For example, children who acquire a language with singular-plural marking, like English, are faster to learn the word for 1 than children learning a language that lacks the singular-plural distinction, perhaps because the word for 1 is always used in singular contexts, highlighting its meaning. These studies are problematic, however, because reported differences in number word learning may be due to unmeasured cross-cultural differences rather than specific linguistic differences. To address this problem, we investigated number word learning in four groups of children from a single culture who spoke different dialects of the same language that differed chiefly with respect to how they grammatically mark number. We found that learning a dialect which features “dual” morphology (marking of pairs) accelerated children’s acquisition of the number word  Members of groups that lack such words, like the Pirahã and Mundurucu, are unable to perform precise numerical computations for large numbers ; . Al. Alone,  numbers ; 8]. He. Heone, one, two, three, four, five, etc.–which is initially recited as a blind routine, without specific meanings for each number word ); ; [18])one cup), whereas larger number words are used with the plural . Previous studies ). n items 2/3 of the time when asked for n, and (b) on 2/3 trials on which they gave n, it was in response to a request for n, and not some other number ).We found that among children acquiring the same language, learning the meaning of the word for 2 differed according to regional variation in the use of dual morphology. Although many children learning all four dialects eventually came to comprehend the dual, those exposed to non-dual dialects appeared to comprehend it later in development, and did not hear it frequently enough that it was adopted in their own spontaneous speech. Whereas children from Ljubljana spontaneously use the dual when labeling sets in the “What’s on this Card” task , we founThese data are consistent with the hypothesis that, when concepts like singular and dual are explicitly marked in a language, children are faster to acquire corresponding number words. Because the Slovenian children in our study lived in the same country, were culturally similar, spoke almost identical languages, and had almost identical counting abilities (as measured by Highest Count), the likelihood that differences in number word learning could be explained by unmeasured cultural differences is much smaller here than in previous work. For example, in some past studies it was reported that English-speaking children in the US became 1-knowers earlier than both Japanese- and Mandarin-speaking children in Japan  a) a26]) aThe relationship that we report between number word learning and the acquisition of number morphology may be important to understanding the nature of children’s first number word meanings, even outside of languages like Slovenian. First, the correlation suggests that the two systems encode similar conceptual content: Learning the singular likely helps children become 1-knowers because both forms encode singleton sets, just as learning the dual facilitates becoming a 2-knower because both encode dual sets. If this is right, then learning concepts like 1, 2, and 3 may not constitute an instance of domain-specific conceptual change that is special to human mathematical cognition. Instead, these concepts may be more general, and foundational to systems of natural language morphology. On this view, young children learning words for 1, 2, and 3 may deploy the same conceptual resources as when they learn singular, dual, and trial forms . This hAnother implication of this work is that the use of number words with informative linguistic cues, like number morphology, may be as important as counting routines to early number word learning even in languages that do not feature dual morphology. Our data, and data from other studies , suggesIn sum, we have presented evidence that morphological marking of number in language facilitates learning of early number word meanings. We compared children learning four dialects of Slovenian and found that, overall, dual learners were faster than non-dual learners to become 2-knowers, when controlling for factors like age and counting ability, and that comprehension of the dual was related to number knowledge in children learning dual dialects, but not in children learning non-dual dialects. Although these children ultimately learned to comprehend the dual–which may have contributed modestly to their becoming 2-knowers–this generally happened after they became 2-knowers, and was not sufficiently robust as to be reflected in their spontaneous speech, which lacked dual usage almost completely. Together, these results support the idea that number word learning likely relies on content similar to that used for acquiring number morphology, and thus that mathematical knowledge may be built on a foundation of concepts that arise spontaneously in natural language, even in absence of formal training with number.S1 FileThis document describes the linguistic and Socio-economic differences between the four locations where children were tested in Slovenia.(PDF)Click here for additional data file.


