responses are often embedded in organizations that predated the pandemic with clear mandates beyond HIV/AIDS. These militate against the development of a clear-cut HIV/AIDSfocused capacity even in the long run in these FBOs [5, 7]. Even more perturbing is that often times, one perceives the FBOs in the response in the form of tiny islands cut off from each other and from the big sea. In this sense, there is a dearth of effective networking and coalition across FBOs in the response. This really militates against capacity development as each FBO's effort becomes disparate from the others, and there is hardly meaningful integration, sharing

of resources, sharing of lessons learnt, and interdependence even on delimited scope.

**6. Conclusion: Strengthening and mainstreaming FBOs response to**

The FBOs are usually very important components of the social life of a large number of South African citizens who are really marginal to the socio-economic spheres of the society. These It was in recognition of the role of the FBOs that the SANAC encourages regular dialog between the FBOs and Civil Society Forum (CSF) of the SANAC. But such dialog should be deepened and made regular in order to address some of the noted predilection of the FBOs in responding to the pandemic including using holy water in place of ARV [8]. In fact, as cursory observation would show, FBOs in the continent (not only South Africa) have often promoted the use of such commodities as holy water, holy oil, holy sand, and anointed spiritual items in perceived treatment of the pandemic. These items are usually seen as general spiritual agencies of miracle cure.

Before enumerating ways through which the FBOs can be repositioned and strengthened in terms of further contributing to the HIV/AIDS response, there is a need to point out that the beginning of effective mainstreaming and integration of the FBOs into the national response framework should be against the appreciation of the variety of FBOs operating in the country. In other words, there is a need to take cognizance of the peculiarities, denominational/religious bends, and defining characteristics of these groups. Thus, a one-size-fits-all approach would not suffice. Therefore, there is a need for tailored engagements that aim at creatively harnessing the strengths of these FBOs as mass organizations. Strategies to be considered include the following:


**5.** Given the ubiquity of FBOs in South Africa, there is no gainsaying the fact that these organizations have the reach and presence even in the remotest areas of the country where the impact or presence of the state and its agencies are almost invisible. The reach of these FBOs can be critically harnessed especially in creating and sustaining awareness about the pandemic and even in functioning as first responders to those affected by the pandemic. FBOs would be critical in the coverage of rural areas and even densely populated urban townships.

**References**

pp. 589-598

[1] Simelela N, Venter W. A brief history of South Africa's response to AIDS. South African

Taking it to the Pulpit: Repositioning FBOs as Critical Agencies in the HIV/AIDS Response…

http://dx.doi.org/10.5772/intechopen.79660

139

[2] Statistics South Africa. Mid-Year Population Estimates [Internet].2016. Available from:

[3] Centre for Health Systems Research and Development (CHSRD) and Centre for HIV/ AIDS Networking (HIVAN). South Africa National HIV/AIDS Database [Internet]. 2004. Available from: www.hivan.org.za/aidsdatasearchadvance.asp. [Accessed: 2018-01-05].

[4] Anugwom E. In: Baker C, Dozon J, Obbo C, Toure M, editors. Perception of AIDS among University Students in Nigeria: Implications for Prevention Programmes in Experiencing and Understanding AIDS in Africa. Dakar and Paris: CODESRIA and Karthala; 1999.

[5] Centre for AIDS Development, Research and Evaluation (CADRE). Faith-Based Responses to HIV/AIDS in South Africa: An analysis of the activities of faith-based organi-

[6] Mash R, Mash B. Faith-based organizations and HIV prevention in Africa: A review.

[7] Anugwom E, Anugwom K. Beyond morality: Assessing the capacity of faith-based organizations (FBOs) in responding to the HIV/AIDS challenge in Southeastern Nigeria.

[8] South African National AIDS Council-Civil Society Forum (SANAC-CSF). Holy Water as ARVs – A Dialogue with Religious Leaders and the CRL Commission [Internet]. 2018. Available from: http://sanac.org.za/2018/01/26/holy-water-as-arvs-a-dialogue-with-

[9] The South African Health News Service. Faith Sector Needed for UNAIDS 90-90-90 Targets [Internet]. 2015. Available from: www.health-e.org.za/2015/06/11/faith-sector-

[10] Schmid B, Thomas E, Olivier J, Cochrane J. The Contribution of Religious Entities to

[11] Olivier J, Wodon Q. Faith-inspired healthcare providers in Africa: Targeting the poor?

[12] Lipsky AB. Evaluating the strength of faith: Potential comparative advantage of faithbased organizations providing health Services in sub-Saharan Africa. Public Adminis-

zations (FBOs) in the national HIV/AIDS database. Johannesburg: CADRE; 2005

African Journal of Primary Health Care & Family Medicine. 2013;**5**(1):1-6

religious-leaders-and-the-crl-commission/htm. [Accessed: 2018-02-02]

needed-for-unaids-90-90-90-targets.htm [Accessed: 2018-01-09]

Health in Sub-Saharan Africa. Cape Town: ARHAP; 2008

Contact Magazine. 2011;**193**:14-17

tration and Development. 2011;**31**(1):25-36

Iranian Journal of Public Health. 2018;**47**(1):70-76

Medical Journal. 2014;**104**(3 Suppl 1):249-251

http://www.statssa.gov.za/?p=8176 [Accessed: 2017-12-15]

As Keikelame et al. [27] have rightly opined, "South African FBOs need to engage more vocally in advocacy to address the social and contextual factors that increase HIV vulnerability, such as poverty and gender inequality." In other words, these organizations should use the good will and acceptance they enjoy among the people to engage in actions and dialog that aim at whittling down and eradicating practices and values which engender or perpetuate both poverty and gender inequality especially gender-based violence which has in recent years become a social plague in the society. When women and minorities are treated as second-class citizens or as inferior members of the society, they are easily denied or deprived the opportunity to make informed decisions, oppose sexual predation, and abuse in the communities.

Equally worth noting is that even though most FBOs in South Africa are opposed to both premarital and extra-marital sex by members, the messages given out often vary between churches or sects [37]. In this case, there is a difference since the approach in Zionist and mainline churches seems to be that while promiscuity is bad, abstinence is unrealistic and that premarital sex with only one partner is admissible (which contrasts with the loud and clear directives against premarital sex and the condom among Pentecostal and Catholic churches) [37]. Thus, the messages between FBOs may differ and call for the acute realization of this difference in the process of interfacing and integrating FBOs response as a whole and within the broader state-wide response.

As Mash and Mash [6] have contended, there is a need for the church to take up the challenge of empowering young women and recognize the need to protect their sexually active youth members. This challenge should go beyond the orbits of the church membership to include all spheres of influence of the church in the lives of both members and non-members. The call to evangelize should now embody the call to add value to the national response in an integrated and systematic manner that does not denigrate, devalue, or distort the philosophy and knowledge foundation of the national response.

## **Author details**

Edlyne Eze Anugwom

Address all correspondence to: eanugwom@uwc.ac.za

University of the Western Cape, Cape Town, South Africa

## **References**

**5.** Given the ubiquity of FBOs in South Africa, there is no gainsaying the fact that these organizations have the reach and presence even in the remotest areas of the country where the impact or presence of the state and its agencies are almost invisible. The reach of these FBOs can be critically harnessed especially in creating and sustaining awareness about the pandemic and even in functioning as first responders to those affected by the pandemic. FBOs would be critical in the coverage of rural areas and even densely populated urban townships.

As Keikelame et al. [27] have rightly opined, "South African FBOs need to engage more vocally in advocacy to address the social and contextual factors that increase HIV vulnerability, such as poverty and gender inequality." In other words, these organizations should use the good will and acceptance they enjoy among the people to engage in actions and dialog that aim at whittling down and eradicating practices and values which engender or perpetuate both poverty and gender inequality especially gender-based violence which has in recent years become a social plague in the society. When women and minorities are treated as second-class citizens or as inferior members of the society, they are easily denied or deprived the opportunity to make informed decisions, oppose sexual predation, and

Equally worth noting is that even though most FBOs in South Africa are opposed to both premarital and extra-marital sex by members, the messages given out often vary between churches or sects [37]. In this case, there is a difference since the approach in Zionist and mainline churches seems to be that while promiscuity is bad, abstinence is unrealistic and that premarital sex with only one partner is admissible (which contrasts with the loud and clear directives against premarital sex and the condom among Pentecostal and Catholic churches) [37]. Thus, the messages between FBOs may differ and call for the acute realization of this difference in the process of interfacing and integrating FBOs response as a whole and within

As Mash and Mash [6] have contended, there is a need for the church to take up the challenge of empowering young women and recognize the need to protect their sexually active youth members. This challenge should go beyond the orbits of the church membership to include all spheres of influence of the church in the lives of both members and non-members. The call to evangelize should now embody the call to add value to the national response in an integrated and systematic manner that does not denigrate, devalue, or distort the philosophy

abuse in the communities.

138 Public Health - Emerging and Re-emerging Issues

the broader state-wide response.

**Author details**

Edlyne Eze Anugwom

and knowledge foundation of the national response.

Address all correspondence to: eanugwom@uwc.ac.za

University of the Western Cape, Cape Town, South Africa


[13] Morgan R, Green A, Boesten J. Aligning faith-based and national HIV/AIDS prevention responses? Factors influencing the HIV/AIDS prevention policy process and response of faith-based NGOs in Tanzania. Health Policy and Planning. 2013;**29**(3):313-322

[28] Aukst-Margetic B, Margetic B. Religiousity and health outcomes: Review of literature.

Taking it to the Pulpit: Repositioning FBOs as Critical Agencies in the HIV/AIDS Response…

http://dx.doi.org/10.5772/intechopen.79660

141

[29] Thorton A, Camburn D. Religious participation and adolescent sexual behaviour and

[30] Hubbard D, Wingwood G, DiClemente R. Religiousity and risky sexual behaviour in African-American adolescent females. The Journal of Adolescent Health. 2003;**33**(1):2-8

[31] Zaleski E, Schiaffino K. Religiousity and risk-taking behaviour during the transition to

[32] Jones R, Darroch J, Singh S. Religious differentials in the sexual and reproductive behaviour of young women in the United States. The Journal of Adolescent Health. 2005;

[33] Agadjanian V. Gender, religious involvement and HIV/AIDS prevention in Mozambique.

[34] Nweneka C. Sexual practices of church youth in the era of HIV/AIDS: Playing the ostrich.

[35] Mash R, Kareithi R, Mash B. Survey of sexual behaviour among Anglican youth in the

[36] Anugwom E, Anugwom K. Socio-cultural factors in the access of women to HIV/ AIDS prevention Services in South-southern Nigeria. Iranian Journal of Public Health.

[37] Garner R. Safe sect? Dynamic religion and AIDS in South Africa. JMAS. 2000;**38**(1):41-69

western cape. South African Medical Journal. 2006;**96**(2):124-127

attitudes. Journal of Marriage and the Family. 1989;**51**(3):641-653

Collegium Antropologicum. 2005;**29**(1):365-371

college. Journal of Adolescence. 2000;**23**(2):223-227

Social Science & Medicine. 2005;**61**(7):1529-1539

AIDS Care. 2007;**19**(8):966-969

**36**(4):279-288

2016;**45**(6):754-760


[28] Aukst-Margetic B, Margetic B. Religiousity and health outcomes: Review of literature. Collegium Antropologicum. 2005;**29**(1):365-371

[13] Morgan R, Green A, Boesten J. Aligning faith-based and national HIV/AIDS prevention responses? Factors influencing the HIV/AIDS prevention policy process and response of

[14] Pew Research Center. Pew Forum on Religion and Public Life: Religion in South Africa 15 years after the end of apartheid [Internet]. 2009. Available from: http://pewresearch.

[15] Byamugisha G, Steiner L, Williams G, Zondi P. Journeys of Faith: Church – Based Responses to HIV/AIDS in Three Southern African Countries. St. Albans, UK: Teaching

[16] Chikwendu E. Faith-based Organization in Anti-HIV/AIDS work among African youth

[17] Liebowitz J. The Impact of Faith-Based Organizations on HIV Prevention and Mitigation in Africa. Durban: Health Economics and HIV/AIDS Research Division (HEARD); 2002

[18] African Religious Health Assets Programme (ARHAP)Appreciating Assets: The Contri-

[19] UNAIDS. Religion and Faith Based Organization (FBO) Working Group Strategy Deve-

[20] Keuogh L, Marshall K. Faith Communities Engage the HIV/AIDS Crisis: Lessons Learned and Paths Forward. Georgetown: Berkeley Center for Religion, Peace and

[21] Casale M, Nixon S, Flicker S, Rubincam C, Jenney A. Dilemmas and tensions facing a faith-based organization promoting HIV prevention among young people in South

[22] Dilger H, Burchardt M, Dijk R. Introduction - the redemptive movement: HIV treatment and the production of new religious spaces. African Journal of AIDS Research. 2010;

[23] Tiendrebeogo G, Buyckx M. Bulletin 361: Faith-Based Organizations and HIV/AIDS Prevention and Impact Mitigation in Africa. Amsterdam: Royal Tropical Institute; 2004

[24] Bateman C. Time to 'stop pedaling backwards' – Motsoaledi. South African Medical

[25] Treatment Action Campaign (TAC). Calculation of Mortality in South African confirms Massive Increase in AIDS Deaths [Internet]. 2005. Available from: http://www.tac.org.

[26] South African National AIDS Council (SANAC). Let Our Actions Count: South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022. Hatfield: SANAC; 2017

[27] Keikelame M, Murphy C, Ringheim K, Woldehanna S. Perceptions of HIV/AIDS leaders about faith-based organizations' influence on HIV/AIDS stigma in South Africa. African

bution of Religion to Universal Access in Africa. Cape Town: WHO; 2006

faith-based NGOs in Tanzania. Health Policy and Planning. 2013;**29**(3):313-322

org/pubs/1201/south-africa-religion.htm. [Accessed: 2010-06-21]

and women. Dialectical Anthropology. 2004;**28**:307-327

Africa. African Journal of AIDS Research. 2010;**9**:135-145

za/newsletter/2005/ns31-01-2005.htm. [Accessed: 2010-06-15]

lopment Meeting. Geneva: UNAIDS; 2008

World Affairs; 2007

Journal. 2009;**99**(11):778-779

Journal of AIDS Research. 2010;**9**(1):63-70

**9**:373-383

AIDS at Low Cost (TALC); 2002

140 Public Health - Emerging and Re-emerging Issues


**Chapter 8**

**Provisional chapter**

**An Exploratory Study on the Association Between**

**An Exploratory Study on the Association Between** 

**Women with Disabilities**

**Women with Disabilities**

http://dx.doi.org/10.5772/intechopen.77324

**Abstract**

in their workplace.

Jung Youn Park, Ji Young Park and Soo Hyun Sung

Jung Youn Park, Ji Young Park and Soo Hyun Sung

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

**Social Capital and Self-Rated Health of South Korean**

**Social Capital and Self-Rated Health of South Korean** 

The purpose of this chapter was to explore the relationship between social capital and self-rated health status as assessed in the activities of the everyday life of South Korean women with disabilities. For this purpose, the authors analyzed the 8th data of the panel survey of employment for the disabled (PSED) that included a sample of 275 women with disabilities who are paid worker. The authors found that working environment, working hours, personal development possibilities, communicationand interpersonal-relationships, the fairness of performance assessment, welfare benefits, training opportunities, and job satisfaction differed significantly in relation to the self-rated health status of women with disabilities. The authors also found that for working hours, communication, and interpersonal relationships, significantly higher self-rated health status was found for satisfied compared to the satisfaction group. For personal development possibilities, welfare benefits, and training opportunities, self-rated health status was significantly higher for the satisfaction group than the dissatisfied group. For fairness of the performance assessment, self-rated health status of the satisfaction group was significantly higher than in the dissatisfied and the normal group. Therefore, in order to improve the self-rated health of South Korean women with disabilities, it is necessary to provide working environment considering their disability characteristics and various training opportunities

**Keywords:** women, disabilities, social capital, everyday life, health

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.77324

#### **An Exploratory Study on the Association Between Social Capital and Self-Rated Health of South Korean Women with Disabilities An Exploratory Study on the Association Between Social Capital and Self-Rated Health of South Korean Women with Disabilities**

DOI: 10.5772/intechopen.77324

Jung Youn Park, Ji Young Park and Soo Hyun Sung Jung Youn Park, Ji Young Park and Soo Hyun Sung

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.77324

#### **Abstract**

The purpose of this chapter was to explore the relationship between social capital and self-rated health status as assessed in the activities of the everyday life of South Korean women with disabilities. For this purpose, the authors analyzed the 8th data of the panel survey of employment for the disabled (PSED) that included a sample of 275 women with disabilities who are paid worker. The authors found that working environment, working hours, personal development possibilities, communicationand interpersonal-relationships, the fairness of performance assessment, welfare benefits, training opportunities, and job satisfaction differed significantly in relation to the self-rated health status of women with disabilities. The authors also found that for working hours, communication, and interpersonal relationships, significantly higher self-rated health status was found for satisfied compared to the satisfaction group. For personal development possibilities, welfare benefits, and training opportunities, self-rated health status was significantly higher for the satisfaction group than the dissatisfied group. For fairness of the performance assessment, self-rated health status of the satisfaction group was significantly higher than in the dissatisfied and the normal group. Therefore, in order to improve the self-rated health of South Korean women with disabilities, it is necessary to provide working environment considering their disability characteristics and various training opportunities in their workplace.

**Keywords:** women, disabilities, social capital, everyday life, health

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **1. Introduction**

#### **1.1. Women with disabilities in South Korea**

The number of registered people with disabilities in South Korea has steadily increased from 2,148,686 in 2005 to 2,683,477 in 2011 and then to 2,726,910 in 2014 [1]. Women with disabilities constitute 42% of this total [2].

very important for the national policy to promote the health of women with disabilities across

An Exploratory Study on the Association Between Social Capital and Self-Rated Health of South…

http://dx.doi.org/10.5772/intechopen.77324

145

Self-rated health is an individual's subjective, internal judgment of their health and psychological status. Self-rated health may predict mortality as found in major health surveys such as the National Health and Nutrition Examination Survey and National Health Examination Follow-up Study in the United States in the 1990s [19, 20]. Since then, the importance of selfrated health has increased in various fields of study, including not only mortality rates but also in assessing the outcomes of clinical treatment, and satisfaction with the use of medical services after treatment [21–23]. The further advantages of assessing subjective health status include the potential to identify internal information, which may be affecting the current health status of an individual [24], and that the questions required to identify current health status are simple to complete. Thus, this method is very useful for understanding the health status of socially vulnerable groups such as the elderly and the disabled with low accessibility to medical facilities and/or health-related information [20, 25, 26]. In South Korea, 53.4% of the total disabled population, and 63.3% of women with disabilities have negative perceptions about their self-rated health status [1]. Nevertheless, research on the self-rated health of

Over the past two decades, various researchers have looked at social capital as a major factor influencing self-rated health [27–31]. This concept of social capital is based on the definitions provided by Putnam (1993) and Coleman (1994). According to Putnam (1993), social capital is a micro level concept aimed at improving the efficiency of society by facilitating coordinated actions [32]. Coleman (1994) on the other hand, defines social capital as a macrolevel concept aimed at improving the efficiency of society by facilitating coordinated actions [33]. Measures of social capital based on these definitions have focused specifically on "trust" within the context of interpersonal and intergroup relationships. For instance, interpersonal trust has been assessed by asking questions, such as, "Generally speaking, would you say most people can be trusted? [30]," "[Can] most people can be trusted [31]," and "Generally speaking, would you say that most people can be trusted, or that you can't be too careful? [29]." On the contrary, intergroup trust has been assessed by asking questions, such as, "Would you say that most of the time people try to be helpful, or are they mostly looking out for themselves? [30]"

However, although the notion of social capital focusing on trust considers the role of interpersonal or intergroup factors, it does not take into account the actual conditions under, which such trust can be formed [26]. What does actual condition mean that trust can form here? According to Bourdieu (1986), social capital should be defined as "the aggregate of the actual or potential resources which are linked to possession of a durable network of more or less institutionalized relationships of mutual acquaintance and recognition […] these relationships may exist only in the practical state, in material and/or symbolic exchanges which help to maintain them [34]." Therefore, to examine the actual conditions in which trust can be formed either

all age groups located in this blind spot of South Korean health care.

