The control of vector-borne diseases (VBD) is one of the greatest challenges on the global health agenda. Rapid and uncontrolled urbanization has heightened the interest in addressing these challenges through an integrated vector management (IVM) approach. The aim was to identify components related to impacts, economic evaluation, and sustainability that might contribute to this integrated approach to VBD prevention.
We conducted a scoping review of available literature (2000–2016) using PubMed, Web of Science, Cochrane, CINAHL, Econlit, LILACS, Global Health Database, Scopus, and Embase, as well as Tropical Diseases Bulletin, WHOLIS, WHO Pesticide Evaluation Scheme, and Google Scholar. MeSH terms and free-text terms were used. A data extraction form was used, including TIDieR and ASTAIRE. MMAT and CHEERS were used to evaluate quality.
Of the 42 documents reviewed, 30 were focused on dengue, eight on malaria, and two on leishmaniasis. More than a half of the studies were conducted in the Americas. Half used a quantitative descriptive approach (n = 21), followed by cluster randomized controlled trials (n = 11). Regarding impacts, outcomes were: a) use of measures for vector control; b) vector control; c) health measures; and d) social measures. IVM reduced breeding sites, the entomology index, and parasite rates. Results were heterogeneous, with variable magnitudes, but in all cases were favourable to the intervention. Evidence of IVM impacts on health outcomes was very limited but showed reduced incidence. Social outcomes were improved abilities and capacities, empowerment, and community knowledge. Regarding economic evaluation, only four studies performed an economic analysis, and intervention benefits outweighed costs. Cost-effectiveness was dependent on illness incidence. The results provided key elements to analyze sustainability in terms of three dimensions (social, economic, and environmental), emphasizing the implementation of a community-focused eco-bio-social approach.
IVM has an impact on reducing vector breeding sites and the entomology index, but evidence of impacts on health outcomes is limited. Social outcomes are improved abilities and capacities, empowerment, and community knowledge. Economic evaluations are scarce, and cost-effectiveness is dependent on illness incidence. Community capacity building is the main component of sustainability, together with collaboration, institutionalization, and routinization of activities. Findings indicate a great heterogeneity in the interventions and highlight the need for characterizing interventions rigorously to facilitate transferability.
Integrated vector management (IVM) is an approach using both chemical and non-chemical methods, including environmental management [1, 2]. It is part of a comprehensive strategy encompassing a variety of other vector control methods, such as collaboration with the health sector and other sectors, educational campaigns, advocacy, social mobilization, evidence-based decision making, and capacity building . IVM may also refer to the concurrent control of multiple diseases transmitted by different vectors in a given zone, or to one tool controlling several vector-borne diseases transmitted by the same vector . This strategic framework, adopted in 2004 for all vector-borne diseases (VBDs), is considered a rational decision-making approach for the optimal use of resources for vector control .
The financial crisis of recent years has raised doubts about the possibility of continuing the development of current interventions , which in turn has increased vulnerability factors in many populations . This period of crisis has also consequently reinforced interest in knowing about and fostering the impacts, cost-effectiveness, and sustainability of programs and interventions. As part of the plan to improve the epidemiological situation, World Health Organization (WHO) began, in 2004, to concentrate on developing IVM . However, as implementing integrated approaches is a slow and complex process, IVM remains an approach with great promise for the control of vector-borne and other infectious diseases related to poverty worldwide .
Among key vector control elements, the scientific literature highlights program administration, vector surveillance, control activities, public education, and intergovernmental coordination [2, 9]. In relation to implementation, policy-setting, capacity-building and advocacy, the decision-making process is essential to IVM . Our aim in this paper is to contribute to the understanding of key factors that can positively influence population health, by considering the management of available human and financial resources. Specifically, the aim of this review is to identify components related to impact, cost-effectiveness, and sustainability that may facilitate implementation of an IVM approach in urban settings to prevent vector-borne diseases.
We used an eDelphi survey to identify the six topics considered highest priority by a panel of 109 international experts (43% research sector, 52% public health sector, 5% private sector). The eDelphi was a three-round process: 1) participants suggested topics to be considered, resulting in more than 80 being proposed; 2) the proposed topics were rated from "1–eliminate" to "5–top priority"; 3) the 20 subjects rated 4 or 5 by more than 65% of the participants were then rated a second time. By the end of the process, the present topic had obtained the mean score of 4.08 ± 0.71 and was ranked the 3rd (rated 4 or 5 by 79% of participants in the final round).
We reviewed the available literature using electronic databases: PubMed, Web of Science Database, Cochrane Library, CINAHL Complete Database, Econlit, LILACS, Global Health Database (CABS abstracts + Public Health and Tropical Medicine), Scopus, and Embase. This was complemented with a search of the following resources: Tropical Diseases Bulletin, WHO Pesticide Evaluation Scheme WHOLIS, and Google Scholar.
Key words included: program evaluation, cost analysis, impact analysis, cost-effectiveness, sustainability, vector-borne diseases, integrated vector management, urban areas, and their alternative expressions. Both MeSH (Medical Subject Headings) terms and free-text terms were used. The search strategy adopted for the different databases was validated by a librarian specialized in public health and is described in Additional file 2.
The included studies: 1) examined programs or interventions addressed by an IVM program; 2) referred to VBDs included in the WHO list; 3) presented relevant outcome measures in relation to impact, economic evaluation, and/or sustainability; 4) were conducted in urban settings according to 2014 United Nations criteria ; 5) were written in English, Spanish, French, or Portuguese; and 5) were published between 2000 and 2016.
Integrated vector management involves both chemical and non-chemical methods, including environmental management . It is a comprehensive strategy characterized by WHO  as integrating vector control methods, educational campaigns, collaboration with the health sector and other sectors, advocacy, social mobilization, evidence-based decision-making, and/or capacity-building [2, 10, 12].
Impact refers to the extent to which a given intervention or service produces health outcomes in the individuals to whom it is offered . It can be also evaluated in relation to various objectives, such as meeting societal needs . Impact reflects the effects of an action or intervention .
Economic evaluation is a comparative analysis of alternative courses of action in terms of both their costs and consequences .
Sustainability is a condition for ensuring programs can continue to operate over the long term. It can be mainly connected with using, over an extended period of time, the components and activities needed to achieve outcomes that will control the illness .
References were saved in a Zotero library and reviewed to identify potentially relevant papers. Titles and abstracts were assessed independently by two reviewers to determine whether papers met the inclusion criteria; those satisfying the criteria were saved as potential documents (first screening). Additional sources were obtained after screening by cross-checking the references of previously identified papers. Differences between reviewers were resolved by consensus by a third reviewer. The selected documents were then assessed with full text screening independently by two reviewers (second screening).
The documents were subjected to an evaluation of their methodologies using the Mixed Method Appraisal Tool (MMAT)  and, for economic evaluation studies, the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) .
Information was extracted from each document using an Excel form to capture general information and two different tools, Template for Intervention Description and Replication (TIDieR)  and AnalySe de la Transférabilité et Accompagnement à l'adaptation des InteRventions en promotion de la santE (ASTAIRE) , to analyze the potential for transferability of the interventions. Specific information, such as intervention type and outcomes measured, was also included. Each item was classified as either reported or not fully reported (including omitted or poorly reported).
Data were synthesized and content analysis was performed according to categories related to the three dimensions previously established: impact evaluation, economic assessment, and sustainability. This facilitated comparison among the different studies and identification of gaps in public health policy and research in accordance with the IVM.
A total of 1660 documents were retrieved, of which 409 were potentially eligible and 42 were included in the review. Figure 1 presents a flow diagram of the studies selection process. Additional file 3 lists the selected studies.
The studies reviewed had worldwide distribution. More than half were conducted in the Americas region (58.1%, n = 25), including Colombia, Cuba, Brazil, Argentina, Ecuador, Mexico, Uruguay, Venezuela, Brazil, and the United States, followed by the regions of Asia (18.6%), Africa (18.6%), and Oceania (4.7%) (Table 1). Of the 42 documents reviewed, 30 (71.4%) were focused on dengue vectors, eight (19%) on malaria vectors, and two on leishmaniasis. Half of the studies used a quantitative descriptive approach (n = 21); the others used quantitative randomized controlled trials (cluster) (n = 11), quantitative non-randomized methods (n = 6), and mixed methods (n = 4).
Figure 2 shows the results produced by the MMAT analysis : 72.7% of the quantitative randomized studies were considered well conducted (three or more items addressed), as were half of the quantitative non-randomized studies, 52.4% of the quantitative descriptive studies, and all the mixed methods studies.
The studies analyzed 22 vertical-approach and 20 community-approach interventions.
Vertical-approach interventions took a variety of forms: a) educational interventions (EIs) for vector control within the community plus intersectoral work [22–31]; b) EIs plus modification of road infrastructure with use of slow-release insecticide ; c) EIs supported by an entomological survey ; d) EIs with periodic visits to houses for follow-up ; f) EIs plus larvicide treatment and insecticide spraying [35–39]; g) EIs plus spraying, with activities to control immature mosquitoes ; h) indoor ultra-low volume (ULV) application ; i) EI plus large-scale installation of insecticide-treated screens and curtains ; and j) EI plus long-lasting insecticide-treated curtains and water container covers [43, 38] (Table 1).
Other groups of interventions (n = 20) involved a community approach with various components [44–63]: 1) community-based control [44–48]; 2) ecosystemic and environmental community-based approaches [49–53]; 3) community-based larviciding programs [54–58]; 4) community-based approach with window screens, ceilings, and closed eaves ; 5) community-based intervention with entomological vector surveillance ; 6) environmental management and high-resolution aerial photography with ground-based validation ; 7) mass control of vectors in street catch basins and community participation ; and 8) support to program managers with situational information and community involvement .
Figure 3 indicates how the studies reported different aspects of the interventions, through the lens of the ASTAIRE tool. Results showed that, in the four categories upon which the tool is structured (population, environment, implementation, and support for transfer), the data reporting in the papers was very limited. The ASTAIRE items most often reported were "Communication of elements needed for transfer" (32% of articles), "Epidemiologic and socioeconomic characteristics" (31%), and "Institutional environment directly influencing intervention" (29%). The most frequently omitted ASTAIRE item was "Mechanisms for motivating providers". On the other hand, according to the TIDieR checklist analysis, although no case provided detailed information, authors generally described the procedures and materials used in the intervention, as well as locations and providers. Conversely, articles rarely reported whether the intervention was modified during its course (describing in that case the changes implemented), or whether any strategies were used to improve compliance with the intervention or implementation fidelity.
The impact of the interventions was measured in several ways, as shown in Additional file 4, providing a more detailed description of the outcomes measures used. Here we present the main results in four subsections related to such outcomes measures.
Two studies considered the use of vector control methods when measuring the impact of interventions. In studying an intervention to support program managers, Valadez et al.  used as an outcome the possession of insecticide treated bed-nets and indoor residual spraying (proportion of people protected). They found that intervention districts exhibited significant reductions in use of insecticide treated bed-nets and indoor residual spraying (the change in coverage proportion ranged from 35.9% (95% CI: +/− 26.2%) to 49.6% (95% CI: +/− 6.7%). Vanlerberghe et al.  measured the insecticide-treated materials coverage achieved with an intervention consisting of container inspections and treatment, insecticide-treated curtains, and educational interventions. They used this variable to analyze whether using insecticide-treated window curtains could reduce Aedes aegypti levels, depending on coverage attained.
Some studies used intermediate outcomes to measure the vector control impact of the intervention, even though most of the studies considered final outcomes. Intermediate outcomes were the number of positive containers with larvae and/or pupae by house [22, 23, 30], overall average of positive containers with larvae and/or pupae (C+/C) , percentage of water-filled containers positive for larvae and/or pupae [25, 33, 48], and catch basins positive for larvae and pupae . The results from Espinoza-Gómez et al.  stress that using an EI, preceded by intersectoral integration with the community, had a significantly stronger effect on reducing breeding sites for Aedes aegypti than did chemical spraying. Escudero-Támara and Villareal-Amaris  found a reduction of the number of Aedes breeding sites after an EI. Raju et al.  found a significant reduction in the percentage of primary positive containers for Aedes albopictus, from 33 to 5% for tires, and from 42 to 8% for drums, after communities were mobilized in the Aedes aegypti control program for source reduction in the peri-urban district. Caprara et al.  found a reduction in small discarded water containers in the intervention clusters (100% elimination in all visited houses) following an ecohealth approach. Basso et al.  found that the percentage change in number of containers registered after the intervention (EI with an entomological survey) was thoroughly different among six clusters studied, showing reductions between 26.1% (cluster 4) and 66.5% (cluster 20) in 17 clusters and increases in three clusters ranging from 9.4% (cluster 6) and 53.2% (cluster 13). The study by Pacheco-Coral et al.  revealed only partial success for the strategy in La Dorada (Colombia); houses that did not have larvae were characterized as having female heads of household or residents who were knowledgeable about larvae and the mode of transmission of dengue. Lastly, Ocampo et al.  found a higher percentage of catch basins positive for pupae during the pre-intervention period compared to the intervention period (71.4% versus 57.6%).
