Prevalence of Extended-Spectrum ß-Lactamases (ESBLs) Producing Aeromonas spp. Isolated from Lamellidens marginalis (Lamark, 1819) of Sewage-Fed Wetland: A Phenotypic and Genotypic Approach.

The global rise of zoonotic bacteria resistant to multiple antimicrobial classes and the growing occurrence of infections caused by Aeromonas spp. resistant to ß-lactam antibiotics pose a severe threat to animal and human health. However, the contribution of natural environments, particularly aquatic ecosystems, as ideal settings for the development and spread of antimicrobial resistance (AMR) is a key concern. Investigating the phenotypic antibiotic resistance and detection of ß-lactamase producing Aeromonas spp. in Lamellidens marginalis, which inhabit all freshwater ecosystems of the Indian subcontinent, is essential for implications in monitoring food safety and drug resistance. In the present investigation, 92 isolates of Aeromonas spp. were recovered from 105 bivalves and screened for their antimicrobial resistance patterns. In vitro antibiotic resistance profiling showed a higher Multiple Antibiotic Resistance (MAR) index of 0.8 with the highest resistance against ampicillin/sulbactam (82%), while 58, 44, 39 and 38% of the isolates were resistant to cephalothin, erythromycin, cefoxitin and imipenem, respectively. PCR results revealed that these isolates carried the blaTEM gene (94%), which was followed by the blaCTX-M gene (51%) and the blaSHV gene (45%). A combination of blaSHV, blaCTX-M, and blaTEM genes was found in 17% of the isolates, indicating the presence of all three resistance genes. This is the first investigation which highlights the importance of multidrug-resistant Aeromonas spp. in L. marginalis. The identification of extended-spectrum-ß-lactamases (ESBLs) genes demand the necessity of continuous surveillance and systematic monitoring, considering its potential health risks for both animals and human beings.

Hit-to-lead optimization of 2-aminoquinazolines as anti-microbial agents against Leishmania donovani.

Visceral leishmaniasis is a potentially fatal disease caused by infection by the intracellular protist pathogens Leishmania donovani or Leishmania infantum. Present therapies are ineffective because of high costs, variable efficacy against different species, the requirement for hospitalization, toxicity and drug resistance. Detailed analysis of previously published hit molecules suggested a crucial role of 'guanidine' linkage for their efficacy against L. donovani. Here we report the design of 2-aminoquinazoline heterocycle as a basic pharmacophore-bearing guanidine linkage. The introduction of various groups and functionality at different positions of the quinazoline scaffold results in enhanced antiparasitic potency with modest host cell cytotoxicity using a physiologically relevant THP-1 transformed macrophage infection model. In terms of the ADME profile, the C7 position of quinazoline was identified as a guiding tool for designing better molecules. The good ADME profile of the compounds suggests that they merit further consideration as lead compounds for treating visceral leishmaniasis.

Diel variation of plankton in the highly impacted freshwater zone of Hooghly estuary in relation to ecological alteration.

Plankton are promising ecological monitoring tool that responds quickly to any sort of aquatic ecological alteration, of which many of them are much susceptible to ecological variations. Therefore, monitoring shifts in plankton composition can indicate changes in water quality and aid to identify potential pollution sources. In the present study, the variation in plankton dynamics in relation to ecological variables were monitored in the freshwater zone of the Hooghly estuary from May 2020 to April 2021. The study was conducted in the interval of every six hours. i.e., at 6 A.M., 12 P.M., 6 P.M., and 12 A.M. The present finding revealed the occurrence of 54 phytoplankton and 20 zooplankton taxa/species. Diel variation revealed that among different time intervals, the highest abundance of phytoplankton was recorded 28,307 cells l-1 at 12 P.M, while the lowest was recorded 10,632 cells l-1 at 6 A.M. However, the highest zooplankton abundance was observed 804 ind l-1 at 6 A.M., and the lowest was recorded 156 ind l-1 at 6 P.M. The ANOVA (p < 0.05) analysis indicated significant diel variation for many planktonic genera. The CCA exhibited that most of the phytoplankton were influenced by multiple water quality variables such as temperature, turbidity, calcium, pH, salinity, DO, and nutrients. However, the majority of the zooplankton were affected by turbidity, total phosphorus, sulphate, calcium and available nitrogen. Significant seasonal variation in plankton composition has also been observed. The present study will help to determine the varying diel pattern of planktons in retort to alterations in the water quality parameters and varying ecological niches.

