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Purpose: The 2014 outbreak of Ebola virus disease (EVD) in West Africa was the largest in history. Starting in September 2014, International Medical Corps (IMC) operated five Ebola treatment units (ETUs) in Sierra Leone and Liberia. This paper explores how future infectious disease outbreak facilities in resource-limited settings can be planned, organized, and managed by analyzing data collected on water, sanitation, and hygiene (WASH) and infection prevention control (IPC) protocols. Design/Methodology/Approach: We conducted a retrospective cohort study by analyzing WASH/IPC activity data routinely recorded on paper forms or white boards at ETUs during the outbreak and later merged into a database from two IMC-run ETUs in Sierra Leone between December 2014 and December 2015. Findings: The IMC WASH/IPC database contains data from over 369 days. Our results highlight parameters key to designing and maintaining an ETU. High concentration chlorine solution usage was highly correlated with both daily patient occupancy and high-risk zone staff entries; low concentration chlorine usage was less well explained by these measures. There is high demand for laundering and disinfecting of personal protective equipment (PPE) on a daily basis and approximately 1 (0–4) piece of PPE is damaged each day. Research limitations/Implications: Lack of standardization in the type and format of data collected at ETUs made constructing the WASH/IPC database difficult. However, the data presented here may help inform humanitarian response operations in future epidemics. [ABSTRACT FROM AUTHOR]

The expansion of the human species out of Africa in the Pleistocene, and the subsequent development of agriculture in the Holocene, resulted in waves of linguistic diversification and replacement across the planet. Analogous to the growth of populations or the speciation of biological organisms, languages diversify over time to form phylogenies of language families. However, the dynamics of this diversification process are unclear. Bayesian methods applied to lexical and phonetic data have created dated linguistic phylogenies for 18 language families encompassing ~3,000 of the world’s ~7,000 extant languages. In this paper we use these phylogenies to quantify how fast languages expand and diversify through time both within and across language families. The overall diversification rate of languages in our sample is ~0.001 yr-1 (or a doubling time of ~700 yr) over the last 6,000 years with evidence for nonlinear dynamics in language diversification rates over time, where both within and across language families, diversity initially increases rapidly and then slows. The expansion, evolution, and diversification of languages as they spread around the planet was a non-constant process. [ABSTRACT FROM AUTHOR]

Background: The Ghana Health Service in collaboration with partner institutions implemented a five-year primary health systems strengthening program known as the Ghana Essential Health Intervention Program (GEHIP). GEHIP was a plausibility trial implemented in an impoverished region of northern Ghana around the World Health Organizations (WHO) six pillars combined with community engagement, leadership development and grassroots political support, the program organized a program of training and action focused on strategies for saving newborn lives and community-engaged emergency referral services. This paper analyzes the effect of the GEHIP program on child survival. Methods: Birth history data assembled from baseline and endline surveys are used to assess the hazard of child mortality in GEHIP treatment and comparison areas prior to and after the start of treatment. Difference-in-differences (DiD) methods are used to compare mortality change over time among children exposed to GEHIP relative to children in the comparison area over the same time period. Models test the hypothesis that a package of systems strengthening activities improved childhood survival. Models adjusted for the potentially confounding effects of baseline differentials, secular mortality trends, household characteristics such as relative wealth and parental educational attainment, and geographic accessibility of clinical care. Results: The GEHIP combination of health systems strengthening activities reduced neonatal mortality by approximately one half (HR = 0.52, 95% CI = 0.28,0.98, p = 0.045). There was a null incremental effect of GEHIP on mortality of post-neonate infants (from 1 to 12 months old) (HR = 0.72; 95% CI = 0.30,1.79; p = 0.480) and post-infants (from 1 year to 5 years old) -(HR = 1.02; 95% CI = 0.55–1.90; p = 0.940). Age-specific analyses show that impact was concentrated among neonates. However, effect ratios for post-infancy were inefficiently assessed owing to extensive survival history censoring for the later months of childhood. Children were observed only rarely for periods over 40 months of age. Conclusion: GEHIP results show that a comprehensive approach to newborn care is feasible, if care is augmented by community-based nurses. It supports the assertion that if appropriate mechanisms are put in place to enable the various pillars of the health system as espoused by WHO in rural impoverished settings where childhood mortality is high, it could lead to accelerated reductions in mortality thereby increasing survival of children. Policy implications of the pronounced neonatal effect of GEHIP merit national review for possible scale-up. [ABSTRACT FROM AUTHOR]