**1.2. Self-rated health**

women with disabilities is very limited.

**1.3. Self-rated health and social capital**

and "How much can you trust people [31]."

Women with disabilities are in a very vulnerable position in terms of health care due to complex interactions between a number of factors [3]. As we know, the burden of domestic labor, as well as childbirth and childcare is traditionally placed on women. Moreover, the entry of women into the labor market due to industrialization and family nuclearization, which are the characteristics of modern capitalist societies, adds to the burdens of social and economic activity, in addition to domestic work [3–5]. In particular, and unlike other English speaking countries, inequality of gender roles based on patriarchal values is very deeply rooted in South Korea. This presents various conflicts and problems between the roles traditionally required for women and the new roles that modern capitalist society demands [6–9]. This situation for South Korean women can be a very negative factor in terms of their health. However, despite the impact of these stressors on women, health policy in South Korea mainly focuses on maternity issues, specifically, pregnancy and childbirth [4]. Of course, such a phenomenon can be seen as critical when considering that the total fertility rate in South Korea is the lowest in the world, being 1.21 births per woman in 2014 [4]. However, since South Korea's extremely low birth rate problem is not the only cause health conditions for women of childbearing age, the excessive emphasis on the health of women during the fertility period is not only detrimental to the effectiveness of the policy but also the equity of the health policy for women of all ages.

Disability can have a negative impact on the most basic conditions required for the management of health [10, 11]. In general, people with disabilities have very low access to medical facilities, due to physical and/or environmental constraints. Previous research has indicated that factors affecting the accessibility of people with disabilities include architectural elements within health care facilities [12], medical equipment [13–16], and the degree of understanding of disability in health care facilities staff [14]. Further factors associated with disability can negatively affect an individual's health care. This is evident in the health promotion policy of South Korea. Article 1 of the National Health Promotion Act, which was enacted in 1995, states "The purpose of this Act is to improve the health of the citizens by providing them with the correct knowledge about health with which they can enhance the awareness of the value of and develop a sense of responsibility for health, and by creating a given condition where they can spontaneously lead a healthy life." In other words, it means that individuals can acquire various health-related information provided by the national healthcare system to prevent them from being managed [17, 18]. However, due to the abovementioned problems of accessibility [12–16], combined with low levels of health literacy due to the low educational level [1], and issues relating to compliance, people with disabilities may experience problems in acquiring health-related information, and this can make management difficult. In addition, the health promotion policy which mainly focuses on people with disabilities in South Korea remains at the same basic level as the production of relevant statistical data [4]. Therefore, it is very important for the national policy to promote the health of women with disabilities across all age groups located in this blind spot of South Korean health care.

## **1.2. Self-rated health**

**1. Introduction**

women of all ages.

constitute 42% of this total [2].

144 Public Health - Emerging and Re-emerging Issues

**1.1. Women with disabilities in South Korea**

The number of registered people with disabilities in South Korea has steadily increased from 2,148,686 in 2005 to 2,683,477 in 2011 and then to 2,726,910 in 2014 [1]. Women with disabilities

Women with disabilities are in a very vulnerable position in terms of health care due to complex interactions between a number of factors [3]. As we know, the burden of domestic labor, as well as childbirth and childcare is traditionally placed on women. Moreover, the entry of women into the labor market due to industrialization and family nuclearization, which are the characteristics of modern capitalist societies, adds to the burdens of social and economic activity, in addition to domestic work [3–5]. In particular, and unlike other English speaking countries, inequality of gender roles based on patriarchal values is very deeply rooted in South Korea. This presents various conflicts and problems between the roles traditionally required for women and the new roles that modern capitalist society demands [6–9]. This situation for South Korean women can be a very negative factor in terms of their health. However, despite the impact of these stressors on women, health policy in South Korea mainly focuses on maternity issues, specifically, pregnancy and childbirth [4]. Of course, such a phenomenon can be seen as critical when considering that the total fertility rate in South Korea is the lowest in the world, being 1.21 births per woman in 2014 [4]. However, since South Korea's extremely low birth rate problem is not the only cause health conditions for women of childbearing age, the excessive emphasis on the health of women during the fertility period is not only detrimental to the effectiveness of the policy but also the equity of the health policy for

Disability can have a negative impact on the most basic conditions required for the management of health [10, 11]. In general, people with disabilities have very low access to medical facilities, due to physical and/or environmental constraints. Previous research has indicated that factors affecting the accessibility of people with disabilities include architectural elements within health care facilities [12], medical equipment [13–16], and the degree of understanding of disability in health care facilities staff [14]. Further factors associated with disability can negatively affect an individual's health care. This is evident in the health promotion policy of South Korea. Article 1 of the National Health Promotion Act, which was enacted in 1995, states "The purpose of this Act is to improve the health of the citizens by providing them with the correct knowledge about health with which they can enhance the awareness of the value of and develop a sense of responsibility for health, and by creating a given condition where they can spontaneously lead a healthy life." In other words, it means that individuals can acquire various health-related information provided by the national healthcare system to prevent them from being managed [17, 18]. However, due to the abovementioned problems of accessibility [12–16], combined with low levels of health literacy due to the low educational level [1], and issues relating to compliance, people with disabilities may experience problems in acquiring health-related information, and this can make management difficult. In addition, the health promotion policy which mainly focuses on people with disabilities in South Korea remains at the same basic level as the production of relevant statistical data [4]. Therefore, it is Self-rated health is an individual's subjective, internal judgment of their health and psychological status. Self-rated health may predict mortality as found in major health surveys such as the National Health and Nutrition Examination Survey and National Health Examination Follow-up Study in the United States in the 1990s [19, 20]. Since then, the importance of selfrated health has increased in various fields of study, including not only mortality rates but also in assessing the outcomes of clinical treatment, and satisfaction with the use of medical services after treatment [21–23]. The further advantages of assessing subjective health status include the potential to identify internal information, which may be affecting the current health status of an individual [24], and that the questions required to identify current health status are simple to complete. Thus, this method is very useful for understanding the health status of socially vulnerable groups such as the elderly and the disabled with low accessibility to medical facilities and/or health-related information [20, 25, 26]. In South Korea, 53.4% of the total disabled population, and 63.3% of women with disabilities have negative perceptions about their self-rated health status [1]. Nevertheless, research on the self-rated health of women with disabilities is very limited.

#### **1.3. Self-rated health and social capital**

Over the past two decades, various researchers have looked at social capital as a major factor influencing self-rated health [27–31]. This concept of social capital is based on the definitions provided by Putnam (1993) and Coleman (1994). According to Putnam (1993), social capital is a micro level concept aimed at improving the efficiency of society by facilitating coordinated actions [32]. Coleman (1994) on the other hand, defines social capital as a macrolevel concept aimed at improving the efficiency of society by facilitating coordinated actions [33]. Measures of social capital based on these definitions have focused specifically on "trust" within the context of interpersonal and intergroup relationships. For instance, interpersonal trust has been assessed by asking questions, such as, "Generally speaking, would you say most people can be trusted? [30]," "[Can] most people can be trusted [31]," and "Generally speaking, would you say that most people can be trusted, or that you can't be too careful? [29]." On the contrary, intergroup trust has been assessed by asking questions, such as, "Would you say that most of the time people try to be helpful, or are they mostly looking out for themselves? [30]" and "How much can you trust people [31]."

However, although the notion of social capital focusing on trust considers the role of interpersonal or intergroup factors, it does not take into account the actual conditions under, which such trust can be formed [26]. What does actual condition mean that trust can form here? According to Bourdieu (1986), social capital should be defined as "the aggregate of the actual or potential resources which are linked to possession of a durable network of more or less institutionalized relationships of mutual acquaintance and recognition […] these relationships may exist only in the practical state, in material and/or symbolic exchanges which help to maintain them [34]." Therefore, to examine the actual conditions in which trust can be formed either within interpersonal or between intergroups, it is necessary to consider the "field [34–36]" in which these activities are specifically carried out, that is, everyday life [26].

1 (very poor) to 4 (excellent). The independent variables were the relating to the social capital of women with disabilities in the workplace, namely, ten factors that can give credibility to workers with disabilities. These were: job stability, working environment, working hours, personal development possibilities, communication and interpersonal relationships, the fairness of performance assessment, welfare benefits, training opportunities, acceptance and understanding of people with disabilities, and overall job satisfaction. Each variable was measured through the following questions: "How satisfied are you with the job stability of your current job?" "How satisfied are you with the working environment of your current job?", "How satisfied are you with the working hours of the job you are currently working on?", "How satisfied are you with the possibility of personal development in the job you are currently working for?", "How satisfied are you with communication and interpersonal relationships in the job you are currently working for?", "How satisfied are you with the performance assessment of the job you are currently working on?", "How satisfied are you with the welfare benefits of the job you are currently working on?", "How satisfied are you with the job training opportunities you are currently working for?", "How satisfied are you with the current acceptance and understanding of the people with disabilities of the job you are working on?", and "Given the overall details, how much do you satisfied with your current job?" In the original data, the response to each item was measured as 1 (very unsatisfactory) to 5 (very satisfied), but in this study, we re-coded these to 1 (unsatisfactory) to 3 (satisfactory) to reduce the number of cases difference between response groups. In the case of the performance assessment item, if there was no specific performance assessment system, it was judged whether the compensation

An Exploratory Study on the Association Between Social Capital and Self-Rated Health of South…

http://dx.doi.org/10.5772/intechopen.77324

147

system corresponding to the personnel affairs department was operated fairly [38].

analysis because they did not satisfy the assumption of equal distribution.

**3. Results**

ANOVA analysis.

The purpose of this study was to explore the relationship between social capital and selfrated health status of women with disabilities. Therefore, we focused on the differences in self-rated health status according to the level of thought and satisfaction of their job. To do this, we conducted one-way ANOVA to see whether the mean difference between the groups was statistically significant. Before performing ANOVA, it was verified whether the data for each variable met the assumptions of independence (the error between the population and the population is independent of one another), normality (the distribution of the population corresponding to each group is the normal distribution), and equal distribution (the variance of the population corresponding to each group is the same). The variables for understanding and acceptance of people with disabilities, and job stability were excluded from the final

Analyses were conducted using SPSS 22.0, which includes descriptive statistics and one-way

**Table 1** shows the descriptive statistics results for the demographic characteristics of the study sample. In terms of type of disability, 152 were with external physical disability, 104 were with sensory disorder, 8 were with mental disorder, and 11 were with internal physical disability. With regards to educational attainment, 29 were received no education, 79 completed

## **1.4. Everyday life for women with disabilities**

This study focused on the outdoor activities of women with disabilities in order to examine an area of everyday life for which the social capital of South Korean women with disabilities could be assessed. In the case of people with disabilities, external activities are restricted unless necessary due to the physical and environmental constraints [26, 37]. According to the Korea Institute for Health and Social Affairs (2014), the major outdoor of activities of South Korean women with disabilities are (1) commuting to school and commuting to work (30.8%), (2) walking and exercise (26.0%), and (3) seeking medical consultation (13.0%) [1]. Therefore, this study focused on women with disabilities who commute to work within the economically active population (age range 18–60 years old). This was based on the fact that this is one key area of everyday life for women with disabilities. The purpose of this study was to investigate the relationship between social capital (i.e., social action, interpersonal relationships, and trust) and self-rated health, in the everyday life of South Korean women with disabilities. Specifically, we hypothesized that greater social capital would be associated with better selfrated health.

## **2. Method**

## **2.1. Data and sample**

In this study, we used data from the panel survey of employment for the disabled (PSED) in South Korea, with a specific interest in the major everyday life areas of women with disabilities concentrated on economic activities. The PSED is a survey of the panels representing the people with disabilities in South Korea and a longitudinal survey that conducts follow-up surveys every year from 2008 to present. Basic data on the participation of people with disabilities in the labor market were obtained. The survey included demographic characteristics, disability characteristics, economic activity status, waged/non-waged work/unemployment, effort and support for employment, vocational ability, employment attitude and environment, daily life, and quality of life. We used the survey data of the 8th PSED to examine whether social capital was related to the economic activity of women with disabilities. These data were collected from May to July 2015, and were collected from 3983 to 5092 registered people with disabilities aged 15–75 years old at the time of the survey [38]. The sample used in this study was first screened for the basis of economically active population age (18–60 years) among 1530 women surveyed, followed by self-employed (69), unpaid family workers (73), and economically inactive population (1113) were excluded from the survey. In addition, the total sample for the analyses was 275 women with disabilities who are paid worker.

### **2.2. Measures**

The dependent variable was self-rated health. This was measured by the following question: "What is your overall health status at the moment?" Response options ranged from 1 (very poor) to 4 (excellent). The independent variables were the relating to the social capital of women with disabilities in the workplace, namely, ten factors that can give credibility to workers with disabilities. These were: job stability, working environment, working hours, personal development possibilities, communication and interpersonal relationships, the fairness of performance assessment, welfare benefits, training opportunities, acceptance and understanding of people with disabilities, and overall job satisfaction. Each variable was measured through the following questions: "How satisfied are you with the job stability of your current job?" "How satisfied are you with the working environment of your current job?", "How satisfied are you with the working hours of the job you are currently working on?", "How satisfied are you with the possibility of personal development in the job you are currently working for?", "How satisfied are you with communication and interpersonal relationships in the job you are currently working for?", "How satisfied are you with the performance assessment of the job you are currently working on?", "How satisfied are you with the welfare benefits of the job you are currently working on?", "How satisfied are you with the job training opportunities you are currently working for?", "How satisfied are you with the current acceptance and understanding of the people with disabilities of the job you are working on?", and "Given the overall details, how much do you satisfied with your current job?" In the original data, the response to each item was measured as 1 (very unsatisfactory) to 5 (very satisfied), but in this study, we re-coded these to 1 (unsatisfactory) to 3 (satisfactory) to reduce the number of cases difference between response groups. In the case of the performance assessment item, if there was no specific performance assessment system, it was judged whether the compensation system corresponding to the personnel affairs department was operated fairly [38].

The purpose of this study was to explore the relationship between social capital and selfrated health status of women with disabilities. Therefore, we focused on the differences in self-rated health status according to the level of thought and satisfaction of their job. To do this, we conducted one-way ANOVA to see whether the mean difference between the groups was statistically significant. Before performing ANOVA, it was verified whether the data for each variable met the assumptions of independence (the error between the population and the population is independent of one another), normality (the distribution of the population corresponding to each group is the normal distribution), and equal distribution (the variance of the population corresponding to each group is the same). The variables for understanding and acceptance of people with disabilities, and job stability were excluded from the final analysis because they did not satisfy the assumption of equal distribution.

## **3. Results**

within interpersonal or between intergroups, it is necessary to consider the "field [34–36]" in

This study focused on the outdoor activities of women with disabilities in order to examine an area of everyday life for which the social capital of South Korean women with disabilities could be assessed. In the case of people with disabilities, external activities are restricted unless necessary due to the physical and environmental constraints [26, 37]. According to the Korea Institute for Health and Social Affairs (2014), the major outdoor of activities of South Korean women with disabilities are (1) commuting to school and commuting to work (30.8%), (2) walking and exercise (26.0%), and (3) seeking medical consultation (13.0%) [1]. Therefore, this study focused on women with disabilities who commute to work within the economically active population (age range 18–60 years old). This was based on the fact that this is one key area of everyday life for women with disabilities. The purpose of this study was to investigate the relationship between social capital (i.e., social action, interpersonal relationships, and trust) and self-rated health, in the everyday life of South Korean women with disabilities. Specifically, we hypothesized that greater social capital would be associated with better self-

In this study, we used data from the panel survey of employment for the disabled (PSED) in South Korea, with a specific interest in the major everyday life areas of women with disabilities concentrated on economic activities. The PSED is a survey of the panels representing the people with disabilities in South Korea and a longitudinal survey that conducts follow-up surveys every year from 2008 to present. Basic data on the participation of people with disabilities in the labor market were obtained. The survey included demographic characteristics, disability characteristics, economic activity status, waged/non-waged work/unemployment, effort and support for employment, vocational ability, employment attitude and environment, daily life, and quality of life. We used the survey data of the 8th PSED to examine whether social capital was related to the economic activity of women with disabilities. These data were collected from May to July 2015, and were collected from 3983 to 5092 registered people with disabilities aged 15–75 years old at the time of the survey [38]. The sample used in this study was first screened for the basis of economically active population age (18–60 years) among 1530 women surveyed, followed by self-employed (69), unpaid family workers (73), and economically inactive population (1113) were excluded from the survey. In addition, the total sample for the analyses was 275 women with disabilities who are paid worker.

The dependent variable was self-rated health. This was measured by the following question: "What is your overall health status at the moment?" Response options ranged from

which these activities are specifically carried out, that is, everyday life [26].

**1.4. Everyday life for women with disabilities**

146 Public Health - Emerging and Re-emerging Issues

rated health.

**2. Method**

**2.2. Measures**

**2.1. Data and sample**

Analyses were conducted using SPSS 22.0, which includes descriptive statistics and one-way ANOVA analysis.

