Baral et al. BMC Public Health 2013, 13482httpwww.biomed.docx

Baral et al. BMC Public Health 2013, 13:482
http://www.biomedcentral.com/1471-2458/13/482
DEBATE Open Access
Modified social ecological model: a tool to guide
the assessment of the risks and risk contexts of
HIV epidemics
Stefan Baral1*, Carmen H Logie2, Ashley Grosso1, Andrea L
Wirtz1 and Chris Beyrer1
Abstract
Background: Social and structural factors are now well accepted
as determinants of HIV vulnerabilities. These
factors are representative of social, economic, organizational
and political inequities. Associated with an improved
understanding of multiple levels of HIV risk has been the
recognition of the need to implement multi-level HIV
prevention strategies. Prevention sciences research and
programming aiming to decrease HIV incidence requires
epidemiologic studies to collect data on multiple levels of risk
to inform combination HIV prevention packages.
Discussion: Proximal individual-level risks, such as sharing
injection devices and unprotected penile-vaginal or
penile-anal sex, are necessary in mediating HIV acquisition and
transmission. However, higher order social and
structural-level risks can facilitate or reduce HIV transmission
on population levels. Data characterizing these risks is
often far more actionable than characterizing individual-level
risks. We propose a modified social ecological model
(MSEM) to help visualize multi-level domains of HIV infection
risks and guide the development of epidemiologic
HIV studies. Such a model may inform research in

epidemiology and prevention sciences, particularly for key
populations including men who have sex with men (MSM),
people who inject drugs (PID), and sex workers. The
MSEM builds on existing frameworks by examining multi-level
risk contexts for HIV infection and situating individual
HIV infection risks within wider network, community, and
public policy contexts as well as epidemic stage. The
utility of the MSEM is demonstrated with case studies of HIV
risk among PID and MSM.
Summary: The MSEM is a flexible model for guiding
epidemiologic studies among key populations at risk for HIV
in diverse sociocultural contexts. Successful HIV prevention
strategies for key populations require effective
integration of evidence-based biomedical, behavioral, and
structural interventions. While the focus of epidemiologic
studies has traditionally been on describing individual-level risk
factors, the future necessitates comprehensive
epidemiologic data characterizing multiple levels of HIV risk.
Background
There is an increasing recognition of the importance of
the social and structural drivers of acquisition and trans-
mission of HIV [1,2]. While there is no singular defin-
ition, structural drivers can be conceptualized as those
social, economic, organizational, and political power and
domination factors which contribute to social inequities
[2-4]. These structural drivers do not directly cause the
acquisition or onward transmission of HIV; rather they
* Correspondence: [email protected]
1Center for Public Health and Human Rights, Johns Hopkins
Bloomberg
School of Public Health, Johns Hopkins University, 615 N.
Wolfe Street,
Baltimore, MD 21205, USA
Full list of author information is available at the end of the
article

© 2013 Baral et al.; licensee BioMed Central Lt
Commons Attribution License (http://creativec
reproduction in any medium, provided the or
mediate lower order risks such as those at the individual
or network levels. Enhanced understanding of the vari-
ous levels of HIV risk contributes to the recognition that
HIV prevention measures must be delivered in the form
of packages of services addressing multi-level HIV infec-
tion risks. As combination HIV prevention interventions
focus on biomedical, behavioral and structural compo-
nents, there is the need for a theoretical framework to
guide the collection of data to characterize drivers of
HIV risk at each of these levels [1,2].
Models may be used to visually represent theoretical ex-
planations of biological, social and structural influences on
disease processes, and can serve as useful guides for prac-
tice, research, intervention and policy development [4,5].
d. This is an Open Access article distributed under the terms of
the Creative
ommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and
iginal work is properly cited.
mailto:s[email protected]
http://creativecommons.org/licenses/by/2.0
Baral et al. BMC Public Health 2013, 13:482 Page 2 of 8
Some models have been used to articulate underlying indi-
vidual motivations for behaviors, such as the health belief
model, the theory of planned action, and the model of be-
havior change [6,7]. Other models, for instance the social
ecological model, have functioned to situate health and

health behaviors in the context of physical, social and pol-
icy environments [8,9].
Social ecological models are used to explain the com-
plex associations between social (e.g. social networks)
and structural (e.g. access to care) factors, individual
practices, the physical environment and health [9]. The
social ecological model contextualizes individuals’ be-
haviors using dimensions including intrapersonal (e.g.
knowledge, attitudes, behavior), interpersonal/network
(social networks, social support), community (e.g. rela-
tionships among organizations/ institutions), and public
policy (e.g. local, state, national laws) to provide a frame-
work for describing the interactions between these levels
[10]. Ecosocial approaches employ biological and social
analyses of population health to explore factors underpin-
ning social inequalities and health disparities. Ecological
models focusing on intrapersonal factors have been widely
used in the design of effective interventions aimed at
modifying individual behaviors [4]. However, few models
have been developed to guide the measurement of individ-
ual level risks, both biologic and behavioral, as well as
higher order levels of risk in the context of HIV infection.
The HIV epidemic can arguably be considered to be a
group of interrelated epidemics, each with its own indi-
vidual, social and structural risk factors. Sub-epidemics
within populations have differing dynamics. No one
model can describe all risk factors across these diverse
domains. Conceptualizing epidemiological profiles from
a social ecological theoretical stance therefore necessi-
tates model specificity and contextual, multi-level ana-
lyses that incorporate social structure, social and
community norms, and biological factors [5]. McLeroy
[10] described: “one of the problems with many
ecological models of social behavior is that they lack

sufficient specificity to guide conceptualization of a spe-
cific problem or to identify appropriate interventions”
(p. 355). To adequately describe and address the com-
plexity of an epidemic such as HIV, unique and granular
models can be developed for specific populations to
measure relevant risks and risk contexts. After a com-
prehensive review of the literature, we found no model
designed to date that encapsulates individual HIV trans-
mission risks in the context of social and structural
drivers of the epidemic. Auerbach et al. [1] developed a
model to assess social and structural drivers of HIV to
inform intervention development. Poundstone et al. [9]
presented a heuristic framework of the social epidemi-
ology of HIV that highlights the social and structural de-
terminants of the epidemic. Other models have
examined ecological-level risk factors for HIV such as
structural violence [11,12] and social factors such as
stigma and discrimination [4].
We build on past frameworks by a) examining multi-
level risks and risk contexts for HIV infection and b)
situating individual risks in the network, community,
and public policy contexts as well as the epidemic stage.
We developed the modified social ecological model
(MSEM) to help visualize multi-level domains of HIV
infection risks and guide the development of epidemio-
logic studies of HIV. We argue that data on risk factors
and these multiple levels should be collected routinely
as part of any epidemiologic study.
Discussion
The modified social ecological model (MSEM)
The MSEM is composed of five layers of risk for HIV in-
fection: individual, network, community, policy, and
stage of the HIV epidemic. The MSEM modifies the so-
cial ecological model by modifying the levels of risk as

well as adding the stage or level of the HIV epidemic to
the social ecological model, and is based on the premise
that while individual level risks are necessary for the
spread of disease, they are insufficient to explain popula-
tion level epidemic dynamics. The higher order social
and structural levels of risk (network, community, pol-
icy, stage of epidemic) represent risk factors outside of
the control of any individual person [13]. And though
policy makers tend to target interventions at individual
level risks, they are only one component affecting the
transmission of HIV among marginalized populations
[2,4,9]. We present an MSEM figure that highlights
these levels of risk (Figure 1) that can be adapted to
contextualize HIV transmission risk among vulnerable
populations. Factors can span levels and therefore the
boundaries between levels may be understood as porous
rather than distinct.
Individual factors are biologic or behavioral character-
istics associated with vulnerability to acquire or transmit
illness or infection [9,10]. These risks should be mea-
sured when there is biological or public health plausibil-
ity of being actual risk factors, ideally secondary to a
rigorous systematic review with meta-analysis. While ob-
jective approaches to the synthesis of evidence for all
levels of risk are preferred, in 2012, there is generally
only sufficient levels of evidence for systematic reviews
and meta-analysis of individual-level risk factors given
the focus on this level of risk in the majority of epi-
demiological assessments of HIV.
Social and sexual networks are comprised of interper-
sonal relationships including family, friends, neighbors
and others that directly influence health and health be-
haviors in multiple ways [10]. Networks, not bound by
geography, socioeconomic status, or cultural, racial, or