Concerning final outcomes, and in the case of dengue control, most studies used entomology indices, such as the pupae per person index (PPI) [33, 38, 43, 48–52, 57], the pupal index (PI) [33, 30], the pupae per hectare index (PHI) , the Breteau index [25, 33, 43, 45, 48, 57], the premises or house index (HI) [25, 33, 48, 57], the density of adult Aedes aegypti , the density of immature Aedes aegypti [34, 41], and the ovitrap index [24, 28]. The outcomes used for malaria control interventions were parasite rates  and the entomological inoculation rate . Comparators between studies were diverse, and results were also heterogeneous with very variable magnitude. In all cases, the results were favourable to the analyzed intervention, with the exception of one study that reported the same effectiveness as the comparator .
The incidence of illness was the health outcome used in four studies, including dengue-related illness , malaria , and cutaneous leishmaniasis [29, 42]. Ocampo et al.  found a reduction in dengue incidence (RR = 0.19) with an intervention based on community participation and mass control of vectors in street catch basins. Regarding malaria, Geissbühler et al.  concluded that larviciding reduced malaria infection risk among children ≤5 years of age (OR = 0.28) and provided protection at least as good as personal use of an insecticide-treated bed-net (OR = 0.76). Finally, in relation to leishmaniasis, Noazin et al.  evaluated an intervention based on installing deltamethrin-impregnated screens and curtains as a preventive measure for anthropologic cutaneous leishmaniasis (ACL). Their findings showed the short-term effectiveness of such preventive measures (RR = 0.84), but also highlighted the necessity of long-term sustainable strategies. Da Costa et al.  evaluated a strategy based on capture of sandflies and identification of vector species, chemical control through insecticide application, serological investigation and elimination of infected dogs, rodent control, and educational measures aimed at the local community. These results showed a 31.6% decrease in leishmaniasis cases (comparison pre-post intervention).
Regarding social measures, studies measured interventions' effects on people's knowledge, attitudes, and practices, as well as population empowerment and participation in control activities conducted by intersectoral collaboration and at the household level. Outcomes used were knowledge of symptoms and transmission modalities [26, 27, 31, 55, 56], knowledge and beliefs about control measures , changes in people's behaviour to control Aedes aegypti breeding sites [23–25], people's abilities and adequate practices for controlling the vector , empowerment of prevention and control measures [26, 50, 52], household participation in dengue control activities , intersectoral participation in dengue control activities , and health worker capacity indicators . All results from these studies were favourable to the evaluated intervention with a pre-post comparison with variable magnitudes. The impact outcomes in relation to study quality are presented in Fig. 3.
Among the selected papers, three studies performed cost-effectiveness analyses [35, 40, 55], one a cost-benefit analysis , and one a cost-utility analysis . All adopted a societal perspective, and Maheu-Giroux and Castro  and Baly et al.  also adopted a provider perspective (Tanzanian Ministry of Health and Social Welfare and Ministry of Health, respectively). The time horizons over which costs and consequences were evaluated ranged between 3 months  and 10 years , and the time horizons used by the other papers were 3  and 5 years . Only two papers used a discount rate for costs and outcomes, which was 3% [35, 55]. Three of the four articles included a sensitivity analysis to determine the robustness of the results [35, 46, 55].
The cost-effectiveness analyses used different measures. Maheu-Giroux and Castro  used three outcomes: malaria infections averted, malaria-associated deaths prevented, and disability-adjusted life years (DALY). Baly et al.  used the difference between the baseline averages of larval indices and Aedes foci numbers at baseline, and these average indices for the subsequent periods constituted the effectiveness measure. Shepard et al.  used quality adjusted life years (QALY) gained, taking into account the reduction in the number of yard and porch hours lost in a typical summer week due to mosquitoes. With regard to the cost-benefit and cost-utility analyses, monetary values were calculated from contingency valuations—in one of them directly by face-to-face interviews  and in the other by extracting values from the literature .
For two papers, the costing sources were interviews [35, 46], a third used documents , and the last one used both interviews and documents . With reference to the CHEERS checklist items, two studies had a high risk of bias [35, 40] and the other two had a low risk [46, 55]. Finally, although some elements, such as malaria incidence  or amount of rainfall , were identified as key factors that could affect an intervention, the results seemed to suggest that interventions performed by a combination of different stakeholders are more cost-effective than interventions performed by only one type of actor [40, 46].
Despite the lack of specific outcomes related to sustainability, the results presented here provide several avenues for improving intervention effectiveness and empowering sustainable effects. Specifically, 17 of the 42 papers addressed activities that, in line with the authors' recommendations, could reinforce the sustainability of the vector control approaches. Based on these papers, we can consider three interrelated dimensions of sustainability in an IVM: social, economic, and environmental.
Although they were not the only studies to include community participation, in nine papers, all concerned with dengue, community involvement was the central axis of their preventive approach and/or vector control.
Community capacity-building was identified as the main component in the development of sustainability. In four papers, the increase in people's knowledge about the prevention of vector transmission was articulated around community-based campaigns. In three of these studies the observational units were households. For instance, in a randomized community trial conducted by Espinoza-Gómez et al. , in which the educational campaign consisted of a series of house-by-house visits, community participation was found to be more effective than control methods such as insecticide spraying. Overall, the findings of this study provided evidence that an intervention that is personalized and based on the active participation of community leaders is more effective than the traditional vertical strategy of applying chemicals. The other two studies in this same line were pre–post evaluations of EIs. In the intervention by Pai et al. , the results showed the effectiveness of a short-term community-based cleanliness campaign, especially with regard to people's knowledge and behaviour (surveyed) regarding vector transmission and prevention, which increased significantly from 57.4% before to 88.4%. after the campaign. The sources of dengue vectors were analyzed based on changes in the ovitrap index, which also decreased significantly, from 66.7% before the campaign to 39.3% 3 months afterward . In the quasi-experimental study by Escudero-Támara and Villareal-Amaris , capacity-building was linked with a communication strategy—specifically, the main concepts of the Communication for Behavioural Impact (COMBI) toolkit. At the end of the intervention with each of the participant groups, 64.8% were classified as being in the action stage, and a significant reduction in intradomiciliary Aedes breeding sites, from 92.6 to 35.2% (P = 0.001), had been achieved . Another study, also following a quasi-experimental design, focused on schoolchildren by using a game as a teaching–learning tool to impart knowledge and prevention skills about dengue; results showed that the children's knowledge and skills, measured prior to the program (6.5 and 18.4 points, respectively) were higher in the final test (8.25 and 22.9 points, respectively; P < 0.05) .
The community-based trial conducted by Cáceres-Manrique et al.  showed the efficacy of social mobilization to improve knowledge and practices and highlighted its role in public empowerment with regard to preventive and control measures—key elements to ensure the sustainability of community-based strategies. Similarly, the study by Toledo et al.  evaluated the sustainability of an intervention strategy to achieve active participatory control over a two-year period. Their results suggested that enhancing the sustainability of community-based strategies requires, at the very least, institutionalizing the provision of basic sanitation services, but also engaging in collaborations with other community partners and creating coordinating groups to strengthen community involvement.
In connection with the above points, our review also highlighted the results of implementing an eco-bio-social approach focused on the community. Three studies were designed following this approach [49–51]. Their results provided evidence of the positive influence of establishing a collaboration framework among local governments, program planners, and communities. In the multi-country study by Sommerfeld et al. , the results showed that vector management was more sustainable when it complemented or replaced other interventions by: a) targeting water container interventions that achieved a significant reduction in vectors; b) using novel non-insecticidal intervention tools; and c) involving different partners. Following the same approach, Wai et al.  emphasized that, for sustainability and population empowerment, a key element is the connection established between the different interest groups. The project conducted by Mitchell-Foster et al. , which compared the effectiveness and feasibility of scaling up an eco-bio-social approach for implementing an integrated community-based dengue prevention strategy to the effectiveness of existing insecticide-based approaches, also suggested that ecosystems approaches to vector-borne diseases such as dengue are primarily successful when elements of social mobilization are incorporated, together with intersectoral collaborations.
Six papers addressed various components that contributed to understanding sustainability-building from an economic perspective. In two of these, resource optimization was the key element, manifested in one by the integration of two programs  and in the other through a combination of interventions, such as indoor residual spraying and the use of long-lasting insecticidal bed-nets .
Three other studies were specifically designed to determine the cost of public sector vector control programs, but they also provided findings on sustainability from the cost analysis standpoint [36, 45, 47]. Thus, Packierisamy et al.  studied differences in costs and resource consumption between district health departments (DHDs) and local authorities (LAs) and found that inspection services, fogging, and larviciding aimed at dengue vector control by LAs were more cost-efficient than the approaches developed by the DHDs. Thalagala et al.  confirmed that public sector costs of dengue control activities and direct costs of hospitalizations imposed a significant economic burden in contexts such as Sri Lanka; specifically, the total public sector cost of dengue control activities in the district studied during the epidemic year of 2012 was estimated at US$971 360, indicating a per capita cost of US$0.42 for dengue control activities. These findings underscore the importance of prevention activities to reduce patient numbers and strengthen health system sustainability. Baly et al.  found that the annual per-household cost documented by their study was higher than the per-household cost of most routine Aedes control programs worldwide. Thus, program sustainability was connected with conventional routinization activities, mainly related with insecticide use.
Finally, the intervention program by Samuelsen et al. , the only one that used both entomological and anthropological approaches to examine sociocultural aspects of a mosquito control intervention, showed that the most commonly used method (the coil) for the prevention of mosquito nuisance in Burkina Faso was the one the local population considered not only least expensive but also least effective. Their findings prompted them to suggest that processes aimed at ensuring economic sustainability must to take into consideration that the choice of control measures by the local population and by the system as a whole is primarily based on financial accessibility (Table 2).
Four papers provided elements for understanding sustainability from an environmental perspective, although with clearly related implications for social dimensions. Wai et al.  conducted an intervention study to build a partnership-driven ecosystem management intervention and then to analyze its feasibility, process, and effectiveness in reducing vector densities. Their results showed that, for sustainability, the partnership approach with targeted container interventions was found to be superior to the vertical approach. Along the same lines, Samuelsen et al.  found not only that reducing VBD-related morbidity and mortality requires a combination of biolarvicide treatment and insecticide treated nets, but also that, to enhance sustainability, such combinations must take into account local sociocultural factors.
Only one study intervention was based on regular application of microbial larvicides using a community-based but vertically managed approach. This procedure, developed to reduce malaria prevalence and as a complement to the existing protection provided by insecticide-treated bed-nets, was considered a useful IVM strategy, especially in rapidly growing urban settings . Another article called attention to the design of covers or biological control methods for water storage containers as a relevant component of the sustainability of a control program .
WHO recommends IVM as the main strategy for vector control and encourages member states to adopt this approach . However, many VBD-endemic countries have not adopted this strategic framework to guide their actions [12, 65]. This scoping review was intended to provide information to support the development of strategies based on this approach. We have also highlighted the implications and the identified gaps in terms of both future research and public health policy and/or practice around this issue.
This study shows that evidence on IVM integration in endemic countries, and particularly in Africa, is limited. From a methodological standpoint, half of the studies in this review had performed a quantitative descriptive analysis, reflecting the need to produce evidence based on more robust quantitative methods; in this respect, randomized controlled trials could be an option. We also identified a significant gap in the use of qualitative methods within this field of study, especially to understand the process of intervention implementation. Finally, there is a major lack of evidence regarding the economic evaluation of IVM.