Previously free of rabies, Bali experienced an outbreak in 2008, which has since caused a large number of human fatalities. In response, both mass dog culling and vaccination have been implemented. In order to assess potential community-driven interventions for optimizing rabies control, we conducted a study exploring the relationship between dogs, rabies, and the Balinese community. The objectives of this study were to: i) understand the human-dog relationship in Bali; ii) explore local knowledge, attitudes, and practices (KAPs) relating to rabies; and iii) assess potential community-driven activities to optimize rabies control and surveillance.n = 300; CI = 95 %; error margin = 5 %) and focus group discussions (FGDs) in 10 villages in the Denpasar, Gianyar, and Karangasem regencies. The questionnaire included a Likert scale to assess community knowledge and attitudes. For the knowledge assessment, three points were given for a correct answer, while wrong answers and uncertain answers were given zero points. For the attitudes assessment, three points were given for a positive answer, two points for a neutral answer, and one point for a negative answer. Respondent knowledge was categorized as good (score >40), fair (score 20–40), or poor (score <20), based on a maximum total score 60. Respondent attitudes were categorized as positive (score >26), neutral (score 13–26), or negative (score <13), based on a maximum total score of 39. Mixed-gender FGDs in each sub-village (banjar) were conducted, each involving 7–15 participants to complement the questionnaire results. On a follow-up research trip in mid-2013, the data analysis was triangulated and validated using semi-structured interviews. Questionnaire data were analyzed descriptively using SPSS 17.0, while qualitative data from interviews and FGDs were analyzed manually according to accepted methods of coding and memo writing. The chi-square test was then used to analyze the statistical relationships between knowledge and attitudes of the respondents.Conducted between February and June 2011, the study combined a questionnaire (ahimsa (non-violence) into education campaigns, engaging communities through the local banjar sociopolitical system, and working with traditional legal structures to increase local compliance with rabies control.Out of the total 300 respondents, most were predominantly male (82 %), Hindu (99 %), married (96 %), older than 30 years of age (92 %), and owned dogs (72 %). Dog ownership was motivated by culture, personal taste, and function, with dogs was being used as guards (85 %) and companion animals (27 %), and was sometimes related to religious or traditional obligations (2 %). Relating to their culture and local beliefs, and eventually becoming their way of life, 79 % of respondents kept free-roaming dogs. With the rabies outbreak in Bali and Western breeds becoming more popular, more responsible dog ownership  became more acceptable and changed community perceptions on keeping dogs, even though the sustainability of this practice cannot be gauged. In addition, the economic situation posed major problems in rural areas. The level of community knowledge about rabies and its associated control programs were generally fair and community attitudes were positive. However, community KAPs still need to be improved. A total of 74 % respondents reported to have vaccinated their dogs in 2011, but only few were found to report rabid animals to livestock officers (12 %) and a significant number believed that washing a bite wound was not important (62 %). Moreover, free-roaming dog practices and discarding of unwanted female puppies still continue and possibly create difficulties for rabies elimination as these practices potentially increase the stray dog population. We identified three major sociocultural aspects with potential for community-driven interventions to optimize current rabies elimination efforts: integrating local notions of banjar and village levels, such as public awareness activities, vaccination, dog registration, dog population management, and rapid response to dog bites, were identified as being able to complement the rabies control program in Bali. The program also needs recognition or acknowledgement from governments, especially local government as well as regular mentoring to improve and sustain community participation.The human-dog relationship in Bali is multifaceted. Due to the uniqueness of the culture and the local beliefs, and encouraged by a socioeconomic aspect, a number of local practices were found to be constituting risk factors for continued rabies spread. Community knowledge and attitudes, which can consequently result in behavioral changes, needs to be improved across different genders, ages, educational backgrounds, and roles in the community, regardless of the individual village’s experiences with rabies. Furthermore, community-driven activities based on sociocultural conditioning and community capacity at the The online version of this article (doi:10.1186/s40249-015-0061-1) contains supplementary material, which is available to authorized users. Please see Additional file Rabies is a significant but neglected disease predominantly transmitted through dog bites and responsible