**Table 1** shows the descriptive statistics results for the demographic characteristics of the study sample. In terms of type of disability, 152 were with external physical disability, 104 were with sensory disorder, 8 were with mental disorder, and 11 were with internal physical disability. With regards to educational attainment, 29 were received no education, 79 completed


elementary school, 47 completed middle school, 92 completed high school, and 28 completed college. For marital status, 131 were unmarried, 142 were married, 36 were divorced, 65 were separation by death, and 6 were separation. Regarding working hours for 1 week, 31 were less than 18 hours, 51 were between 18 and 36 hours, and 193 were more than 36 hours. In terms of continuous service year, 162 were between 1 and 5 years, 66 were between 6 and 10 years, 39 were 11 and 20 years, 5 were between 21 and 30 years, and 3 were more than 31 years. With regards to periodic job, 29 responded "yes" whereas 246 responded "no." For contract of employment, 79 responded "yes" whereas 196 responded "no." Regarding regular work, 69 responded "yes "whereas 206 responded "no." In terms of the possibility of continuous work, 69 responded "yes" whereas 206 responded "no." Regarding the average age and average

**Variable Group M SD F P Scheffe** Working environment Dissatisfied group(a) 2.21 .550 5.594 .004\* —

Working hours Dissatisfied group(a) 2.35 .629 6.663 .001\* b < c

Personal development possibilities Dissatisfied group(a) 2.26 .727 7.291 .001\* a < c

Fairness of performance assessment Dissatisfied group(a) 2.10 .553 9.371 .000\* a,b < c

Welfare benefits Dissatisfied group(a) 2.20 .586 14.553 .000\* a < c

Training opportunities Dissatisfied group(a) 2.11 .614 11.768 .000\* a < c

Overall job satisfaction Dissatisfied group(a) 2.07 .616 7.398 .001\* —

**Table 2.** One-way ANOVA results by group (dissatisfied, normal, and satisfied).

Communication and interpersonal

relationship

\*p < .005.

Normal group(b) 2.39 .613 Satisfaction group(c) 2.59 .564

An Exploratory Study on the Association Between Social Capital and Self-Rated Health of South…

http://dx.doi.org/10.5772/intechopen.77324

149

Normal group(b) 2.33 .638 Satisfaction group(c) 2.61 .572

Normal group(b) 2.42 .597 Satisfaction group(c) 2.72 .536

Normal group(b) 2.34 .051 Satisfaction group(c) 2.61 .054

Normal group(b) 2.41 .613 Satisfaction group(c) 2.71 .589

Normal group(b) 2.46 .623 Satisfaction group(c) 2.74 .538

Normal group(b) 2.45 .599 Satisfaction group(c) 2.78 .584

Normal group(b) 2.38 .631 Satisfaction group(c) 2.62 .567

Dissatisfied group(a) 2.31 .208 6.242 .002\* b < c

1 Based on the week before the survey.

**Table 1.** Demographic data and descriptive statistics for the sample.


**Table 2.** One-way ANOVA results by group (dissatisfied, normal, and satisfied).

**Variable M SD N (%)**

disability Sensory disorder Mental disorder Internal physical disability

Elementary Middle High College

Married Divorced

Separation

18~36 hours More than 36 hours

6–10 years 11–20 years 21–30 years More than 31 years

No

No

No

Yes No

Separation by death

152 (55.3) 104 (37.8) 8 (2.9) 11 (4.0)

29 (10.5) 79 (28.7) 47 (17.1) 92 (33.5) 28 (10.2)

26 (9.5) 142 (51.6) 36 (13.1) 65 (23.6) 6 (2.2)

31 (11.3) 51 (18.5) 193 (70.2)

162 (59.0) 66 (24.0) 39 (14.0) 5 (2.0) 3 (1.0)

29 (89.5) 246 (10.5)

79 (28.7) 196 (71.3)

69 (25.1) 206 (74.9)

69 (25.1) 206 (74.9)

Type of disability External physical

Education attainment Uneducated

Marital status Unmarried

Working hours for one week1 Less than 18 hours

Continuous service years 1–5 years

Periodic job Yes

Contract of employment Yes

Regular work Yes

**Table 1.** Demographic data and descriptive statistics for the sample.

Total 275 (100.0)

Possibility of continuous

Based on the week before the survey.

work

1

Self-rated health 2.45 .62 Average age 54 10.22 Average income (\$) 10,372 7551

148 Public Health - Emerging and Re-emerging Issues

elementary school, 47 completed middle school, 92 completed high school, and 28 completed college. For marital status, 131 were unmarried, 142 were married, 36 were divorced, 65 were separation by death, and 6 were separation. Regarding working hours for 1 week, 31 were less than 18 hours, 51 were between 18 and 36 hours, and 193 were more than 36 hours. In terms of continuous service year, 162 were between 1 and 5 years, 66 were between 6 and 10 years, 39 were 11 and 20 years, 5 were between 21 and 30 years, and 3 were more than 31 years. With regards to periodic job, 29 responded "yes" whereas 246 responded "no." For contract of employment, 79 responded "yes" whereas 196 responded "no." Regarding regular work, 69 responded "yes "whereas 206 responded "no." In terms of the possibility of continuous work, 69 responded "yes" whereas 206 responded "no." Regarding the average age and average annual income were 54 years old and 11,072,600 Korean won (KRW; equivalent to \$ 10.372 USD), respectively. In terms of descriptive analysis for the key variable, the average for selfrated health was 2.45 (SD = .62).

three groups of dissatisfaction, normal, and satisfaction. As a result, the difference in self-rated health status in terms of both overall working satisfaction and the working environment were significant, but there were no differences between the groups for these variables. This suggests that these variables are closely related to self-rated health status, but not in terms of the level of satisfaction. Personal development possibilities, welfare benefits, and training opportunities were found to be higher in relation to self-rated health status for the satisfied group than in the dissatisfied group. These variables may be associated with direct and indirect comparisons with peers, so the items in a variety of conflicts can be caused by it, to a higher self-rated health status of the satisfied group more than dissatisfied groups for each variable. For working hours, communication and interpersonal relationships, higher self-rated health was found for the satisfied group compared to the normal group. It should be noted here that the difference in self-rated health status between the normal group and the satisfaction group, rather than the dissatisfied group, was statistically significant. This may mean that dissatisfaction with working hours, communication-and interpersonalrelationships may lead to resignation or disruption in human relationships, which may be less relevant to current self-rated health status. It is important to note that these results may indicate that invisible conflicts (i.e., the application of flexible working systems considering the characteristics of disability, microaggression, etc.) that occur are closely related to self-rated health status [37]. For Fairness of performance assessment, self-rated health was higher in the satisfaction group than in the dissatisfied and the normal group. Responses to this item included whether the compensation system corresponding to the personnel affairs department was fairly operated if there was no performance assessment system to the job. This question thus considers whether respondents felt that evaluation and compensation were properly performed. It is worth noting here that even if the personnel department thinks that it is not fair (dissatisfied group) and fairly unfair or justifiable (normal group), it is closely related to the self-rated health status of women with disabilities.

An Exploratory Study on the Association Between Social Capital and Self-Rated Health of South…

http://dx.doi.org/10.5772/intechopen.77324

151

Importantly, we found that social capital is positively associated with self-rated health, which is partially consistent with past study findings. Social capital may affect health behaviors through social control over divergent health-related behavior, such as trust between individuals, and reciprocity [30, 39–41], and has an influence on the self-rated health at the community levels [31]. In addition, social capital may influence health outcomes, psychological health,

One limitation of this study is that the number of women with disabilities is relatively small for analysis. As a result, it has been difficult to determine the extent and causality of the relationship between social capitals on the self-rated health status of women with disabilities. A further limitation is that we did not take into account the types of disability or various types of jobs undertaken by women with disabilities. Subsequent studies should consider such variables in order to more specifically examine the relationship between social capital and self-

South Korea's unequal gender role recognition based on patriarchal Confucian values still exists today. As a result, women in South Korea are experiencing various conflicts and problems that arise between the role of domestic work traditionally demanded of them, and the new role of wage

self-rated health [26–29], and mental health [42].

rated health status of women with disabilities.

**5. Conclusion**

**Table 2** shows the results of the one-way ANOVAs. We analyzed whether, there is a statistically significant difference in the mean value of self-rated health status according to the level of thought and satisfaction of their job. As a result, there were statistically significant differences in the mean value for self-rated health according to all analyzed variables, that is, working environment of the employment of the women with disability (F = 5.594, p < .004), working hours (F = 6.663, p < .001), personal development possibilities (F = 7.291, p < .001), communication and interpersonal relationships (F = 6.242, p < .002), fairness of performance assessment (F = 9.371, p < .000), welfare benefits (F = 14.553, p < .000), training opportunities (F = 5.594, p < .004), and overall job satisfaction (F = 5.594, p < .004).

Scheffe tests were conducted to determine whether there were any differences between the groups for each variable (see **Table 2**). As a result, the difference in self-rated health status between the dissatisfied group (a), the normal group (b), and the satisfied group (c) of the overall satisfaction level of the working environment and the job was statistically significant. However, the comparisons did not show any differences between groups. For working hours, the self-rated health status of the satisfaction group was significantly higher than for the normal group (b < c). For personal development possibilities, self-rated health status was significantly higher for the satisfaction group than the dissatisfied group (a < c). For communication and interpersonal relationships, significantly higher self-rated health status was found for satisfied compared to the satisfaction group (b < c). For fairness of the performance assessment, the self-rated health status of the satisfaction group was significantly higher than in the dissatisfied and the normal group (a, b < c). For welfare benefits, self-rated health status was significantly higher for the satisfaction group than the dissatisfied group (a < c). For training opportunities, the self-rated health status of the satisfaction group was significantly higher than the dissatisfied group (a < c).

## **4. Discussion**

The purpose of this study was to explore the relationship between social capital and self-rated health status as assessed in the activities of the everyday life of South Korean women with disabilities. These data were obtained from the national survey on persons with disabilities (2014), which mainly concentrated on economic activities [1]. Based on this, we examined whether there was a difference in self-rated health status according to the levels of job satisfaction and related variables as a measure of social capital in women with disability.

We found that working environment, working hours, personal development possibilities, communication-and interpersonal-relationships, the fairness of performance assessment, welfare benefits, training opportunities, and overall working satisfaction differed significantly in relation to the self-rated health status of women with disabilities.

In order to, investigate the difference of self-rated health status according to satisfaction level of each variable, Scheffe test was performed after dividing the response item of each variable into three groups of dissatisfaction, normal, and satisfaction. As a result, the difference in self-rated health status in terms of both overall working satisfaction and the working environment were significant, but there were no differences between the groups for these variables. This suggests that these variables are closely related to self-rated health status, but not in terms of the level of satisfaction. Personal development possibilities, welfare benefits, and training opportunities were found to be higher in relation to self-rated health status for the satisfied group than in the dissatisfied group. These variables may be associated with direct and indirect comparisons with peers, so the items in a variety of conflicts can be caused by it, to a higher self-rated health status of the satisfied group more than dissatisfied groups for each variable. For working hours, communication and interpersonal relationships, higher self-rated health was found for the satisfied group compared to the normal group. It should be noted here that the difference in self-rated health status between the normal group and the satisfaction group, rather than the dissatisfied group, was statistically significant. This may mean that dissatisfaction with working hours, communication-and interpersonalrelationships may lead to resignation or disruption in human relationships, which may be less relevant to current self-rated health status. It is important to note that these results may indicate that invisible conflicts (i.e., the application of flexible working systems considering the characteristics of disability, microaggression, etc.) that occur are closely related to self-rated health status [37]. For Fairness of performance assessment, self-rated health was higher in the satisfaction group than in the dissatisfied and the normal group. Responses to this item included whether the compensation system corresponding to the personnel affairs department was fairly operated if there was no performance assessment system to the job. This question thus considers whether respondents felt that evaluation and compensation were properly performed. It is worth noting here that even if the personnel department thinks that it is not fair (dissatisfied group) and fairly unfair or justifiable (normal group), it is closely related to the self-rated health status of women with disabilities.

Importantly, we found that social capital is positively associated with self-rated health, which is partially consistent with past study findings. Social capital may affect health behaviors through social control over divergent health-related behavior, such as trust between individuals, and reciprocity [30, 39–41], and has an influence on the self-rated health at the community levels [31]. In addition, social capital may influence health outcomes, psychological health, self-rated health [26–29], and mental health [42].

One limitation of this study is that the number of women with disabilities is relatively small for analysis. As a result, it has been difficult to determine the extent and causality of the relationship between social capitals on the self-rated health status of women with disabilities. A further limitation is that we did not take into account the types of disability or various types of jobs undertaken by women with disabilities. Subsequent studies should consider such variables in order to more specifically examine the relationship between social capital and selfrated health status of women with disabilities.

## **5. Conclusion**

annual income were 54 years old and 11,072,600 Korean won (KRW; equivalent to \$ 10.372 USD), respectively. In terms of descriptive analysis for the key variable, the average for self-

**Table 2** shows the results of the one-way ANOVAs. We analyzed whether, there is a statistically significant difference in the mean value of self-rated health status according to the level of thought and satisfaction of their job. As a result, there were statistically significant differences in the mean value for self-rated health according to all analyzed variables, that is, working environment of the employment of the women with disability (F = 5.594, p < .004), working hours (F = 6.663, p < .001), personal development possibilities (F = 7.291, p < .001), communication and interpersonal relationships (F = 6.242, p < .002), fairness of performance assessment (F = 9.371, p < .000), welfare benefits (F = 14.553, p < .000), training opportunities (F = 5.594,

Scheffe tests were conducted to determine whether there were any differences between the groups for each variable (see **Table 2**). As a result, the difference in self-rated health status between the dissatisfied group (a), the normal group (b), and the satisfied group (c) of the overall satisfaction level of the working environment and the job was statistically significant. However, the comparisons did not show any differences between groups. For working hours, the self-rated health status of the satisfaction group was significantly higher than for the normal group (b < c). For personal development possibilities, self-rated health status was significantly higher for the satisfaction group than the dissatisfied group (a < c). For communication and interpersonal relationships, significantly higher self-rated health status was found for satisfied compared to the satisfaction group (b < c). For fairness of the performance assessment, the self-rated health status of the satisfaction group was significantly higher than in the dissatisfied and the normal group (a, b < c). For welfare benefits, self-rated health status was significantly higher for the satisfaction group than the dissatisfied group (a < c). For training opportunities, the self-rated health status of the satisfaction group was significantly higher

The purpose of this study was to explore the relationship between social capital and self-rated health status as assessed in the activities of the everyday life of South Korean women with disabilities. These data were obtained from the national survey on persons with disabilities (2014), which mainly concentrated on economic activities [1]. Based on this, we examined whether there was a difference in self-rated health status according to the levels of job satisfac-

We found that working environment, working hours, personal development possibilities, communication-and interpersonal-relationships, the fairness of performance assessment, welfare benefits, training opportunities, and overall working satisfaction differed signifi-

In order to, investigate the difference of self-rated health status according to satisfaction level of each variable, Scheffe test was performed after dividing the response item of each variable into

tion and related variables as a measure of social capital in women with disability.

cantly in relation to the self-rated health status of women with disabilities.

rated health was 2.45 (SD = .62).

150 Public Health - Emerging and Re-emerging Issues

than the dissatisfied group (a < c).

**4. Discussion**

p < .004), and overall job satisfaction (F = 5.594, p < .004).

South Korea's unequal gender role recognition based on patriarchal Confucian values still exists today. As a result, women in South Korea are experiencing various conflicts and problems that arise between the role of domestic work traditionally demanded of them, and the new role of wage labor required by modern capitalist society. This double distress has a very negative effect on the health status of South Korean women [4, 5]. Nevertheless, despite the impact of these stressors on women, health policy in South Korea mainly focuses on maternity issues, specifically, pregnancy and childbirth [4]. In addition, their disability characteristics can have a negative impact on the most basic conditions for their health care, such as access to health care facilities or the acquisition of relevant information. Moreover, the health promotion policy, which mainly focuses on people with disabilities in South Korea remains at the same basic level as the production of relevant statistical data [4]. Thus, women with disabilities in South Korea are experiencing the triple distress of domestic work, wage labor, and disability, which means that women with disabilities in Korea are located in vulnerable areas of health care. Considering this situation, it is the most realistic and timely alternative for improving the health of women with disabilities in South Korea by examining the self-rated health status and social capital factors influencing it.

**References**

January 18, 2018]

Welfare; 2016. p. 2017

00344

Ministry of Health and Welfare; 2014

[1] Korean Institute of Health and Social Affairs. The National Survey on Persons with Disabilities 2014. Sejong, South Korea: Division of Policy for Persons with Disabilities,

An Exploratory Study on the Association Between Social Capital and Self-Rated Health of South…

http://dx.doi.org/10.5772/intechopen.77324

153

[2] Ministry of Health and Welfare, Registration status of people with disabilities [Internet]. 2016. Available from: http://www.mohw.go.kr/react/jb/sjb030301vw.jsp [Accessed:

[3] Lewis J. Gender and the development of welfare regimes. Journal of European Social

[4] Ministry of Health and Welfare, Korea Health Promotion Foundation. The 4th Health

[5] Korea Centers for Disease Control and Prevention. The National Health Statistics I: The 7th National Health and Nutrition Examination Survey. Sejong: Ministry of Health &

[6] Kim MH. Transformation of family ideology in upper middle class families in urban

[7] Kim MH. Gender, class and family in late-industrializing South Korea. Asian Journal of Women's Studies. 1995;**1**:58-56. DOI: https://doi.org/10.1080/12259276.1995.11665768 [8] Sung S. Women reconciling paid and unpaid work in a confucian welfare state: The case of South Korea. Social Policy & Administration. 2003;**37**:342-360. DOI: 10.1111/1467-9515.

[9] Pascall G, Sung S. Gender and east asian welfare states. from confusianism to gender equality? East Asia, Fourth Annual East Asian Social Policy research network (EASP)

[10] Johnstone D.An Introduction to Disability Studies. 2nd ed. NY: David Fulton Publishers; 2001 [11] Thomas C. Sociologies of Disability and Illness: Contested Ideas in Disability Studies

[12] Story MF, Schwier E, Kailes JI. Perspectives of patients with disabilities on the accessibility of medical equipment: Examination tables, imaging equipment, medical chairs, and weight scales. Disability and Health Journal. 2009;**2**:169-179. DOI: https://doi.

[13] Pharr J. Accessible medical equipment for patients with disabilities in primary care clinics: Why is it lacking? Disability and Health Journal. 2013;**6**:124-132. DOI: http://dx.doi.

[14] Graham CL, Mann JR. Accessibility of primary care physician practice sites in South Carolina for people with disabilities. Disability and Health Journal. 2008;**1**:209-214. DOI:

Policy. 1992;**2**:159-173. DOI: https://doi.org/10.1177/095892879200200301

Plan 2016 ~ 2020. Sejong: Ministry of Health & Welfare; 2015. p. 384

South Korea. Ethnology. 1993;**32**:69-85. DOI: 10.2307/3773546

International Conference, 20th-21st October. 2007

and Medical Sociology. NY: Palgrave Macmillan; 2007

org/10.1016/j.dhjo.2009.05.003

org/10.1016/j.dhjo.2012.11.002

10.1016/j.dhjo.2008.06.001

## **Acknowledgements**

The first author wishes to express his deepest gratitude to Dr. Jun Sung Hong, assistant professor, Sungkyunkwan University, for his guidance and support, who contributed tremendously to this article.