The MMAT analysis  revealed variability in the quality of available evidence. In this regard, it should be noted that our descriptions of quality are based on how the authors presented their study; in certain cases, the information available in the paper was insufficient to answer some of the questions. Similarly, many papers did not provide the information needed to complete the TIDieR checklist and the ASTAIRE tool. This raises the need for authors to provide more detailed information to characterize their interventions, to help in assessing their transferability and whether results can be extrapolated from one setting to another. In this respect, scientific journals have a key role to play: to advance the field of population health intervention research (PHIR), they will need to publish more intervention research and related case studies .
The main limitation of our review is related to the studies' approaches, given that the term "integrated vector management" itself refers to a framework or a strategy, rather than to a particular procedure. In many cases, this made it difficult to decide whether a study had been designed within this approach. This may have limited the number of papers considered for the final phase of analysis. Like other scoping reviews, our study is subject to the same limitations as any literature review, which include the potential omission of relevant sources of information and the review being dependent on the information available (publication bias). Moreover, because our subject is very much linked to public policies, there is potential for positive-results bias, meaning that authors (and journals) are more likely to publish positive results than negative or inconclusive findings. On the other hand, another limitation of this scoping review is that new tools for vector control are not addressed in detail. It is important to point out that several new tools are undergoing entomological trials, but only a few are brought under epidemiological evaluations of efficacy. In this sense, it is necessary to highlight the key role that the Vector Control Advisory Group of WHO is playing in facilitating rigorous evaluation and testing of new tools and technologies.
Our results highlighted the difficulty of comparing the different studies in the review given the diversity of interventions and components addressed, as well as the heterogeneity within each study. Our findings showed that, for successful community involvement, it is critical to take into account the intervention's contextual elements. The literature revealed the importance, for decision-makers, of performing pilot studies before implementation, so that programs can be adapted to the context and relevant human factors . However, such contextualization of procedures should not impede the standardized application of certain instruments and research methods related to the different sciences working on vector control and prevention .
In recent years, the social determinants of health framework has furthered the debate on the relationship between inequalities and disease, in particular favouring approaches that take into account the conditions in which people's lives unfold. This framework has not only led indirectly to the examination of social relations as health determinants, but has also generated a corpus of knowledge that provides greater understanding of inequalities within global health processes . The results of this review showed, however, that this theoretical framework is rarely taken into consideration in the formulation of studies about vector control. Especially evident was the absence of any consideration of health inequalities in the interpretation of results. Yet this approach may provide a better understanding of non-biological factors, such as determinants that depend on cultural and socioeconomic conditions, related to vector-borne morbidity and mortality . Therefore, we consider that to advance further in this field the researchers should take into account to a greater extent how action in different sectors is affected by the particular political, social and cultural contexts, and how the complex mix of politics, economic development, culture and collective action interact to influence the population health outcomes. This requires extend the existing knowledge by exploring the influence of the broader determinants of health using innovative mixed methods.
The results of this review emphasize the need to generate more scientific evidence, leveraging all the potential offered by the different evaluation designs in public health . In this regard, what emerges from our analyses as a notable deficiency is the dearth of health policy evaluations focusing on effectiveness assessment using data from real-world conditions . Research methods also need to be strengthened to support evidence-based decision-making that takes into account local conditions of diseases and disease transmission. Mixed methods combining quantitative, qualitative, and participatory techniques can be a good way of taking into account all sectors involved and analyzing the side-effects of strategies .
Particularly relevant for the IVM approach are aspects related to economic assessments and sustainability. Although the problem of VBDs has been worsening globally in recent years, we found few economic evaluations that met our inclusion criteria. This is another key line of research that should be strengthened; given the scarcity of resources, economic evaluation is becoming more important as a tool to inform resource allocation by comparing various alternatives for action in terms of their costs and effects on health . Many studies used intermediate outcomes as a measure of effectiveness, but this can lead to suboptimal recommendations. Ideally evaluations should focus on final health outcomes [16, 19]. Along the same lines, to monitor the sustainability of interventions, longitudinal research is required over an extended period. In particular, evidence is needed on the environmental sustainability of interventions.
Most studies that met the inclusion criteria for the review were focused on dengue. This highlights the need to implement integrated control strategies for other diseases. In this regard, researchers might consider adopting a multi-disease approach to IVM, that is, taking into account all prevalent VBDs within one control strategy .
• Researchers need to provide more detailed characterizations of interventions and their processes, so that their transferability can be better assessed.
• Researchers need to produce more evidence based on randomized trials (cluster) and the use of qualitative and mixed methods.
• Researchers need to identify more health outcomes when evaluating programs.
• More research is needed on integrated approaches with assessments of impacts on entomological and health outcomes.
• Economic evaluation studies with a long time horizon are needed.
• More research is needed that takes into consideration the social determinants of health.
• Research is needed to increase understanding of VBDs from the standpoint of health inequalities.
• More studies are needed that provide in-depth descriptions of the pathways or mechanisms through which context and intervention influence population health.
• More studies are needed that monitor the sustainability of interventions over the long term.
• More studies are needed that consider the incidence of illness as a key factor to determine the cost-effectiveness of an intervention in a specific context.
• Research is needed to calculate affordability, once cost-effectiveness is ensured, through budget impact analysis.
IVM has impacts on reducing breeding sites [22, 23, 25, 30, 33, 48, 62], improving the entomology index [24, 25, 28, 30, 33, 34, 38, 41, 43, 45, 48–52, 57], and lowering parasite rates . The results in the papers we reviewed were heterogeneous with variable magnitudes, although in all cases they were favourable to the intervention. Evidence related to IVM's impact on health outcomes was very limited [29, 42, 58, 62].
Achieving sustainability is one of the major current challenges in VBD control programs . Our findings showed that, to foster sustainability, interventions must focus especially on capacity building in the recipient community. According to the studies we reviewed, this element is generally understood as the interaction between human capital, organizational resources, and social capital within a given context that can be leveraged to solve collective problems and improve or maintain the community's well-being [74, 75]. Thus, in top-down programs the capacity for sustainability requires both organizational capability and people's expertise. Attempting to implement a community participation process to gather support for program activities without capacity building and real active community involvement may be one of the clearest ways to create an unsustainable initiative. From a public health perspective, among other implications for practice, this should lead to a growing interest in the application of participatory research methods to generate greater mobilisation and community interest on health determinants, increasing the empowerment and social change potential of the interventions .
An intervention's effectiveness will depend on many factors. Especially important are social mobilization to achieve long-lasting behaviours, the durability of materials used for the interventions, and the coverage attained or the specific environmental conditions. Likewise, an intervention's effectiveness also depends on people's positive perceptions of the control methods used, always keeping in mind, however, that their choice of method could be based primarily on financial accessibility rather than perceived effectiveness . IVM interventions need to take into account local sociocultural factors. While it remains a challenge to involve local urban populations in control efforts and prevention activities, our findings stress that any measures adopted should be based more on community involvement than on vertical approaches .
Within this field of intervention research, planning for sustainability is a core issue in implementing processes for improving population health [74, 76]. The literature suggests that, to promote sustainability, it is essential to focus on the routinization of activities resulting from a program. Therefore, maintaining the health benefits achieved involves more than just continuing an intervention or program; a host organization is also needed to continue the program's activities . As such, institutionalization is also a key process on the path toward sustainability. Along these lines, one relevant factor influencing the impact and sustainability of a community-based approach to vector control could be the municipal provision of sanitation services . Given the importance of the institutionalization process, another key IVM-related strategy to foster the sustainability of community-based strategies is to promote intersectoral coordination . Our results provided evidence of the positive impacts of collaboration among communities, local governments, and program planners. This underscores the importance, especially in urban endemic zones, of integrating the efforts and resources of all actors involved with prevention and control strategies. In the case of research-based interventions, this reinforces the need for seeing sustainability as a further stage of the implementation process [17, 78].
From an environmental standpoint, the results also underlined the need to consider the different elements that can influence a program's sustainability in a specific urban area. For instance, the results from Shepard et al.'s  study of an integrated pest management program to control the Asian tiger mosquito showed that climatic conditions can negatively influence an intervention when planners do not anticipate the potential impact of the rainy season in a given urban context. Similarly, impact assessment of entomological and clinical parameters is also relevant for the future of integrated approaches. This may help identify relationships between larval control, environmental management, and chemicals used . In any case, as interventions become more effective, we can assume there will be less need for chemical products. This is considered a relevant environmental outcome because it could translate into lower vector resistance to those products. Among other considerations, this reinforces the 'One Health' approach developed by the WHO to designing and implementing programmes, policies, legislation and research in which different sectors, such as public health, animal health, plant health and the environment, work together to achieve better population health outcomes .
This research determined the importance of designing, developing, and analyzing multi-partnership interventions with an emphasis on community participation. Related to this approach, within an IVM strategy, eco-bio-social research could be considered an important framework for systematic assessment of vector control needs and for developing partnership strategies at the local level .
• Interventions should be mainly based on community involvement.
• Interventions must be specially focused on community capacity building.
• Interventions must be tailored to local sociocultural factors.
• Less use of chemical products is considered a relevant environmental outcome.
• Interventions must take into account the specific environmental conditions and aspects such as social mobilization activities to achieve more lasting behaviours, increase the durability of materials used, or enhance the coverage attained.
• Institutionalization must also be a key process leading to sustainability, combined with conventional routinization activities such as provision of basic sanitation services.
• Programs undertaken by local authorities may be more efficient than those developed at a more aggregated level.
• Planners could adopt a multi-disease approach to IVM.
• The community involvement approach requires sociocultural contextualization of interventions.
• Researchers could adopt a multi-disease approach to IVM.
IVM has an impact on reducing vector breeding sites and improving the entomology index, whereas evidence of health outcomes impact is limited. Social outcomes of IVM are improvement of abilities and capacities, empowerment, and community knowledge. Economic evaluations are scarce, and cost-effectiveness is dependent on disease incidence. Community capacity building is the main component of sustainability, together with a collaboration framework, institutionalization, and routinization of activities.
We would like to thank Sylvie Fontaine, public health research librarian at the University of Montreal, for her careful review of the search strategy; and Mariam Otmani del Barrio, from the Unit on Vectors, Environment and Society at TDR (Special Program for Tropical Diseases Research and Training), for her comments on our final manuscript. This study was conducted as part of the VERDAS consortium project, funded by TDR hosted by the World Health Organization (WHO) and sponsored by the United Nations Children's Fund (UNICEF), the United Nations Development Programme (UNDP), the World Bank, and WHO.
This study was funded by WHO/TDR.
CBT, SD and VR defined the research question. JMM, AO, CBT and SD identified and selected the relevant studies. JMM, CBT, AO, ST and ML extracted the data. JMM, CBT, ST and AO summarized the data and wrote the draft. JMM, CBT, AO, ST, ML, SD and VR reviewed the article and approved the final version.
The study protocol was approved by the Human Research Ethics Committee, University of Montreal.