for an estimated 55,000 to more than 70,000 human deaths annually worldwide, but occurring mostly in Asia and Africa –4. The rSince 2008, rabies has cost the Balinese government more than US $13 million, led to the death of more than 150 people, and has been responsible for tens of thousands of expensive human post-exposure prophylactic (PEP) treatments that are given after suspected rabid dog bites –12.Ubiquitous around markets, temples, beaches, garbage dumps, and rice paddies, the majority of Bali’s dogs are owned, free-roaming, indigenous street dogs. Known to be independent, aggressive, and territorial, the Balinese street dog remains one of the most genetically diverse canine populations, related to the Australian Dingo and Chow Chow , 14. A sAside from a unique dog population, Bali has also long been known for its unique culture, arts, and religion, and a diverse amount of anthropological research has been conducted on the island since the early Dutch colonial era. Much of this work has shown the interrelatedness between Balinese religion, society, and the natural world; for instance, the importance of water temples in regulating irrigation networks used in rice cultivation as well as the central role of the Balinese cockfight to notions of identity and socialization , 18. A mDue to the island’s dense dog population, current efforts to eliminate rabies from Bali have received much international attention. If successful, the Balinese elimination campaign could help set a precedent for the feasibility of rabies elimination through mass dog vaccination in Asia . While abanjars (sub-villages) selected purposively from 10 villages in Denpasar city, and the Gianyar and Karangasem districts. These areas were chosen due to their demographic and economic differences, representing an urban, suburban, and rural district, respectively  towards dogs, rabies, and canine vaccination was first administered, which used both open and closed-ended questions. A total of 30 participants per banjar  participated in the questionnaire, with a proportional number of government officers, religious leaders, and members of the general population being selected in each village.This cross-sectional study was conducted from February to June 2011 in 10 banjar, which lasted between one to two hours and involved 7–15 participants. The participants were often the same people who had answered our previous questionnaires, but the FDGs also included other key persons, such as traditional leaders and village leaders. The FGDs revisited the same questions as our questionnaires but allowed for much more nuanced explorations of emerging themes and sub-themes. During a follow-up research trip in mid-2013, semi-structured interviews were used to triangulate and validate the data analysis.The questionnaire included a Likert scale to assess knowledge and attitudes using a scoring system. For the knowledge assessment, three points were given for a correct answer, while wrong answers and uncertain answers were given zero points. Respondent knowledge was categorized as good (score >40), fair (score 20–40), or poor (score <20), based on a maximum total score of 60. For the attitude assessment, three points were given for a positive answer, two points for a neutral answer, and one point for a negative answer. Respondent attitudes were categorized as positive (score >26), neutral (score 13–26), or negative (score <13), based on a maximum total score of 39. In order to triangulate and further explore, we subsequently conducted interviews as well as one mixed-gender focus group discussion (FGD) in each Questionnaire data were analyzed descriptively using SPSS 17.0, while qualitative data from interviews and FGDs were analyzed manually according to accepted methods of coding and memo writing. The chi-square test was then used to analyze the statistical relationships between knowledge and attitudes of the respondents. According to our system, approval for this study was obtained from the Political Unity and Nation Agency at Bali Province and Livestock Services Office of Bali Province, and acknowledged by the Directorate of Animal Health, Directorate General of Livestock and Animal Health, Ministry of Agriculture, Republic of Indonesia.Slightly less than three-quarters of the questionnaire respondents 72 %) reported to own a dog. Out of the total number of respondents, most were predominantly male (82 %), Hindu (99 %), married (96 %), and older than 30 years of age (92 %). The respondents’ demographic profiles are presented in Table  % reportThe Mahabharata was continuously invoked to explain why the Balinese respected and tolerated so many free-roaming dogs. The story goes that after enduring the death of his family on a perilous journey to the Gates of Heaven, an ill-kept dog faithfully accompanies King Yudhistira and when the dog  is refused entry into the celestial city by the God Indra, Yudhistira refuses to enter without the dog. At this point, the dog transformed into the God Dharma (representing righteousness and justice) and Yudhistira is commended for his loyalty. In the words of one male focus group participant:“Keeping dogs for the Balinese is just part of the way we are…we respect dogs due to the story