Individual
Community
Stage of Epidemic
Public Policy
Network
Level of Risks
Figure 1 Modified social ecological model for HIV risk in
vulnerable populations.
religious lines, include: “the webs of human relationships
(including dyadic, familial, social, sexual, and drug-using)
through which social (including sexual) exchange occurs
and social norms are played out” [2, p. 2]. HIV risks—
and other health outcomes—are associated with social
influence, social engagement, disease prevalence, access
to information, intimate contact and social networks [9].
In the MSEM, networks are operationalized as a group
of people who have a higher probability of exposure to
infectious disease from each other mediated through
sexual exposure, shared use of injection, and/or
non-injection drug paraphernalia, or increased physical
contact. Sexual and social network levels of risk include
biologic (e.g. HIV infection rates) and behavioral (e.g.
sexual contact, shared use of injection drug parapherna-
lia) factors that potentiate HIV transmission among indi-

vidual members of a network [14,15]. Alternatively
family and social networks can provide social support
and reinforce social norms and behavior that serve as
protective factors and reduce HIV transmission risks
[15]. The measurement of network-centric data in HIV
epidemiological studies is crucial given how determi-
native network characteristics are in predisposing or
protecting individuals within those networks to the ac-
quisition and transmission of HIV.
Community environments can either promote health
and well-being or be a source of stigma. The definition
of who and/or what constitutes a ‘community’ is
contested but generally includes: network ties; relation-
ships between organizations and groups; and geograph-
ical/political regions [10]. Cultural, economic, religious,
geographic lines, prison walls, or any combination of the
above may bind communities. Urban, neighborhood, or
community deprivation and disadvantage can increase
vulnerability to HIV [16]. Socio-cultural norms and
values, social cohesion and network structures are
shaped by larger social-structural forces and influence
interpersonal processes and individual behaviors [1,13].
Interpretation of community norms may increase or
mitigate the risk level for HIV infection within the
community. For example, interventions focused on
establishing condom use norms have demonstrated effi-
cacy in increasing condom use [13,17]. Stigma affecting
populations at risk for the acquisition and transmission
of HIV often manifest at the level of the community in
limiting the provision and/or uptake of HIV prevention,
treatment, and care services.
Laws and policies of any state provide the general
framework for shaping the risk of marginalized popula-
tions as well as the general population [18]. These pol-

icies and their financing [19] and implementation either
promote or decrease the community’s ability to provide
preventive or harm reduction services (e.g. needle ex-
change; condom provision in prisons) to its constituents
by passing laws making such actions legal or illegal or by
providing or disrupting funding mechanisms supporting
these programs [13,20,21]. Legal and policy environ-
ments play a critical role in hindering—or supporting—
HIV prevention programs among sex workers [22].
There are numerous examples worldwide of laws-such
as criminalization of homosexuality, sex work and sub-
stance use, or criminalization of prevention practices,
such needle exchange or methadone assisted treatment
(MAT)—founded in morals, cultural relativism, and pol-
itical will rather than the results of public health science.
In such contexts, although marginalized populations
such as sex workers, people who inject drugs (PID) and
men who have sex with men (MSM) have elevated HIV
infection risks there are a lack of scientifically proven
targeted prevention and harm reduction strategies [22].
Policies determine allocation of economic resources to
education, health care, job training, financial assistance
and HIV prevention services and therefore play a sub-
stantial role in shaping structural contexts of HIV risk
[13]. Downstream, these laws and policies likely impact
networks; for example, incarceration can both disrupt
and create new networks. Similarly, policies can drive
conflict and economic disruption affecting the provision
and uptake of services, the makeup of social and sexual
networks. Often the highest impact of such adverse
effects are on populations already marginalized [23].

Ultimately it is the stage of the epidemic within the so-
cial and sexual network, community, and country that
will determine the risk of disease acquisition for the in-
dividual [13,24]. No behavior, policy or law, community
determinant, network attribute, or individual character-
istic can create infectious disease; rather these can only
create conditions which either increase or decrease the
probability of acquisition or onward transmission of an
already prevalent disease. The stage of the epidemic can
be quantified in several ways including HIV incidence
and HIV prevalence. In the context of populations with
high prevalence of HIV, mean and total community viral
load has been used as a marker of population-level
transmission of HIV. Thus, the risk associated with any
individual practice such as unprotected anal intercourse
should be interpreted within the context of the stage of
the epidemic as the risk of this practice should be con-
sidered as high-risk only in the context of a high burden
of HIV infection and viral load.
We present two case studies to demonstrate the use of
the MSEM in enhancing understanding regarding the
multifactorial, multilevel infection risks of different HIV
epidemics: 1) parenteral transmission of HIV among
PID; and 2) sexual transmission of HIV among MSM.
Individual
Community
Stage of Epidemic
Public Policy
Network

Level of Risks
Legend: VCT (voluntary coun
(men who have sex with men
Figure 2 Modified ecological model for HIV risk in people who
inject
Case study 1: Parenteral transmission of HIV among
people who inject drugs (PID)
Approximately 20.0%, or 3 million, of PID are living with
HIV across the globe [25]. There is a wealth of literature
devoted to the individual-level risk factors for HIV
acquisition and transmission among PID (Figure 2). HIV
infection has been associated with: the duration and
frequency of drug use, injecting practices (e.g. ‘jerking’,
‘scaling’, backloading, etc.), drug injection location, co-
infections (HCV, HBV, sexually transmitted infections
[STI], genital ulcerative disease[GUD]), sexual risk fac-
tors (e.g. unprotected receptive anal intercourse, fre-
quency and number of sexual partners), type of drug
used (e.g. poppers, meth), marginalized groups (e.g.
Black and minority ethnic populations [BME]), psychi-
atric comorbidities, sharing drug use paraphernalia as
well as other non-drug use related risks including
tattooing, blood transfusions and organ and tissue trans-
plants [21,26-28] .
The network risk factors that drive the spread of HIV
predominantly through moderation of these individual
level risk factors are less appreciated. Networks of
people who use drugs include social networks, injection
networks of people with whom the person injects drugs,
and sexual networks. Sexual/injection networks are more
proximal in the exposure to HIV, though social networks
may provide differential effects depending on the health
literacy of members. Social and peer-group norms,

population mobility, drug costs, exposure and access to
drugs, sexual roles (e.g. receptive or insertive inter-
course), availability of condoms in networks, and high
HIV/STI prevalence in social/sexual networks can result
in transmission of HIV and other co-infections such as
HCV [27]. Higher risk injection practices among heroin
injecting networks, such as sharing contaminated drug
selling and testing); ARV (anti retro-viral); MSM
); MAT (methadone assisted treatment)
drugs.
solutions and needles, are more common in unsafe so-
cial environments (e.g. visible areas with limited privacy
and/or security) [29]. In addition, accurate knowledge of
HIV characteristics and the prevalence of injection and
unprotected sex within social and/or sexual networks of
PID contribute to the rate of HIV spread [21,27].
Relevant features of HIV prevention for PID at the
community level include access to evidence-based harm
reduction strategies such as needle and syringe programs
(NSP), methadone maintenance programs, community
health centers, safe injection sites, HIV education and
preventive services, voluntary counseling and testing
(VCT), health literacy, and access to antiretroviral
therapy (ARV) [21]. Community-based services and
community advocacy, engagement, and mobilization, in
conjunction with a strong civil society and peer initia-
tives can address and reduce HIV risk among PID;
conversely stigma, discrimination and marginalization of
drug users exacerbates HIV risk [21,28]. Inequitable

social norms contribute to HIV risks among PID who
are: women, younger, sexual minority, and/or Black and
minority ethnic (BME) populations [21,27,30]. For ex-
ample, unbalanced power relations with male partners
limit women’s ability to negotiate both safer sex and
refusal to share needles [27].
The legality of many of the aforementioned harm re-
duction strategies is determined at the level of public
policy. Policies determine a range of risk exposures for
PID, including coverage of NSP, substitution therapies,
drug treatment, HIV testing and counseling, sexual
health education, criminalization of PID, condom avail-
ability, ARV access, drug trafficking routes, inclusion in
national HIV surveillance, and police surveillance—all
salient factors in shaping HIV risk among PID
[20,21,27]. Less than one-third of PID globally have
Individual
Community
Stage of Epidemic
Public Policy
Network
Level of Risks
Legend: V
therapy); I
Figure 3 Modified ecological model for HIV risk in men who
have sex
access to HIV prevention services and approximately 5%
have access to NSP [20,21]. Access by PID to these ser-

vices is greatly diminished, if not non-existent, when the
provision of these services is criminalized. Furthermore,
highly punitive drug laws resulting in frequent incarcer-
ation of PID also plays a role in propagating spread of
disease by both limiting the access to harm reduction
strategies and by concentrating uniformly high risk indi-
viduals in the same network [27]. Shifting the focus to
human rights contexts, advocacy and drug treatment
from detention, as well as provision of NSP and treat-
ment in prisons, is therefore key to HIV prevention
[20,21,28]. Income generation and employment pro-
grams, social housing, and access to free harm reduction
materials (e.g. condoms, syringes) are examples of pro-
grams that can reduce HIV risk among PID [21,27].
Again, each of these factors is contextualized by the
stage of the HIV epidemic and HIV prevalence in any
particular setting, underscoring the need for country and
population specific approaches [20,21,28].
Case study 2: Sexual transmission of HIV among MSM
In all settings where MSM have been studied, there is a
disproportionate burden of HIV among MSM when
compared to other men [31,32]. Sexual transmission
risks among MSM are significantly shaped by inequit-
able social and structural contexts that influence individ-
ual’s sexual practices and access to HIV prevention
[4,31] Figure 3 presents the levels of risk faced by MSM
and some of the risk factors present at each level.
Among MSM, individual level acquisition risks have
focused on the highest probability exposure: unprotected
anal intercourse (UAI), and specifically on correlates of
receptive anal intercourse [33]. Use of party drugs such
as methamphetamines and alkyl nitrates (poppers) has
CT (voluntary counseling and testing); ART (anti-retroviral
DU (injection drug use); GUD (genital ulcer disease)

with men.
been associated with heightened sexual exposure among
MSM in several settings [33,34]. And as with men who
only report sex with women, HIV transmission in MSM
is associated with genitourinary disease, being uncircum-
cised, high frequency of male partners, and high lifetime
number of male partners [15,35]. For those living with
HIV, the biggest determinant of onward sexual transmis-
sion of HIV is the viral load of the insertive partner.
Social and sexual network level factors include the
density and size of networks; these shape HIV risk for
its members [36]. Larger networks provide increased op-
portunities for exposure to varied sexual practices and
HIV positive potential partners [36]. Larger sexual net-
works have also been associated with increased reporting
of unprotected anal intercourse among MSM in several
settings [37,38]. Using phylogenetic methods, studies
have consistently shown that HIV is transmitted in epi-
sodic bursts of transmissions among MSM. Moreover,
sexual networks determine risk, particularly among sex-
ual networks configured of MSM with higher rates of
sex work, drug use and accessing the internet for sexual
partners [14,15,39]. Separately, higher risk networks in-
cluding MSM with higher viral load related to undiag-
nosed HIV infection, acutely infected MSM, or those
with late stage infection HIV infection. High prevalence
of infections causing genital ulcerative disease will in-
crease the probability of HIV transmission within net-
works. Interpersonal skills training with MSM regarding