Today, BOMB is a multi-media publishing house that creates, disseminates, and preserves artist-generated content from interviews to artists' essays to new literature. BOMB includes a quarterly print magazine, a daily online publication, and a digital archive of its previously published content from 1981 onward.
Steel's portfolio from his new 'Enlargements' series in available in the magazine's portfolio section.


Retinal detachment is serious as well as vision damaging. It occurs when the retina – the lining of the back of the eye – separates from its supportive tissue. The retina cannot function detached. Unless it is reattached quickly, the patient's vision will suffer. The retina converts light rays to impulses that travel through the optic nerve to our brain, which in turn are interpreted as the images we see. A detached retina makes this functioning impossible.
You may be experiencing a retinal detachment if you suddenly notice spots, floaters and flashes of light.
Other symptoms may include blurry vision, poor vision or a shadowy curtain coming down from the top of or across the eye from the side. These symptoms can happen gradually as the retina slowly tears away from the tissue, or very suddenly if the retina detaches immediately.
No pain is felt with retinal detachment. Experiencing any of the above symptoms requires an immediate consultation with your eye doctor. Fast treatment increases the chances of regaining loss of vision.
Sudden injury or shock to the eye or face can be a cause of a detached retina. Extremely nearsighted people can have stretched eyeballs and therefore much thinner retinas which could be prone to tearing.
Cataract surgery, eye diseases, tumors, and other systemic diseases like diabetes or sickle cell may also cause retinal detachments. New blood vessels growing under the retina which may occur with diabetic retinopathy, may separate the retina from its support tissue.
Surgery is the only effective treatment for a torn or detached retina. The procedure your doctor selects may depend on the severity and location of the tear.
Laser surgery – Photocoagulation- is typically selected for retinal breaks and tears that have not yet become retinal detachments. The surgeon directs a laser beam into your eye through the pupil to "weld" the damaged retina to its supporting tissue. Photocoagulation requires no surgical incision and causes the least irritation to the eye compared to other treatments.
Cryopexy, the surgeon applies a freeze probe to the outer surface of the eye over the area of defective retina. The scarring that occurs from the freezing reattaches the retina to its support tissue.
Pneumatic retinopexy is generally used to treat a retinal detachment in the upper half of the retina. The surgeon injects an expandable gas bubble into the eye, positioning the bubble on the torn or detached retina. As the gas bubble expands, it pushes the detached retina against its tissue base. The surgeon then may use laser photocoagulation or cryopexy to firmly reattach the retina to the tissue. The body absorbs the gas bubble after a while and precautions are advised by your doctor until that happens.
Another process of pneumatic retinopexy uses an injection of silicone oil rather than expandable gas to press the detached retina against its support tissue. In this alternative procedure, the silicone oil must be removed from the eye after the retina is reattached.
Scleral buckling is a very common surgery used to treat a retinal detachment. The surgeon places a soft silicone band around the eye, indenting the outside of the eye toward the detached retina. The band is sutured against the tough outer white coating of the eye (the sclera). The surgeon drains all fluid between the retina and its support tissue, and reattaches the retina with laser photocoagulation or cryopexy.
In many cases, detached retinas are successfully reattached with surgery. However, be aware of the risks. Your vision may not necessarily return to normal. Patients who have the best results from retinal detachment surgery are those who seek attention immediately upon noticing any symptoms. Also much easier to repair are detachments that do not involve the central retina (the macula).