of Yudhistira…they have a number of functions but many times people just want dogs around and they feel that life is quiet, or something is missing or not complete if a dog is not there. We are used to having so many dogs around since we were young”.According to focus group participants, dogs were a ubiquitous part of the Balinese landscape and people were accustomed to having many free-roaming dogs around their fields, streets, homes, and markets since childhood. Representative of the influence of Hinduism, the popular story of King Yudhistira in the Hindu epic “owned but free-roaming”, the Balinese dog was described as “semi-wild”, “fiercely independent”, “untamable”, and “very territorial”, spending most of the day roaming within one to four kilometers, and some only returning to their owner compound at night. While dogs were fed a mixture of leftover and commercial dog food, they also ate from local hotels, restaurants, religious offerings, and garbage dumps. Due to recent health messaging campaigns, the majority of the respondents (84 %) felt that dogs should be caged and put on leashes, although these recommendations have not been widely put into practice. The study showed that 79 % of respondents kept their dogs roaming free. Leashed dogs were perceived to be too aggressive and confining dogs was, in the words of one interviewee, “against the spirit of the Balinese dog”. Although most owners reported that they could handle their dogs within the family compound (97 %), focus group participants emphasized that this only lasted a few seconds before the dog resisted. Those who fed the dog were usually the same ones that could touch it—and most physical contact was confined to the time when the dog was a puppy.Considered ahimsa (non-violence) towards the unwanted puppies. However, this local practice was also thought to maintain the stray dog population.Not all owned dogs were indigenous Balinese street dogs. Although mostly found in the southern tourist region (including Denpasar and Gianyar), Western breeds were considered to be confined on leashes and kept within the home as companion animals. The population of these companion dogs has increased since the 1990s in parallel to private veterinary practices in Bali and the growth of the expat community. A second significant characteristic of the dog population is the presence of stray dogs, thought to range from 2 to 10 % in the study villages. Considered more aggressive and prone to physically harming people, stray dogs caused discomfort and fear among community members and were widely believed to be responsible for the spread of rabies in Bali. People emphasized that the stray population was maintained by the growth of open garbage dumps , as well as the local practice of discarding unwanted female puppies. In total, 76 % of the questionnaire respondents who had dogs preferred male dogs due to their perceived superior guard dog abilities and the fact that in mating season, packs of unruly males gather at the homes of female dogs, causing a great nuisance to their owners. While male dogs could be given to friends as gifts, female puppies were generally not appreciated. However, unwanted females were not killed outright but often discarded in garbage areas, near restaurants and waterways. This practice was considered widespread throughout the island and motivated by the Hindu principle of “the Paris Hilton poodle”, alluding to a popular Western celebrity. Western breeds were linked to symbols of affluence and modernity while they were also generally considered much better companion animals. Despite this, the Balinese dog was believed to be superior in a number of areas. The most widely cited was that they barked louder and more often at strangers, making them better guard dogs. During focus groups, it became clear that dogs function more as an “alarm bell” alerting family members to strangers than as attack dogs, as crime was believed to be low and the dogs were absent (roaming) for most of the day. Farmers living near mountainous areas also reported the use dogs for hunting small animals and for protecting agricultural land from monkeys.Questionnaire respondents reported to use dogs as guards (85 %) and some as companion animals (27 %), while only 2 % related dog ownership to religious or traditional obligations. The idea of dogs being used for recreational purposes was seen as a recent phenomenon. As foreign breeds have been increasingly imported, it is not uncommon to see both expats and the Balinese with small non-indigenous breeds on their scooters in urban areas; what one interviewee called alarm bell. Dogs were considered to be able to “see”, “sense”, and “know” when evil spirits were around the home and acted as de facto “evil spirit alarms”. Alerted by unusual howling, people would reportedly pray for protection, stay indoors, or avoid some future activity to evade calamity. These types of events were believed to coincide with specific times in the Balinese calendar when the movement of spirits was believed to be more prevalent. As one interviewee, a male village leader, noted:Kajeng Kliwon when spirits roam, you find the dogs are howling like mad”.