## **Conflict of interest**

No potential conflicts of interest are reported by the authors.

## **Notes and thanks**

This study is based on the concern of the first author in relation to healthy lives for people with disabilities and the experience of Ph.D. student Ji Young Park and Dr. Soo Hyun Sung in the field of health in women with disabilities. The authors would like to express their sincere appreciation to InTechOpen for providing us with this opportunity to present this work.

## **Author details**

Jung Youn Park1 , Ji Young Park1 \* and Soo Hyun Sung2

\*Address all correspondence to: kayuputih@skku.edu

1 Department of Social Welfare, Sungkyunkwan University, Seoul, South Korea

2 Department of Policy Development, National Development Institute of Korean Medicine, Seoul, South Korea

## **References**

labor required by modern capitalist society. This double distress has a very negative effect on the health status of South Korean women [4, 5]. Nevertheless, despite the impact of these stressors on women, health policy in South Korea mainly focuses on maternity issues, specifically, pregnancy and childbirth [4]. In addition, their disability characteristics can have a negative impact on the most basic conditions for their health care, such as access to health care facilities or the acquisition of relevant information. Moreover, the health promotion policy, which mainly focuses on people with disabilities in South Korea remains at the same basic level as the production of relevant statistical data [4]. Thus, women with disabilities in South Korea are experiencing the triple distress of domestic work, wage labor, and disability, which means that women with disabilities in Korea are located in vulnerable areas of health care. Considering this situation, it is the most realistic and timely alternative for improving the health of women with disabilities in South Korea by examin-

The first author wishes to express his deepest gratitude to Dr. Jun Sung Hong, assistant professor, Sungkyunkwan University, for his guidance and support, who contributed tremen-

This study is based on the concern of the first author in relation to healthy lives for people with disabilities and the experience of Ph.D. student Ji Young Park and Dr. Soo Hyun Sung in the field of health in women with disabilities. The authors would like to express their sincere appreciation to InTechOpen for providing us with this opportunity to present this work.

\* and Soo Hyun Sung2

2 Department of Policy Development, National Development Institute of Korean Medicine,

1 Department of Social Welfare, Sungkyunkwan University, Seoul, South Korea

ing the self-rated health status and social capital factors influencing it.

No potential conflicts of interest are reported by the authors.

, Ji Young Park1

\*Address all correspondence to: kayuputih@skku.edu

**Acknowledgements**

152 Public Health - Emerging and Re-emerging Issues

dously to this article.

**Conflict of interest**

**Notes and thanks**

**Author details**

Jung Youn Park1

Seoul, South Korea


[15] Mudrick NR, Breslin ML, Liang M, Yee S. Physical accessibility in primary health care settings: Results from California on-site reviews. Disability and Health Journal. 2012;**5**:159-167. DOI: 10.1016/j.dhjo.2012.02.002

[29] Giordano GN, Ohlsson H, Lindström M. Social capital and health: Purely a question of context? Health & Place. 2011;**17**:946-953. DOI: https://doi.org/10.1016/j.healthplace.2011.

An Exploratory Study on the Association Between Social Capital and Self-Rated Health of South…

http://dx.doi.org/10.5772/intechopen.77324

155

[30] Kawachi I, Kennedy BP, Glass R. Social capital and self-rated health: A contextual analy-

[31] Subramanian SV, Kim DJ, Kawachi I. Social trust and self-rated health in US communities: A multilevel analysis. Journal of Urban Health: Bulletin of the New York Academy

[32] Putnam RD. Making Democracy Work: Civic Traditions in Modern Italy. Princeton, NJ:

[33] Coleman JS. Foundations of Social Theory. Cambridge, MA: Belknap Press of Harvard

[34] Bourdieu P. The forms of capital. In: Richardson JG, editor. Handbook of Theory and Research for the Sociology of Education. Westport, CT: Greenwood Press; 1986. 248 p

[35] Bourdieu P. The Logic of Practice (R. Nice, Trans.). Cambridge, England: Polity Press.

[36] Bourdieu P. Practical Reason: On the Theory of Action. Stanford, CA: Stanford University

[37] Park JY. Disability discrimination in South Korea: Routine and everyday aggressions toward disabled people. Disability & Society. 2017;**32**:918-922. DOI: 10.1080/09687599.2017.

[38] Korea Employment Agency for the Disabled. Panel Survey of Employment for the Disabled. Seongnam: Korea Employment Agency for the Disabled; 2015. pp. 45-310 [39] Ferlander S. The importance of different forms of social capital for health. Acta Sociologica. 2007;**50**:116-128. DOI: https://doi.org/10.1177/0001699307077654

[40] Kawachi I. Commentary: Social capital and health: Making the connections one step at the time. International Journal of Epidemiology. 2006;**35**:989-993. DOI: https://doi.

[41] Kunitz SJ. Accounts of social capital: The mixed health effects of personal communities and voluntary groups. In: Leon DA, Walt G, Editors. Poverty, Inequality and Health. An

International Perspective. Oxford, England: Oxford University Press; 2001. 159 p

in the new millennium. Social Science and Medicine. 2000;**51**:843-857

[42] Berkman LF, Glass T, Brissette T, Seeman TE. From social integration to health: Durkheim

sis. American Journal of Public Health. 1999;**89**:1187-1193

Princeton University Press; 1993. 167 p

(Original work published; 1980. p. 1990

University Press; 1994. 300 p

Press; 1998

1321223

org/10.1093/ije/dyl117

of Medicine. 2002;**79**:S21-S34. DOI: 10.1093/jurban/79.suppl\_1.S21

04.004


[29] Giordano GN, Ohlsson H, Lindström M. Social capital and health: Purely a question of context? Health & Place. 2011;**17**:946-953. DOI: https://doi.org/10.1016/j.healthplace.2011. 04.004

[15] Mudrick NR, Breslin ML, Liang M, Yee S. Physical accessibility in primary health care settings: Results from California on-site reviews. Disability and Health Journal.

[16] Maragh-Bass AC, Griffin JM, Phelan S, Rutten LJ, Morris MA. Healthcare provider perceptions of accessible exam tables in primary care: Implementation and benefits to patients with and without disabilities. Disability and Health Journal. 2018;**11**:155-160.

[17] Jallinoja P, Absetz P, Kuronen R, Nissinen A, Talja M, Uutela A, Patja K. The dilemma of patient responsibility for lifestyle change: Perceptions among primary care physicians and nurses. Scandinavian Journal of Primary Health Care. 2007;**25**:244-249. DOI:

[18] Buyx A, Prainsack B. Lifestyle-related diseases and individual responsibility through the prism of solidarity. Clinical Ethics. 2012;**7**:79-85. DOI: 10.1258/ce.2012.012008 [19] Idler EL, Angel RJ. Self-rated health and mortality in the NHANES-1 epidemiologic

[20] Subramanian SV, Huijts T, Avendano M. Self-reported health assessments in the 2002 world health survey: How do they correlate with education? Bulletin of the World

[21] Burström B, Fredlund P. Self rated health: Is it as good a predictor of subsequent mortality among adults in lower as well as in higher social classes? Journal of Epidemiology &

[22] Fayers PM, Sprangers MAG. Understanding self-rated health. Lancet. 2002;**359**:187-188.

[23] Goldman N, Glei DA, Chang MC. The role of clinical risk factors in understanding self-rated health. Annals of Epidemiology. 2003;**14**:49-57. DOI: https://doi.org/10.1016/

[24] Idler EL, Benyamini Y. Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior. 1997;**38**:21-37. DOI: 10.2307/2955359

[26] Park JY, Kim JW. Understanding the association between social capital and selfrated health of south Korean elderly with disabilities. Social Work in Public Health.

[27] Giordano GN, Lindström M. Social capital and change in psychological health over time. Social Science & Medicine. 2010;**72**:1219-1227. DOI: 10.1016/j.socscimed.2011.02.029 [28] Giordano GN, Lindström M. The impact of changes in different aspects of social capital and material conditions on self-rated health over time: A longitudinal cohort study. Social Science & Medicine. 2010;**70**:700-710. DOI: https://doi.org/10.1016/j.socscimed.

[25] Sen A. Why health equity? Health Economics. 2002;**11**:659-666. DOI: 10.1002/hec.762

follow-up study. American Journal of Public Health. 1990;**80**:446-452

Health Organization. 2010;**88**:131-138. DOI: 10.2471/BLT.09.067058

Community Health. 2001;**55**:836-840. DOI: 10.1136/jech.55.11.836

DOI: https://doi.org/10.1016/S0140-6736(02)07466-4

2016;**31**:498-503. DOI: 10.1080/19371918.2016.1160339

2012;**5**:159-167. DOI: 10.1016/j.dhjo.2012.02.002

DOI: http://dx.doi.org/10.1016/j.dhjo.2017.04.005

10.1080/02813430701691778

154 Public Health - Emerging and Re-emerging Issues

S1047-2797(03)00077-2

2009.10.044


**Chapter 9**

Provisional chapter

**Dilemmas and Impasses in Public Health Policies**

Dilemmas and Impasses in Public Health Policies

**Directed at People Who Make Use of Alcohol and**

Directed at People Who Make Use of Alcohol and Other

DOI: 10.5772/intechopen.76354

The first Brazilian public policies directed at people who make use of alcohol and other drugs focused on criminalization and punishment. In 1932, medicine and its strategies of governmentality began to work within this field. The Penal Code of 1941 brought the ideal of abstinence to the Brazilian public arena, which was then broadly disseminated by the legislation up until 2006, when a new mental health policy began to be implemented for this population. In this chapter, we analyze the tensions between models that focus on care and those that have a safety perspective in programs for users of alcohol and other drugs in the central region of the city of São Paulo. We analyzed public domain documents: documentary material on the legal landmarks of policies; revision of literature; and news in Brazilian media about governmental actions in this area. Results of the analysis indicate that the tension between harm reduction models and the abstinence model persisted in governmental actions over the years. Regarding the central region, there was a diversification in the offer of treatment models and approaches. But these models took form as a market dispute: for sellable goods, employability of professionals, and the

Keywords: Brazilian public health, alcohol and other drug policies, harm reduction,

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

**Other Drugs in Brazil**

Drugs in Brazil

Pedro Paulo Freire Piani

Pedro Paulo Freire Piani

Abstract

Maria Cristina Gonçalves Vicentin,

Maria Cristina Gonçalves Vicentin,

http://dx.doi.org/10.5772/intechopen.76354

Jacqueline Isaac Machado Brigagão and

Jacqueline Isaac Machado Brigagão and

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

interests of the pharmaceutical industry.

abstinence, mental health

#### **Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs in Brazil** Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs in Brazil

DOI: 10.5772/intechopen.76354

Maria Cristina Gonçalves Vicentin, Jacqueline Isaac Machado Brigagão and Pedro Paulo Freire Piani Maria Cristina Gonçalves Vicentin, Jacqueline Isaac Machado Brigagão and Pedro Paulo Freire Piani

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76354

#### Abstract

The first Brazilian public policies directed at people who make use of alcohol and other drugs focused on criminalization and punishment. In 1932, medicine and its strategies of governmentality began to work within this field. The Penal Code of 1941 brought the ideal of abstinence to the Brazilian public arena, which was then broadly disseminated by the legislation up until 2006, when a new mental health policy began to be implemented for this population. In this chapter, we analyze the tensions between models that focus on care and those that have a safety perspective in programs for users of alcohol and other drugs in the central region of the city of São Paulo. We analyzed public domain documents: documentary material on the legal landmarks of policies; revision of literature; and news in Brazilian media about governmental actions in this area. Results of the analysis indicate that the tension between harm reduction models and the abstinence model persisted in governmental actions over the years. Regarding the central region, there was a diversification in the offer of treatment models and approaches. But these models took form as a market dispute: for sellable goods, employability of professionals, and the interests of the pharmaceutical industry.

Keywords: Brazilian public health, alcohol and other drug policies, harm reduction, abstinence, mental health

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## 1. Introduction

Brazil is a South American country with continental dimensions and a population of over 208 million inhabitants, in a territory of 8,516,000 km<sup>2</sup> divided into 5 regions, 26 states, and 1 federal district where the capital is located. Its population of young people between 14 and 29 years of age is of approximately 51 million. This vast territory is made up of big cities and 5570 municipalities [1].

Braços Abertos), implemented in 2013, developed by the municipal government, and the Fresh Start Program (Programa Recomeço), also implemented in 2013 and developed by the state

Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs…

http://dx.doi.org/10.5772/intechopen.76354

159

From a methodological point of view, we used the following strategies: (1) revision of legal regulations that refer to mental health policies and drug policies, aiming at understanding the Brazilian panorama. These are public domain documents available in the databases of the ministries of Health and Justice. We focused on documents from the period between 2006 and 2013, when the country underwent changes in drug legislation, as well as outlining care relating to alcohol and other drugs within mental health policies (2) revision of literature on governmental actions carried out in the city of São Paulo, in particular the research conducted by public agencies on the impact of service programs and media news on the actions developed by the territory's government. In this manner, the chapter was developed with basis on a revision of literature with the introduction of an analytical angle derived from this institutional analysis—the analysis of critical events that allows for a clarification of the power plays at

work in a determined situation, as well as arguing for certain naturalizations [3].

producing disputes and tension between the models that guide these actions.

use of alcohol and other drugs

We shall begin by presenting a brief historical overview of policies and laws that relate to drug use in order to situate within history how actions of welfare, health care, and safety became part of the governmental agenda. Next, we shall present the perspective of the prevailing Brazilian health policies so as to demonstrate the ramifications of this perspective within the programs developed in the municipality of São Paulo. We present a contextualization of the area where the programs are developed, and of how the public powers intervened with the neighborhood's population by means of government strategies over the past decades,

2. Brief historical overview of the laws and public policies that relate to the

The first policies and laws that relate to drug use in Brazil were guided by the punitive model and configured within the field of public safety. In 1830, the Municipal Chamber of Rio de Janeiro established a court fine for the "vagrant blacks" that were caught smoking marijuana, and in 1890 the Brazilian penal code expressed, in an explicit manner, the prohibition of the use of substances considered poisonous, stating the need to create complementary guidelines [4]. In 1932, the sphere of health was incorporated in the Brazilian legal framework relating to drug use. From then on, as medicine and its sanitary model for society began to influence and guide Brazilian legislation in a number of sectors, it is possible to observe a link between those heath policies that prescribed treatments, often guided by the ideal of abstinence and social isolation by means of hospitalization, and legal mechanisms of repression and prohibition of

drug use in many of the laws and public policies relating to the use of drugs [4, 5].

The policies that derived from international conventions and American politics, denominated "war on drugs", which started in the 1970s and were broadened in the following decades, also had a lot of influence upon the legislation, policies, and programs proposed by the Brazilian

government.

Portuguese colonization began in 1500, and although independence took place in 1822, the country did not become a republic until 1889. Throughout history, democracy in the country suffered many ruptures, with the last military government lasting over 20 years; the Federal Constitution of 1988 was a landmark for the country's new political organization. Portuguese is the official language, and completely hegemonic, spoken in all regions, but there is a vast ethnic and cultural diversity. Within the last decade, Brazil has rated among the biggest world economies, ranging between seventh and ninth place. With commodities sought by the international market, besides biodiversity reserves and large cities, Brazil can be considered an economic powerhouse, although one with structural difficulties and international interests that block development. Minerals, oil, agriculture, livestock farming, the energy sector, the automobile industry, aviation, and other goods make up the large internal and external offer of the Brazilian economy, with bilateral trade on all continents.

In a country marked by deep social inequality, with a heritage of traits that trace back to colonialism, slavery, and authoritarianism, the 1988 Federal Constitution—a result of a number of social movements—was a milestone for the new democratic political order of the nation, instituting an increase of processes that guarantee and give access to rights, especially in regard to social policies, such as in the case of the Brazilian Unified Health System (Sistema Único de Saúde—SUS). The movements known as sanitary reform and psychiatric reform soon became an international reference [2] and their establishment took place amid disputes between segments defending State actions in health and segments defending private sector health care.

In the field of policies relating to the use of alcohol and other drugs in Brazil, it is possible to observe two lines of state actions. One, punitive, which focuses its actions in the public safety arena, and another, in public health, which prescribes treatment and health-care actions for those who make problematic use of alcohol and other drugs. In this chapter, our aim is to discuss the tensions and polarizations between different health-care models, both those guided by the perspective of reducing harm and those guided by an ideal of abstinence and safety, using as a basis health-care actions aimed at people who make use of alcohol and other drugs. We present as an analyzing event<sup>1</sup> the actions undertaken over the past 4 years in the Luz neighborhood in the center of São Paulo, an area known as Crackland ("Cracolândia"), when different intervention programs were set up "competing" for the local population and drug users. Two programs are the focus of this analysis: the Open Arms Program (Programa de

<sup>1</sup> Analyzing events: critical events that allow a clarification of the forces at play in a determined situation, as well as arguing for certain naturalizations [3].

Braços Abertos), implemented in 2013, developed by the municipal government, and the Fresh Start Program (Programa Recomeço), also implemented in 2013 and developed by the state government.

1. Introduction

158 Public Health - Emerging and Re-emerging Issues

5570 municipalities [1].

health care.

1

arguing for certain naturalizations [3].

Brazilian economy, with bilateral trade on all continents.