safer sex negotiation was associated with reduced UAI
[40] as were interventions focused on promoting con-
dom use within social networks [17].
Community norms and values that stigmatize same-
sex practices and sexually diverse populations present
significant barriers to accessing HIV prevention among
MSM, as well as access to other health care services
[2,4,31,41,42]. Stigma in communities limits coverage of
services by limiting both the provision and uptake of
HIV prevention, treatment, and care services. Provision
is limited through limited funding for these services and
limited legality and willingness of entities to provide ser-
vices. Even when services are provided, coverage is lim-
ited by reduced health seeking practices and utilization
of health and HIV services among MSM, due to fear of
disclosure and discrimination, may reduce knowledge of
UAI risks and access to prevention methods (e.g. con-
doms, lubricant). Sexually diverse populations face wide-
spread social exclusion from families, friends, cultural,
religious and health institutions which inhibit disclosure
of sexual orientation and/or HIV-positive serostatus and
play a key role in exacerbating HIV risk [31]. Other
stigma and discrimination not related to sexual prac-
tices, may also elevate risk, for example, BME MSM in
developed country settings have higher HIV infection
risks in comparison to Caucasian/white MSM [43],
highlighting the importance of understanding the role
intersecting forms of social and structural discrimination
(e.g. racism, homophobia) play in shaping health out-
comes and risk [4].
Public policies such as the criminalization of homo-
sexuality in more than 80 countries and exclusion from
national surveillance programs are, to some extent, to
blame for the dearth of targeted, accessible prevention

strategies for MSM and thus continually increasing
global incidence rates of HIV [31,41,44,45]. The vast
majority of MSM globally do not have access to HIV
prevention, treatment and care services [42,46]. Discrim-
ination of sexual minorities by police and health care
providers are global phenomena: anti-discrimination
training and policies are therefore imperative to protect
human rights and promote health [44,47-49]. Ultimately,
the act of men having sex with men is not inherently
dangerous; in fact, only in the context of an advanced
stage of the epidemic among MSM and lack of prevent-
ive services (or awareness/uptake of services) are actually
risk exposures for HIV infection [50]. The porous nature
of these levels should also be considered; while receptive
anal sex (individual risk) poses higher HIV infection
rates this in fact occurs in a dyadic process (network)
influenced by socio-cultural norms (community).
Summary
This paper has proposed a model to guide epidemiologic
studies of HIV in collecting the data needed to enhance
characterization of multi-layered risk contexts. The
modified social ecological model functions as a useful
framework with which to characterize and visualize the
various layers of risks for HIV. The model includes five
levels of risk: individual, network, community, public
policy, and stage of epidemic. Each level provides a con-
text in which to understand subsequent levels and there
is interaction between each level and factors within
levels. Other than epidemic stage, each of the levels
function as targets for prevention strategies. One of the
unique challenges of conceptualizing a model for infec-
tious diseases is the porous nature of these levels. The
flexibility of the model was demonstrated by describing
two contemporary HIV epidemics: transmission of HIV
among PID among MSM, though the model could be

adapted to understand risks faced by other populations.
Behavioral and biomedical interventions tend to focus
on decreasing individual and network level risks of HIV.
However, the effectiveness of these interventions as mea-
sured by reductions of HIV incidence will ultimately be
limited by the community, public policy, and epidemic
stages in which they are operationalized. To date, the
majority of evaluations of biomedical and behavioral
interventions have focused on efficacy rather than real-
world effectiveness. Moving forward, there has been a
renewed emphasis on implementation science to assess
the effectiveness of interventions. There appears to be
consensus that translating efficacious interventions to
effective programs necessitates addressing higher order
risk factors. However, to date there remains a limited
evidence base in the peer-reviewed literature supporting
structural interventions. Moreover, the interventions or
programs attempting to change community dynamics
such as stigma or public policy are more difficult to im-
plement and evaluate than individual-level interventions
amenable to rapid scale-up and blinded randomized tri-
als [51]. Similarly, new approaches are needed for the
evaluation of evidence supporting such interventions
transcending randomized controlled trials [52].
Ultimately, defining and characterizing individual level
risks of HIV transmission is imperative in better under-
standing the dynamics of an epidemic. However, it is the
higher order social and structural level of risks that likely
facilitate HIV transmission on a population level. Simply

said, it no longer contributes to our understanding of
HIV to characterize that higher numbers of sexual part-
ners, lower levels of condom use, and the sharing of
drug injecting devices are associated, causally or not,
with HIV infection. Ensuring that every epidemiologic
study for HIV also characterizes social and structural
factors that underlie high risk practices will likely result
in far more actionable data in furthering the HIV pre-
vention sciences.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
The idea of developing a social ecological framework to guide
epidemiological studies was developed by SB. SB and CB
conceptualized
and led the writing of the paper. CL conducted a literature
review, helped
refine the model, and wrote significant portions of the
manuscript. All
authors contributed to the conceptual development of the model,
supported writing sections of the manuscript, critical revision of
the
manuscript, and approved the final version.
Funding
The study was funded by amFAR, Foundation for AIDS
Research, who
supported SB, CB, AG and AW. CL was funded by a Canadian
Institutes of
Health Research (CIHR) Institute of Gender and Health
Training Fellowship.
Author details
1Center for Public Health and Human Rights, Johns Hopkins

Bloomberg
School of Public Health, Johns Hopkins University, 615 N.
Wolfe Street,
Baltimore, MD 21205, USA. 2Faculty of Social Work,
University of Calgary,
2500 University Drive NW, Calgary, AB T2N 1N4, Canada.
Received: 3 December 2012 Accepted: 9 May 2013
Published: 17 May 2013
References
1. Auerbach JD, Parkhurst JO, Caceres CF: Addressing social
drivers of HIV/
AIDS for the long-term response: conceptual and
methodological
considerations. [Review]. Glob Public Health 2011, 6(Suppl
3):S293–S309.
doi:10.1080/17441692.2011.594451.
2. Mahajan AP, Sayles JN, Patel VA, Remien RH, Sawires SR,
Ortiz DJ, Szekeres
G, Coates TJ: Stigma in the HIV/AIDS epidemic: a review of
the literature
and recommendations for the way forward. [Research Support,
Non-U.S.
Gov’t Review]. AIDS 2008, 22(Suppl 2):S67–S79.
doi:10.1097/01.
aids.0000327438.13291.62.
3. Farmer PE, Nizeye B, Stulac S, Keshavjee S: Structural
violence and clinical
medicine. PLoS Med 2006, 3(10):e449.
doi:10.1371/journal.pmed.0030449.
4. Parker R, Aggleton P: HIV and AIDS-related stigma and

discrimination: a
conceptual framework and implications for action. Soc Sci Med
2003,
57(1):13–24. doi:10.1016/s0277-9536(02)00304-0.
5. Krieger N: Epidemiology and the web of causation: has
anyone seen the
spider? Soc Sci Med 1994, 39(7):887–903. doi:10.1016/0277-
9536(94)90202-x.
6. Amaro H, Raj A: On the margin: power and women’s HIV
risk reduction
strategies. Sex Roles 2000, 42(7):723–749.
doi:10.1023/a:1007059708789.
7. DiClemente RJ, Crosby RA, Kegler MC: Emerging theories
in health promotion
practice and research: strategies for improving public health,
Volume First. San
Francisco, CA: John Wiley & Sons; 2002.
8. Krieger N: The ostrich, the albatross, and public health: an
ecosocial
perspective–or why an explicit focus on health consequences of
discrimination and deprivation is vital for good science and
public
health practice. [Review]. Public Health Rep 2001, 116(5):419–
423.
9. Poundstone KE, Strathdee SA, Celentano DD: The social
epidemiology of
human immunodeficiency virus/acquired immunodeficiency
syndrome.
[Meta-Analysis Research Support, U.S. Gov’t, P.H.S.].
Epidemiol Rev 2004,
26:22–35. doi:10.1093/epirev/mxh005.

10. McLeroy KR, Bibeau D, Steckler A, Glanz K: An ecological
perspective on
health promotion programs. [Review]. Health Educ Q 1988,
15(4):351–377.
11. Chakrapani V, Newman PA, Shunmugam M, McLuckie A,
Melwin F:
Structural violence against Kothi-identified men who have sex
with men
in Chennai, India: a qualitative investigation. [Research
Support, Non-U.S.
Gov’t Research Support, U.S. Gov’t, Non-P.H.S.]. AIDS Educ
Prev 2007,
19(4):346–364. doi:10.1521/aeap.2007.19.4.346.
12. Lane SD, Rubinstein RA, Keefe RH, Webster N, Cibula DA,
Rosenthal A,
Dowdell J: Structural violence and racial disparity in HIV
transmission.
[Editorial]. J Health Care Poor Underserved 2004, 15(3):319–
335.
13. Wellings K, Collumbien M, Slaymaker E, Singh S, Hodges
Z, Patel D, Bajos N:
Sexual behaviour in context: a global perspective. Lancet 2006,
368(9548):1706–1728.
14. Rothenberg R: How a net works: implications of network
structure for the
persistence and control of sexually transmitted diseases and
HIV.
Sex Transm Dis 2001, 28(2):63–68.
15. Wohlfeiler D, Potterat JJ: Using gay men’s sexual networks
to reduce