Ghana has made significant stride towards universal health coverage (UHC) by implementing the National Health Insurance Scheme (NHIS) in 2003. This paper investigates the progress of UHC indicators in Ghana from 1995 to 2015 and makes future predictions up to 2030 to assess the probability of achieving UHC targets. National representative surveys of Ghana were used to assess health service coverage and financial risk protection. The analyses estimated the coverage of 13 prevention and four treatment service indicators at the national level and across wealth quintiles. In addition, we calculated catastrophic health payments and impoverishment to assess financial hardship and used a Bayesian regression model to estimate trends and future projections as well as the probabilities of achieving UHC targets by 2030. Wealth-based inequalities and regional disparities were also assessed. At the national level, 14 out of the 17 health service indicators are projected to reach the target of 80% coverage by 2030. Across wealth quintiles, inequalities were observed amongst most indicators with richer groups obtaining more coverage than their poorer counterparts. Subnational analysis revealed while all regions will achieve the 80% coverage target with high probabilities for the prevention services, the same cannot be applied to the treatment services. In 2015, the proportion of households that suffered catastrophic health payments and impoverishment at a threshold of 25% non-food expenditure were 1.9% (95%CrI: 0.9–3.5) and 0.4% (95%CrI: 0.2–0.8), respectively. These are projected to reduce to 0.4% (95% CrI: 0.1–1.3) and 0.2% (0.0–0.5) respectively by 2030. Inequality measures and subnational assessment revealed that catastrophic expenditure experienced by wealth quintiles and regions are not equal. Significant improvements were seen in both health service coverage and financial risk protection over the years. However, inequalities across wealth quintiles and regions continue to be cause of concerns. Further efforts are needed to narrow these gaps. [ABSTRACT FROM AUTHOR]

Background: A community’s cultural beliefs, attitudes and discourse can affect their responses in surveys. Knowledge of these cultural factors and how to comply with them or adjust for them during data collection can improve data quality. Objective: This study describes implications of features of Gambian culture related to women’s reproductive health, and mortality, when collecting data in surveys. Methods: 13 in-depth interviews of female interviewers and a focus group discussion among male interviewers were conducted in two rural health and demographic surveillance systems as well as three key informant interviews in three regions in The Gambia. Results: From the fieldworker’s viewpoint, questions relating to reproduction were best asked by women as culturally pregnancies should be concealed, and menstruation is considered a sensitive topic. Gambians were reluctant to speak about decedents and the Fula did not like to be counted, potentially affecting estimation of mortality. Asking about siblings proved problematic among the Fula and Serahule communities. Proposals made to overcome these challenges were that culturally-appropriate metaphors and symbols should be used to discuss sensitive matters and to enumerating births/deaths singly instead of collecting summary totals, which had threatening connotations. This was as opposed to training interviewers to ask standardised and precise verbatim questions. Contribution: This paper presents indigenous Gambian solutions by fieldworkers to culturally sensitive topics when collecting pregnancy outcomes and mortality data in demographic and health surveys. For researchers collecting maternal mortality data, it highlights the potential shortcomings of the sibling history methodology. [ABSTRACT FROM AUTHOR]