Brazil is a South American country with continental dimensions and a population of over 208 million inhabitants, in a territory of 8,516,000 km<sup>2</sup> divided into 5 regions, 26 states, and 1 federal district where the capital is located. Its population of young people between 14 and 29 years of age is of approximately 51 million. This vast territory is made up of big cities and

Portuguese colonization began in 1500, and although independence took place in 1822, the country did not become a republic until 1889. Throughout history, democracy in the country suffered many ruptures, with the last military government lasting over 20 years; the Federal Constitution of 1988 was a landmark for the country's new political organization. Portuguese is the official language, and completely hegemonic, spoken in all regions, but there is a vast ethnic and cultural diversity. Within the last decade, Brazil has rated among the biggest world economies, ranging between seventh and ninth place. With commodities sought by the international market, besides biodiversity reserves and large cities, Brazil can be considered an economic powerhouse, although one with structural difficulties and international interests that block development. Minerals, oil, agriculture, livestock farming, the energy sector, the automobile industry, aviation, and other goods make up the large internal and external offer of the

In a country marked by deep social inequality, with a heritage of traits that trace back to colonialism, slavery, and authoritarianism, the 1988 Federal Constitution—a result of a number of social movements—was a milestone for the new democratic political order of the nation, instituting an increase of processes that guarantee and give access to rights, especially in regard to social policies, such as in the case of the Brazilian Unified Health System (Sistema Único de Saúde—SUS). The movements known as sanitary reform and psychiatric reform soon became an international reference [2] and their establishment took place amid disputes between segments defending State actions in health and segments defending private sector

In the field of policies relating to the use of alcohol and other drugs in Brazil, it is possible to observe two lines of state actions. One, punitive, which focuses its actions in the public safety arena, and another, in public health, which prescribes treatment and health-care actions for those who make problematic use of alcohol and other drugs. In this chapter, our aim is to discuss the tensions and polarizations between different health-care models, both those guided by the perspective of reducing harm and those guided by an ideal of abstinence and safety, using as a basis health-care actions aimed at people who make use of alcohol and other drugs. We present as an analyzing event<sup>1</sup> the actions undertaken over the past 4 years in the Luz neighborhood in the center of São Paulo, an area known as Crackland ("Cracolândia"), when different intervention programs were set up "competing" for the local population and drug users. Two programs are the focus of this analysis: the Open Arms Program (Programa de

Analyzing events: critical events that allow a clarification of the forces at play in a determined situation, as well as

From a methodological point of view, we used the following strategies: (1) revision of legal regulations that refer to mental health policies and drug policies, aiming at understanding the Brazilian panorama. These are public domain documents available in the databases of the ministries of Health and Justice. We focused on documents from the period between 2006 and 2013, when the country underwent changes in drug legislation, as well as outlining care relating to alcohol and other drugs within mental health policies (2) revision of literature on governmental actions carried out in the city of São Paulo, in particular the research conducted by public agencies on the impact of service programs and media news on the actions developed by the territory's government. In this manner, the chapter was developed with basis on a revision of literature with the introduction of an analytical angle derived from this institutional analysis—the analysis of critical events that allows for a clarification of the power plays at work in a determined situation, as well as arguing for certain naturalizations [3].

We shall begin by presenting a brief historical overview of policies and laws that relate to drug use in order to situate within history how actions of welfare, health care, and safety became part of the governmental agenda. Next, we shall present the perspective of the prevailing Brazilian health policies so as to demonstrate the ramifications of this perspective within the programs developed in the municipality of São Paulo. We present a contextualization of the area where the programs are developed, and of how the public powers intervened with the neighborhood's population by means of government strategies over the past decades, producing disputes and tension between the models that guide these actions.

## 2. Brief historical overview of the laws and public policies that relate to the use of alcohol and other drugs

The first policies and laws that relate to drug use in Brazil were guided by the punitive model and configured within the field of public safety. In 1830, the Municipal Chamber of Rio de Janeiro established a court fine for the "vagrant blacks" that were caught smoking marijuana, and in 1890 the Brazilian penal code expressed, in an explicit manner, the prohibition of the use of substances considered poisonous, stating the need to create complementary guidelines [4]. In 1932, the sphere of health was incorporated in the Brazilian legal framework relating to drug use. From then on, as medicine and its sanitary model for society began to influence and guide Brazilian legislation in a number of sectors, it is possible to observe a link between those heath policies that prescribed treatments, often guided by the ideal of abstinence and social isolation by means of hospitalization, and legal mechanisms of repression and prohibition of drug use in many of the laws and public policies relating to the use of drugs [4, 5].

The policies that derived from international conventions and American politics, denominated "war on drugs", which started in the 1970s and were broadened in the following decades, also had a lot of influence upon the legislation, policies, and programs proposed by the Brazilian government. It is worth pointing out that, between 1964 and 1985, Brazil was under a military dictatorship marked by governmental actions that repressed individual and collective rights. Within this context, Law 6.368/1976 was approved, which talked of the measures for prevention and repression of illegal traffic and the improper use of intoxicating substances or those that create physical or psychic dependence, and other provisions. The principles that guide this law in its different articles are guided by the idea of repression, criminalization, and social exclusion, since the treatments it advocates are centered upon incarceration and isolation, as demonstrated by article 9 of the aforementioned law: The health care networks of the States, Territories and Federal District will count on, whenever necessary and possible, suitable establishments for treating those dependent on the substances referred to by the present Law. §1 While the establishments referred to in this article are not created, the existing network will adapt units for this purpose [6]. This law made possible the proliferation of so-called therapeutic communities in Brazil, which are private services managed by civil society entities, generally linked to religious institutions, that adopt hospitalization, social isolation, and abstinence as their main treatment strategies for drug users [5].

In the field of mental health, the anti-mental institution movement and the fight for a society without mental asylums that took place in the 1980s and 1990s were crucial for the reorganization of services and approval of Law 10.216 in 2001. This law established new parameters for mental health care, investing in structuring a public network of mental health care services, including the establishment of the Psychosocial Care Centers (Centros de Atenção Psicossocial —CAPS). Following on from the new law, the Ministry of Health created the National Policy for integral care for users of alcohol and other drugs [8]. This policy is clearly guided by the harm reduction model, and allows for the implementation of a specific care network for those who make use of alcohol and other drugs, named CAPS-AD [5]. These centers basically perform outpatient care and group activities, taking treatment possibilities beyond psychiatric care, since they include other health-care professionals and focus on social reinsertion. This policy breaks with exclusionist hospitalization strategies and highlights the importance of the following principle in public health: The offer of care for people who present problems due to the use of alcohol and other drugs should be based on mechanisms for specialized psychosocial attention taking place outside hospitals, duly connected to the mental health care network and to the rest of the health network. These mechanisms must make deliberate and efficient use of the concepts of territory and network, as well as a broader logic of harm reduction, carrying out an active and systematic search for the needs to be attended to, in a manner that is integrated with the cultural environment and community within which they are inserted, and according to the principles of the Psychiatric Reform [8].

Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs…

http://dx.doi.org/10.5772/intechopen.76354

161

But, as in Brazil, the matter of use of alcohol and other drugs has always been on the agenda for health-care and public safety organizations, in 2005 the National Office for Policies About Drugs (Secretaria Nacional de Políticas Sobre Drogas—SENAD), connected to the Ministry of Justice, established the National Drug Policy (Política Nacional sobre Drogas—PND), which despite including the strategy of harm reduction—brings back the possibility of hospitalization as treatment, whether in therapeutic communities or psychiatric hospitals: Promote and guarantee the coordination and integration, in a national network, of interventions for treatment, recovery, harm reduction, and social and occupational reinsertion (primary care centers, outpatient centers, CAPS, CAPS-AD, therapeutic communities, groups for self-help and mutual aid, general and psychiatric hospitals, day hospitals, emergency services, fire department, specialized clinics, support and community centers, and assisted living) within the Brazilian Unified Health System and the Unified System of Social Care, for the user and their family, by means of decentralized distribution and the

The Ministry of Health was responsible for the introduction of a public health policy and a code of ethics for care when dealing with drug users. As a guardian of sanitary reform, the Ministry implemented the first support programs in mental health for users who had difficulty with social insertion; program benefits included payment of one minimum wage, and support for families and users in order to help them return home. As from 2010, with the elaboration and implementation of the project Crack Plan, it's possible to win (Plano Crack, é possível vencer), the funding for hospitalization has grown in all Brazilian capitals. The triad of prevention, care, and authority, despite the proposal of integration, emphasized funding for a return to psychiatric hospitalization and security measures. Coming from a different perspective, the Oswaldo Cruz Foundation (FIOCRUZ) created in 2014 a program for alcohol, crack, and other drugs, taking actions beyond crack, which had been chosen by the federal government as the

monitoring of technical and financial resources [9].

In 2002, a new law comes into effect, Law 10.409, but due to a number of unconstitutional aspects and technical deficiencies, it was vetoed in many aspects, with only its procedural part put into action. Thus, Law 6.368/1976 was still valid in regard to its penal aspects. In this manner, this law remained in place for over 30 years, or in other words, it guided both governmental and civil society actions and programs, as well as the development of a mentality about treatments and health issues relating to people who make use of drugs, until in August 2006 Law 11.343 was set in place, revoking both previous laws. This law introduced the novelty of non-incarceration sentencing in cases of drug possession for own use, and included the availability of health treatment for users.

Over the last 30 years, Brazil went through many transformations, especially in the field of health. Since the 1970s, different civil society groups, such as health care professionals, women's groups, academics, and social movements fighting for housing rights gathered under a banner of sanitary reform that fought for changes in how health care was organized in the country. This movement was responsible for elaborating and discussing proposals during the 8th National Health Conference in 1986, which established the principals and guidelines for health care that would be included in the 1988 Constitution, as well as the basis for the Brazilian Unified Health System (SUS).

Thus, during the country's re-democratization process, health care was acknowledged as a right of all citizens and a duty of the State, and SUS, created in 1990, has as its principles universal access, integrality, and equity, which means it is a system where processes of health and sickness are understood to be a result of social determinants of health such as poverty, housing, and others. Within SUS, everyone has access to public health services, and these services seek to guarantee that different people have their needs attended to [2, 7]. This has meant a profound reorganization of health services and the supply of health care in Brazil, reaching all levels of care, a diversity of professionals, and public and private institutions, and moving an immense productive chain within national development, while employing an economically active population in Brazil. With all this repercussion, it is not hard to interpret that the construction of this system is proving to be durable and extensive.

In the field of mental health, the anti-mental institution movement and the fight for a society without mental asylums that took place in the 1980s and 1990s were crucial for the reorganization of services and approval of Law 10.216 in 2001. This law established new parameters for mental health care, investing in structuring a public network of mental health care services, including the establishment of the Psychosocial Care Centers (Centros de Atenção Psicossocial —CAPS). Following on from the new law, the Ministry of Health created the National Policy for integral care for users of alcohol and other drugs [8]. This policy is clearly guided by the harm reduction model, and allows for the implementation of a specific care network for those who make use of alcohol and other drugs, named CAPS-AD [5]. These centers basically perform outpatient care and group activities, taking treatment possibilities beyond psychiatric care, since they include other health-care professionals and focus on social reinsertion. This policy breaks with exclusionist hospitalization strategies and highlights the importance of the following principle in public health: The offer of care for people who present problems due to the use of alcohol and other drugs should be based on mechanisms for specialized psychosocial attention taking place outside hospitals, duly connected to the mental health care network and to the rest of the health network. These mechanisms must make deliberate and efficient use of the concepts of territory and network, as well as a broader logic of harm reduction, carrying out an active and systematic search for the needs to be attended to, in a manner that is integrated with the cultural environment and community within which they are inserted, and according to the principles of the Psychiatric Reform [8].

government. It is worth pointing out that, between 1964 and 1985, Brazil was under a military dictatorship marked by governmental actions that repressed individual and collective rights. Within this context, Law 6.368/1976 was approved, which talked of the measures for prevention and repression of illegal traffic and the improper use of intoxicating substances or those that create physical or psychic dependence, and other provisions. The principles that guide this law in its different articles are guided by the idea of repression, criminalization, and social exclusion, since the treatments it advocates are centered upon incarceration and isolation, as demonstrated by article 9 of the aforementioned law: The health care networks of the States, Territories and Federal District will count on, whenever necessary and possible, suitable establishments for treating those dependent on the substances referred to by the present Law. §1 While the establishments referred to in this article are not created, the existing network will adapt units for this purpose [6]. This law made possible the proliferation of so-called therapeutic communities in Brazil, which are private services managed by civil society entities, generally linked to religious institutions, that adopt hospitalization, social isola-

In 2002, a new law comes into effect, Law 10.409, but due to a number of unconstitutional aspects and technical deficiencies, it was vetoed in many aspects, with only its procedural part put into action. Thus, Law 6.368/1976 was still valid in regard to its penal aspects. In this manner, this law remained in place for over 30 years, or in other words, it guided both governmental and civil society actions and programs, as well as the development of a mentality about treatments and health issues relating to people who make use of drugs, until in August 2006 Law 11.343 was set in place, revoking both previous laws. This law introduced the novelty of non-incarceration sentencing in cases of drug possession for own use, and

Over the last 30 years, Brazil went through many transformations, especially in the field of health. Since the 1970s, different civil society groups, such as health care professionals, women's groups, academics, and social movements fighting for housing rights gathered under a banner of sanitary reform that fought for changes in how health care was organized in the country. This movement was responsible for elaborating and discussing proposals during the 8th National Health Conference in 1986, which established the principals and guidelines for health care that would be included in the 1988 Constitution, as well as the basis for the

Thus, during the country's re-democratization process, health care was acknowledged as a right of all citizens and a duty of the State, and SUS, created in 1990, has as its principles universal access, integrality, and equity, which means it is a system where processes of health and sickness are understood to be a result of social determinants of health such as poverty, housing, and others. Within SUS, everyone has access to public health services, and these services seek to guarantee that different people have their needs attended to [2, 7]. This has meant a profound reorganization of health services and the supply of health care in Brazil, reaching all levels of care, a diversity of professionals, and public and private institutions, and moving an immense productive chain within national development, while employing an economically active population in Brazil. With all this repercussion, it is not hard to interpret

that the construction of this system is proving to be durable and extensive.

tion, and abstinence as their main treatment strategies for drug users [5].

included the availability of health treatment for users.

Brazilian Unified Health System (SUS).

160 Public Health - Emerging and Re-emerging Issues

But, as in Brazil, the matter of use of alcohol and other drugs has always been on the agenda for health-care and public safety organizations, in 2005 the National Office for Policies About Drugs (Secretaria Nacional de Políticas Sobre Drogas—SENAD), connected to the Ministry of Justice, established the National Drug Policy (Política Nacional sobre Drogas—PND), which despite including the strategy of harm reduction—brings back the possibility of hospitalization as treatment, whether in therapeutic communities or psychiatric hospitals: Promote and guarantee the coordination and integration, in a national network, of interventions for treatment, recovery, harm reduction, and social and occupational reinsertion (primary care centers, outpatient centers, CAPS, CAPS-AD, therapeutic communities, groups for self-help and mutual aid, general and psychiatric hospitals, day hospitals, emergency services, fire department, specialized clinics, support and community centers, and assisted living) within the Brazilian Unified Health System and the Unified System of Social Care, for the user and their family, by means of decentralized distribution and the monitoring of technical and financial resources [9].

The Ministry of Health was responsible for the introduction of a public health policy and a code of ethics for care when dealing with drug users. As a guardian of sanitary reform, the Ministry implemented the first support programs in mental health for users who had difficulty with social insertion; program benefits included payment of one minimum wage, and support for families and users in order to help them return home. As from 2010, with the elaboration and implementation of the project Crack Plan, it's possible to win (Plano Crack, é possível vencer), the funding for hospitalization has grown in all Brazilian capitals. The triad of prevention, care, and authority, despite the proposal of integration, emphasized funding for a return to psychiatric hospitalization and security measures. Coming from a different perspective, the Oswaldo Cruz Foundation (FIOCRUZ) created in 2014 a program for alcohol, crack, and other drugs, taking actions beyond crack, which had been chosen by the federal government as the banner of the fight, though not without criticism from sectors already working with integral care for users. This institution, besides working on training network professionals, carried out a large survey project in Brazil, the National Survey on Use of Crack—Pesquisa Nacional sobre o Uso do Crack [10] which brought a new dimension to crack addiction, indicating less use than had been propagated in the media and presenting a user profile according to aspects such as gender, age, education level, occupation, and patterns of usage.

public powers. This phenomenon was strengthened by a rise in parliamentary representatives linked to religious institutions. This context provoked a change in how drug policies were carried out. The Ministry of Health had established guidelines from a human rights perspective, adopting criteria and regulations for the implementation of health care services that respected access and integrality in their actions. The Ministry of Justice took on drug policies in 2011 by means of the National Office for Policies About Drugs (Secretaria Nacional de Políticas sobre Drogas—SENAD). The guidelines continued, but a growth was observed in programs that came under the responsibility of religious institutions. In 2015, with presidential changes due to impeachment, new managers took over the ministries of Health and Justice, promoting the implementation of a new policy that focused on treatment of chemical depen-

Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs…

http://dx.doi.org/10.5772/intechopen.76354

163

On an international level, a debate was gaining ground, especially after the creation of the Global Commission on Drug Policy in 2011, made up of former Heads of State and specialists, and which contested the war on drugs as an efficient combat policy, indicating by means of studies and statements a different path to tackle the drug problem. In the Commission's first report, with the title War on Drugs, released in June 2011, the organization proposed 11 recommendations to substitute the criminalization and punishment of drug users for an offer of health services, support, and treatment of users, besides highlighting the need to advance in regulating psychoactive substances. Commissions linked to the UN, such as the Expert Committee in Drug Dependence and the International Narcotics Control Board, were still focusing on the classification of narcotics as forbidden and ignoring research and the cumulative knowl-

3. Tensions between health-care models within the same territory: the

resulted from urban expulsion and economic and social segregation.

The arrival of crack in the urban landscape of São Paulo<sup>2</sup> dates back to the 1990s, and the establishment of public sales and usage zones gradually turned the so-called cracklands into symbols of immorality, abandonment, and demonization; this legitimized, as from 2010, the compulsory rounding up of the street population, making social and urban exclusion invisible and becoming a historical process connected to the aggravation of the social inequality that

In the 1960s, before the central region of São Paulo became infamous for the commerce and use of drugs and crack, prostitution was the main target for police actions in the area. Initially protected by territorial confinement, the neighborhood engaged in an ever-changing game between the tolerated, the permitted, and the repressed [11]. As from the 1950s, however, with the city's growth and urban development, the grouping of licit and illicit activities surrounding this practice would migrate to other nearby territories [12], and this area would become a constant target for police and urban interventions aimed at "re-qualifying" the region, besides

For this contextualization about territory and the "Operação Sufoco" we based ourselves on the text [34].

dency, compulsory hospitalization, and religious therapeutic communities.

edge of the World Health Organization (WHO).

Cracolândia case

2

Implementing the principles and administrative directives that guide SUS, in other words, decentralization, regionalization, hierarchy, and community participation, is a complex task, due to multiple factors such as the country's territorial extension, regional differences, and political, social, and economic issues

Decentralization of actions in health is one of the administrative directives that, in the day-today application of measures, seeks to involve all three levels of government: federal, state, and municipal. According to [11]: The Federal Constitution of 1988 made it so that Brazil became a peculiar case of a Federation with three entities considered primary parties within the pact: Union, states and municipalities—only Belgium and India give local power a similar status. Indeed, one could observe a greater political, administrative, and financial autonomy of municipalities in regard to the previous period, followed by a decentralization of resources and attributions.

Thus, responsibility fell to the federal government to formulate and follow up on the execution of national health policies, while the states were responsible for more complex services, besides the management, formulation, and coordination of some policies, and the municipalities took responsibility for executing actions and offering direct services. In this manner, the three public spheres participate in the national policy and its execution with distinct responsibilities, either set out by the legal system or pressured into it by the law.

As from 2006, the construction of the new policy within the national plan brought, on one hand, directives that indicated a need for a new posture in regard to user care; on the other hand, setting the programs in place highlighted that there were still indicatives and financing issues that allowed for a questioning of actions and the resurgence of religious and philanthropic institutions that turned to user care, choosing to trust in confinement and isolation, with little social insertion, and that competed for public resources.