Doreen filled in for Mark today and along with Ken, had a full list of guests. First was Dennis Bonilla from University of Phoenix regarding Cyber attacks. From Cucina Antica was Chef Neil Fusco with today's recipes for Pumpkin Day. CVS Health's Papatya Tankut on getting flu vaccines this year. Chris Lloyd from Lucia Capital Group was back for his weekly visit and author Hal Johnson talked about his new spooky book of tales from Lumberjacks, just in time for Halloween. Lastly was Solar Sandy in studio talking about saving money on solar.


text:
Q: How to return SAP error message in excel cell through VBA? I wrote an automation script that uses the following SAP GUI:
objSess.findById("wnd[0]").Maximize
objSess.findById("wnd[0]/tbar[0]/okcd").Text = "flqaf"
objSess.findById("wnd[0]").sendVKey 0
objSess.findById("wnd[0]").sendVKey 17
objSess.findById("wnd[1]/usr/cntlALV_CONTAINER_1/shellcont/shell").CurrentCellColumn = "TEXT"
objSess.findById("wnd[1]/usr/cntlALV_CONTAINER_1/shellcont/shell").SelectedRows = "0"
objSess.findById("wnd[1]/usr/cntlALV_CONTAINER_1/shellcont/shell").DoubleClickCurrentCell
objSess.findById("wnd[0]/usr/ctxtS_BELNR-LOW").Text = W_BPNumber
objSess.findById("wnd[0]/usr/ctxtS_BELNR-LOW").SetFocus
objSess.findById("wnd[0]/usr/ctxtS_BELNR-LOW").caretPosition = 10
objSess.findById("wnd[0]").sendVKey 8
objSess.findById("wnd[0]").sendVKey 0
objSess.findById("wnd[0]/tbar[0]/btn[3]").press

Everything works fine, however sometimes the problem aborts in SAP and exactly when that happens I want to capture it by writing the term "error" into an excel cell.
I tried adding this line in vba
objSheet.Cells(iRow, 5) = GuiStatusbar.Text

As well as
objSheet.Cells(iRow, 5) = objSessFindById("wnd[0]/sbar").Text

The code still runs fine but my cells in column 5 remain empty. Any ideas how to solve this?

A: It might help if you wait a little.
fo example:
...
objSess.findById("wnd[0]").sendVKey 0

waitTill = Now() + TimeValue("00:00:01")
While Now() < waitTill
 DoEvents
Wend

if objSess.findById("wnd[0]/sbar").messageType = "E" then 'other types: W, I, S, A
 objSheet.Cells(iRow, 5) = objSessFindById("wnd[0]/sbar").Text
end if

objSess.findById("wnd[0]/tbar[0]/btn[3]").press
...

Regards, ScriptMan

redpajama_set_name: RedPajamaStackExchange


text:
What's (something) between friends? - Idioms by The Free Dictionary
https://idioms.thefreedictionary.com/What%27s+(something)+between+friends%3f
What's (something) between friends?
This amount money is a trivial concern because we are friends. A: "Hey, let me pay my share for lunch." B: "It's okay, I'll get it. What's a few bucks between friends?"
See also: between
what's ... between friends?
(spoken) used for refusing an offer by a friend to pay you for something because the amount is small: 'I owe you €2 for that coffee.' 'Don't be silly, Steve, what's €2 between friends?'
What's (something) between friends?
What's the word?
What's up, G?
What's with someone/something?
What's your age?
What's your damage?
whataboutery
what-d'you-call-him/-her/-it/-them
whatever (one) says goes
whatever floats (one's) boat
Whatever happened to (someone or something)?
whatever turns (one) on
whatever turns you on
What'll it be?
what's (someone's) beef (with someone or something)
What's (someone's) problem?
What's (something) in aid of?
What's (something) when it's at home?
What's (up) with (someone)?
What's (up) with (something)?
What's all that about?
what's all this
what's all this in aid of?
what's all this/that?
What's biting (someone)?
What's buzzin'?
What's coming off?
what's coming to one
What's done cannot be undone
what's done is done
What's eating (someone)?
what's eating somebody?
what's eating someone
what's eating you
what's eating you?
What's eating?
what's good for the goose is good for the gander
what's got into somebody?
What You Think You See Is What You Think You Get
What You Thought You Saw, You Didn't Get
What You Type Is What You Get
What You Up To
What You Up to At the Moment?
What You Up To?
What You Wanna Talk About
What You Want Is What You Get
What You Want May Not Be What You Get
What You Want to Talk About
What You Want?
What You Wearing
What You Write Is What You Get
What You're Made Of
what you've never had you never miss
what'll
What'll you have?
what're the odds
what're the odds?
what're they playing at
what're they playing at?
what're you playing at
what're you playing at?
What's (someone's) game?
What's (someone) playing at?
What's A Nice Girl Like You
What's a Nice Girl Like You Doing in a Place Like This?
What's a spline?
what's all this?
what's become of
what's beef
what's between friends
What's between friends?
what's biting
what's biting her
what's biting her?
what's biting him
what's biting him?
what's biting me
what's biting me?
what's biting someone
what's biting someone?

redpajama_set_name: RedPajamaCommonCrawl


In the previous tutorial, encoder and decoder circuits were built using SN-7400 series logic gate ICs. The multiplexer and demultiplexer are also combinational circuits similar to encoder and decoder. A multiplexer is a circuit that accepts many inputs and channelize digital data to only one output. The combinational circuit of a multiplexer is similar to encoder with only difference that the multiplexer has select inputs that determine from which input the data should be channelized to the output. Like encoder, a multiplexer circuit can be built using AND, NOT and OR gates.
A demultiplexer functions exactly opposite of a multiplexer, i.e. a demultiplexer accepts only one input and channelize data to many outputs. The combinational circuit of demultiplexer is similar to decoder except that demultiplexer has select inputs that determine to which output line input binary data must be channelized. Like decoder, demultiplexer circuit can be built using AND gates and NOT gates.
The multiplexers are used in telephony, communication systems and computer memories. They are also used as parallel to serial data converters. The demultiplexers are used in communication systems, computers chips for connecting ALU with registers and in serial to parallel converters. In communication systems, since the data communication is always bidirectional, both multiplexer and demultiplexer are used together. In such systems, the multiplexer and demultiplexer used are designed to be compatible to each other.
In this tutorial, a 4-input multiplexer and a 4-output demultiplexer are designed. The 4-input multiplexer has 4 input lines, 2 select inputs and one data input. The 4-output demultiplexer has one data input, 2 select inputs and 4 outputs.
The multiplexer and demultiplexer are also combinational circuits. Their output depends only on the current value of inputs. Each circuit has a unique truth table from which the respective boolean expression for each output can be derived. The minimized boolean expression is then converted into logic gate diagram which is built on a breadboard using 7400 series ICs.
The IC requires a supply voltage of 5V which can be tolerated up to 5.25V. The voltage at the inputs of AND gates must be 2V for high logic and 0V for low logic. The output of the AND gates has a voltage of 3.4 V for high logic and up to 0.8 V for low logic. The IC operates on positive logic system. The propagation delay while transiting from LOW to HIGH level at the output ranges between 4 to 18 ns while propagation delay while transiting from HIGH to LOW level at the output ranges between 3 to 18 ns.
The IC requires a supply voltage of 5V which can be tolerated up to 7V. The voltage at the inputs of OR gates must be 2V for high logic and 0V for low logic. The output of the OR gates has a voltage of 3.4 V for high logic and 0.35 V for low logic. The IC operates on positive logic system. The propagation delay while transiting from LOW to HIGH level at the output comes 3 to 15 ns while propagation delay while transiting from HIGH to LOW level at the output also comes 3 to 15 ns.
The IC requires a supply voltage of 5V which can be tolerated up to 7V. The voltage at the inputs of NOT gates must be 2V for high logic and 0.8 V for low logic. The output of the NOT gates have a voltage of 3.4 V for high logic and 0.2 V for low logic. The IC operates on positive logic system. The propagation delay while transiting from LOW to HIGH level at the output is 22 ns while propagation delay while transiting from HIGH to LOW level at the output is 15 ns.
It must be noted that the selected ICs have compatible input, output and supply voltage levels as they are taken from a common family (74XX series) of digital ICs.
From the truth table, the multiplexer can be constructed using AND gates, NOT gates and OR gates. Since there are two select pins and data from each input is routed through one AND gate, 3-input AND gates are required for the circuit. Here, for constructing the multiplexer circuit, 7404 IC for NOT gate, 7411 IC for AND gate and 7432 IC for OR gate are used.
Communication systems – Communication system is a set of system that enables communication between two points or locations like transmission system, relay and tributary station, and communication networks. The efficiency of communication system can be increased considerably using multiplexer. Multiplexer allows the process of transmitting different type of data such as audio, video at the same time using a single transmission line.
Telephone network – In telephone networks, multiple audio signals are integrated on a single line for transmission with the help of multiplexers. In this way, multiple audio signals can be isolated and eventually, the desired audio signals reach the intended recipient.
Computer memories – Multiplexers are used to implement huge amount of memory into the computer systems by reducing the number of copper lines required to connect the memory to other parts of the computer circuit at the same time.
Transmission from the computer system of a satellite – Multiplexer can be used for the transmission of data signals from the computer system of a satellite or spacecraft to the ground system using the GPS (Global Positioning System) satellites.
Demultiplexer - The function of a Demultiplexer is opposite to multiplexer function. It takes information from one line and distributes it to a given number of output lines. For this reason, the demultiplexer is also known as a data distributor. A decoder can also be used as demultiplexer.
From the truth table, the demultiplexer can be constructed using AND gates and NOT gates. Since there are two select pins and one data input, 3-input AND gates are required for the circuit. Here, for constructing the demultiplexer circuit, 7404 IC for NOT gate and 7411 IC for AND gates are used.
Communication Systems – Communication systems use multiplexer to carry multiple data like audio, video and other form of data using a single line for transmission. This process makes the transmission easier. The demultiplexer receives the output signals of the multiplexer and converts them back to the original form of the data at the receiving end. The multiplexer and demultiplexer work together to carry out the process of transmission and reception of data in a communication system.
ALU (Arithmetic Logic Unit) – In an ALU circuit, the output of ALU can be stored in multiple registers or storage units with the help of demultiplexer. The output of ALU is fed as the data input to the demultiplexer. Each output of demultiplexer is connected to multiple registers where data can be stored in them.
Serial to Parallel Converter – A serial to parallel converter is used for reconstructing parallel data from incoming serial data stream. In this technique, serial data from the incoming serial data stream is given as data input to the demultiplexer at the regular intervals. A counter is attaching to the control input of the demultiplexer. This counter directs the data signal to the output of the demultiplexer where these data signals are stored. When all data signals have been stored, the output of the demultiplexer can be retrieved and read out in parallel.
The circuits designed above can be tested by giving supply voltage to the ICs by a battery via 7805 voltage regulator. The same voltage can be dropped to 2V level using a variable resistor for HIGH logic while providing LOW logic through ground. The output signals can be checked by connecting LEDs at the output pins of each combinational circuit. The circuits can be checked by verifying truth tables for each circuit.
In the next tutorial, learn about sequential logic circuits.