To diagnose ≥90% HIV-infected residents (diagnostic coverage), the Bukoba Combination Prevention Evaluation (BCPE) implemented provider-initiated (PITC), home- (HBHTC), and venue-based (VBHTC) HIV testing and counseling (HTC) intervention in Bukoba Municipal Council, a mixed urban and rural lake zone community of 150,000 residents in Tanzania. This paper describes the methods, outcomes, and incremental costs of these HTC interventions. PITC was implemented in outpatient department clinics in all eight public and three faith-based health facilities. In clinics, lay counselors routinely screened and referred eligible patients for HIV testing conducted by HTC-dedicated healthcare workers. In all 14 wards, community teams offered HTC to eligible persons encountered at 31,293 home visits and at 79 male- and youth-frequented venues. HTC was recommended for persons who were not in HIV care or had not tested in the prior 90 days. BCPE conducted 133,695 HIV tests during the 2.5 year intervention (PITC: 88,813, 66%; HBHTC: 27,407, 21%; VBHTC: 17,475, 13%). Compared with other strategies, PITC conducted proportionally more tests among females (65%), and VBHTC conducted proportionally more tests among males (69%) and young-adults aged 15–24 years (42%). Of 5,550 (4.2% of all tests) HIV-positive tests, 4,143 (75%) clients were newly HIV diagnosed, including 1,583 males and 881 young adults aged 15–24 years. Of HIV tests conducted 3.7%, 1.8%, and 2.1% of PITC, HBHTC, and VBHTC clients, respectively, were newly HIV diagnosed; PITC accounted for 79% of all new diagnoses. Cost per test (per new diagnosis) was $4.55 ($123.66), $6.45 ($354.44), and $7.98 ($372.67) for PITC, HBHTC, and VBHTC, respectively. In a task-shifting analysis in which lay counselors replaced healthcare workers, estimated costs per test (per new diagnosis) would have been $3.06 ($83.15), $ 4.81 ($264.04), and $5.45 ($254.52), for PITC, HBHTC, and VBHTC, respectively. BCPE models reached different target groups, including men and young adults, two groups with consistently low coverage. Implementation of multiple models is likely necessary to achieve ≥90% diagnostic coverage. [ABSTRACT FROM AUTHOR]

Introduction: HIV self-testing (HIVST) offers a useful addition to HIV testing services and enables individuals to test privately. Despite recommendations to the contrary, repeat HIV testing is frequent among people already on anti-retroviral treatment (ART) and there are concerns that oral self-testing might lead to false negative results. A study was conducted in Khayelitsha, South Africa, to assess feasibility and uptake of HIVST and linkage-to-care following HIVST. Methods: Participants were recruited at two health facilities from 1 March 2016 to 31 March 2017. People under 18 years, or with self-reported previously-diagnosed HIV infection, were excluded. Participants received an OraQuick Rapid HIV-1/2 Antibody kit, and reported their HIVST results by pre-paid text message (SMS) or by returning to the facility. Those not reporting within 7 days were contacted by phone. Electronic and paper-based clinical and laboratory records were retrospectively examined for all participants to identify known HIV outcomes, after matching for name, date of birth, and sex. These findings were compared with self-reported HIVST results where available. Results: Of 639 participants, 401 (62.8%) self-reported a negative HIVST result, 27 (4.2%) a positive result, and 211 (33.0%) did not report. The record search identified that of the 401 participants self-reporting a negative HIVST result, 19 (4.7%) were already known to be HIV positive; of the 27 self-reporting positive, 12 (44%) were known HIV positive. Overall, records showed 57/639 (8.9%) were HIV positive of whom 39/57 (68.4%) had previously-diagnosed infection and 18/57 (31.6%) newly-diagnosed infection. Of the 428 participants who self-reported a result, 366 (85.5%) reported by SMS. Conclusions: HIVST can improve HIV testing uptake and linkage to care. SMS is acceptable for reporting HIVST results but negative self-reports by participants may be unreliable. Use of HIVST by individuals on ART is frequent despite recommendations to the contrary and its implications need further consideration. [ABSTRACT FROM AUTHOR]

The genus Cyphostemma (Planch.) Alston (Vitaceae) includes about 150 species distributed in eastern and southern Africa and Madagascar. Some species are used in traditional medicine and their biological activities, including antiproliferative effects against cancer cell lines, have been demonstrated. To date no investigations on Cyphostemma essential oils have been carried out. Essential oils, which play important roles in plant defenses have been demonstrated to be active in the treatment of several human diseases and to enhance bioavability of other drugs. The aim of this paper was to identify the chemical composition of the essential oil of the leaves of Cyphostemma juttae (Dinter & Gilg) Desc. and to verify some biological activities on two triple negative breast cancer cell lines (MDA-MB-231, SUM 149), characterized by the over-expression of the transcription factor NF-κB. In the essential oil, obtained by hydrodistillation and analysed by gas chromatography-mass spectrometry, 39 compounds were detected and with phytol (30%) dominating the chemical composition. C. juttae essential oil reduced cell growth and showed a pro-oxidant activity in both cell lines. Moreover, C. juttae essential oil caused a substantial decrease of NF-κB activation and consequently a significant reduction of some NF-κB target genes. The present study shows for the first time the cytotoxic properties of C. juttae essential oil and highlight its availability to interfere with NF-κB pathway, suggesting a potential therapeutic use in triple negative breast cancers (TNBCs) of this essential oil. [ABSTRACT FROM AUTHOR]