Environmental bisphenol A disrupts methylation of steroidogenic genes in the ovary of Paradise threadfin Polynemus paradiseus via abnormal DNA methylation: Implications for human exposure and health risk assessment.

Bisphenol A, endocrine-disrupting chemicals (EDCs) impacting disease development via epigenetic modifications, is crucial in transcriptional regulation. However, ecotoxicology's limited exploration of epigenetics prompted our study's objective: examining the extended exposure of riverine Bisphenol A (BPA), a potent EDC, on DNA methylation during female paradise threadfin (Polynemus paradiseus) reproductive maturation. Assessing BPA contamination in riverine water, we collected fish samples from two locations with distinct contamination levels. In the highly contaminated region (Hc), we observed elevated DNA methylation in aromatase (7.5-fold), 20ß-HSD (3-fold), and FSHR (2-fold) genes. Hormone receptor investigation highlighted an escalating connection between transcriptional hyper-methylation and contamination levels. Additionally, our study revealed a positive correlation between oocyte growth and global DNA methylation, suggesting BPA's potential to modify DNA methylation in female paradise threadfins. This effect likely occurs through changes in hormone receptor expression, persisting throughout oocyte maturation. Notably, our research, the first of its kind in estuarine areas, confirmed BPA contamination in paradise threadfins, raising concerns about potential health risks for humans.

Bioaccumulation of polystyrene microplastics and changes in antioxidant and AChE pattern in a freshwater snail (Filopaludina bengalensis) from river Ganga.

Microplastic pollution is a leading global problem affecting terrestrial and marine aquatic ecosystems. Due to the stagnant nature of microplastics, the toxic effect of microplastics is more pronounced to benthic organisms than the surface feeder. Hence, the present study effort was to study the microplastic bioaccumulation pattern and changes in the enzymatic and nonenzymatic antioxidant and AChE pattern of freshwater snail Filopaludina bengalensis, which were subjected to 0.5 ppm to 5 ppm levels of polystyrene microsphere (∼ 30 µm) for 27 days. The study showed that microplastics were easily accumulated in the test organism in a dose and time-dependent manner, amounting to 82 ± 6.02 particles /individuals at a 5 ppm dose on the 27th day. However, no mortality was observed at the test microplastic dosages. The enzymatic antioxidant profile (SOD and catalase) showed limited variability and remained stable with increased duration and microplastic dose. However, the nonenzymatic antioxidant profile showed distinct variability with the complete seizing of the DPPH activity on the 27th day at 5 ppm microplastic dose and a gradual decrease of ABTS and FRAP activity at all the dose ranges. Even the AChE activity decreased with higher exposure concentrations. The present study for the first time shows the direct impact of microplastics on a freshwater snail widely available in the Indian subcontinent, indicating the role of microplastic pollution will create havoc in the Ganga river eco-biosystem in the long run.

Receptor model-based source apportionment and ecological risk assessment of metals in sediment of river Ganga, India.

Ganga river surface sediment was sampled from 11 locations, which revealed average concentrations (mg/kg) of metals in the order Mn (296.93) > Zn (61.94) > Cr (54.82) > Cu (30.19) > Pb (24.42) > Cd (0.36). Sediment quality guidelines showed metals rarely to occasionally exhibit adverse biological effects. Indices like potential ecological risk, contamination security index, hazard quotients, multiple probable effect concentrations quality, mean probable effects level quotients, mean effects range median quotient suggest nil to a very low level of pollution with low ecological risk. Contamination factor, geo accumulation index, enrichment factor, quantification of contamination revealed that Pb and Cd originated from anthropogenic activities. APCS-MLR model revealed that metals contributed from natural sources (Zn, Mn, Cr; 20.18 %), industrial-agricultural (Cd; 21.35 %); and discharge of paints, Pb batteries, fossil fuel (Pb; 8.49 %). Present findings will serve as an effective guideline for managing and ameliorating pollution in the river system.

Hemato-biochemical alteration in the bronze featherback Notopterus notopterus (Pallas, 1769) as a biomonitoring tool to assess riverine pollution and ecology: a case study from the middle and lower stretch of river Ganga.