sexually transmitted disease (STD)/human immunodeficiency
virus (HIV)
transmission. Sex Transm Dis 2005, 32:S48–S52.
doi:10.1097/1001.
olq.0000175394.0000181945.0000175368.
16. Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee
SA: The social
structural production of HIV risk among injecting drug users.
[S0277–9536(05), 00023–7 pii;
10.1016/j.socscimed.2004.12.024 doi].
Soc Sci Med 2005, 61(5):1026–1044.
17. Wang K, Brown K, Shen SY, Tucker J: Social network-
based interventions
to promote condom use: a systematic review. [Review]. AIDS
Behav 2011,
15(7):1298–1308. doi:10.1007/s10461-011-0020-1.
18. Berkman LF, Glass T, Brissette I, Seeman TE: From social
integration to
health: Durkheim in the new millennium. [Review]. Soc Sci
Med 2000,
51(6):843–857.
19. Hecht R, Bollinger L, Stover J, McGreevey W, Muhib F,
Madavo CE, de
Ferranti D: Critical choices in financing the response to the
global HIV/
AIDS pandemic. [Research Support, Non-U.S. Gov’t]. Health
Aff (Millwood)
2009, 28(6):1591–1605. doi:10.1377/hlthaff.28.6.1591.
20. Beyrer C, Wirtz AL, Baral S, Peryskina A, Sifakis F:
Epidemiologic links
between drug use and HIV epidemics: an international

perspective.
J Acquir Immune Defic Syndr 2010, 55(Suppl 1):S10–S16.
doi:10.1097/
QAI.0b013e3181f9c0c9.
21. Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin
C, Hickman M:
Prevention of HIV infection for people who inject drugs: why
individual,
structural, and combination approaches are needed. Lancet
2010,
376(9737):285–301. doi:10.1016/S0140-6736(10)60742-8.
22. Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker
MR, Sherman SG,
Kerrigan D: Burden of HIV among female sex workers in low-
income and
middle-income countries: a systematic review and meta-
analysis.
Lancet Infect Dis 2012, 12:538–549.
23. Friedman SR, Kippax SC, Phaswana-Mafuya N, Rossi D,
Newman CE:
Emerging future issues in HIV/AIDS social research. [Editorial
Research
http://dx.doi.org/10.1080/17441692.2011.594451
http://dx.doi.org/10.1097/01.aids.0000327438.13291.62
http://dx.doi.org/10.1371/journal.pmed.0030449
http://dx.doi.org/10.1016/s0277-9536(02)00304-0
http://dx.doi.org/10.1016/0277-9536(94)90202-x
http://dx.doi.org/10.1023/a:1007059708789
http://dx.doi.org/10.1093/epirev/mxh005
http://dx.doi.org/10.1521/aeap.2007.19.4.346
http://dx.doi.org/10.1097/1001.olq.0000175394.0000181945.000

0175368
http://dx.doi.org/10.1097/1001.olq.0000175394.0000181945.000
0175368
http://dx.doi.org/10.1007/s10461-011-0020-1
http://dx.doi.org/10.1377/hlthaff.28.6.1591
http://dx.doi.org/10.1097/QAI.0b013e3181f9c0c9
http://dx.doi.org/10.1097/QAI.0b013e3181f9c0c9
http://dx.doi.org/10.1016/S0140-6736(10)60742-8
Support, N.I.H., Extramural Research Support, Non-U.S. Gov’t
Review].
AIDS 2006, 20(7):959–965.
doi:10.1097/01.aids.0000222066.30125.b9.
24. Beyrer C: HIV epidemiology update and transmission
factors: risks and
risk contexts–16th International AIDS Conference epidemiology
plenary.
[Review]. Clin Infect Dis 2007, 44(7):981–987.
doi:10.1086/512371.
25. Mathers BM, Degenhardt L, Phillips B, Wiessing L,
Hickman M, Strathdee SA,
Wodak A, Panda S, Tyndall M, Toufik A, Mattick RP: Global
epidemiology of
injecting drug use and HIV among people who inject drugs: a
systematic review. [S0140–6736(08), 61311–2 pii;
10.1016/S0140–6736
(08)61311–2 doi]. Lancet 2008, 372(9651):1733–1745.
26. Kuo I, Sherman SG, Thomas DL, Strathdee SA: Hepatitis B
virus infection
and vaccination among young injection and non-injection drug

users:
missed opportunities to prevent infection. Drug Alcohol Depend
2004,
73(1):69–78.
27. Strathdee S, et al: HIV and the risk environment among
people who inject
drugs: past, present, and projections for the future. Lancet 2010.
In Press.
28. Wolfe D, Carrieri MP, Shepard D: Treatment and care for
injecting drug
users with HIV infection: a review of barriers and ways
forward.
[Research Support, Non-U.S. Gov’t Review]. Lancet 2010,
376(9738):355–366. doi:10.1016/S0140-6736(10)60832-X.
29. Koester S, Glanz J, Baron A: Drug sharing among heroin
networks:
implications for HIV and hepatitis B and C prevention. AIDS
Behav 2005,
9(1):27–39. doi:10.1007/s10461-005-1679-y.
30. El-Bassel N, Terlikbaeva A, Pinkham S: HIV and women
who use drugs:
double neglect, double risk. Lancet 2010, 376(9738):312–314.
doi:10.1016/
S0140-6736(10)61026-4.
31. Baral S, Sifakis F, Cleghorn F, Beyrer C: Elevated risk for
HIV infection
among men who have sex with men in low- and middle-income
countries 2000–2006: a systematic review. PLoS Med 2007,
4(12):e339.
doi:10.1371/journal.pmed.0040339.

32. Beyrer C, Baral SD, van Griensven F, Goodreau SM,
Chariyalertsak S, Wirtz AL,
Brookmeyer R: Global epidemiology of HIV infection in men
who have sex
with men. Lancet 2012, 380(9839):367–377.
doi:10.1016/S0140-6736(12)60821-6.
33. Koblin BA, Husnik MJ, Colfax G, Huang Y, Madison M,
Mayer K, Barresi PJ,
Coates TJ, Chesney MA, Buchbinder S: Risk factors for HIV
infection among
men who have sex with men. [Multicenter Study Research
Support, N.I.
H., Extramural]. AIDS 2006, 20(5):731–739. doi:10.1097/01.
aids.0000216374.61442.55.
34. Beyrer C, Sripaipan T, Tovanabutra S, Jittiwutikarn J,
Suriyanon V, Vongchak
T, Srirak N, Kawichai S, Razak MH, Celentano DD: High HIV,
hepatitis C and
sexual risks among drug-using men who have sex with men in
northern
Thailand. [Research Support, N.I.H., Extramural Research
Support, Non-U.
S. Gov’t Research Support, U.S. Gov’t, P.H.S.]. AIDS 2005,
19(14):1535–1540.
35. Buchbinder SP, Vittinghoff E, Heagerty PJ, Celum CL,
Seage GR III, Judson
FN, McKirnan D, Mayer KH, Koblin BA: Sexual risk, nitrite
inhalant use, and
lack of circumcision associated with HIV seroconversion in men
who
have sex with men in the United States. J Acquir Immune Defic
Syndr 2005,
39(1):82–89.

36. Smith AMA, Grierson J, Wain D, Pitts M, Pattison P:
Associations between
the sexual behaviour of men who have sex with men and the
structure
and composition of their social networks. Sex Transm Infect
2004,
80(6):455–458.
37. Choi KH, Gibson DR, Han L, Guo Y: High levels of
unprotected sex with
men and women among men who have sex with men: a potential
bridge of HIV transmission in Beijing, China. AIDS Educ Prev:
Off Publ Int
Soc AIDS Educ 2004, 16(1):19–30.
38. Choi KH, McFarland W, Neilands TB, Nguyen S, Louie B,
Secura GM, Behel S,
Mackellar D, Valleroy L: An opportunity for prevention:
prevalence,
incidence, and sexual risk for HIV among young Asian and
Pacific
Islander men who have sex with men, San Francisco. Sex
Transm Dis
2004, 31(8):475–480.
39. Rothenberg RB, Potterat JJ, Woodhouse DE, Muth SQ,
Darrow WW, Klovdahl
AS: Social network dynamics and HIV transmission. AIDS
1998,
12(12):1529–1536.
40. Herbst JH, Sherba RT, Crepaz N, Deluca JB, Zohrabyan L,
Stall RD, Lyles CM:
A meta-analytic review of HIV behavioral interventions for
reducing

sexual risk behavior of men who have sex with men. J Acquir
Immune
Defic Syndr 2005, 39(2):228–241.
41. Beyrer C: Global prevention of HIV infection for neglected
populations:
men who have sex with men. [Review]. Clin Infect Dis 2010,
50(Suppl 3):S108–S113. doi:10.1086/651481.
42. Smith AD, Tapsoba P, Peshu N, Sanders EJ, Jaffe HW: Men
who have sex with
men and HIV/AIDS in sub-Saharan Africa. Lancet 2009,
374(9687):416–422.
43. Harawa NT, Greenland S, Bingham TA, Johnson DF,
Cochran SD,
Cunningham WE, Celentano DD, Koblin BA, LaLota M,
MacKellar DA,
McFarland W, Shehan D, Stoyanoff S, Thiede H, Torian L,
Valleroy LA:
Associations of race/ethnicity with HIV prevalence and HIV-
related
behaviors among young men who have sex with men in 7 urban
centers in the United States. [Comparative Study Research
Support, N.I.
H., Extramural Research Support, U.S. Gov’t, P.H.S.]. J Acquir
Immune Defic
Syndr 2004, 35(5):526–536.
44. Baral S, Adams D, Lebona J, Kaibe B, Letsie P, Tshehlo R,
Wirtz A, Beyrer C: A
cross-sectional assessment of population demographics, HIV
risks and
human rights contexts among men who have sex with men in
Lesotho.
[Research Support, Non-U.S. Gov’t]. J Int AIDS Soc 2011,
14:36. doi:10.1186/

1758-2652-14-36.
45. Poteat T, Diouf D, Drame FM, Ndaw M, Traore C, Dhaliwal
M, Beyrer C, Baral
S: HIV risk among MSM in senegal: a qualitative rapid
assessment of the
impact of enforcing laws that criminalize same sex practices.
PLoS One
2011, 6(12):e28760. doi:10.1371/journal.pone.0028760.
46. Saavedra J, Izazola-Licea JA, Beyrer C: Sex between men in
the context of
HIV: the AIDS 2008 Jonathan Mann memorial lecture in health
and
human rights. J Int AIDS Soc 2008, 11:9. doi:10.1186/1758-
2652-11-9.
47. Baral S, Trapence G, Motimedi F, Umar E, Iipinge S,
Dausab F, Beyrer C: HIV
prevalence, risks for HIV infection, and human rights among
men who
have sex with men (MSM) in Malawi, Namibia, and Botswana.
PLoS One
2009, 4(3):e4997.
48. Logie C: The case for the world health organization’s
commission on the
social determinants of health to address sexual orientation. Am
J Public
Health 2012. doi:10.2105/AJPH.2011.300599.
49. Newman PA, Chakrapani V, Cook C, Shunmugam M,
Kakinami L:
Determinants of sexual risk behavior among men who have sex
with
men accessing public sex environments in Chennai, India.