Background: Modeling contributes to health program planning by allowing users to estimate future outcomes that are otherwise difficult to evaluate. However, modeling results are often not easily translated into practical policies. This paper examines the barriers and enabling factors that can allow models to better inform health decision-making. Description: The Decision Makers’ Program Planning Tool (DMPPT) and its successor, DMPPT 2, are illustrative examples of modeling tools that have been used to inform health policy. Their use underpinned Voluntary Medical Male Circumcision (VMMC) scale-up for HIV prevention in southern and eastern Africa. Both examine the impact and cost-effectiveness of VMMC scale-up, with DMPPT used initially in global advocacy and DMPPT 2 then providing VMMC coverage estimates by client age and subnational region for use in country-specific program planning. Their application involved three essential steps: identifying and engaging a wide array of stakeholders from the outset, reaching consensus on key assumptions and analysis plans, and convening data validation meetings with critical stakeholders. The subsequent DMPPT 2 Online is a user-friendly tool for in-country modeling analyses and continuous program planning and monitoring. Lessons learned: Through three iterations of the DMPPT applied to VMMC, a comprehensive framework with six steps was identified: (1) identify a champion, (2) engage stakeholders early and often, (3) encourage consensus, (4) customize analyses, (5), build capacity, and (6) establish a plan for sustainability. This framework could be successfully adapted to other HIV prevention programs to translate modeling results to policy and programming. Conclusions: Models can be used to mobilize support, strategically plan, and monitor key programmatic elements, but they can also help inform policy environments in which programs are conceptualized and implemented to achieve results. The ways in which modeling has informed VMMC programs and policy may be applicable to an array of other health interventions. [ABSTRACT FROM AUTHOR]

Invasive cervical cancer is the most prevalent cancer among women in Sub-Saharan Africa. In 2013, the World Health Organization (WHO) emitted recommendations to start Highly Active Antiretroviral Therapy (HAART) regardless of CD4 count. Although HAART has been shown to reduce the prevalence of high-risk human papillomavirus (HR-HPV) genotypes, it is unclear whether it confers a protective effect specifically for HPV 16. This review summarizes the existing evidence regarding the effect of HAART on HPV 16 infection, as this genotype may not be influenced by immunity level and explores its implications for Sub Saharan Africa. A comprehensive literature review was undertaken and quality assessment was carried out on the selected papers. Four cohort studies and three cross-sectional studies were identified for which the overall quality score assessment ranged from weak/moderate (Score of 1.8) to strong (Score of 3). The evidence yielded by our review was conflicting. Thus, the high heterogeneity between study populations and results did not allow us to draw any firm conclusions as to whether HAART has an impact on HPV 16 acquisition/prevalence. As only three studies were conducted in Africa, there are insufficient grounds for solid comparison between geographic regions. In light of inadequate data, HPV unvaccinated women on HAART should still receive more frequent follow-up. [ABSTRACT FROM AUTHOR]

Background: Gastric cancer survival rates in Africa are low as many cases are diagnosed late. Currently, there are no inexpensive, non-invasive and simple techniques that can be employed in poor resource settings for early case detection. In this study, we explored the possibility using blood in gastric juice as a screening tool to identify patients requiring referral for endoscopy. Methods: The study was conducted at the University Teaching Hospital endoscopy unit in Lusaka, Zambia. During esophagogastroduodenoscopy, gastric juice was aspirated and the pH determined using pH paper test strips. The presence of blood was tested using urinalysis reagent strips. Results: We enrolled 276 patients; 147(53%) were female and median age was 49 years (IQR 40–64 years). The presence of blood was associated with mucosal lesions, [OR 2.1; 95% CI 1.2–3.7, P = 0.004]. It was also associated with gastric cancer, [OR 6.7; 95% CI 2–35, P = 0.0005], even at 1:10 and 1:100 dilutions, [OR 5.4; 95% CI 2.3–13.8, P<0.0001] and [OR 9.1; 95% CI 3.5–23, P<0.0001] respectively. The sensitivity for gastric cancer detection using blood in gastric juice was 91% and the specificity was 41%. Analysis using the intensity of blood in gastric juice yielded an area under the receiver operating characteristic curve of 0.78; 95% CI 0.71–0.86 with a sensitivity of 79% and a specificity of 77%. Conclusions: The presence of blood in gastric juice is associated with gastric mucosal lesions. It has a high sensitivity but low specificity for gastric cancer detection. [ABSTRACT FROM AUTHOR]