The new policy presented prevention, care, and authority as lines of action, taking into consideration an approach centered upon construction of the person as a subject of rights, upon humanization, and upon the establishment of links within the service network, the family, and the community. The introduction of public programs and statutes for professional training took place all over Brazil, with regional reference centers implemented in the states supported by the vast network of public federal universities that worked with professional training for intersectoral services. The reach of this policy was initially extensive. The mental health care network was widened by psychosocial care centers, therapeutic residential units, street clinics, and specialized reference centers, strengthening deinstitutionalization as a movement for the creation of new mechanisms and therapeutic spaces.

However, the service network could not cope with user monitoring and care. There were also a growing number of religious therapeutic communities that still had no direct support from the public powers. This phenomenon was strengthened by a rise in parliamentary representatives linked to religious institutions. This context provoked a change in how drug policies were carried out. The Ministry of Health had established guidelines from a human rights perspective, adopting criteria and regulations for the implementation of health care services that respected access and integrality in their actions. The Ministry of Justice took on drug policies in 2011 by means of the National Office for Policies About Drugs (Secretaria Nacional de Políticas sobre Drogas—SENAD). The guidelines continued, but a growth was observed in programs that came under the responsibility of religious institutions. In 2015, with presidential changes due to impeachment, new managers took over the ministries of Health and Justice, promoting the implementation of a new policy that focused on treatment of chemical dependency, compulsory hospitalization, and religious therapeutic communities.

banner of the fight, though not without criticism from sectors already working with integral care for users. This institution, besides working on training network professionals, carried out a large survey project in Brazil, the National Survey on Use of Crack—Pesquisa Nacional sobre o Uso do Crack [10] which brought a new dimension to crack addiction, indicating less use than had been propagated in the media and presenting a user profile according to aspects such as

Implementing the principles and administrative directives that guide SUS, in other words, decentralization, regionalization, hierarchy, and community participation, is a complex task, due to multiple factors such as the country's territorial extension, regional differences, and

Decentralization of actions in health is one of the administrative directives that, in the day-today application of measures, seeks to involve all three levels of government: federal, state, and municipal. According to [11]: The Federal Constitution of 1988 made it so that Brazil became a peculiar case of a Federation with three entities considered primary parties within the pact: Union, states and municipalities—only Belgium and India give local power a similar status. Indeed, one could observe a greater political, administrative, and financial autonomy of municipalities in regard to the

Thus, responsibility fell to the federal government to formulate and follow up on the execution of national health policies, while the states were responsible for more complex services, besides the management, formulation, and coordination of some policies, and the municipalities took responsibility for executing actions and offering direct services. In this manner, the three public spheres participate in the national policy and its execution with distinct responsibilities, either

As from 2006, the construction of the new policy within the national plan brought, on one hand, directives that indicated a need for a new posture in regard to user care; on the other hand, setting the programs in place highlighted that there were still indicatives and financing issues that allowed for a questioning of actions and the resurgence of religious and philanthropic institutions that turned to user care, choosing to trust in confinement and isolation,

The new policy presented prevention, care, and authority as lines of action, taking into consideration an approach centered upon construction of the person as a subject of rights, upon humanization, and upon the establishment of links within the service network, the family, and the community. The introduction of public programs and statutes for professional training took place all over Brazil, with regional reference centers implemented in the states supported by the vast network of public federal universities that worked with professional training for intersectoral services. The reach of this policy was initially extensive. The mental health care network was widened by psychosocial care centers, therapeutic residential units, street clinics, and specialized reference centers, strengthening deinstitutionalization as a movement for the

However, the service network could not cope with user monitoring and care. There were also a growing number of religious therapeutic communities that still had no direct support from the

gender, age, education level, occupation, and patterns of usage.

previous period, followed by a decentralization of resources and attributions.

set out by the legal system or pressured into it by the law.

creation of new mechanisms and therapeutic spaces.

with little social insertion, and that competed for public resources.

political, social, and economic issues

162 Public Health - Emerging and Re-emerging Issues

On an international level, a debate was gaining ground, especially after the creation of the Global Commission on Drug Policy in 2011, made up of former Heads of State and specialists, and which contested the war on drugs as an efficient combat policy, indicating by means of studies and statements a different path to tackle the drug problem. In the Commission's first report, with the title War on Drugs, released in June 2011, the organization proposed 11 recommendations to substitute the criminalization and punishment of drug users for an offer of health services, support, and treatment of users, besides highlighting the need to advance in regulating psychoactive substances. Commissions linked to the UN, such as the Expert Committee in Drug Dependence and the International Narcotics Control Board, were still focusing on the classification of narcotics as forbidden and ignoring research and the cumulative knowledge of the World Health Organization (WHO).

## 3. Tensions between health-care models within the same territory: the Cracolândia case

The arrival of crack in the urban landscape of São Paulo<sup>2</sup> dates back to the 1990s, and the establishment of public sales and usage zones gradually turned the so-called cracklands into symbols of immorality, abandonment, and demonization; this legitimized, as from 2010, the compulsory rounding up of the street population, making social and urban exclusion invisible and becoming a historical process connected to the aggravation of the social inequality that resulted from urban expulsion and economic and social segregation.

In the 1960s, before the central region of São Paulo became infamous for the commerce and use of drugs and crack, prostitution was the main target for police actions in the area. Initially protected by territorial confinement, the neighborhood engaged in an ever-changing game between the tolerated, the permitted, and the repressed [11]. As from the 1950s, however, with the city's growth and urban development, the grouping of licit and illicit activities surrounding this practice would migrate to other nearby territories [12], and this area would become a constant target for police and urban interventions aimed at "re-qualifying" the region, besides

<sup>2</sup> For this contextualization about territory and the "Operação Sufoco" we based ourselves on the text [34].

the "mega operations" that often occurred, gathering different public departments to combat irregularities and illegalities in the neighborhood.

The lack of drugs and the difficulty caused by attachment to them will make people seek treatment. How can you lead users to treatment? Not by reason, but by suffering. Those seeking help are those who cannot stand that situation any longer. Pain and

Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs…

http://dx.doi.org/10.5772/intechopen.76354

165

As soon as the operation began, accusations of police abuse, aggression, and violation of rights began to multiply. In addition, the practice of involuntary or legally mandated hospitalization of users intensified. The right to life started being used as a justification for the suppression of the capacity of users to determine their own lives. Such is the interpretation published by the Brazilian Psychiatry Association (Associação Brasileira de Psiquiatria), defending the need for

Freedom has limits. What has no limits and is unquestionable is the right to life. Even if, to fully exercise this right, the citizen must relinquish freedom for a period of time.7

Within medical knowledge, there is evidence of different prescriptions and ethical positions on

There is no scientific support signaling that dependency treatment should be preferably carried out by means of hospitalization. Paradoxically, hospitalization that has been badly conducted or erroneously recommended tends to generate negative consequences. In the case of compulsory hospitalization, relapse rates reach 95%! In general, the best results are those obtained by means of outpatient treatment [19].

You have to care for those people who are always on the streets (due to abusive use of crack). This [involuntary/compulsory hospitalization] is an act of solidarity and not

It is important to underline that what was being debated was not the possibility of involuntary and compulsory hospitalization, since these approaches are listed in the Psychiatric Reform law [21] as therapeutic tools to be recommended as exceptions, being popular practices in mental health. The controversy was focused on mass involuntary hospitalization as a form of treatment. Thus, Operação Sufoco was already marked by heterogeneous discourses and practices set in motion by governmental actions, with homeless chemical dependents described either as undesirable segments or the subjects of rights [17]. In addition, if these hospitalizations were proving a failure in terms of connection to hospitalization services, the offer of street side care—by both social welfare and health care teams—was also impaired by the operation. The professionals working in the region reported that, with the migration, they lost contact with many users and that these became more reactive and resistant to their efforts, identifying them with the repression carried out by the government.

"Internação compulsória e direito à vida". Correio Braziliense, 06/March/2012. Available at: <www.correiobraziliense.com.

suffering make people reach out for help [18].

hospitalization without patient consent:

private imprisonment [20].

br>. Accessed on: 12/December/2014.

the issue:

7

Following this track, the 2000s brought the Nova Luz project, predicting a radical transformation of the neighborhood, declaring the region as a public-use area3 and attracting investments, by means of fiscal incentives. By proposing the demolition of existing buildings for the reconstruction of the neighborhood [13], the "New Luz" went from social blight to highly valued real estate. Based on the idea of "urban rebirth", this legitimized the expulsion of certain social groups from decadent regions of the city, especially the poor and homeless population, often by violent and repressive means4 —a process that took place in a number of metropolises and is known as gentrification [14]—and with the State and businesses as the main agents, in publicprivate partnerships. However, this process incurs disputes [15], offering resistance to the logic of urban segregation, whether this takes the shape of social movements and neighborhood associations<sup>5</sup> , or whether simply due to the determination of those who frequent the region to remain, despite repressive measures.

Thus, as signaled by different scholars [16, 17], it is a case of considering the so-called crackland less as a specific geographic location within the city and more as an "itinerant territoriality": a dynamic constantly instituted within the relationships established with the city by those who are marginalized and living with illegality, determined by the force applied by repressive mechanisms of the public powers and the resistance strategies of the users.

The year of 2012 began with "Operation Suffocation" ("Operação Sufoco"), "an integrated action involving State and Municipality to rescue people in vulnerable conditions, fight drug traffic and create a suitable environment for social areas", with three phases: "consolidation of the area", predicting actions by the Military Police of the State of São Paulo and the Metropolitan Civil Police to control and occupy the area, promoting arrests of drug dealers, users, and fugitives from the law; "social action", that, at a second moment, would initiate welfare and health care; and "area maintenance"<sup>6</sup> .

The state coordinator of Drug Policies from the State Department of Justice and Defense of Citizenship (Secretaria de Estado da Justiça e Defesa da Cidadania) justified these actions:

<sup>3</sup> The conflicts surrounding Nova Luz and the resistance organized around the actions were vividly reported in the documentary Luz, part of the project Museo de Los Desplazados, of the artistic collective LeftHandRotation. Available at: <http://vimeo.com/32848727>. Accessed on: 19/January/2014.

<sup>4</sup> The dossier published by the Centro Vivo Forum (2007) denounces a number of rights violations that indicate social hygiene as the predominant policy of government actions, especially under mayors José Serra and Gilberto Kassab (2005– 2012). This points to a lack of housing policies in the center of the city and, consequently, the relocation of the poor population to the outskirts, including at times forced removal with collusion of the government and supported by police violence. Regarding the street population, the dossier mentions anti-homeless ramps; the closure of shelters in the center and their relocation to the outskirts; coercive measures with children; recurring expulsion actions with regards to street dwellers and "urban cleansing", the famous "rapa" [35, 36].

<sup>5</sup> One result of the resistance that emerged was suspension of the Nova Luz project, by court order, in January 2012, and reelaboration of the project by mayor Fernando Haddad (PT), in 2013. ("Haddad shelves Kassab's plan for Luz". Folha de São Paulo, 24/January/2013).

<sup>6</sup> Military Police of the State of São Paulo. Operação Integrada Centro Legal. Available at: <http://www.policiamilitar. sp.gov. br/hotsites/centrolegal/index.html>. Accessed on: 15/December/2012.

The lack of drugs and the difficulty caused by attachment to them will make people seek treatment. How can you lead users to treatment? Not by reason, but by suffering. Those seeking help are those who cannot stand that situation any longer. Pain and suffering make people reach out for help [18].

the "mega operations" that often occurred, gathering different public departments to combat

Following this track, the 2000s brought the Nova Luz project, predicting a radical transformation of the neighborhood, declaring the region as a public-use area3 and attracting investments, by means of fiscal incentives. By proposing the demolition of existing buildings for the reconstruction of the neighborhood [13], the "New Luz" went from social blight to highly valued real estate. Based on the idea of "urban rebirth", this legitimized the expulsion of certain social groups from decadent regions of the city, especially the poor and homeless population, often

is known as gentrification [14]—and with the State and businesses as the main agents, in publicprivate partnerships. However, this process incurs disputes [15], offering resistance to the logic of urban segregation, whether this takes the shape of social movements and neighborhood

Thus, as signaled by different scholars [16, 17], it is a case of considering the so-called crackland less as a specific geographic location within the city and more as an "itinerant territoriality": a dynamic constantly instituted within the relationships established with the city by those who are marginalized and living with illegality, determined by the force applied by repressive mechanisms of the public powers and the resistance strategies of the users.

The year of 2012 began with "Operation Suffocation" ("Operação Sufoco"), "an integrated action involving State and Municipality to rescue people in vulnerable conditions, fight drug traffic and create a suitable environment for social areas", with three phases: "consolidation of the area", predicting actions by the Military Police of the State of São Paulo and the Metropolitan Civil Police to control and occupy the area, promoting arrests of drug dealers, users, and fugitives from the law; "social action", that, at a second moment, would initiate welfare and

The state coordinator of Drug Policies from the State Department of Justice and Defense of Citizenship (Secretaria de Estado da Justiça e Defesa da Cidadania) justified these actions:

The conflicts surrounding Nova Luz and the resistance organized around the actions were vividly reported in the documentary Luz, part of the project Museo de Los Desplazados, of the artistic collective LeftHandRotation. Available

The dossier published by the Centro Vivo Forum (2007) denounces a number of rights violations that indicate social hygiene as the predominant policy of government actions, especially under mayors José Serra and Gilberto Kassab (2005– 2012). This points to a lack of housing policies in the center of the city and, consequently, the relocation of the poor population to the outskirts, including at times forced removal with collusion of the government and supported by police violence. Regarding the street population, the dossier mentions anti-homeless ramps; the closure of shelters in the center and their relocation to the outskirts; coercive measures with children; recurring expulsion actions with regards to street

One result of the resistance that emerged was suspension of the Nova Luz project, by court order, in January 2012, and reelaboration of the project by mayor Fernando Haddad (PT), in 2013. ("Haddad shelves Kassab's plan for Luz". Folha de

Military Police of the State of São Paulo. Operação Integrada Centro Legal. Available at: <http://www.policiamilitar. sp.gov.

.

, or whether simply due to the determination of those who frequent the region to

—a process that took place in a number of metropolises and

irregularities and illegalities in the neighborhood.

by violent and repressive means4

164 Public Health - Emerging and Re-emerging Issues

remain, despite repressive measures.

health care; and "area maintenance"<sup>6</sup>

at: <http://vimeo.com/32848727>. Accessed on: 19/January/2014.

dwellers and "urban cleansing", the famous "rapa" [35, 36].

br/hotsites/centrolegal/index.html>. Accessed on: 15/December/2012.

associations<sup>5</sup>

3

4

5

6

São Paulo, 24/January/2013).

As soon as the operation began, accusations of police abuse, aggression, and violation of rights began to multiply. In addition, the practice of involuntary or legally mandated hospitalization of users intensified. The right to life started being used as a justification for the suppression of the capacity of users to determine their own lives. Such is the interpretation published by the Brazilian Psychiatry Association (Associação Brasileira de Psiquiatria), defending the need for hospitalization without patient consent:

Freedom has limits. What has no limits and is unquestionable is the right to life. Even if, to fully exercise this right, the citizen must relinquish freedom for a period of time.7

Within medical knowledge, there is evidence of different prescriptions and ethical positions on the issue:

There is no scientific support signaling that dependency treatment should be preferably carried out by means of hospitalization. Paradoxically, hospitalization that has been badly conducted or erroneously recommended tends to generate negative consequences. In the case of compulsory hospitalization, relapse rates reach 95%! In general, the best results are those obtained by means of outpatient treatment [19].

You have to care for those people who are always on the streets (due to abusive use of crack). This [involuntary/compulsory hospitalization] is an act of solidarity and not private imprisonment [20].

It is important to underline that what was being debated was not the possibility of involuntary and compulsory hospitalization, since these approaches are listed in the Psychiatric Reform law [21] as therapeutic tools to be recommended as exceptions, being popular practices in mental health. The controversy was focused on mass involuntary hospitalization as a form of treatment. Thus, Operação Sufoco was already marked by heterogeneous discourses and practices set in motion by governmental actions, with homeless chemical dependents described either as undesirable segments or the subjects of rights [17]. In addition, if these hospitalizations were proving a failure in terms of connection to hospitalization services, the offer of street side care—by both social welfare and health care teams—was also impaired by the operation. The professionals working in the region reported that, with the migration, they lost contact with many users and that these became more reactive and resistant to their efforts, identifying them with the repression carried out by the government.

<sup>7</sup> "Internação compulsória e direito à vida". Correio Braziliense, 06/March/2012. Available at: <www.correiobraziliense.com. br>. Accessed on: 12/December/2014.

At the end of 2012, when Operação Sufoco was completing a year and showing signs of failure, since it was clear that Cracolândia had survived and the use and sale of drugs in the Luz neighborhood persisted, a new intervention was created, focusing on making more beds available for treatment of this population. The year of 2013 began with a cooperation agreement signed by the State Government, in partnership with the Ministry of Public Prosecution and the Brazilian Bar Association (as well as the Public Defender's Office, which joined the effort despite not being mentioned in the agreement), looking at setting up a legal office at the Reference Center for Tobacco, Alcohol and Other Drugs (Centro de Referência Tabaco, Álcool e Outras Drogas—CRATOD), a health care unit in the Luz region, bringing together doctors, judges, and lawyers in order to "accelerate procedures for the process of compulsory hospitalization (predicted by law), in order to protect the lives of those who need it most"<sup>8</sup> .