“A dog is a type of alarm bell for spirits because it is more sensitive than people to the negative powers and can see sorcerers approaching you. Some people believe it is because dogs have evil spirits inside of them, but I disagree. Dogs are loyal creatures and want to warn their owners of the dangers…you find that on certain times of the month, on sacred days such as There was also a second, more nuanced way that dogs played the role of an “…it would make you dirty and destroy your aura since evil spirits can be inside dogs and this should be avoided”.It was found that some groups of people also eat dogs, a practice that is widespread in other areas of Indonesia including North Sumatra, North Sulawesi, and East Nusa Tenggara. During the initial rabies outbreak, there were reports that dogs were being stolen and moved to northern Bali to be served in restaurants, which may have facilitated the spread of the virus. While it was difficult to confirm this, focus groups and interviews gave varying reports about the popularity of dog meat. Some people commented that it was widely consumed until the rabies epidemic created a fear of transmission, while others reported that it was only practiced in areas with migrant non-Balinese populations. There were few reasons given for the consumption of dog meat. The most accepted was that certain parts of a dog were eaten under the supervision of a traditional doctor for medical conditions, including a dog’s heart for the treatment of asthma. The second, albeit a less discussed idea, related to the consumption of dog for the increase of the male libido, linked to the belief that dog meat could confer magical powers and increase sexual dexterity. To some, however, dogs were synonymous with evil spirits and these respondents were opposed to eating dogs on religious grounds, arguing that this practice should be avoided because, in the words of one focus group participant,Bhuta Yadnya is the practice of providing specific types of ritual sacrifices of flowers and food to feed and show respect to evil spirits that are believed to hide in natural objects and places. Such sacrifices appease these demons, at which point they turn into guards that defend the household from other spirits. The sacrifice that involves dogs is believed to target evil spirits residing throughout the banjar area and is done when advised under the direction of a priest. This was reported to occur numerous times every year in each of the study villages by different households. The type of dog needed was the blang bungkem, a dog with reddish brown fur and a black snout, chosen because its red color corresponds to the symbolic color of the evil spirit targeted for such sacrifices. There was no reported breeding of the blang bungkem; this breed was considered relatively rare to find but could be bought at certain markets if not found within the community. An elaborate ceremony, which can cost many hundreds of dollars to conduct, is involved in the sacrifice where the body parts of the dog are offered up to the evil spirit(s). Interviewed priests explained that the dog then attains a higher state of re-incarnation as spiritual balance is returned to the community.Dogs also played a very specific role in religious ceremonies. Contrary to Indian Hinduism, the Balinese use animals in their religious sacrifices, including dogs. The Considered a dangerous and fatal disease, 97 % of the questionnaire respondents had heard of rabies (see Table Most respondents (86 %) believed that visiting a local hospital or clinic was necessary after a suspected rabid dog bite and that injection and/or vaccinations (post-exposure prophylactic [PEP]) should be sought. More than half of the respondents (61 %) wrongly believed there was a medicine to treat rabies. Only 39 % understood that injections and/or vaccinations can only block the virus transmission, and was not the same as medicine. While PEP treatment was freely available in the outbreak situation, 22 % of the questionnaire respondents believed there was a fee involved, while 34 % did not know whether there was a fee or not.A significant number of respondents (62 %) did not think that washing a wound from a suspected rabid dog bite was important. Our results show that respondents understood that they should visit a hospital or get treatment, but didn’t really consider this to be a matter that required urgent treatment. Moreover, a widespread local belief (held prior to the rabies outbreak) was that dog licks could heal wounds and this led to the practice of not washing wounds, including bite wounds. Only 12 % of the respondents reported that it was important to consult with local livestock officers in case of dog bites. This small number could be attributed to the fact, at least partially, that most people (76 %) reported that killing a suspected rabid dog was the immediate community response, with only a small number believing that rabid dogs should be caught (13 %) or let go (12 %). A total of 17 % reported that they had previously been bitten by a dog.n = 300, 62 %) had a fair knowledge about rabies  , even though there was no significant variation in the range of the respondents’ roles: 32 % worked for the local government, 33 % were traditional leaders, and 35 % were just part of the