In this paper, we examine the inequality in the dynamics of the total fertility rate within 21 sub-Saharan African countries by wealth quintiles. We also examine the associated inequality within each country in the proximate determinants of fertility–marriage, contraception, and breastfeeding. Applying Bongaarts’ proximate determinants of fertility framework, for 14/21 countries we analyze, we find that those in the richest wealth quintiles have had a more rapid decline in fertility rates than those in the poorest wealth quintiles. The rapid decline for those in the richest wealth quintiles is attributable to delayed marriage and modest increases in contraceptive use. Although the poorest lag in fertility decline, postpartum abstinence and breastfeeding are the most important factors for them for fertility regulation. Further encouraging maternal health programs that focus on natural methods of fertility regulation will work in favor of the poorest in sub-Saharan Africa in moving through the demographic transition. [ABSTRACT FROM AUTHOR]

This paper investigates suitability of supervised machine learning classification methods for classification of biomes using pollen datasets. We assign modern pollen samples from Africa and Arabia to five biome classes using a previously published African pollen dataset and a global ecosystem classification scheme. To test the applicability of traditional and machine-learning based classification models for the task of biome prediction from high dimensional modern pollen data, we train a total of eight classification models, including Linear Discriminant Analysis, Logistic Regression, Naïve Bayes, K-Nearest Neighbors, Classification Decision Tree, Random Forest, Neural Network, and Support Vector Machine. The ability of each model to predict biomes from pollen data is statistically tested on an independent test set. The Random Forest classifier outperforms other models in its ability correctly classify biomes given pollen data. Out of the eight models, the Random Forest classifier scores highest on all of the metrics used for model evaluations and is able to predict four out of five biome classes to high degree of accuracy, including arid, montane, tropical and subtropical closed and open systems, e.g. forests and savanna/grassland. The model has the potential for accurate reconstructions of past biomes and awaits application to fossil pollen sequences. The Random Forest model may be used to investigate vegetation changes on both long and short time scales, e.g. during glacial and interglacial cycles, or more recent and abrupt climatic anomalies like the African Humid Period. Such applications may contribute to a better understanding of past shifts in vegetation cover and ultimately provide valuable information on drivers of climate change. [ABSTRACT FROM AUTHOR]

Background: Crime and violence causes massive disruptions to the health, survival and development of populations. In South Africa, incredibly high rates of crime and violence are noted. The country also has a very large youth population whose health, survival and development are key to economic growth. Among other efforts to encourage healthy youth development and the promotion of social activities such as sports, youth groups, choirs and so forth. This study examines the relationship between perceived community safety and the uptake of social activities among youth in South Africa. Data and methods: This paper uses data from the National Youth Lifestyle Survey (2008) with an unweighted sample of 4,391 youth (age12-22 years old). Using chi-square and logistic regression analysis the association between perceived community safety and social activity participation are tested. Findings: The results indicate that youth participation in social activities in South Africa is high (55% of males and 45% of females). Among males, the most prominent activity is sports (51.8%), while for females there is high participation in choir and singing groups (55.68%). More than 50% of males perceive their communities as risky while less than half of females feel the same. Male youth are more likely to participate in social activities if they perceive their communities as risky (OR = 1.04). Females (OR = 0.83), youth have a negative view of their future (OR = 0.43) are less likely to participate in social activities. Conclusions: There exists an association between youth’s perception of community safety and their participation in social activities. Whether sports and groups are protective or enabling environments for youth from unsafe communities is moot. More in-depth research is needed on why youth participate in these clubs and groups to truly understand the role of social activities in South African societies. [ABSTRACT FROM AUTHOR]