Fishes are poikilothermic animals and are rapid responders to any sort of ecological alteration. The responses in the fish can be easily assessed from their hematological and biochemical responses. To study the variation in the hemato-biochemical parameters in retort to ecological alteration and ecological regime, a study was conducted at six different sampling stations of the middle and lower stretches of river Ganga. Various hematological and biochemical responses of fishes were also monitored in response to multiple ecological alterations. For the assessment of ecological alteration, various indices were calculated such as the water pollution index (WPI), National Sanitation Foundation-water quality index (NSF-WQI), and Nemerow's pollution index (NPI) has been calculated based on various water quality parameters such as dissolved oxygen (DO), pH, total dissolved solids (TDS), total alkalinity (TA), total hardness (TH), electrical conductivity (EC), biochemical oxygen demand (BOD), chlorinity (CL), total nitrogen (TN), and total phosphorus (TP). The hematological parameters such as WBC, RBC, platelet, hemoglobin, and hematocrit were monitored. The serum biochemical parameters such as SGPT, SGOT, ALP, amylase, bilirubin, glucose, triglyceride (TRIG), and cholesterol (CHOL) were investigated. The study revealed that NSF-WQI varied from 45.08 at Buxar to 110.63 at Rejinagar and showed a significantly positive correlation with SGPT, SGOT, ALP, TRIG, CHOL, and WBC, whereas a significantly negative correlation was observed between TRIG and RBC. WPI varied from 19 to 23 and showed a significant positive correlation with SGOT and a negative correlation was observed with total nitrogen. The PCA analysis illustrated the significance of both natural as well as anthropogenic factors on riverine ecology. Strong positive loading was observed with SGPT, SGOT, ALP, and platelet. The study signified the need for monitoring the hemato-biochemical responses of fishes in response to alterations in the ecological regime.

Encoding the Photoreceptors of the Human Eye.

This review aims to assess the anatomy of the human eye with a focus on exploring opportunities to mimic certain functionalities of photoreceptors in the optical system. This can help restore vision issues in people who had normal vision earlier, but their vision was impaired due to reasons that damaged parts of the eye; however, the functionality of the optic nerve remained intact. It is a conceptual article where the methodology to simulate artificial photoreceptors is discussed.

Variation of Aulacoseira granulata as an eco-pollution indicator in subtropical large river Ganga in India: a multivariate analytical approach.

Aulacoseira granulata (Ehrenberg) Simonsen 1979 are considered as the eco-variable species which varies in density and diversity along with their morphological traits with the interference of environmental changes, so it is considered as one of the major ecological indicators of the water quality of lotic as well as lentic aquatic ecosystems. To assess major environmental factors which contribute to A. granulata bloom in the riverine system, a study was carried out from 2018 to 2019 comprising four different seasons at 11 sampling sites of river Ganga in the middle and lower stretch of river Ganga comprising freshwater and estuarine zones. For the analysis, different univariate, as well as multivariate, analytical tools such as principal component analysis (PCA) and water pollution index (WPI) were used. In the finding, it was observed that the average abundance of A. granulata was found maximum during the winter season. Among all the studied sites, the maximum average abundance was at Balagarh (71,576 cell l-1) and minimum at Diamond Harbour (68 cell l-1). The environmental factors such as dissolved oxygen, depth, and altitude showed a significant influence on the growth of A. granulata, while the water temperature negatively influenced the growth rate of A. granulata. The WPI showed a significantly negative correlation with cell length. Finally, the study concludes that the blooming of A. granulata is highly influenced by varied environmental conditions along the river Ganga, suggesting possible eutrophication. Therefore, a certain minimum flow and depth especially during the lean season have to be maintained for the sustenance of planktonic biota in the river Ganga.

"All circuits ended": Family experiences of transitioning from pediatric to adult healthcare for young adults with medical complexity in Oregon.