or thank loyal customers with your heartfelt message printed on the wraps.
I would like someone to contact me with more information regarding Loyalty Marketing with Candy from BizGrams, Promotional Candy. I saw it in the Target Marketing Directory.


text:
Across the Table with Tony Lucca
Growing up, Tony Lucca wasn't the child that used music as an escape or dreamed of being a rockstar to land the hearts of girls in his math class. He was raised in Detroit, surrounded by a family of musicians and had his first paid gig was with his cousin, Cole Garlak, when they were just twelve years old.
"It was so easy to imagine music as a career from that point forward," Tony expressed, looking back on his first shows with Cole. "We were too young to realize it had anything to do with girls, but smart enough to know it was more than a hobby."
It's clear when talking with Tony that he is comfortable in a lane of his own. He may be on the same road as other artists, but he's forging ahead in the fast lane, constantly switching up his stylization to reflect the panel of musicians that inspire him daily.
"I like to think that instead of being inspired by one person, I have a panel of judges. The Judicial Branch of my musical career, if you will," he joked. "That branch would consist of Jeff Tweedy, Jonie Mitchell, Miles Davis," he motioned to the speaker on the ceiling where Miles' trumpeting was warmly coming through, "since he's here with us.
Now, you won't see shades of these people in my music. Instead, I'll refer to their careers when I'm stuck on ideas with mine. 'What would they do?' I'll sometimes ask myself. A lot of the time, songwriting is about painting pictures and making it rhyme. Most of the time, you find you have to just get out of your own damn way."
Tony's discography includes ten studio albums, and nine E.P.'s, so it's safe to say when he's not keeping busy out on the road – he's writing.
Tony says his songwriting is a mixture of "ideas out of nowhere" and "co-writes where you work to tell someone else's story."
"There are those moments where you have to grab your phone and record a voice memo because something comes to you. You can't turn it on or off. A song can have any kind of influence, chemical or otherwise and it's really a discipline to refine it.
You have to allow yourself to write whatever comes into your mind. I tend to be influenced a lot by what I listen to. God forbid I hear something I like!" He laughed. "I'm a musical chameleon in the sense that if I listen to something enough, I can morph my sound into it and sometimes I have to be careful with that. But you never want to shut out an idea. Sometimes I'll be writing a song that pretty soon sounds a lot like a Pop track and I'll picture Tweedy putting out his cigarette and leaving the room. You just have to let it happen."
Tony's musical upbringing hit new heights when he was a cast member on The All New Mickey Mouse Club with cast mates such as Justin Timberlake and Christina Aguilera, who he would later sing for when he finished third on The Voice in 2012 (winning a record deal in the process).
Tony & Christina on set of The All New Mickey Mouse Club
"I wouldn't say I rely on the relationships I made from my time on that show," he responded when I asked if his fellow clubhouse celebrities have come in handy throughout his career, "I trust in them. It's actually the relationships with lesser well-known artists that you rely on because you're available a lot more to help one another out. As far as my fellow-cast-mates though, we flirt with the idea of a reunion quite a bit. I never understood reunions until I went to my twenty-year high school one and then I thought, 'now I see why you do this.' With the show, it would be a lot harder because press would be involved and things like that, so unless the crew got together and organized it, I don't think it would happen."
As for his time on The Voice, Tony describes it all as being an act of "timing."
"I was in-between projects and the opportunity had presented itself before at a time where I didn't feel ready. I thought to myself 'how long are you going to sit on the sidelines and kick yourself once this opportunity passes you by.' There was a crossroads on my domestic-front, moving from L.A. a few years prior, and I thought my work finally spoke for itself. I entered the show with a clear heart and an urge to share my music."
As a fan, you'd probably think this was the pinnacle of Tony's career, but he has other thoughts;
"The show still, to this day, has a lot to prove. I'm grateful for my time on it, but I don't think I ever really see anything as a pinnacle because I'm always striving for more. Playing the Beatles' with Adam Levine, it was awesome! Singing at the Packers vs. Lions, Thanksgiving Day Game – incredible! A sold out birthday show – even better! But I just take them as once-in-a-lifetime experiences and move on to the next best thing. In a non-jaded way," he laughed.
Even with such a large repertoire of songs, I imagined that Tony wouldn't be a lot like other artists who insist all songs are like their children and they can never choose a favorite (well, that coupled with the fact that Tony has a very honest perspective and doesn't really filter what he says). I was right.
"Usually the most recent of my songs becomes my favorite. It resonates with me the most. When I listen back to Canyon Songs, which has it's tenth anniversary this year, I can remember where I was coming from at that time and feel it all again." I compared it to looking back at old photos and Tony couldn't have agreed more. "Ryan Adams, another one of my favorites, said it best in a tweet that he wrote to celebrate the fifteenth anniversary of, Heartbreaker. He said something about 'while it's a naive record, I still love ya' and that's genuinely how you feel listening back to old work," Tony confessed.
Tony has been on tour with Kelly Clarkson, Maroon 5 and *NSYNC to name a few, not to mention his fellow Hotel Cafe kin including Josh Kelley, Sara Bareilles and Joey Ryan of the Milk Carton Kids (who's song "Michigan" will forever have my heart).
"Have you ever been to NYC?" Tony asked me, before going onto describe the difference between large tours and smaller, more intimate ones. "NYC is jaw-dropping," he went on. "We're talking dream-like proportions. There are canyons of high rises and you're so grateful to be there, but you feel so small. I lived there for a while and I remember there would be moments I would think 'what am I doing here? What can I physically do here?'" I knew exactly what he meant. One of those I-hope-you still-feel-small-when-you-stand-beside-the-ocean moments. "That's how it feels like being on a large your," he said. "You get a sense of being at a carnival. You try to be respectful and avoid your headliners camps and there's a sense of pressure for everyone involved where it really feels like a job. Smaller scale shows are unique. You break a string, or forget the words and the show suddenly has character. You improvise. There's no room for that on a large tour."
Tony's self-titled album was released in 2015 and encompasses twelve brand-new songs. Check out a track-by-track review here. The album came about through collaboration with his fans, in an ode to his crowd-funding campaigns and those that supported him enough to raise his original kick-starter goal of $25K in a matter of thirty hours. In one word, he describes the album as "rejuvenating."
"I truly felt like a storyteller and," he looked as if he came to a small revelation, "I would describe it as a pinnacle of my career for sure. It was refreshing to tell something that belonged to someone else and share their story for them."
With over twenty years in his musical career, Tony is an artist who knows himself. I have no doubt that Tony will continue to tell stories, while adding to his own, and I think we're all lucky souls to be able to share in that process.
I currently have this on repeat, but you can fall in love with your own:
Posted in Across the TableTagged adam levine, album, album review, artist interview, coffee talk, football performance, jonie mitchel, justin timberlake, kelly clarkson, mickey mouse club, music, music blog, music talk, Nashville blog, nashville music, new music, rob thomas, skye media, thanksgiving day game, the beatles, the voice, tony lucca, tony lucca music, tweedyBy Shannon W1 Comment
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text:
Graduate students in the Department of Pharmacology enter through the UT Southwestern Graduate School of Biomedical Sciences. All students (except those in the Medical Scientist Training Program) take a core curriculum the first year and perform laboratory rotations. They then select a laboratory in which to carry out their doctoral research. Any faculty member in the Department who has an appointment in the Graduate School can serve as a training mentor.
Graduate students are free to join any of the 10 graduate programs, regardless of laboratory mentor. Qualifying exams are taken in the second year, after which students advance to candidacy. Students generally work in labs for an additional two to four years before receiving their Ph.D. See Resources for Graduate Students at UT Southwestern for more information about graduate student training at UT Southwestern.
Graduate training in the Pharmacological Sciences may be integrated with any of the graduate programs. The curriculum includes high-level, specialized courses and a journal club. The Department of Pharmacology has been the recipient of a predoctoral training grant in Pharmacological Sciences from the National Institute of General Medical Services (National Institutes of Health) for more than three decades.
The Alfred Gilman Memorial Student Award for Excellence in Research is awarded every year by the Department of Pharmacology to honor the scientific achievements of a senior student in the Department. The award comes with a monetary prize and a name placard that is displayed outside the Department of Pharmacology's office.
The Department of Pharmacology is currently home to around 50 postdoctoral scholars. Please check below for postdoctoral positions currently available. See Postdoctoral Training Opportunities for more information about postdoctoral training at UT Southwestern.
Pharmacology Faculty
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Navy Inquiry Faults Two Top Officers Aboard Roosevelt for Handling of Virus
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WASHINGTON — The 2 high officers aboard the plane service Theodore Roosevelt made poor choices in response to the outbreak of the coronavirus onboard the warship, based on the ultimate outcomes of a Navy inquiry launched Friday.
Because of the findings, Capt. Brett E. Crozier won't be restored to command of the virus-stricken ship, and his boss onboard, Rear. Adm. Stuart P. Baker, may have his promotion to two-star admiral placed on maintain.
There shall be no different punitive motion taken in opposition to Captain Crozier.
The conclusions of the investigation have been introduced by Navy Secretary Kenneth Braithwaite and Adm. Michael M. Gilday, the chief of naval operations, at a Pentagon information convention.