This is our expectation for all who are working with us and for many others who depart this

Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs…

http://dx.doi.org/10.5772/intechopen.76354

167

In 2014, the new municipal government (Mayor Fernando Haddad, Partido dos Trabalhadores 2013–2016) "exchanges Sufoco for Open Arms"12. The Open Arms Program (De Braços Abertos —DBA)<sup>13</sup> introduced a "rights package" (housing, food, employment, and health), in the words of the national coordinator of mental health at the time, Roberto Tykanori Kinoshita. This placed focus not upon the drugs, but upon the subjectivities, the new groupalities, and the broadening of contractualities<sup>14</sup> of users [23], bringing tension to the actions already

The DBA, a name chosen by users and workers in assembly, was based on low-threshold treatment services15 and inspired by successful international experiences in treating those in high vulnerability situations who make use of alcohol and other drugs, such as Housing First, in New York and Vancouver16. The program aims for the social rehabilitation of beneficiaries by means of job offers—sweeping, gardening, building maintenance, cosmetics and beauty, painting and sculpture, furniture restoration—with an income of R\$ 15 for 4 hours per day of labor, paid weekly, as well as housing in hotels in the area and meal tickets for the Restaurante Popular program. Health treatment is encouraged, although not a condition for inclusion in the program, but on average 60% seek some form of health treatment. Over 450 people signed up and received benefits. In fact, the complexity of care would be confirmed later by research carried out by the Oswaldo Cruz Foundation [6]: "The profile of crack users at scenes of usage is composed by 80% men, in the group of 20–30 years of age; 8 in 10 are black; 8 in 10 did not reach high school;

As pointed out by [23], "the money received weekly for labor creates a new duration, forcing a distinct temporality from the immediacy of crack", and is used for personal hygiene products and

11Link: http://programarecomeco.sp.gov.br/noticias/selo-recomeco-vai-recolocar-dependentes-quimicos-no-mercado-de-

<sup>12</sup>"'Cracolândia' troca Sufoco por Braços Abertos", Carta Capital, 16/January/2015.http://www.cartacapital.com.br/ sociedade/cracolandia-troca-sufoco-por-bracos-abertos-mas-ha-duvidas-sobre-novo-programa-6234.html. Accessed on

13The De Braços Abertos program began in January 2014, with actions coordinated by the municipal departments of Health (SMS), Social Assistance and Development (SMADS), Development, Labor and Entrepreneurship (SDTE), Urban Safety (SMSU) And Human Rights and Citizenship (SMDHC). ("Programa 'De Braços Abertos' completa um ano com diminuição do fluxo de usuários e da criminalidade na região", site of the Prefeitura de São Paulo, 16/January/2015). <sup>14</sup>"Contractuality—The Contract with the Operation Work Program (Programa Operação Trabalho—POT) contributes to a rupture with the logic that is characteristic of drug use and addiction, lengthening the time between one moment of usage and the next. Work creates a new temporality in the life of program beneficiaries, who start to have new sources of satisfaction in

<sup>15</sup>"Low-Threshold: the principle of not imposing abstinence as a condition for remaining in care, or for accessing the

<sup>16</sup>"Housing First: intervention method already tested and evaluated in several countries of the world; proposes the offer of housing for people living on the streets and users who make intense use of alcohol and other drugs. Some international evaluations point to a reduction in consumption of alcohol and other drugs, of violence and, above all, of the supposed

offered benefits." The expression literally means a low bar in terms of entry and triggers [27].

perception of urban disorder due to an excess of conflict on the streets [27].

implemented and that were based on police and legal "compulsion".

40% live on the streets; 49% came from the prison system."

their daily lives, besides perspectives for the future." [38].

difficult path".

trabalho/

21/August/2015.

11

Reigniting conflicting interfaces with mental health, the Judiciary, by inaugurating a sort of "special court", added tension to the divergences on the compulsory nature of these hospitalizations occurring with the justice system itself, bolstered by an alignment of the networks regarding the cases. By operating as an administrator for hospital beds, this sets up hospitalization as a primary response that is often fundamentally repressive-punitive in character. In this manner, the scene is set for complex relationships between distinct ethical-political concepts relating to the street population, where hospitalization is lauded as the answer to social misery and to the threat posed by certain segments, contrasting with the viewpoint that defends life and rights. The acts of social expulsion and taking people off the streets are backed by the use of logics by health care services that back repression and incarceration, such as penal-sanitary logics [22], even if these are in constant tension with practices that seek to establish care within the territory and in networks of protection.

Two cases in Brazil's largest city highlight these tensions in care models. The years of 2013 and 2014 would bring new modulations. The Fresh Start Program (Programa Recomeço)9 , launched by the São Paulo state government in 2013, leant on the integrated work of the Judiciary and Executive powers in order to facilitate medical treatment and hospitalization. Operating with the legal office created at the CRATOD, the program aimed at paying R\$ 1350 per user hospitalized at associated entities, most of which were therapeutic communities, with a total monthly investment of R\$ 4 million in what became known as the "bolsa-crack" (crack stipend)10. The program adopted the punitive perspective of a "world free from drugs" and a metaphysical-religious view of its subjects, as can be seen in a fragment of the "message" from the communications office of the State Department of Justice and Defense of Citizenship of São Paulo to its beneficiaries, available on the Programa Recomeço site: "May God preserve you in his image and likeness.

<sup>8</sup> "Entenda o que é internação compulsória de dependentes químicos". Portal do Governo do Estado de São Paulo [online]. 29/ January/2013. Available at: <http://www.saopaulo.sp.gov.br/spnoticias/lenoticia.php?id=225,660>. Accessed on: 29/April/ 2013.

<sup>9</sup> Joint action by the Department of Health, Department of Social Development, and Department of Justice and Defense of Citizenship.

<sup>10</sup>"Cartão para tratamento de usuário de crack custará R\$ 4 milhões mensais". Tatiana Santiago. Portal G1, 09/May/2013. Available at: <http://g1.globo.com/sao-paulo/noticia/2013/05/cartao-para-tratamento-de-usuario-de-crack-custara-r-4-milhoesmensais.html>. Accessed on: 12/December/2014.

This is our expectation for all who are working with us and for many others who depart this difficult path". 11

At the end of 2012, when Operação Sufoco was completing a year and showing signs of failure, since it was clear that Cracolândia had survived and the use and sale of drugs in the Luz neighborhood persisted, a new intervention was created, focusing on making more beds available for treatment of this population. The year of 2013 began with a cooperation agreement signed by the State Government, in partnership with the Ministry of Public Prosecution and the Brazilian Bar Association (as well as the Public Defender's Office, which joined the effort despite not being mentioned in the agreement), looking at setting up a legal office at the Reference Center for Tobacco, Alcohol and Other Drugs (Centro de Referência Tabaco, Álcool e Outras Drogas—CRATOD), a health care unit in the Luz region, bringing together doctors, judges, and lawyers in order to "accelerate procedures for the process of compulsory hospital-

ization (predicted by law), in order to protect the lives of those who need it most"<sup>8</sup>

establish care within the territory and in networks of protection.

8

2013. 9

Citizenship. 10

mensais.html>. Accessed on: 12/December/2014.

166 Public Health - Emerging and Re-emerging Issues

Reigniting conflicting interfaces with mental health, the Judiciary, by inaugurating a sort of "special court", added tension to the divergences on the compulsory nature of these hospitalizations occurring with the justice system itself, bolstered by an alignment of the networks regarding the cases. By operating as an administrator for hospital beds, this sets up hospitalization as a primary response that is often fundamentally repressive-punitive in character. In this manner, the scene is set for complex relationships between distinct ethical-political concepts relating to the street population, where hospitalization is lauded as the answer to social misery and to the threat posed by certain segments, contrasting with the viewpoint that defends life and rights. The acts of social expulsion and taking people off the streets are backed by the use of logics by health care services that back repression and incarceration, such as penal-sanitary logics [22], even if these are in constant tension with practices that seek to

Two cases in Brazil's largest city highlight these tensions in care models. The years of 2013 and

by the São Paulo state government in 2013, leant on the integrated work of the Judiciary and Executive powers in order to facilitate medical treatment and hospitalization. Operating with the legal office created at the CRATOD, the program aimed at paying R\$ 1350 per user hospitalized at associated entities, most of which were therapeutic communities, with a total monthly investment of R\$ 4 million in what became known as the "bolsa-crack" (crack stipend)10. The program adopted the punitive perspective of a "world free from drugs" and a metaphysical-religious view of its subjects, as can be seen in a fragment of the "message" from the communications office of the State Department of Justice and Defense of Citizenship of São Paulo to its beneficiaries, available on the Programa Recomeço site: "May God preserve you in his image and likeness.

"Entenda o que é internação compulsória de dependentes químicos". Portal do Governo do Estado de São Paulo [online]. 29/ January/2013. Available at: <http://www.saopaulo.sp.gov.br/spnoticias/lenoticia.php?id=225,660>. Accessed on: 29/April/

Joint action by the Department of Health, Department of Social Development, and Department of Justice and Defense of

"Cartão para tratamento de usuário de crack custará R\$ 4 milhões mensais". Tatiana Santiago. Portal G1, 09/May/2013. Available at: <http://g1.globo.com/sao-paulo/noticia/2013/05/cartao-para-tratamento-de-usuario-de-crack-custara-r-4-milhoes-

2014 would bring new modulations. The Fresh Start Program (Programa Recomeço)9

.

, launched

In 2014, the new municipal government (Mayor Fernando Haddad, Partido dos Trabalhadores 2013–2016) "exchanges Sufoco for Open Arms"12. The Open Arms Program (De Braços Abertos —DBA)<sup>13</sup> introduced a "rights package" (housing, food, employment, and health), in the words of the national coordinator of mental health at the time, Roberto Tykanori Kinoshita. This placed focus not upon the drugs, but upon the subjectivities, the new groupalities, and the broadening of contractualities<sup>14</sup> of users [23], bringing tension to the actions already implemented and that were based on police and legal "compulsion".

The DBA, a name chosen by users and workers in assembly, was based on low-threshold treatment services15 and inspired by successful international experiences in treating those in high vulnerability situations who make use of alcohol and other drugs, such as Housing First, in New York and Vancouver16. The program aims for the social rehabilitation of beneficiaries by means of job offers—sweeping, gardening, building maintenance, cosmetics and beauty, painting and sculpture, furniture restoration—with an income of R\$ 15 for 4 hours per day of labor, paid weekly, as well as housing in hotels in the area and meal tickets for the Restaurante Popular program. Health treatment is encouraged, although not a condition for inclusion in the program, but on average 60% seek some form of health treatment. Over 450 people signed up and received benefits.

In fact, the complexity of care would be confirmed later by research carried out by the Oswaldo Cruz Foundation [6]: "The profile of crack users at scenes of usage is composed by 80% men, in the group of 20–30 years of age; 8 in 10 are black; 8 in 10 did not reach high school; 40% live on the streets; 49% came from the prison system."

As pointed out by [23], "the money received weekly for labor creates a new duration, forcing a distinct temporality from the immediacy of crack", and is used for personal hygiene products and

<sup>11</sup>Link: http://programarecomeco.sp.gov.br/noticias/selo-recomeco-vai-recolocar-dependentes-quimicos-no-mercado-detrabalho/

<sup>12</sup>"'Cracolândia' troca Sufoco por Braços Abertos", Carta Capital, 16/January/2015.http://www.cartacapital.com.br/ sociedade/cracolandia-troca-sufoco-por-bracos-abertos-mas-ha-duvidas-sobre-novo-programa-6234.html. Accessed on 21/August/2015.

<sup>13</sup>The De Braços Abertos program began in January 2014, with actions coordinated by the municipal departments of Health (SMS), Social Assistance and Development (SMADS), Development, Labor and Entrepreneurship (SDTE), Urban Safety (SMSU) And Human Rights and Citizenship (SMDHC). ("Programa 'De Braços Abertos' completa um ano com diminuição do fluxo de usuários e da criminalidade na região", site of the Prefeitura de São Paulo, 16/January/2015).

<sup>14</sup>"Contractuality—The Contract with the Operation Work Program (Programa Operação Trabalho—POT) contributes to a rupture with the logic that is characteristic of drug use and addiction, lengthening the time between one moment of usage and the next. Work creates a new temporality in the life of program beneficiaries, who start to have new sources of satisfaction in their daily lives, besides perspectives for the future." [38].

<sup>15</sup>"Low-Threshold: the principle of not imposing abstinence as a condition for remaining in care, or for accessing the offered benefits." The expression literally means a low bar in terms of entry and triggers [27].

<sup>16</sup>"Housing First: intervention method already tested and evaluated in several countries of the world; proposes the offer of housing for people living on the streets and users who make intense use of alcohol and other drugs. Some international evaluations point to a reduction in consumption of alcohol and other drugs, of violence and, above all, of the supposed perception of urban disorder due to an excess of conflict on the streets [27].

clothing, injecting local businesses with over R\$ 30 mil each week. From the perspective of harm reduction, the DBA encourages self-care and the guarantee of rights, within a mindset that is not only individual but also collective, and taking into account the singularity of choices and possibilities.

means of traffic management. The State defines and limits where people can or cannot remain according to situational scenarios and interests. These are triage points, from which, according to certain criteria, it is decided who enters and leaves: who may remain, who must be sent on, and to where, following a logic for distribution of people within urban space [16, 26, 27].

Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs…

http://dx.doi.org/10.5772/intechopen.76354

169

The logics of the programs, however, "are far from agreeing on fixed identities that capture individuals. In the liminarity between care and control, paths of escape emerge upon which the subjects glide (…)" [28]. Evaluative research on the DBA, qualitative-quantitative in nature, and conducted throughout the first semester of 2015, from the perspective of its beneficiaries, brings forth evidence that the program is "for the most part well evaluated by its participants and that, in fact, the public effort in offering employment, food, and housing has resulted in an improvement of objective and subjective conditions in these people's lives and in the general diminishing of the problematic consumption of crack" [29] although "the truculence of the actions coordinated by the Municipal Department of Urban Safety, which is an integral part of the DBA, is a permanent threat to the beneficiaries and to the public

Despite the beneficiaries' desire for continuity of the program, and although research indicated important effects from the program, the waves of resentment, destruction, and production of despair that swept the country after the presidential impeachment in 2016 also brought a promise from the new mayor, João Dória19, of ending the DBA and adopting in the municipality a program aligned with the already-existing Recomeço, named Redemption

By the end of the first year of the new administration, the manager of the Redenção program stated that they were not about to deny the advances and good ideas brought by the DBA, but let it slip, as pointed out by [25], that different mechanisms of power combine to create "governable spaces"—which also means spaces that are protected against the "undesirable behaviors" associated to these ineffable figures of all who are seen as risk carriers and threats to a certain regime of order and safety: in different manners according to circumstances, between use of coercion (and violence) and the policing of conducts, between punishment

This brief incursion into urban policies adopted under the urgency of "crack combat" indicates that policies aimed at the street population that were ushered in after 2010 exacerbated existing tensions between care and protection in policies for health care, welfare, and public safety. If,

19João Dória, affiliated to the PSDB, was elected with 3,085,187 votes, corresponding to 53.29% of valid votes. Doria is the first mayor of São Paulo elected in the first round of voting since 1992, when elections began to have two rounds. He had

as his main campaign marketing strategy his self-attribution as an administrator and not a politician.

visibility of the program".

and "protection", between incarceration and "care".

(Redenção).

4. Conclusions

Recomeço and De Braços Abertos have opposing perspectives regarding models of health and assistance, the concept of subject, and the concepts of rights and public space. The two programs are rivals in competing for the "users" of the Luz region, not only in an ideological sense but also in terms of the physical space where their hospitality "tents" are set up, one facing the other, close to the region's flow of drug use and traffic17.

As pointed out by [24], based on ethnographic studies from the Cracolândia region, a close look at these disputes in terms of treatment and intervention models (involving both the internal quarrels of the public and private entities that offer care for drug users, and the external forces that question the efficiency of their actions) allows us to perceive the complexity of this region, and signalizes that "the State, seen from its tip, or from its margins, is something much more complicated".

Indeed, if this antagonism aligns radically different destinies and lifestyles, especially for users, it must also be viewed in terms of urban space management. After all, even when recognizing the use of drugs as socially determined and integral to the concept of harm reduction, the national drug policy already demonstrated among its political and legal landmarks the "contradictory and veiled coexistence between two antagonistic perspectives" [24].

As put by [25]: "In each of these programs (and in the region of Cracolândia), there is a matter of the coordination of power mechanisms, guided by distinct logics, but which compose themselves and condition to a large degree the manners of circulation of these populations. These programs fix individuals and social groups to their places of implementation—the programs presume a territoriality, a fixing in place, of the populations classified as their targetaudience and, at the same time, end up acting as gravitational poles for others arriving from other places. From one moment to another, they might find themselves obliged to set themselves in motion once again, in search of other hospitality points, due to the effects of repressive actions that operate from a logic of dispersion (liberation, "cleansing" of these spaces), often in the aftermath of the dismantling or deactivation of these programs by the acting governors".

These logics of dispersion and concentration<sup>18</sup> operate in a concerted manner, allowing comprehension of these places within a government rationality of urban populations and spaces, by

<sup>17</sup>Name given by users to define the area of use in the Luz region.

<sup>18</sup>There was a moment of inflection in the forms of state management of the Cracolândia space after Operation Sufoco: from a dispersion rationality, that aimed to prevent gatherings of crack users by means of force (mainly by policing and the resulting "crack processions"), to a government logic based on territorial establishment, on concentrated space, and the multiplication of programs and services offering social assistance, health, and care. In this manner, a field of gravitation around Cracolândia is formed; especially in regard to the extremely poor population with precarious access to housing and employment, and that these subjects that install themselves in the area are made to move on as soon as the local establishments close, going to new locations where they find a possibility of settling [16, 27, 37, 38].

means of traffic management. The State defines and limits where people can or cannot remain according to situational scenarios and interests. These are triage points, from which, according to certain criteria, it is decided who enters and leaves: who may remain, who must be sent on, and to where, following a logic for distribution of people within urban space [16, 26, 27].

The logics of the programs, however, "are far from agreeing on fixed identities that capture individuals. In the liminarity between care and control, paths of escape emerge upon which the subjects glide (…)" [28]. Evaluative research on the DBA, qualitative-quantitative in nature, and conducted throughout the first semester of 2015, from the perspective of its beneficiaries, brings forth evidence that the program is "for the most part well evaluated by its participants and that, in fact, the public effort in offering employment, food, and housing has resulted in an improvement of objective and subjective conditions in these people's lives and in the general diminishing of the problematic consumption of crack" [29] although "the truculence of the actions coordinated by the Municipal Department of Urban Safety, which is an integral part of the DBA, is a permanent threat to the beneficiaries and to the public visibility of the program".

Despite the beneficiaries' desire for continuity of the program, and although research indicated important effects from the program, the waves of resentment, destruction, and production of despair that swept the country after the presidential impeachment in 2016 also brought a promise from the new mayor, João Dória19, of ending the DBA and adopting in the municipality a program aligned with the already-existing Recomeço, named Redemption (Redenção).

By the end of the first year of the new administration, the manager of the Redenção program stated that they were not about to deny the advances and good ideas brought by the DBA, but let it slip, as pointed out by [25], that different mechanisms of power combine to create "governable spaces"—which also means spaces that are protected against the "undesirable behaviors" associated to these ineffable figures of all who are seen as risk carriers and threats to a certain regime of order and safety: in different manners according to circumstances, between use of coercion (and violence) and the policing of conducts, between punishment and "protection", between incarceration and "care".