[Research
Support, Non-U.S. Gov’t]. J LGBT Health Res 2008, 4(2–3):81–
87.
50. Ward H: Prevention strategies for sexually transmitted
infections:
importance of sexual network structure and epidemic phase.
[Review].
Sex Transm Infect 2007, 83(Suppl 1):i43–i49.
doi:10.1136/sti.2006.023598.
51. Blankenship KM, Friedman SR, Dworkin S, Mantell JE:
Structural
interventions: concepts, challenges and opportunities for
research.
[Research Support, N.I.H., Extramural Review]. J Urban Health
2006,
83(1):59–72. doi:10.1007/s11524-005-9007-4.
52. Baral SD, Wirtz A, Sifakis F, Johns B, Walker D, Beyrer C:
The Highest
Attainable Standard of Evidence (HASTE) for HIV/AIDS
Interventions:
toward a public health approach to defining evidence. Public
Health Rep
2012, 127(6):572–584.
doi:10.1186/1471-2458-13-482
Cite this article as: Baral et al.: Modified social ecological
model: a tool
to guide the assessment of the risks and risk contexts of HIV
epidemics.
BMC Public Health 2013 13:482.
Submit your next manuscript to BioMed Central
and take full advantage of:

• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit
http://dx.doi.org/10.1097/01.aids.0000222066.30125.b9
http://dx.doi.org/10.1086/512371
http://dx.doi.org/10.1016/S0140-6736(10)60832-X
http://dx.doi.org/10.1007/s10461-005-1679-y
http://dx.doi.org/10.1016/S0140-6736(10)61026-4
http://dx.doi.org/10.1016/S0140-6736(10)61026-4
http://dx.doi.org/10.1371/journal.pmed.0040339
http://dx.doi.org/10.1016/S0140-6736(12)60821-6
http://dx.doi.org/10.1086/651481
http://dx.doi.org/10.1186/1758-2652-14-36
http://dx.doi.org/10.1186/1758-2652-14-36
http://dx.doi.org/10.1371/journal.pone.0028760
http://dx.doi.org/10.1186/1758-2652-11-9
http://dx.doi.org/10.2105/AJPH.2011.300599
http://dx.doi.org/10.1136/sti.2006.023598
http://dx.doi.org/10.1007/s11524-005-9007-
4AbstractBackgroundDiscussionSummaryBackgroundDiscussion
The modified social ecological model (MSEM)Case study 1:
Parenteral transmission of HIV among people who inject drugs

(PID)Case study 2: Sexual transmission of HIV among
MSMSummaryCompeting interestsAuthors’
contributionsFundingAuthor detailsReferences
<<
/ASCII85EncodePages false
/AllowTransparency false
/AutoPositionEPSFiles true
/AutoRotatePages /PageByPage
/Binding /Left
/CalGrayProfile (Dot Gain 20%)
/CalRGBProfile (sRGB IEC61966-2.1)
/CalCMYKProfile (U.S. Web Coated 050SWOP051 v2)
/sRGBProfile (sRGB IEC61966-2.1)
/CannotEmbedFontPolicy /Error
/CompatibilityLevel 1.4
/CompressObjects /Tags
/CompressPages true
/ConvertImagesToIndexed true
/PassThroughJPEGImages true
/CreateJobTicket false
/DefaultRenderingIntent /Default
/DetectBlends true
/DetectCurves 0.1000
/ColorConversionStrategy /LeaveColorUnchanged
/DoThumbnails true
/EmbedAllFonts true
/EmbedOpenType false
/ParseICCProfilesInComments true
/EmbedJobOptions true
/DSCReportingLevel 0
/EmitDSCWarnings false
/EndPage -1
/ImageMemory 1048576
/LockDistillerParams true
/MaxSubsetPct 100
/Optimize true

/OPM 1
/ParseDSCComments true
/ParseDSCCommentsForDocInfo true
/PreserveCopyPage true
/PreserveDICMYKValues true
/PreserveEPSInfo true
/PreserveFlatness true
/PreserveHalftoneInfo false
/PreserveOPIComments false
/PreserveOverprintSettings true
/StartPage 1
/SubsetFonts true
/TransferFunctionInfo /Apply
/UCRandBGInfo /Preserve
/UsePrologue false
/ColorSettingsFile ()
/AlwaysEmbed [ true
]
/NeverEmbed [ true
]
/AntiAliasColorImages false
/CropColorImages true
/ColorImageMinResolution 300
/ColorImageMinResolutionPolicy /OK
/DownsampleColorImages true
/ColorImageDownsampleType /Bicubic
/ColorImageResolution 300
/ColorImageDepth -1
/ColorImageMinDownsampleDepth 1
/ColorImageDownsampleThreshold 1.50000
/EncodeColorImages true
/ColorImageFilter /DCTEncode
/AutoFilterColorImages true
/ColorImageAutoFilterStrategy /JPEG
/ColorACSImageDict <<
/QFactor 0.15

/HSamples [1 1 1 1] /VSamples [1 1 1 1]
>>
/ColorImageDict <<
/QFactor 0.15
>>
/JPEG2000ColorACSImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 30
>>
/JPEG2000ColorImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 30
>>
/AntiAliasGrayImages false
/CropGrayImages true
/GrayImageMinResolution 300
/GrayImageMinResolutionPolicy /OK
/DownsampleGrayImages true
/GrayImageDownsampleType /Bicubic
/GrayImageResolution 300
/GrayImageDepth -1
/GrayImageMinDownsampleDepth 2
/GrayImageDownsampleThreshold 1.50000
/EncodeGrayImages true
/GrayImageFilter /DCTEncode
/AutoFilterGrayImages true
/GrayImageAutoFilterStrategy /JPEG
/GrayACSImageDict <<
/QFactor 0.15
>>
/GrayImageDict <<
/QFactor 0.15

>>
/JPEG2000GrayACSImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 30
>>
/JPEG2000GrayImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 30
>>
/AntiAliasMonoImages false
/CropMonoImages true
/MonoImageMinResolution 1200
/MonoImageMinResolutionPolicy /OK
/DownsampleMonoImages true
/MonoImageDownsampleType /Bicubic
/MonoImageResolution 1200
/MonoImageDepth -1
/MonoImageDownsampleThreshold 1.50000
/EncodeMonoImages true
/MonoImageFilter /CCITTFaxEncode
/MonoImageDict <<
/K -1
>>
/AllowPSXObjects false
/CheckCompliance [
/None
]
/PDFX1aCheck false
/PDFX3Check false
/PDFXCompliantPDFOnly false
/PDFXNoTrimBoxError true
/PDFXTrimBoxToMediaBoxOffset [
0.00000

0.00000
0.00000
0.00000
]
/PDFXSetBleedBoxToMediaBox true
/PDFXBleedBoxToTrimBoxOffset [
0.00000
0.00000
0.00000
0.00000
]
/PDFXOutputIntentProfile (None)
/PDFXOutputConditionIdentifier ()
/PDFXOutputCondition ()
/PDFXRegistryName ()
/PDFXTrapped /False
/CreateJDFFile false
/Description <<
/ARA
<FEFF06270633062A062E062F06450020064706300647002006
27064406250639062F0627062F0627062A002006440625064606
340627062100200648062B062706260642002000410064006F00
620065002000500044004600200645062A064806270641064206
2900200644064406370628062706390629002006300627062A00
2006270644062C0648062F062900200627064406390627064406
4A06290020064506460020062E06440627064400200627064406
370627062806390627062A00200627064406450643062A062806
4A062900200623064800200623062C0647063206290020062506
2C06310627062100200627064406280631064806410627062A06
1B0020064A06450643064600200641062A062D00200648062B0
62706260642002000500044004600200627064406450646063406
2306290020062806270633062A062E062F062706450020004100
630072006F0062006100740020064800410064006F0062006500
20005200650061006400650072002006250635062F0627063100
200035002E0030002006480627064406250635062F0627063106