"They didn't do sufficient, quickly sufficient," Admiral Gilday instructed reporters, referencing each Captain Crozier and Admiral Baker's preliminary efforts to fight the sickness because the ship pulled into Guam.
"If Captain Crozier was nonetheless in command I might be relieving him," Admiral Gilday mentioned.
The selections mark a reversal for Admiral Gilday, who beforehand had beneficial to his Pentagon superiors that command of the Roosevelt be returned to Captain Crozier, who was relieved in April after he pleaded for extra assist preventing the coronavirus outbreak aboard his ship in an e-mail that finally leaked to the media.
The occasions surrounding Captain Crozier, who has been viewed as a hero by his crew for placing their lives above his profession, had seized the eye of the Navy, the navy and even a nation scuffling with the coronavirus.
Admiral Gilday was fast to distance Captain Crozier's preliminary e-mail from the investigation's last consequence, regardless of it finally ending the captain's profession.
Admiral Gilday as an alternative targeted on a sequence of Captain Crozier's choices because the Roosevelt pulled into Guam, particularly that he weighed ready for lodge rooms on Guam as an alternative of speeding the crew to cramped housing on base.
The three-month saga of the Theodore Roosevelt additionally presents a window into how the navy has tried to regulate to the needs of an unpredictable commander-in-chief. Captain Crozier was fired partially due to fears that President Trump needed him gone, and never understanding how the president feels about reinstating the captain has solid a shadow over the Navy's actions ever since.
In an ill-advised try to manage a rapidly deteriorating public affairs catastrophe after the firing of Captain Crozier, Thomas B. Modly, the performing Navy secretary on the time, flew 8,000 miles to Guam.
Onboard the Roosevelt, he delivered a 15-minute tirade on the crew that, as soon as it leaked, infuriated members of Congress, navy households and even senior Protection Division civilians and navy officers. Mr. Modly was forced to resign.
After a weekslong quarantine in Guam, the Roosevelt resumed operations within the Philippine Sea this month. The 4,600 crew members — minus 200 sailors who stayed behind to recuperate from the coronavirus and have been finally flown to the USA — assumed they might be house someday in July, the scheduled finish of their six-month-long deployment.
However simply days earlier than their departure from the island, sailors have been instructed their deployment had been prolonged.
Up to date June 16, 2020
I've heard a few therapy known as dexamethasone. Does it work?
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, based on scientists in Britain. The drug seems to scale back irritation brought on by the immune system, defending the tissues. Within the examine, dexamethasone lowered deaths of sufferers on ventilators by one-third, and deaths of sufferers on oxygen by one-fifth.
What's pandemic paid depart?
The coronavirus emergency relief package provides many American staff paid depart if they should take break day due to the virus. It provides certified staff two weeks of paid sick depart if they're unwell, quarantined or looking for analysis or preventive look after coronavirus, or if they're caring for sick members of the family. It provides 12 weeks of paid depart to folks caring for kids whose faculties are closed or whose baby care supplier is unavailable due to the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and contains individuals who don't usually get such advantages, like part-time and gig economic system staff. However the measure excludes at the very least half of private-sector staff, together with these on the nation's largest employers, and provides small employers important leeway to disclaim depart.
Does asymptomatic transmission of Covid-19 occur?
Thus far, the proof appears to indicate it does. A broadly cited paper revealed in April means that persons are most infectious about two days earlier than the onset of coronavirus signs and estimated that 44 p.c of latest infections have been a results of transmission from individuals who weren't but exhibiting signs. Just lately, a high knowledgeable on the World Well being Group said that transmission of the coronavirus by individuals who didn't have signs was "very uncommon," but she later walked back that statement.
What's the danger of catching coronavirus from a floor?
Touching contaminated objects after which infecting ourselves with the germs will not be usually how the virus spreads. However it could actually occur. A quantity of studies of flu, rhinovirus, coronavirus and different microbes have proven that respiratory diseases, together with the brand new coronavirus, can unfold by touching contaminated surfaces, notably in locations like day care facilities, workplaces and hospitals. However an extended chain of occasions has to occur for the illness to unfold that means. One of the best ways to guard your self from coronavirus — whether or not it's floor transmission or shut human contact — continues to be social distancing, washing your palms, not touching your face and carrying masks.
How does blood sort affect coronavirus?
A examine by European scientists is the primary to doc a powerful statistical hyperlink between genetic variations and Covid-19, the sickness brought on by the coronavirus. Having Type A blood was linked to a 50 p.c enhance within the probability {that a} affected person would wish to get oxygen or to go on a ventilator, based on the brand new examine.
How many individuals have misplaced their jobs as a result of coronavirus within the U.S.?
The unemployment charge fell to 13.three p.c in Might, the Labor Division mentioned on June 5, an sudden enchancment within the nation's job market as hiring rebounded sooner than economists anticipated. Economists had forecast the unemployment charge to extend to as a lot as 20 p.c, after it hit 14.7 p.c in April, which was the very best for the reason that authorities started conserving official statistics after World Warfare II. However the unemployment charge dipped as an alternative, with employers including 2.5 million jobs, after greater than 20 million jobs have been misplaced in April.
Will protests set off a second viral wave of coronavirus?
Mass protests in opposition to police brutality which have introduced hundreds of individuals onto the streets in cities throughout America are elevating the specter of latest coronavirus outbreaks, prompting political leaders, physicians and public well being consultants to warn that the crowds could cause a surge in cases. Whereas many political leaders affirmed the best of protesters to specific themselves, they urged the demonstrators to put on face masks and preserve social distancing, each to guard themselves and to forestall additional group unfold of the virus. Some infectious illness consultants have been reassured by the truth that the protests have been held open air, saying the open air settings may mitigate the danger of transmission.
My state is reopening. Is it protected to exit?
States are reopening bit by bit. Which means extra public areas can be found to be used and an increasing number of companies are being allowed to open once more. The federal authorities is essentially leaving the choice as much as states, and a few state leaders are leaving the choice as much as native authorities. Even when you aren't being instructed to remain at house, it's nonetheless a good suggestion to restrict journeys outdoors and your interplay with different folks.
What are the signs of coronavirus?
Widespread signs include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. A few of these signs overlap with these of the flu, making detection troublesome, however runny noses and stuffy sinuses are much less widespread. The C.D.C. has also added chills, muscle ache, sore throat, headache and a brand new lack of the sense of style or odor as signs to look out for. Most individuals fall unwell 5 to seven days after publicity, however signs might seem in as few as two days or as many as 14 days.
How can I defend myself whereas flying?
If air journey is unavoidable, there are some steps you can take to protect yourself. Most essential: Wash your palms typically, and cease touching your face. If potential, select a window seat. A study from Emory University discovered that in flu season, the most secure place to sit down on a airplane is by a window, as folks sitting in window seats had much less contact with probably sick folks. Disinfect onerous surfaces. While you get to your seat and your palms are clear, use disinfecting wipes to scrub the onerous surfaces at your seat like the top and arm relaxation, the seatbelt buckle, the distant, display screen, seat again pocket and the tray desk. If the seat is difficult and nonporous or leather-based or pleather, you possibly can wipe that down, too. (Utilizing wipes on upholstered seats may result in a moist seat and spreading of germs reasonably than killing them.)
Ought to I put on a masks?
The C.D.C. has recommended that every one People put on material masks in the event that they exit in public. It is a shift in federal steering reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Till now, the C.D.C., just like the W.H.O., has suggested that peculiar folks don't have to put on masks except they're sick and coughing. A part of the rationale was to protect medical-grade masks for well being care staff who desperately want them at a time when they're in repeatedly brief provide. Masks don't substitute hand washing and social distancing.
What ought to I do if I really feel sick?
If you've been exposed to the coronavirus or think you have, and have a fever or signs like a cough or issue respiratory, name a physician. They need to provide you with recommendation on whether or not try to be examined, the way to get examined, and the way to search medical therapy with out probably infecting or exposing others.
For the way lengthy stays unclear — though one crew member mentioned that it almost certainly needed to do with the Navy's need to concurrently deploy three nuclear-powered carriers within the Western Pacific for a symbolic present of American would possibly and a photograph op.
This sentiment was echoed in an announcement to the crew by the interim skipper, Capt. Carlos Sardiello, simply earlier than the ship departed from Guam. Broadcast from the ship's loudspeakers, Captain Sardiello known as the Roosevelt a "image" to the free world, and its overcome the novel coronavirus a monumental feat.
However the Roosevelt continues to be preventing to vary its luck.
Two F/A-18F Tremendous Hornet aviators have been pressured to eject whereas conducting routine flight operations on the Philippine Sea on Thursday, the Navy mentioned in a statement. Each aviators have been rapidly rescued and are in good situation, however the $64.three million assault airplane was misplaced to the depths. An investigation is underway.
— to www.nytimes.com
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El color de las nubes és una pel·lícula espanyola de 1997 escrita i dirigida per Mario Camus.