## 4. Conclusions

clothing, injecting local businesses with over R\$ 30 mil each week. From the perspective of harm reduction, the DBA encourages self-care and the guarantee of rights, within a mindset that is not only individual but also collective, and taking into account the singularity of choices and possibili-

Recomeço and De Braços Abertos have opposing perspectives regarding models of health and assistance, the concept of subject, and the concepts of rights and public space. The two programs are rivals in competing for the "users" of the Luz region, not only in an ideological sense but also in terms of the physical space where their hospitality "tents" are set up, one facing the

As pointed out by [24], based on ethnographic studies from the Cracolândia region, a close look at these disputes in terms of treatment and intervention models (involving both the internal quarrels of the public and private entities that offer care for drug users, and the external forces that question the efficiency of their actions) allows us to perceive the complexity of this region, and signalizes that "the State, seen from its tip, or from its margins, is something

Indeed, if this antagonism aligns radically different destinies and lifestyles, especially for users, it must also be viewed in terms of urban space management. After all, even when recognizing the use of drugs as socially determined and integral to the concept of harm reduction, the national drug policy already demonstrated among its political and legal landmarks the "con-

As put by [25]: "In each of these programs (and in the region of Cracolândia), there is a matter of the coordination of power mechanisms, guided by distinct logics, but which compose themselves and condition to a large degree the manners of circulation of these populations. These programs fix individuals and social groups to their places of implementation—the programs presume a territoriality, a fixing in place, of the populations classified as their targetaudience and, at the same time, end up acting as gravitational poles for others arriving from other places. From one moment to another, they might find themselves obliged to set themselves in motion once again, in search of other hospitality points, due to the effects of repressive actions that operate from a logic of dispersion (liberation, "cleansing" of these spaces), often in the aftermath of the dismantling or deactivation of these programs by the acting governors". These logics of dispersion and concentration<sup>18</sup> operate in a concerted manner, allowing comprehension of these places within a government rationality of urban populations and spaces, by

There was a moment of inflection in the forms of state management of the Cracolândia space after Operation Sufoco: from a dispersion rationality, that aimed to prevent gatherings of crack users by means of force (mainly by policing and the resulting "crack processions"), to a government logic based on territorial establishment, on concentrated space, and the multiplication of programs and services offering social assistance, health, and care. In this manner, a field of gravitation around Cracolândia is formed; especially in regard to the extremely poor population with precarious access to housing and employment, and that these subjects that install themselves in the area are made to move on as soon as the

local establishments close, going to new locations where they find a possibility of settling [16, 27, 37, 38].

tradictory and veiled coexistence between two antagonistic perspectives" [24].

other, close to the region's flow of drug use and traffic17.

Name given by users to define the area of use in the Luz region.

ties.

17

18

much more complicated".

168 Public Health - Emerging and Re-emerging Issues

This brief incursion into urban policies adopted under the urgency of "crack combat" indicates that policies aimed at the street population that were ushered in after 2010 exacerbated existing tensions between care and protection in policies for health care, welfare, and public safety. If,

<sup>19</sup>João Dória, affiliated to the PSDB, was elected with 3,085,187 votes, corresponding to 53.29% of valid votes. Doria is the first mayor of São Paulo elected in the first round of voting since 1992, when elections began to have two rounds. He had as his main campaign marketing strategy his self-attribution as an administrator and not a politician.

on one hand, they strengthen care practices relating to the use of alcohol and other drugs, consolidating the "chemical dependent" in public policies and the allocation of specific funding, on the other hand, they do not always allow visibility of the complexity that gives rise to these processes, resulting from the combination of a diversity of demands and needs, and belonging to several spheres of interpretation and intervention for which there is no single or definite institutional solution.

References

gov.br/

[Cited March 5, 2018]

ICICT/FIOCRUZ; 2014

March 5, 2018]

providências. Brasilia; 1976

[Cited March 5, 2018]

[1] IBGE|Portal do IBGE [Internet]. [Cited March 5, 2018]. Available from: https://www.ibge.

Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs…

http://dx.doi.org/10.5772/intechopen.76354

171

[2] Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: History, advances, and challenges. Lancet (London, England). 2011;377(9779):1778-1797. Available

[3] Spink M-J, Brigagão JM, Menegon VM, Vicentin M-CG. Health psychology in Brazil the challenges for working in public health settings. Journal of Health Psychology. 2016;21(3): 273-280. Available from: http://journals.sagepub.com/doi/pdf/10.1177/1359105316628759

[4] Brasil. A Política do Ministério da Saúde para atenção integral a usuários de álcool e outras drogas. Brasília: Ministério da Saúde; 2003 Available from: http://bvsms.saude.

[5] Brasil. Conselho Nacional Antidrogas. Resolução n./GSIPR/CH/CONAD, de 27 de outubro de 2005. Brasilia: Política Nacional Sobre Drogas; 2005. Available from: http://www.obid.

[6] Bastos FB, Bertoini L. Pesquisa Nacional sobre o uso de crack: Quem são os usuários de crack e/ou similares do Brasil? Quantos são nas capitais brasileiras? Rio de Janeiro: Editora

[7] Abrucio FL, Franzese C. Federalismo e Políticas Públicas: O impacto das relações intergovernamentais no Brasil. In: ARAÚJO, Maria; BEIRA, Lígia (Org.). Tópicos da Economia

[9] de Souza FF. A Batalha pelo Centro de São Paulo: Santa Ifigênia, Concessão Urbanística e Projeto Nova Luz by Felipe Francisco De Souza – Issuu. Sao Paulo: Paulo's Editora; 2011. p. 224. Available from: https://issuu.com/landreadjustment/docs/batalha\_centro\_sp [Cited

[10] Brasil. Dispõe sobre medidas de prevenção e repressão ao tráfico ilícito e uso indevido de substâncias entorpecentes ou que determinem dependência física ou psíquica, e dá outras

[11] Smith N. A gentrificação generalizada: De uma anomalia local à "regeneração" urbana como estratégia urbana global. In: De volta à cidade: Dos preocessos de gentrificação ás políticas de. Catherine Bidou-Zachariasen – Google Livros. Available from: https://books.google.com. br/books?hl=pt-BR&lr=&id=3H5bhgirfvcC&oi=fnd&pg=PA59&ots=aAyru3i1OD&sig=q9dK GZT9NNX-7HmEgEe0QH0AQpk&redir\_esc=y#v=onepage&q&f=false [Cited March 5, 2018]

[12] Frúgoli HF Jr, Spaggiari E. Da cracolândia aos nóias: Percursos etnográficos no bairro da Luz. Ponto Urbe. 2014;6. Available from: http://journals.openedition.org/pontourbe/1870

senad.gov.br/portais/OBID/biblioteca/documentos/Legislacao/326979.pdf

Paulista para Gestores Públicos. São Paulo: Fundap; 2007;1:13-31

[8] Joanides H. Boca do Lixo. Rio de Janeiro: Laborexto; 2003. p. 120

from: http://www.ncbi.nlm.nih.gov/pubmed/21561655 [Cited March 5, 2018]

gov.br/bvs/publicacoes/politica\_atencao\_alcool\_drogas.pdf

Even though sanitation and roundup operations are not new within urban policies, the drug issue is placed in the field of health as central to management of the street population, reestablishing the duty of medical policing. Painted as a continuum of the "politics of pain and suffering", psychiatric hospitalizations as a primary response reinstall the mandates of protection of the social order and neutralization of the threat attributed to certain individuals. The idea of drug-related danger and the lack of capacity of users to overcome this become a motto to be disseminated in society. The epidemic was in the numbers presented and the discourse that supported them. Within this policy, medicalization as a strategy and process gains force among several social segments [30].

Heterogeneous, the health field tended toward, on one hand, the creation and investment in hospital beds for confinement, and on the other hand, itinerant care mechanisms (such as Community Health Agents, Harm Reducers, and Street Clinics), which widened the focus to include care strategies based on harm reduction and defending life [31]. Thus, the "itinerant" professionals reaffirmed the idea of health as a defense of dignity and social rights, counter to the assimilation of social control roles, such as "medical police" [23]. This tension still marks the policies created in Brazil in the last decades. If the homogeneity of the first decades of policies centered on abstinence and repression was a characteristic of the time, the novelty of the new policy brought a diversification of treatment models and mechanisms. These models persisted not as a planned offer based on the demands raised with users, but based on disputes such as market competition for sellable goods, professional employability, and the interests of the pharmaceutical industry.

Indeed, abandonment and vulnerability become dangerous when complexity stops being taken into account, working instead with single or fragmented institutional responses [32]. By pathologizing complex social demands, and defining them as risky, untreatable, and unrecoverable, we see a heightening of expulsion processes in the social field [33].

## Author details

Maria Cristina Gonçalves Vicentin<sup>1</sup> , Jacqueline Isaac Machado Brigagão2 \* and Pedro Paulo Freire Piani3

\*Address all correspondence to: jac@usp.br


## References

on one hand, they strengthen care practices relating to the use of alcohol and other drugs, consolidating the "chemical dependent" in public policies and the allocation of specific funding, on the other hand, they do not always allow visibility of the complexity that gives rise to these processes, resulting from the combination of a diversity of demands and needs, and belonging to several spheres of interpretation and intervention for which there is no single

Even though sanitation and roundup operations are not new within urban policies, the drug issue is placed in the field of health as central to management of the street population, reestablishing the duty of medical policing. Painted as a continuum of the "politics of pain and suffering", psychiatric hospitalizations as a primary response reinstall the mandates of protection of the social order and neutralization of the threat attributed to certain individuals. The idea of drug-related danger and the lack of capacity of users to overcome this become a motto to be disseminated in society. The epidemic was in the numbers presented and the discourse that supported them. Within this policy, medicalization as a strategy and process gains force

Heterogeneous, the health field tended toward, on one hand, the creation and investment in hospital beds for confinement, and on the other hand, itinerant care mechanisms (such as Community Health Agents, Harm Reducers, and Street Clinics), which widened the focus to include care strategies based on harm reduction and defending life [31]. Thus, the "itinerant" professionals reaffirmed the idea of health as a defense of dignity and social rights, counter to the assimilation of social control roles, such as "medical police" [23]. This tension still marks the policies created in Brazil in the last decades. If the homogeneity of the first decades of policies centered on abstinence and repression was a characteristic of the time, the novelty of the new policy brought a diversification of treatment models and mechanisms. These models persisted not as a planned offer based on the demands raised with users, but based on disputes such as market competition for sellable goods, professional employability, and the interests of

Indeed, abandonment and vulnerability become dangerous when complexity stops being taken into account, working instead with single or fragmented institutional responses [32]. By pathologizing complex social demands, and defining them as risky, untreatable, and unrecoverable, we

, Jacqueline Isaac Machado Brigagão2

\* and

see a heightening of expulsion processes in the social field [33].

1 Department of Social Psychology, Pontifical University of São Paulo, Brazil

or definite institutional solution.

170 Public Health - Emerging and Re-emerging Issues

among several social segments [30].

the pharmaceutical industry.

Maria Cristina Gonçalves Vicentin<sup>1</sup>

2 University of São Paulo, Brazil

\*Address all correspondence to: jac@usp.br

3 Federal University of Pará, Amazonia, Brazil

Author details

Pedro Paulo Freire Piani3


[13] Rui T. Depois da "Operação Sufoco": Sobre espetáculo policial, cobertura midiática. Review of Contemporary. 2013;3(2):287-311

[27] Rui T, Fiore M, Tófoli L. Pesquisa preliminar de avaliação do Programa 'De Braços Abertos. Plataforma Brasileira de Política de Drogas (PBPD)/Instituto Brasileiro de Ciências Criminais (IBCCRIM). Sao Paulo; 2016. Available from: http://pbpd.org.br/wp-content/uploads/2016/

Dilemmas and Impasses in Public Health Policies Directed at People Who Make Use of Alcohol and Other Drugs…

http://dx.doi.org/10.5772/intechopen.76354

173

[28] Piani PPF. Medicalização como Prática Social em Rede. In: Moreira ACG, Brigagão JIM, Piani PPF, editors. Direitos Humanos, Saúde Mental e Drogas. Editora Pakatatu: Belem;

[29] Lancetti A. Cuidado e território no trabalho afetivo. In: Cadernos de Subjetividade. Sao

[30] Pitch T. Responsabilidades limitadas: Actores, conflictos y justicia penal. Buenos Aires:

[31] Rosa M, Vicentin MC. Os intratáveis: O exílio do adolescente do laço social pelas noções de periculosidade e irrecuperabilidade. In: Psicologia Política. 2010. pp. 107-124

[32] Lourau RR. Análise Institucional e práticas de pesquisa. Rev Eletrônica Mnemosine. 1993;

[33] Joia J, Vicentin MCG. Políticas da dor e do sofrimento: Recolhimentos e internações compulsórias no Centro de São Paulo. In: Lemos F, Galindo D, Bicalho P, Ferreira E, Cruz B, Nogueira T, et al., editors. Práticas de Judicialização e Medicalização dos corpos no

[34] Fortes FA de P. A repressão e a proibição ao comércio de "drogas ilícitas": Uma análise a partir do inc. XLIII do art. 5 da Constituição Federal. 2010. [Master dissertation]. Fortaleza: Programa de Pós-Graduação em Direito Stricto Sensu da Universidade Federal do Ceará. Fortaleza. Available from: http://www.dominiopublico.gov.br/download/teste/arqs/cp1

[35] Fórum Centro Vivo. Violações dos Direitos Humanos no Centro de São Paulo: Propostas e Reivindicações para Políticas Públicas. 2006;360. Available from: http://polis.org.br/publi cacoes/violacoes-dos-direitos-humanos-no-centro-de-sao-paulo-propostas-e-reivindicaco

[36] Teixeira A. Economias criminais urbanas e gestão dos ilegalismos na cidade de São Paulo. Available from: http://anpocs.com/index.php/encontros/papers/36-encontro-anual-da-anpo cs/gt-2/gt38-2/8295-economias-criminais-urbanas-e-gestao-dos-ilegalismos-na-cidade-de-

[37] Rolnik R. Territorios em Disputa. UMA Investig NO Cent SÃO PAULO. 2008:26–41. Available from: https://raquelrolnik.files.wordpress.com/2010/02/cidade\_luz.pdf [Cited March 5,

[38] Pedroso LM, Comis MAC, Thomaz RS. A Relação entre os homens e as drogas – Uma história de proibicionismo e redução de danos. In: Mendonça SD, editor. Direitos Humanos

12/Pesquisa-De-Braços-Abertos-1-2.pdf [Cited March 5, 2018]

Paulo: Editora da PUC-SP; 2010. pp. 90-97

contemporâneo. Curiiba: CRV; 2016. pp. 97-121

es-para-politicas-publicas/ [Cited March 5, 2018]

39387.pdf [Cited March 5, 2018]

sao-paulo [Cited March 5, 2018]

no Brasil 2015. Sao Paulo; 2015. p. 2010

2018]

2017;1:30-40

Ad-Hoc; 2003

3(2):7-114


[27] Rui T, Fiore M, Tófoli L. Pesquisa preliminar de avaliação do Programa 'De Braços Abertos. Plataforma Brasileira de Política de Drogas (PBPD)/Instituto Brasileiro de Ciências Criminais (IBCCRIM). Sao Paulo; 2016. Available from: http://pbpd.org.br/wp-content/uploads/2016/ 12/Pesquisa-De-Braços-Abertos-1-2.pdf [Cited March 5, 2018]

[13] Rui T. Depois da "Operação Sufoco": Sobre espetáculo policial, cobertura midiática.

[14] Ferraz A, Manso BP. Governo quer acabar com cracolândia pela estratégia de "dor e sofrimento" – São Paulo – Estadão. Estadao de Sao Paulo. 2012. Available from: http://saopaulo.estadao.com.br/noticias/geral,governo-quer-acabar-com-cracolandia-pela-estrategia-

[15] Silveira X. Dependência não se resolve por decreto. Folha de S Paulo. 2011. Available

[16] Kawaguti L. Internação à força de viciados divide especialistas – BBC Brasil – Notícias. BBC BRASIL. 2012. Available from: http://www.bbc.com/portuguese/noticias/2013/01/

[17] Brazil. Lei n. 10.216, de 06/04/2001: Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental. Brasilia; 2001 p. Diario Oficial da Uniao. Available from: http://hpm.org.br/wp-content/

[18] Assis DA. Risco social e saúde mental como argumento para o encarceramento de crianças

[19] Lancetti A. Enfim, um lance de craque na cracolândia paulistana!. Revista Brasileiros. 2014. Available from: https://www.caminhosdocuidado.org/artigo-de-antonio-lancetti-consultor-

[20] Rui T. Vigiar e cuidar: Notas sobre a atuação estatal na "cracolândia". Revista Brasileira de

[21] Brites CM. Política de Drogas no Brasil: Usos e abusos. In: Bokany V, editor. Drogas no

[22] Vera da Silva Telles. Em torno da Cracolândia Paulista: Apresentação. Ponto Urbe. 2017:(21). Available from: http://journals.openedition.org/pontourbe/3602 [Cited March 5, 2018]

[23] Rui T. Depois da "Operação Sufoco": Sobre espetáculo policial, cobertura midiática e direitos na "cracolândia" paulistana. Contemp Rev Sociol da UFSCar. 2011:287-311. Available from: http://www.contemporanea.ufscar.br/index.php/contemporanea/article/view/

[24] Nasser MMS. Entre a ameaça e a proteção: Categorias, práticas e efeitos de uma política de inclusão na Cracolândia de São Paulo. Revista Horizontes Antropológicos. 2018

[25] Machado LV, Boarini ML. Políticas sobre drogas no Brasil: A estratégia de redução de danos. Psicol Ciência e Profissão. 2013;33(3):580-595. Available from: http://www.scielo.br/scielo.php? script=sci\_arttext&pid=S1414-98932013000300006&lng=pt&tlng=pt [Cited March 3, 2018]

[26] Fromm D. Percursos e refúgios urbanos. Ponto Urbe. 2017;(21). Available from: http://

journals.openedition.org/pontourbe/3604 [Cited March 5, 2018]

Brasil: Entre a Saúde e a Justiça. Sao Paulo: Editora Perseu Abramo; 2015

do-caminhos-do-cuidado-e-publicado-na-revista-brasileiros/ [Cited March 5, 2018]

from: http://www1.folha.uol.com.br/fsp/opiniao/fz2506201107.htm

uploads/2014/09/lei-no-10.216-de-6-de-abril-de-2001.pdf

Review of Contemporary. 2013;3(2):287-311

de-dor-e-sofrimento,818643

172 Public Health - Emerging and Re-emerging Issues

130119\_crack\_internacao\_lk.shtml

e adolescentes. Sao Paulo: Uniban; 2012

Segurança Pública. 2012;6:336-351

144 [Cited March 5, 2018]


## *Edited by Md. Anwarul Azim Majumder, Russell Kabir and Sayeeda Rahman*

The main aim of modern public health is to improve the quality of life and promote health for all. Public health deals with a wide range of individuals and collaborates with various organizations, departments, and agencies to improve health, forestall disease and promote well-being. The field of public health is constantly evolving in response to the needs of communities and populations that are facing demographic, epidemiological and technological challenges. To overcome these challenges, health professionals need to conduct research to generate evidence-based policies to improve the health of the community. Throughout the course of this book, a number of emerging and re-emerging public health issues from different countries are discussed and attempts are made to illustrate a balanced and evidence-based approach towards tackling major public health problems.

Published in London, UK © 2018 IntechOpen © alexkich / iStock

Public Health - Emerging and Re-emerging Issues

Public Health

Emerging and Re-emerging Issues

*Edited by Md. Anwarul Azim Majumder,* 

*Russell Kabir and Sayeeda Rahman*