27062A0020062706440623062D062F062B002E0020064506390
020005000440046002F0041060C0020062706440631062C06270
6210020064506310627062C063906290020062F0644064A06440
02006450633062A062E062F06450020004100630072006F00620
0610074061B0020064A06450643064600200641062A062D0020
0648062B06270626064200200050004400460020062706440645
06460634062306290020062806270633062A062E062F06270645
0020004100630072006F0062006100740020064800410064006F
006200650020005200650061006400650072002006250635062F
0627063100200035002E0030002006480627064406250635062F
062706310627062A0020062706440623062D062F062B002E>
/BGR
<FEFF04180437043f043e043b043704320430043904420435002
004420435043704380020043d0430044104420440043e0439043a
0438002c00200437043000200434043000200441044a043704340
4300432043004420435002000410064006f006200650020005000
44004600200434043e043a0443043c0435043d044204380020043
704300020043a0430044704350441044204320435043d0020043f
04350447043004420020043d04300020043d043004410442043e0
43b043d04380020043f04400438043d0442043504400438002004
3800200443044104420440043e043904410442043204300020043
704300020043f04350447043004420020043d04300020043f0440
043e0431043d04380020044004300437043f04350447043004420
43a0438002e002000200421044a04370434043004340435043d04
3804420435002000500044004600200434043e043a0443043c043
5043d044204380020043c043e0433043004420020043404300020
044104350020043e0442043204300440044f04420020044100200
04100630072006f00620061007400200438002000410064006f00
620065002000520065006100640065007200200035002e0030002
0043800200441043b043504340432043004490438002004320435
0440044104380438002e>
/CHS
<FEFF4f7f75288fd94e9b8bbe5b9a521b5efa76840020005000440
04600206587686353ef901a8fc7684c976262535370673a548c002
000700072006f006f00660065007200208fdb884c9ad88d2891cf6
2535370300260a853ef4ee54f7f75280020004100630072006f006

2006100740020548c002000410064006f00620065002000520065
006100640065007200200035002e003000204ee553ca66f49ad87
248672c676562535f00521b5efa76840020005000440046002065
8768633002>
/CHT
<FEFF4f7f752890194e9b8a2d7f6e5efa7acb76840020004100640
06f006200650020005000440046002065874ef653ef5728684c976
2537088686a5f548c002000700072006f006f00660065007200204
e0a73725f979ad854c18cea7684521753706548679c300260a853e
f4ee54f7f75280020004100630072006f0062006100740020548c0
02000410064006f00620065002000520065006100640065007200
200035002e003000204ee553ca66f49ad87248672c4f86958b555f
5df25efa7acb76840020005000440046002065874ef63002>
/CZE
<FEFF005400610074006f0020006e00610073007400610076006
5006e00ed00200070006f0075017e0069006a007400650020006b
0020007600790074007600e101590065006e00ed00200064006f0
06b0075006d0065006e0074016f002000410064006f0062006500
20005000440046002000700072006f0020006b00760061006c006
90074006e00ed0020007400690073006b0020006e006100200073
0074006f006c006e00ed006300680020007400690073006b00e10
072006e00e100630068002000610020006e00e100740069007300
6b006f007600fd006300680020007a0061015900ed007a0065006e
00ed00630068002e002000200056007900740076006f015900650
06e00e900200064006f006b0075006d0065006e00740079002000
5000440046002000620075006400650020006d006f017e006e00e
90020006f007400650076015900ed007400200076002000700072
006f006700720061006d0065006300680020004100630072006f0
0620061007400200061002000410064006f006200650020005200
65006100640065007200200035002e0030002000610020006e006
f0076011b006a016100ed00630068002e>
/DAN
<FEFF004200720075006700200069006e0064007300740069006
c006c0069006e006700650072006e0065002000740069006c0020
006100740020006f0070007200650074007400650020004100640
06f006200650020005000440046002d0064006f006b0075006d00

65006e007400650072002000740069006c0020006b00760061006
c00690074006500740073007500640073006b007200690076006e
0069006e006700200065006c006c006500720020006b006f00720
0720065006b007400750072006c00e60073006e0069006e006700
2e0020004400650020006f0070007200650074007400650064006
50020005000440046002d0064006f006b0075006d0065006e0074
006500720020006b0061006e002000e50062006e0065007300200
0690020004100630072006f00620061007400200065006c006c00
6500720020004100630072006f006200610074002000520065006
100640065007200200035002e00300020006f00670020006e0079
006500720065002e>
/DEU
<FEFF00560065007200770065006e00640065006e00200053006
90065002000640069006500730065002000450069006e00730074
0065006c006c0075006e00670065006e0020007a0075006d00200
0450072007300740065006c006c0065006e00200076006f006e00
2000410064006f006200650020005000440046002d0044006f006
b0075006d0065006e00740065006e002c00200076006f006e0020
00640065006e0065006e002000530069006500200068006f00630
06800770065007200740069006700650020004400720075006300
6b006500200061007500660020004400650073006b0074006f007
0002d0044007200750063006b00650072006e00200075006e0064
002000500072006f006f0066002d00470065007200e4007400650
06e002000650072007a0065007500670065006e0020006d00f600
63006800740065006e002e002000450072007300740065006c006
c007400650020005000440046002d0044006f006b0075006d0065
006e007400650020006b00f6006e006e0065006e0020006d00690
0740020004100630072006f00620061007400200075006e006400
2000410064006f006200650020005200650061006400650072002
00035002e00300020006f0064006500720020006800f600680065
007200200067006500f600660066006e006500740020007700650
07200640065006e002e>
/ESP
<FEFF005500740069006c0069006300650020006500730074006
100200063006f006e0066006900670075007200610063006900f3
006e0020007000610072006100200063007200650061007200200

064006f00630075006d0065006e0074006f007300200064006500
2000410064006f006200650020005000440046002000700061007
2006100200063006f006e00730065006700750069007200200069
006d0070007200650073006900f3006e002000640065002000630
061006c006900640061006400200065006e00200069006d007000
7200650073006f007200610073002000640065002000650073006
3007200690074006f00720069006f002000790020006800650072
00720061006d00690065006e00740061007300200064006500200
063006f00720072006500630063006900f3006e002e0020005300
65002000700075006500640065006e00200061006200720069007
200200064006f00630075006d0065006e0074006f007300200050
00440046002000630072006500610064006f007300200063006f0
06e0020004100630072006f006200610074002c00200041006400
6f00620065002000520065006100640065007200200035002e003
000200079002000760065007200730069006f006e006500730020
0070006f00730074006500720069006f007200650073002e>
/ETI
<FEFF004b00610073007500740061006700650020006e0065006
900640020007300e4007400740065006900640020006c00610075
0061002d0020006a00610020006b006f006e00740072006f006c0
06c007400f5006d006d006900730065007000720069006e007400
6500720069007400650020006a0061006f006b00730020006b007
60061006c00690074006500650074007300650074006500200041
0064006f006200650020005000440046002d0064006f006b00750
06d0065006e00740069006400650020006c006f006f006d006900
730065006b0073002e002e00200020004c006f006f00640075006
40020005000440046002d0064006f006b0075006d0065006e0074
00650020007300610061007400650020006100760061006400610
02000700072006f006700720061006d006d006900640065006700
610020004100630072006f0062006100740020006e0069006e006
7002000410064006f006200650020005200650061006400650072
00200035002e00300020006a00610020007500750065006d00610
0740065002000760065007200730069006f006f006e0069006400
6500670061002e000d000a>
/FRA
<FEFF005500740069006c006900730065007a002000630065007

30020006f007000740069006f006e00730020006100660069006e
00200064006500200063007200e90065007200200064006500730
0200064006f00630075006d0065006e0074007300200041006400
6f00620065002000500044004600200070006f007500720020006
400650073002000e9007000720065007500760065007300200065
0074002000640065007300200069006d007000720065007300730
069006f006e007300200064006500200068006100750074006500
20007100750061006c0069007400e900200073007500720020006
40065007300200069006d007000720069006d0061006e00740065
00730020006400650020006200750072006500610075002e00200
04c0065007300200064006f00630075006d0065006e0074007300
2000500044004600200063007200e900e90073002000700065007
500760065006e0074002000ea0074007200650020006f00750076
0065007200740073002000640061006e007300200041006300720
06f006200610074002c002000610069006e007300690020007100
75002700410064006f00620065002000520065006100640065007
200200035002e0030002000650074002000760065007200730069
006f006e007300200075006c007400e9007200690065007500720
0650073002e>
/GRE
<FEFF03a703c103b703c303b903bc03bf03c003bf03b903ae03c3
03c403b5002003b103c503c403ad03c2002003c403b903c200200
3c103c503b803bc03af03c303b503b903c2002003b303b903b100
2003bd03b1002003b403b703bc03b903bf03c503c103b303ae03c
303b503c403b5002003ad03b303b303c103b103c603b100200041
0064006f006200650020005000440046002003b303b903b100200
3b503ba03c403cd03c003c903c303b7002003c003bf03b903cc03c
403b703c403b103c2002003c303b5002003b503ba03c403c503c0
03c903c403ad03c2002003b303c103b103c603b503af03bf03c500
2003ba03b103b9002003b403bf03ba03b903bc03b103c303c403a
d03c2002e0020002003a403b10020005000440046002003ad03b3
03b303c103b103c603b1002003c003bf03c5002003ad03c703b50
3c403b5002003b403b703bc03b903bf03c503c103b303ae03c303b
503b9002003bc03c003bf03c103bf03cd03bd002003bd03b100200
3b103bd03bf03b903c703c403bf03cd03bd002003bc03b5002003c
403bf0020004100630072006f006200610074002c002003c403bf0