BACKGROUND: Transition to adult health care for young adults with medical complexity (YAMC) is challenging and much work needs to be done in this area. The Oregon Center for Children and Youth with Special Health Needs participates in a federally-funded Collaborative Improvement and Innovation Network (CoIIN) to improve the quality of care for children with medical complexity. AIMS: This study aimed to explore the experiences of Oregon families of YAMC who had recently transitioned to adult health care providers, and obtain recommendations for transition from family members, to inform the development of the CoIIN quality improvement project. METHODS: We recruited caregivers of YAMC, ages 18 through 22 years, using a purposive sampling approach and conducted semi-structured interviews with 12 parents and grandparents. We analyzed the interview data to generate themes and sub-themes. RESULTS: Families described having little to no notice about transitioning out of pediatric care and reported that their providers did not communicate with them about the steps needed to ensure a continuation of care into adulthood. Poor transition processes contributed to gaps in needed care, decline in health status of the young adults and psychological burden on the family. Families had to take on the responsibility of meeting the transition needs of YAMC and faced challenges in finding adult providers. CONCLUSIONS: The results of this study suggest that YAMC and their families cared for by Oregon health care settings are not adequately prepared for, or supported in, the transition from pediatric to adult health care.

The Link Between Medicaid Expansion and School Absenteeism: Evidence From the Southern United States.

BACKGROUND: Parental Medicaid eligibility has been shown to be linked to positive academic and school outcomes for children. However, the impact of adult Medicaid expansion on children's school absenteeism is largely unexplored in the literature. The aim of this study was to examine whether Medicaid expansion for adults under the Affordable Care Act (ACA), affected school absenteeism of children. METHODS: This study used data from the National Survey of Children's Health 2016 to 2017 and the difference-in-differences method. RESULTS: The decrease in the predicted probability of missing 11 or more school days in Louisiana, after Medicaid expansion, among school-going children from low-income families, was greater by 18 percentage points (p = .007), as compared to the decrease in the predicted probability of missing 11 or more school days in the neighboring nonexpansion states of Texas and Mississippi. CONCLUSION: The positive impacts of Medicaid expansion are not limited to adults, but also extend to children's school absenteeism.

Emergency preparedness: Interviews with senior leadership in Nebraska hospitals.

OBJECTIVE: The objective of this study was to explore perceptions of senior leadership in hospitals on the motivations, cost, benefits, barriers, and facilitators of investment in emergency preparedness. STUDY DESIGN: This is a qualitative study which used a grounded theory approach to develop a theory of hospital emergency preparedness. SETTING AND STUDY PARTICIPANTS: A purposive sample of hospital leaders (n = 11) in the US state of Nebraska were interviewed. RESULTS: Results showed that the environmental risk associated with the hospital location, the hospital's position in the community, and the preparedness requirements of the Centers for Medicare and Medicaid Services contribute to investment decisions. Rural hospitals face unique challenges in preparing for disasters, for example, lack of trained personnel. Facilitators of disaster preparedness include the availability of federal funds, the commitment of leadership, and an organizational mission aligned toward emergency preparedness. Hospitals invest in hazard vulnerability assessments; partnerships with other organizations in the community; staff trainings and infrastructure. CONCLUSIONS: The authors concluded that hospitals in Nebraska are committed toward investing in preparedness activities. The theory of hospital emergency preparedness developed will be used in a subsequent study to develop a decision-support framework for hospital investment in preparedness.

The Crosscutting Benefits of Hospital Emergency Preparedness Investments to Daily Operations: A Hospital Senior Leadership Perspective.

Hospitals are an integral part of community resiliency during and after a disaster or emergency event. In addition to community-level planning through healthcare coalitions, hospitals are required to test and update emergency plans to comply with accreditation standards at their own expense. Justifying costs related to investments in emergency preparedness can be a barrier, as these events are relatively rare. Little is known about the crosscutting benefits of investments in daily operations including patient care. This study investigated whether hospital investments in emergency preparedness had a perceived impact on daily operations from a senior leadership perspective. Using a cross-sectional study design, a 39-item survey was emailed and mailed to chief executive officers of all 105 Nebraska hospitals. Most respondents indicated that drills and exercises, staff training, and updating emergency plans had a positive impact on daily operations. A relatively small proportion (≤11%) of respondents indicated that costs of buying decontamination equipment, personal protective equipment, and costs associated with staff training and drills/exercises had a negative impact on daily operations. No differences were noted between rural and urban locations or between hospitals that allocate funds in the budget versus those that do not. The majority of hospitals in our study are likely to continue to invest over the next 3 years, inferring a sincere commitment by hospital senior leadership to continue to invest in emergency preparedness. Future research using longitudinal design and objective measures of investments and daily benefits is needed to support a business case for hospital preparedness.

The Impact of Medicaid Expansion for Adults Under the Affordable Care Act on Preventive Care for Children: Evidence From the Southern United States.