Introduction and method: Africa is currently host to a number of international genomics research and biobanking consortia, each with a mandate to advance genomics research and biobanking in Africa. Whilst most of these consortia promise to transform the way international health research is done in Africa, few have articulated exactly how they propose to go about this. In this paper, we report on a qualitative interviewing study in which we involved 17 genomics researchers in Africa. We describe their perceptions and expectations of international genomics research and biobanking initiatives in Africa. Results: All interviewees were of the view that externally funded genomics research and biobanking initiatives in Africa, have played a critical role in building capacity for genomics research and biobanking in Africa and in providing an opportunity for researchers in Africa to collaborate and network with other researchers. Whilst the opportunity to collaborate was seen as a benefit, some interviewees stressed the importance of recognizing that these collaborations carry mutual benefits for all partners, including their collaborators in HICs. They also voiced two major concerns of being part of these collaborative initiatives: the possibility of exploitation of African researchers and the non-sustainability of research capacity building efforts. As a way of minimising exploitation, researchers in Africa recommended that genuine efforts be made to create transparent and equitable international health research partnerships. They suggested that this could be achieved through,: having rules of engagement, enabling African researchers to contribute to the design and conduct of international health projects in Africa, and mutual and respectful exchange of experience and capacity between research collaborators. These were identified as hallmarks to equitable international health research collaborations in Africa. Conclusion: Genomics research and biobanking initiatives in Africa such as H3Africa have gone some way in defining aspects of fair and equitable research collaborations in Africa. However, they will need to strive at achieving equitable health research collaborations if they truly aim at setting a gold standard for how international health research should be conducted in Africa. [ABSTRACT FROM AUTHOR]

Background: The population of Ghana is increasingly becoming urbanized with about 70% of the estimated 27 million people living in urban and peri-urban areas. Nonetheless, eight out of the ten regions in Ghana remain predominantly rural where only 32% of the national health sector workforce works. Moreover, the rural-urban disparities in the density of health tutors (staff responsible for pre-service training of health professionals) are enormous. This paper explores perceived needs of health tutors in rural and urban health training institutions in Ghana. Methods: This is a descriptive qualitative study conducted in the Greater Accra and Northern regions of Ghana. The Study used the deductive thematic and sub-thematic analysis approaches. Five health training institutions were randomly sampled, and 72 tutors engaged in separate focus group discussions with an average size of 14 participants per group in each training institution. Results: Perceived rural-urban disparities among health tutors were found in the payment of extra duty allowances; school infrastructure including libraries and internet connectivity; staff accommodation; and opportunities for scholarships and higher education. Health tutors in rural areas generally expressed more frustration with these work conditions than those in urban areas. Conclusions: There is the need to initiate and sustain work incentives that promote motivation of rural health tutors to control ongoing rural-urban migration of qualified staff. It is recommended the following incentives be prioritized to promote retention of qualified health tutors in rural health training schools: payment of research, book and rural allowances; early promotion of rural staff; prioritizing rural tutors for scholarships, and introduction of national best health tutor awards. [ABSTRACT FROM AUTHOR]

The world is undergoing a rapid health transition, with an ageing population and disease burden increasingly defined by disability. In Sub-Saharan Africa the next 40 years are predicted to see reduced mortality, signalling a surge in the impact of chronic diseases. We modelled these epidemiological changes and associated mental health workforce requirements. Years lived with a disability (YLD) predictions for mental and substance use disorders for each decade from 2010 to 2050 for four Sub-Saharan African regions were calculated using Global Burden of Disease 2010 study (GBD 2010) data and UN population forecasts. Predicted mental health workforce requirements for 2010 and 2050, by region and for selected countries, were modelled using GBD 2010 prevalence estimates and recommended packages of care and staffing ratios for low- and middle-income countries, and compared to current staffing from the WHO Mental Health Atlas. Significant population growth and ageing will result in an estimated 130% increase in the burden of mental and substance use disorders in Sub-Saharan Africa by 2050, to 45 million YLDs. As a result, the required mental health workforce will increase by 216,600 full time equivalent staff from 2010 to 2050, and far more compared to the existing workforce. The growth in mental and substance use disorders by 2050 is likely to significantly affect health and productivity in Sub-Saharan Africa. To reduce this burden, packages of care for key mental disorders should be provided through increasing the mental health workforce towards targets outlined in this paper. This requires a shift from current practice in most African countries, involving substantial investment in the training of primary care practitioners, supported by district based mental health specialist teams using a task sharing model that mobilises local community resources, with the expansion of inpatient psychiatric units based in district and regional general hospitals. [ABSTRACT FROM AUTHOR]