02000410064006f00620065002000520065006100640065007200
2000200035002e0030002003ba03b103b9002003bc03b503c403b
103b303b503bd03ad03c303c403b503c103b503c2002003b503ba
03b403cc03c303b503b903c2002e>
/HEB
<FEFF05D405E905EA05DE05E905D5002005D105D405D205D
305E805D505EA002005D005DC05D4002005DB05D305D9002
005DC05D905E605D505E8002005DE05E105DE05DB05D9002
000410064006F006200650020005000440046002005E205D105D
505E8002005D405D305E405E105D4002005D005D905DB05D5
05EA05D905EA002005D105DE05D305E405E105D505EA0020
05E905D505DC05D705E005D905D505EA002005D505DB05DC
05D9002005D405D205D405D4002E002005DE05E105DE05DB
05D9002005D4002D005000440046002005E905E005D505E605
E805D905DD002005E005D905EA05E005D905DD002005DC05
E405EA05D905D705D4002005D105D005DE05E605E205D505
EA0020004100630072006F006200610074002005D5002D00410
064006F006200650020005200650061006400650072002000350
02E0030002005D505D205E805E105D005D505EA002005DE05
EA05E705D305DE05D505EA002005D905D505EA05E8002E>
/HRV
<FEFF005a00610020007300740076006100720061006e006a006
5002000410064006f00620065002000500044004600200064006f
006b0075006d0065006e0061007400610020007a00610020006b0
0760061006c00690074006500740061006e002000690073007000
6900730020006e006100200070006900730061010d0069006d006
100200069006c0069002000700072006f006f0066006500720020
00750072006501110061006a0069006d0061002e0020002000530
0740076006f00720065006e006900200050004400460020006400
6f006b0075006d0065006e007400690020006d006f00670075002
0007300650020006f00740076006f007200690074006900200041
00630072006f00620061007400200069002000410064006f00620
065002000520065006100640065007200200035002e0030002000
690020006b00610073006e0069006a0069006d002000760065007
2007a0069006a0061006d0061002e>
/HUN

<FEFF004d0069006e0151007300e9006700690020006e0079006f
006d00610074006f006b0020006b00e90073007a00ed007400e90
07300e900680065007a002000610073007a00740061006c006900
20006e0079006f006d00740061007400f3006b006f006e002000e9
007300200070007200f300620061006e0079006f006d00f3006b00
6f006e00200065007a0065006b006b0065006c002000610020006
2006500e1006c006c00ed007400e10073006f006b006b0061006c
002c00200068006f007a007a006f006e0020006c00e90074007200
65002000410064006f00620065002000500044004600200064006
f006b0075006d0065006e00740075006d006f006b00610074002e
0020002000410020006c00e90074007200650068006f007a006f0
0740074002000500044004600200064006f006b0075006d006500
6e00740075006d006f006b00200061007a0020004100630072006
f006200610074002c00200061007a002000410064006f00620065
002000520065006100640065007200200035002e0030002000e90
07300200061007a002000610074007400f3006c0020006b00e900
7301510062006200690020007600650072007a006900f3006b006
b0061006c00200020006e00790069007400680061007400f3006b
0020006d00650067002e>
/ITA
<FEFF005500740069006c0069007a007a0061007200650020007
10075006500730074006500200069006d0070006f007300740061
007a0069006f006e0069002000700065007200200063007200650
0610072006500200064006f00630075006d0065006e0074006900
2000410064006f006200650020005000440046002000700065007
200200075006e00610020007300740061006d0070006100200064
00690020007100750061006c0069007400e000200073007500200
07300740061006d00700061006e00740069002000650020007000
72006f006f0066006500720020006400650073006b0074006f007
0002e0020004900200064006f00630075006d0065006e00740069
00200050004400460020006300720065006100740069002000700
06f00730073006f006e006f0020006500730073006500720065002
000610070006500720074006900200063006f006e002000410063
0072006f00620061007400200065002000410064006f006200650
02000520065006100640065007200200035002e00300020006500
2000760065007200730069006f006e00690020007300750063006

3006500730073006900760065002e>
/JPN
<FEFF9ad854c18cea51fa529b7528002000410064006f00620065
00200050004400460020658766f8306e4f5c6210306b4f7f752830
57307e30593002537052376642306e753b8cea309267005927965
0306b4fdd306430533068304c3067304d307e3059300230c730b9
30af30c830c330d730d730ea30f330bf3067306e53705237307e30
5f306f30d730eb30fc30d57528306b9069305730663044307e3059
30023053306e8a2d5b9a30674f5c62103055308c305f0020005000
440046002030d530a130a430eb306f3001004100630072006f006
2006100740020304a30883073002000410064006f006200650020
00520065006100640065007200200035002e003000204ee5964d3
067958b304f30533068304c3067304d307e30593002>
/KOR
<FEFFc7740020c124c815c7440020c0acc6a9d558c5ec0020b370
c2a4d06cd0d10020d504b9b0d1300020bc0f0020ad50c815ae30c5
d0c11c0020ace0d488c9c8b85c0020c778c1c4d560002000410064
006f0062006500200050004400460020bb38c11cb97c0020c791c
131d569b2c8b2e4002e0020c774b807ac8c0020c791c131b41c002
00050004400460020bb38c11cb2940020004100630072006f0062
006100740020bc0f002000410064006f006200650020005200650
06100640065007200200035002e00300020c774c0c1c5d0c11c00
20c5f40020c2180020c788c2b5b2c8b2e4002e>
/LTH
<FEFF004e006100750064006f006b00690074006500200161006
90075006f007300200070006100720061006d0065007400720075
00730020006e006f0072011700640061006d00690020006b00750
07200740069002000410064006f00620065002000500044004600
200064006f006b0075006d0065006e007400750073002c0020006
b007500720069006500200073006b00690072007400690020006b
006f006b0079006200690161006b0061006900200073007000610
075007300640069006e007400690020007300740061006c006900
6e0069006100690073002000690072002000620061006e0064007
9006d006f00200073007000610075007300640069006e00740075
0076006100690073002e0020002000530075006b0075007200740
069002000500044004600200064006f006b0075006d0065006e00

7400610069002000670061006c006900200062016b00740069002
0006100740069006400610072006f006d00690020004100630072
006f006200610074002000690072002000410064006f006200650
02000520065006100640065007200200035002e00300020006100
72002000760117006c00650073006e0117006d006900730020007
60065007200730069006a006f006d00690073002e>
/LVI
<FEFF0049007a006d0061006e0074006f006a0069006500740020
0161006f00730020006900650073007400610074012b006a00750
06d00750073002c0020006c0061006900200069007a0076006500
690064006f00740075002000410064006f0062006500200050004
4004600200064006f006b0075006d0065006e0074007500730020
006b00760061006c0069007400610074012b00760061006900200
06400720075006b010101610061006e0061006900200061007200
2000670061006c006400610020007000720069006e00740065007
200690065006d00200075006e0020007000610072006100750067
006e006f00760069006c006b0075006d007500200069006500730
0700069006500640113006a00690065006d002e00200049007a00
76006500690064006f006a0069006500740020005000440046002
00064006f006b0075006d0065006e007400750073002c0020006b
006f0020007600610072002000610074007601130072007400200
06100720020004100630072006f00620061007400200075006e00
2000410064006f006200650020005200650061006400650072002
00035002e0030002c0020006b0101002000610072012b00200074
006f0020006a00610075006e0101006b0101006d0020007600650
07200730069006a0101006d002e>
/NLD (Gebruik deze instellingen om Adobe PDF-documenten
te maken voor kwaliteitsafdrukken op desktopprinters en
proofers. De gemaakte PDF-documenten kunnen worden
geopend met Acrobat en Adobe Reader 5.0 en hoger.)
/NOR
<FEFF004200720075006b0020006400690073007300650020006
9006e006e007300740069006c006c0069006e00670065006e0065
002000740069006c002000e50020006f007000700072006500740
0740065002000410064006f006200650020005000440046002d00
64006f006b0075006d0065006e00740065007200200066006f007

20020007500740073006b00720069006600740020006100760020
006800f800790020006b00760061006c006900740065007400200
07000e500200062006f007200640073006b007200690076006500
7200200065006c006c00650072002000700072006f006f0066006
50072002e0020005000440046002d0064006f006b0075006d0065
006e00740065006e00650020006b0061006e002000e50070006e0
0650073002000690020004100630072006f006200610074002000
65006c006c00650072002000410064006f0062006500200052006
5006100640065007200200035002e003000200065006c006c0065
0072002000730065006e006500720065002e>
/POL
<FEFF0055007300740061007700690065006e006900610020006
4006f002000740077006f0072007a0065006e0069006100200064
006f006b0075006d0065006e007400f3007700200050004400460
020007a002000770079017c0073007a010500200072006f007a00
64007a00690065006c0063007a006f015b0063006901050020006
f006200720061007a006b00f30077002c0020007a006100700065
0077006e00690061006a0105006301050020006c0065007000730
07a01050020006a0061006b006f015b0107002000770079006400
720075006b00f30077002e00200044006f006b0075006d0065006
e0074007900200050004400460020006d006f017c006e00610020
006f0074007700690065007200610107002000770020007000720
06f006700720061006d006900650020004100630072006f006200
61007400200069002000410064006f00620065002000520065006
100640065007200200035002e0030002000690020006e006f0077
0073007a0079006d002e>
/PTB
<FEFF005500740069006c0069007a00650020006500730073006
1007300200063006f006e00660069006700750072006100e700f5
0065007300200064006500200066006f0072006d0061002000610
0200063007200690061007200200064006f00630075006d006500
6e0074006f0073002000410064006f00620065002000500044004
60020007000610072006100200069006d00700072006500730073
00f5006500730020006400650020007100750061006c006900640
0610064006500200065006d00200069006d007000720065007300
73006f0072006100730020006400650073006b0074006f0070002