Argument
La història gira entorn del vell casalot càntabre que Donya Lola reivindica davant els requeriments de propietat del ric hereu del seu difunt amant. S'entrellacen les vides de nens i adults en un univers hostil: un vell fuster de ribera i un pescador furtiu que troba una partida de droga, una jove relacionada amb productes ecològics, un advocat que la festeja, un nen espanyol que es fa passar per bosnià, una colla de traficants..., aflorant la solidaritat d'uns i la voracitat d'uns altres.

Repartiment
 Julia Gutiérrez Caba: Lola
 Ana Duato: Tina
 Antonio Valero: Valerio
 Josep Maria Domènech: Colo
 Simón Andreu: Quiroga
 Pedro Barrejón: Bartolomé
 Adis Suijic: Mirsad
 Ramón Langa: Mateo
 Manuel Zarzo: Pedro
 Tito Valverde: José María
 Blanca Portillo: Madre
 Miguel Arribas: Ex policía
 Antonio Dechent: Conductor
 Joaquín Climent: Padre
 Fabiola Toledo: Presentadora

Palmarès cinematogràfic
XII Premis Goya

Medalles del Cercle d'Escriptors Cinematogràfics

VII Premis de la Unión de Actores

Referències

Pel·lícules d'Espanya del 1997

redpajama_set_name: RedPajamaWikipedia


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PSP Investments ranks as a Montréal Top Employer for a third consecutive year
MONTRÉAL, CANADA, January 30, 2020 – The Public Sector Pension Investment Board (PSP Investments) is proud to have been named as one of Montréal's Top Employers for 2020. The growing pension investment manager, whose primary business offices are located in Montréal, has been recognized as one of the city's best places to work for a third consecutive year.
"We are honoured by this recognition which reinforces our reputation as an investor that spots the edge," said Neil Cunningham, President and Chief Executive Officer, at PSP Investments. "As we complete two decades of operations, our focus on creating an exceptional workplace drives our investment efforts on behalf of contributors and beneficiaries who dedicated their careers to serving Canada."
With $168 billion in assets under management and offices in Ottawa, Montréal, New York, London and Hong Kong, PSP Investments is committed to employing world-class practices to support its expanding global workforce. The company's application was judged on the basis of eight criteria: physical workplace; work atmosphere and social; training and skills development; employee communications; performance management and community involvement.
"Our people are at the root of our employee experience and investment successes. They help us reinforce a strong work culture that encourages authenticity, relationship building and diverse perspectives," said Giulia Cirillo, Senior Vice President and Chief Human Resources and Global Communications Officer, at PSP Investments. "As we continue to grow our global investments and geographical footprint, we maintain a strong commitment to inclusion and diversity. Through the activities of our i&D Council, its eight affinity groups and 100 direct contributors, we are co-creating a dynamic and innovative work environment across three continents."
The Public Sector Pension Investment Board (PSP Investments) is one of Canada's largest pension investment managers with CAD$168 billion of net assets as at March 31, 2019. It manages a diversified global portfolio composed of investments in public financial markets, private equity, real estate, infrastructure, natural resources and private debt. Established in 1999, PSP Investments manages net contributions to the pension funds of the federal Public Service, the Canadian Forces, the Royal Canadian Mounted Police and the Reserve Force. Headquartered in Ottawa, PSP Investments has its principal business office in Montréal and offices in New York, London and Hong Kong. For more information, visit investpsp.com or follow us on Twitter and LinkedIn.
Maria Constantinescu
Email: media@investpsp.ca
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Q: Are C# Collections value types or reference Types? I am busy learning C# here, Are C# Collections value types or reference Types?, Since Arrays a reference types and I know Strings are reference types as well.
Thank You.

A: You could create a value type collection (so a struct MyCollection<T> : IEnumerable<T>), but it would be nearly useless (because you could make it read-only, and it would be simple, or you could try to make it mutable, but it would be very difficult to make it "value-type" copiable, so that a copy of the collection is a distinct entity from the original) (and note that it would be still nearly useless, because if you use a value type through one if its interfaces, you normally box it). So in the end, don't :-)
All the .NET "stock" collections that I can remember are reference types. So arrays, List<>, ArrayList, Dictionary<,>, ...


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Madison Jr High Cheerleaders Compete at Blackfoot Stampede Cheer Competition
9th grade cheer team
Written By: Brinlee Lords
On Saturday, December 11, 2021, your Madison Jr. High cheerleaders competed in Blackfoot at the First Annual Blackfoot Stampede Show-down. The 7th-8th grade squad competed against five other cheer teams and placed 3rd in the show division. Although some stunts were wobbly when the girls competed, the single stunts hit, and the group stunt hit. While we tumbled, some girls touched the mat after their tumble pass, making us lose points.
Liv Hacking, cheer captain for 8th-grade, states, "Nobody is perfect but, that is what's so perfect about them." Turning awards flyer and 8th-grade captain Liv Hacking did the tumble off and got 3rd. All the girls did an excellent job.
The 9th grade competed against two teams in show and three teams in pom. They placed 2nd in show and in pom they got 3rd. They did great! A couple of girls missed their tumbling pass, but other than that, they were together. Sid Stoddard, captain of the 9th-grade team, states, "The after hair was worse than the routine."
All these girls have put in a lot of time and effort to prepare for these competitions.
Ludy Navarrete states, "I am so, so proud of the teams and their performances at our first competition at Blackfoot Stampede. We have been battling injuries and illness and our girls performed like campions. They overcame a lot of challenges and came together and left everything on the mat. MJH cheer will only get better from here. #Gocats!" Lots of the girls have gone through different kinds of pains and tears.
They have two more competitions coming up after Christmas break, Upper Valley Classic held at the Madison High School January 7-8th, 2022, Cupids held by Highland High School January 14, 2022, Possible Performance on January 29, 2022, held by Bonneville High School.
We are all so grateful for our coaches Ludy Navarrete and her daughter Lex Navarrete. They have done so much to make us girls a team. They are great leaders and examples to all of us, we have come so far with these coaches and have grown a bond that will never be broken. We all just wanted our coaches to know how much we care about them and how much they have done for us.


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The Poorest County in Each State
Thomas C. Frohlich
Last Updated: December 4, 2019 7:16 am
1. Sumter County, Alabama
> County median household income, 2009-2013: $22,186
> State median household income, 2009-2013: $43,253
> Poverty rate, 2009-2013: 38.0%
> Unemployment, 2013: 9.9%
Alabama had a median annual household income of $43,253 over the five years through 2013, one of the lowest in the nation. A typical Sumter County household earned barely more than half of that figure, with a median annual household income of $22,186 between 2009 and 2013. Sumter County also had one of the nation's highest poverty rates. Between 2009 and 2013, 38% of residents lived in poverty, versus the comparable national poverty rate of 15.4%.
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2. Bethel Census Area, Alaska
> Unemployment, 2013: 15.4%
A typical household in Bethel — the poorest part of Alaska — earned nearly $52,000 annually between 2009 and 2013. While this figure was over $19,000 lower than the state's median household income, Bethel households did not earn much less than a typical American household. Bethel's unemployment rate, on the other hand, was quite high, at 15.4% in 2013.
3. Apache County, Arizona
Residents of Arizona's poorest county clearly struggled with poverty over the five years through 2013. Apache County's poverty rate of more than 36% was more than double the national rate of 15.4% and one of the highest among the states' poorest counties. Apache also had one of the highest unemployment rates in 2013, at nearly 20%.
4. Lee County, Arkansas
During the five years through 2013, Arkansas had a median annual household income of less than $41,000, lower than in every state except for Mississippi. A typical household in Lee County, the state's poorest, earned nearly $16,000 less than the statewide figure. As in other poor counties, Lee residents had relatively low educational attainment rates. Just 7.1% of adults had completed at least a bachelor's degree between 2009 and 2013, and 70.1% had finished at least high school, some of the lower rates among the 50 counties reviewed.
ALSO READ: The Most Dangerous States in America
5. Lake County, California
As in many low-income areas, California's Lake County had a relatively high poverty rate. The county's poverty rate between 2009 and 2013 was 25%, versus a national rate of 15.4%. More than 35% of children were estimated to be living in poverty over that period as well, considerably higher than the national rate of 21.3%.
Read more: Special Report, featured, U.S. Bureau of Labor Statistics, U.S. Census Bureau, unemployment
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