INTRODUCTION: The Affordable Care Act of 2010 expanded Medicaid to low-income adults at or below 138% of the Federal Poverty Level (FPL). The aim of this study was to examine if expanding Medicaid to adults had an impact on preventive health care utilization of children from low-income families (focusing on families with annual incomes 0%-99% and 100%-199% of the FPL). METHODS: This study used data from the 2016 and 2017 National Survey of Children's Health and a quasi-experimental difference-in-differences method. The dependent variable was the number of preventive care visits in the past year and the primary independent variable was the Medicaid expansion status of the state. Louisiana expanded Medicaid in 2016 (treatment group) and neighboring nonexpansion states of Texas and Mississippi constituted the control group. Differences in dependent variable were calculated between survey years 2016 and 2017. RESULTS: In Louisiana, the change in the predicted probability of at least 1 preventive care visit among children of ages 0-17 years, from 0% to 99% FPL families, was higher by 26 percentage points after Medicaid was expanded (2017 vs. 2016), as compared with the change in the predicted probability (2017 vs. 2016) of at least 1 preventive care visit among children of ages 0-17 years, from 0% to 99% FPL families in the nonexpansion states, Texas and Mississippi. CONCLUSIONS: Children in poverty residing in a Medicaid expansion state, Louisiana, had increased likelihood of having an annual preventive care visit after expansion of Medicaid eligibility under the Affordable Care Act, as compared with children in nonexpansion states. Thus, this study showed that the implications of the public health insurance expansion for adults were not limited to adult health outcomes, but extended to children's health care utilization.

From silos to coalitions: The evolution of the US Hospital Preparedness Program.

OBJECTIVE: The objective of this article is to trace the hospital emergency preparedness movement in the United States, strengthen the case for hospital investments in emergency preparedness, and make recommendations to ensure sustainability of the program. Design/Approach: This article is a narrative review. Main themes from the literature about the US Hospital Preparedness Program (HPP) are discussed, beginning with the trends in funding levels of the HPP, the rise of regional healthcare coalitions, preparedness performance measures, and the challenges faced over the past 15 years of HPP activities. Finally, recommendations are made about ways to sustain the program. FINDINGS: The HPP was established in 2002 and funding for the program has seen a 56 percent decrease over the last 16 years. Beyond the initial investment in supplies and equipment, hospitals have received very little of the healthcare preparedness funding. Disaster drills and exercises to test emergency plans in hospitals are perceived as a costly distraction from daily work. The biggest challenge is the lack of engagement and support from hospital leadership. CONCLUSIONS: To ensure the sustainability of the HPP, the positive impact of preparedness activities on the hospital's day-to-day operations must be demonstrated.

Barriers of colorectal cancer screening in rural USA: a systematic review.

INTRODUCTION: Colorectal cancer (CRC) screening rates are lower in rural areas in the USA. To guide the design of interventions to improve CRC screening, a systematic review was conducted to identify CRC screening barriers for rural populations. METHODS: A search was conducted in four literature databases - Medline, CINAHL, Embase, and Scopus - for articles from 1998 to 2017 that examine CRC screening barriers in rural areas. This review included a total of 27 articles reporting perceived CRC screening barriers by rural residents or providers or examining factors associated with CRC screening of rural populations in the USA. RESULTS: The most frequently reported barriers were high screening cost and lack of insurance coverage, embarrassment or discomfort undergoing screening, lack of knowledge or perceived need on CRC screening, and lack of physician recommendation. These barriers were confirmed in quantitative studies examining their association with CRC screening status. Age, marital status, and race/ethnicity were the most frequently reported factors associated with CRC screening in rural areas. Lack of prevention attitude toward cancer, perceived lack of privacy, shortage of specialists, and distance to test facilities were reported as rural-specific barriers for CRC screening. CONCLUSIONS: Main barriers for CRC screening at both the individual and healthcare system level are identified in rural areas and they are in line with those found in urban areas in general. In particular, lack of prevention attitude toward cancer, perceived lack of privacy, shortage of specialists, and distance to test facilities disproportionately hamper CRC screening for rural Americans.

Patient Characteristics and Causes of Facial Fractures in the State of California.