0006500200064006900730070006f00730069007400690076006f
0073002000640065002000700072006f00760061002e0020004f0
07300200064006f00630075006d0065006e0074006f0073002000
5000440046002000630072006900610064006f007300200070006
f00640065006d0020007300650072002000610062006500720074
006f007300200063006f006d0020006f0020004100630072006f00
6200610074002000650020006f002000410064006f00620065002
000520065006100640065007200200035002e0030002000650020
007600650072007300f50065007300200070006f0073007400650
0720069006f007200650073002e>
/RUM
<FEFF005500740069006c0069007a00610163006900200061006
30065007300740065002000730065007401030072006900200070
0065006e007400720075002000610020006300720065006100200
064006f00630075006d0065006e00740065002000410064006f00
6200650020005000440046002000700065006e007400720075002
00074006900700103007200690072006500200064006500200063
0061006c006900740061007400650020006c006100200069006d0
07000720069006d0061006e007400650020006400650073006b00
74006f00700020015f0069002000700065006e007400720075002
0007600650072006900660069006300610074006f00720069002e
002000200044006f00630075006d0065006e00740065006c00650
02000500044004600200063007200650061007400650020007000
6f007400200066006900200064006500730063006800690073006
50020006300750020004100630072006f006200610074002c0020
00410064006f00620065002000520065006100640065007200200
035002e00300020015f0069002000760065007200730069007500
6e0069006c006500200075006c0074006500720069006f0061007
20065002e>
/RUS
<FEFF04180441043f043e043b044c04370443043904420435002
004340430043d043d044b04350020043d0430044104420440043e
0439043a043800200434043b044f00200441043e0437043404300
43d0438044f00200434043e043a0443043c0435043d0442043e04
32002000410064006f006200650020005000440046002c0020043
f044004350434043d04300437043d043004470435043d043d044b

044500200434043b044f0020043a0430044704350441044204320
435043d043d043e04390020043f04350447043004420438002004
3d04300020043d043004410442043e043b044c043d044b0445002
0043f04400438043d044204350440043004450020043800200443
044104420440043e04390441044204320430044500200434043b0
44f0020043f043e043b044304470435043d0438044f0020043f044
0043e0431043d044b04450020043e0442044204380441043a043e
0432002e002000200421043e043704340430043d043d044b04350
020005000440046002d0434043e043a0443043c0435043d044204
4b0020043c043e0436043d043e00200020043e0442043a0440044
b043204300442044c002004410020043f043e043c043e0449044c
044e0020004100630072006f00620061007400200438002000410
064006f0062006500200052006500610064006500720020003500
2e00300020043800200431043e043b043504350020043f043e043
70434043d043804450020043204350440044104380439002e>
/SKY
<FEFF0054006900650074006f0020006e0061007300740061007
60065006e0069006100200070006f0075017e0069007400650020
006e00610020007600790074007600e100720061006e006900650
0200064006f006b0075006d0065006e0074006f00760020004100
64006f00620065002000500044004600200070007200650020006
b00760061006c00690074006e00fa00200074006c0061010d0020
006e0061002000730074006f006c006e00fd00630068002000740
06c0061010d006900610072014800610063006800200061002000
74006c0061010d006f007600fd006300680020007a00610072006
9006100640065006e0069006100630068002e0020005600790074
0076006f00720065006e00e900200064006f006b0075006d00650
06e00740079002000500044004600200062007500640065002000
6d006f017e006e00e90020006f00740076006f0072006901650020
0076002000700072006f006700720061006d006f0063006800200
04100630072006f00620061007400200061002000410064006f00
620065002000520065006100640065007200200035002e0030002
000610020006e006f0076016100ed00630068002e000d000a>
/SLV
<FEFF005400650020006e0061007300740061007600690074007
60065002000750070006f0072006100620069007400650020007a

00610020007500730074007600610072006a0061006e006a00650
0200064006f006b0075006d0065006e0074006f00760020004100
64006f0062006500200050004400460020007a00610020006b006
1006b006f0076006f00730074006e006f0020007400690073006b0
061006e006a00650020006e00610020006e0061006d0069007a00
6e006900680020007400690073006b0061006c006e0069006b006
9006800200069006e0020007000720065007600650072006a0061
006c006e0069006b00690068002e0020002000550073007400760
0610072006a0065006e006500200064006f006b0075006d006500
6e0074006500200050004400460020006a00650020006d006f006
7006f010d00650020006f0064007000720065007400690020007a
0020004100630072006f00620061007400200069006e002000410
064006f0062006500200052006500610064006500720020003500
2e003000200069006e0020006e006f00760065006a01610069006
d002e>
/SUO
<FEFF004b00e40079007400e40020006e00e40069007400e4002
000610073006500740075006b007300690061002c0020006b0075
006e0020006c0075006f0074002000410064006f0062006500200
050004400460020002d0064006f006b0075006d0065006e007400
740065006a00610020006c0061006100640075006b00610073007
4006100200074007900f6007000f60079007400e400740075006c
006f0073007400750073007400610020006a00610020007600650
064006f0073007400750073007400610020007600610072007400
65006e002e00200020004c0075006f00640075007400200050004
40046002d0064006f006b0075006d0065006e0074006900740020
0076006f0069006400610061006e0020006100760061007400610
020004100630072006f0062006100740069006c006c0061002000
6a0061002000410064006f0062006500200052006500610064006
5007200200035002e0030003a006c006c00610020006a00610020
0075007500640065006d006d0069006c006c0061002e>
/SVE
<FEFF0041006e007600e4006e00640020006400650020006800e
4007200200069006e0073007400e4006c006c006e0069006e0067
00610072006e00610020006f006d0020006400750020007600690
06c006c00200073006b006100700061002000410064006f006200

650020005000440046002d0064006f006b0075006d0065006e007
40020006600f600720020006b00760061006c0069007400650074
0073007500740073006b007200690066007400650072002000700
0e5002000760061006e006c00690067006100200073006b007200
6900760061007200650020006f006300680020006600f60072002
0006b006f007200720065006b007400750072002e002000200053
006b006100700061006400650020005000440046002d0064006f0
06b0075006d0065006e00740020006b0061006e002000f6007000
70006e00610073002000690020004100630072006f00620061007
40020006f00630068002000410064006f00620065002000520065
006100640065007200200035002e00300020006f0063006800200
0730065006e006100720065002e>
/TUR
<FEFF004d00610073006100fc0073007400fc002000790061007a
013100630131006c0061007200200076006500200062006100730
06b01310020006d0061006b0069006e0065006c00650072006900
6e006400650020006b0061006c006900740065006c00690020006
200610073006b013100200061006d0061006301310079006c0061
002000410064006f0062006500200050004400460020006200650
06c00670065006c0065007200690020006f006c0075015f007400
750072006d0061006b0020006900e70069006e002000620075002
00061007900610072006c0061007201310020006b0075006c006c
0061006e0131006e002e00200020004f006c0075015f0074007500
720075006c0061006e0020005000440046002000620065006c006
70065006c0065007200690020004100630072006f006200610074
002000760065002000410064006f0062006500200052006500610
0640065007200200035002e003000200076006500200073006f00
6e0072006100730131006e00640061006b00690020007300fc007
200fc006d006c00650072006c00650020006100e70131006c0061
00620069006c00690072002e>
/UKR
<FEFF04120438043a043e0440043804410442043e04320443043
9044204350020044604560020043f043004400430043c04350442
0440043800200434043b044f0020044104420432043e044004350
43d043d044f00200434043e043a0443043c0435043d0442045604
32002000410064006f006200650020005000440046002c0020044

f043a04560020043d04300439043a04400430044904350020043f
045604340445043e0434044f0442044c00200434043b044f00200
43204380441043e043a043e044f043a04560441043d043e043304
3e0020043404400443043a04430020043d04300020043d0430044
104420456043b044c043d043804450020043f04400438043d0442
04350440043004450020044204300020043f04400438044104420
440043e044f044500200434043b044f0020043e04420440043804
3c0430043d043d044f0020043f0440043e0431043d04380445002
00437043e04310440043004360435043d044c002e002000200421
04420432043e04400435043d045600200434043e043a0443043c0
435043d0442043800200050004400460020043c043e0436043d04
300020043204560434043a0440043804420438002004430020004
100630072006f006200610074002004420430002000410064006f
00620065002000520065006100640065007200200035002e00300
02004300431043e0020043f04560437043d04560448043e045700
20043204350440044104560457002e>
/ENU (Use these settings to create Adobe PDF documents for
quality printing on desktop printers and proofers. Created PDF
documents can be opened with Acrobat and Adobe Reader 5.0
and later.)
>>
/Namespace [
(Adobe)
(Common)
(1.0)
]
/OtherNamespaces [
<<
/AsReaderSpreads false
/CropImagesToFrames true
/ErrorControl /WarnAndContinue
/FlattenerIgnoreSpreadOverrides false
/IncludeGuidesGrids false
/IncludeNonPrinting false
/IncludeSlug false
/Namespace [

(Adobe)
(InDesign)
(4.0)
]
/OmitPlacedBitmaps false
/OmitPlacedEPS false
/OmitPlacedPDF false
/SimulateOverprint /Legacy
>>
<<
/AddBleedMarks false
/AddColorBars false
/AddCropMarks false
/AddPageInfo false
/AddRegMarks false
/ConvertColors /NoConversion
/DestinationProfileName ()
/DestinationProfileSelector /NA
/Downsample16BitImages true
/FlattenerPreset <<
/PresetSelector /MediumResolution
>>
/FormElements false
/GenerateStructure true
/IncludeBookmarks false
/IncludeHyperlinks false
/IncludeInteractive false
/IncludeLayers false
/IncludeProfiles true
/MultimediaHandling /UseObjectSettings
/Namespace [
(Adobe)
(CreativeSuite)
(2.0)
]
/PDFXOutputIntentProfileSelector /NA

/PreserveEditing true
/UntaggedCMYKHandling /LeaveUntagged
/UntaggedRGBHandling /LeaveUntagged
/UseDocumentBleed false
>>
]
>> setdistillerparams
<<
/HWResolution [2400 2400]
/PageSize [595.440 793.440]
>> setpagedevice

Baral et al. BMC Public Health 2013, 13482httpwww.biomed.docx

Recommended

Recommended

More Related Content

Similar to Baral et al. BMC Public Health 2013, 13482httpwww.biomed.docx

Similar to Baral et al. BMC Public Health 2013, 13482httpwww.biomed.docx (20)

More from jasoninnes20

More from jasoninnes20 (20)

Recently uploaded

Recently uploaded (20)

Baral et al. BMC Public Health 2013, 13482httpwww.biomed.docx