PURPOSE: Each year, more than 400,000 emergency department (ED) visits in the United States are due to facial fractures. To inform targeted interventions to prevent facial fractures, the purpose of this study was to identify patient characteristics associated with causes of facial fractures in California. MATERIALS AND METHODS: The 2005 to 2011 California State Emergency Department Database was used for this cross-sectional study. The study population was composed of all ED visits for facial fractures. The primary outcome was cause of injury: fall, firearm injury, motor vehicle traffic accident, pedal cycle accident, pedestrian accident, transport accident, and assault. Predictor variables included patient characteristics, such as age, gender, insurance type, and race and ethnicity. Multivariable logistic regression models were used. RESULTS: There were 198,870 ED visits for facial fractures from 2005 to 2011. The patients' average age was 35.7 years. Most ED visits were by male patients (71%), privately insured patients (35%), and white patients (52%). Approximately 65% of visits were on weekdays and 93% were routinely discharged. Closed fractures of nasal bones, other facial bones, orbital floor, malar and maxillary bones, and mandible were the most prevalent (91%) facial fractures. Assaults (44%), falls (24%), and motor vehicle traffic crashes (6%) were the top 3 causes of facial fractures. Elderly patients (odds ratio [OR] = 6.17), female patients (OR = 2.25), and Medicare enrollees (OR = 1.51) were statistically more likely to have fall-related fractures than patients 45 to 64 years old, male patients, and privately insured patients. Blacks (OR = 0.46) and micropolitan residents (OR = 0.76) were statistically less likely to have fall-related fractures than whites and metropolitan residents. CONCLUSIONS: Violence among youth and falls among the elderly are predominant causes of facial fractures. The uninsured contribute to more than one fourth of ED visits for facial fractures. Interventions targeted at these population groups can curb the prevalence of these fractures.

Unveiling the Interaction between Fatty-Acid-Modified Membrane and Hydrophilic Imidazolium-Based Ionic Liquid: Understanding the Mechanism of Ionic Liquid Cytotoxicity.

Ionic liquids (ILs) are considered as "green solvents" for more than 2 decades. However, recent studies suggest that some ILs exhibit greater toxicity compared to common solvents. As a proactive effort to better understand the molecular origin of the cytotoxicity, the work herein presents the systemic characterization of the interaction between model membrane composed of fatty acids and popular imidazolium-based hydrophilic IL. The fusion kinetics between the vesicles demonstrates the swelling of the vesicle. Further, membrane fluidity is determined using the isomerization kinetics of a lipophilic dye, merocyanine-540, and in the presence of IL, the fluidity of the inner water pool of the vesicle is increased. The results can be directly correlated to the cytotoxicity generated by IL in K562 cell, a human erythroleukemic cell line. High-concentration IL ruptures the cell membrane and causes membrane permeabilization. Thus, the results would help to facilitate the rational design of nontoxic ILs.

Promoting colorectal cancer screening through a new model of delivering rural primary care in the USA: a qualitative study.

INTRODUCTION: Despite the known benefits of colorectal cancer (CRC) screening, rural areas have consistently reported lower screening rates than their urban counterparts. Alternative healthcare delivery models, such as accountable care organizations (ACOs), have the potential to increase CRC rates through collaboration among healthcare providers with the aim of improving quality and decreasing cost. However, researchers have not sufficiently explored how this innovative model could influence the promotion of cancer screening. The purpose of the study was to explore the mechanism of how CRC screening can be promoted in ACO-participating rural primary care clinics. METHODS: The study collected qualitative data from in-depth interviews with 21 healthcare professionals employed in ACO-participating primary care clinics in rural Nebraska. Participants were asked about their views on opportunities and challenges to promote CRC screening in an ACO context. Data were analyzed using a grounded theory approach. RESULTS: The study found that the new healthcare delivery model can offer opportunities to promote cancer screening in rural areas through enhanced electronic health record use, information sharing and collaborative learning within ACO networks, use of standardized quality measures and performance feedback, a shift to preventive/comprehensive care, adoption of team-based care, and empowered care coordinators. The perceived challenges were found in financial instability, increased staff workload, lack of provider training/education, and lack of resources in rural areas. CONCLUSIONS: This study found that the innovative care delivery model, ACO, could provide a well-designed platform for promoting CRC screening in rural areas, if sustainable resources (eg finance, health providers, and education) are provided. This study provides 'practical' information to identify effective and sustainable intervention programs to promote preventive screening. Further efforts are needed to facilitate delivery system reforms in rural primary care, such as improving performance evaluation measures and methods.