general community  in villages without rabies experience, while no significant relationship was found between knowledge and these variables in villages with rabies experience.Based on the village status, there was a significant relationship observed between knowledge and the variables of sex and age  between respondents’ attitudes and the examined variables , both based on the total number of respondents and the village status.The majority of the respondents had positive attitudes towards the rabies control program (96 %), while 4 % had neutral feelings towards it, and no one showed a negative attitude (see Table n = 300) in villages without rabies experience. However, a significant relationship between these variables was found in villages with rabies experience   reported that there was a free vaccination program in their area, and that it had been conducted by the government (66 %) or an NGO (34 %). A high percentage (94 %) agreed that annual vaccination was necessary for rabies control. A total of 74 % claimed to have had their dog(s) vaccinated during the first island-wide vaccination campaign in 2011. Focus group participants were unanimous that the majority of dogs were not vaccinated at central points but rather by dog-catching teams moving around the Similar to a recent study done in Tanzania , other r“resistant” to the catching system, which was ascribed to their traumatic experience of being caught and vaccinated, as well as their “intelligence” and “memory” of the event. Second, specific ecological areas such as garbage dumps and large forest or agricultural areas were thought to be difficult for dog-catchers, especially when targeting stray dogs. In one of the study villages which had experienced two rabies deaths and many more suspected rabid dogs, over 60 % of the area was covered with snakeskin fruit trees. Snakeskin fruit trees are short, dense, thorny trees obstructing visibility and mobility. Besides guarding houses, dogs are also used to guard these plantations and it was believed that these trees allowed dogs to “hide” during the vaccination campaigns due to the remoteness of and inaccessibility to the area.Community members referred to two main challenges related to dog-catchers. A general perception was that it was becoming exceedingly more difficult to catch dogs during the second (in late 2011) and third (in 2013) vaccination rounds since the dogs were believed to have become Interestingly, slightly more than half of the questionnaire respondents (57 %) agreed that rabies vaccination was not too expensive for the community and focus groups consistently highlighted that a significant number of people would be willing to pay for the vaccination of puppies, if this service was not widely available (which it was not).ahimsa (or non-violence) towards all sentient beings. At the first outbreak, government culling targeted any dog that was not tied or left indoors. Many expressed anger at having their animals killed (some of which had been vaccinated) and complained about the large number of corpses left by the culling teams. The culling had generated some reluctance during the first round of vaccinations as people hid their dogs in fear that the vaccination teams would kill them. However, most had accepted and even welcomed the culling, regardless of their religious beliefs, due to the widespread fear of rabies. A total of 83 % of the questionnaire respondents reported that the elimination of stray dogs was necessary to eliminate rabies, despite the acknowledgement that it was difficult to differentiate between an owned and a stray dog, as well as that the stray dog population had not been dramatically affected by the culling. Although culling initially reduced the dog population , it was perceived that the stray dog population was again quickly growing. It was found that the traditional methods of canine sterilization were practiced only in isolation . While some expressed reluctance to having their dogs sterilized (due to a perception that it made them less aggressive), there was an expectation that the government should conduct more sensitization for the benefit of population control, provide free sterilization services, and address the problem of stray dogs.Most respondents reported that dog culling had taken place in their village (74 %) and that it had been carried out by the government; only 2 % claimed that culling had been done by the community itself. This aversion to culling was explained in reference to the Hindu principle of “The fear of rabies has really changed the way we are keeping dogs [in Bali]. We now vaccinate dogs and feed them well, not like before!…Some people do not want to keep dogs anymore saying that they prefer their own safety to having a dog…and more people are starting to leash or even cage their dogs in town areas…even when Bali becomes rabies-free, people will still keep these better habits”.The introduction of rabies in Bali was perceived to have impacted Balinese attitudes towards dogs. Most of the questionnaire respondents (83 %) reported that the outbreak changed the way they kept dogs, motivating them to keep less dogs and, for some, to confine and leash them. Whilst adoption of leashing was limited to urban areas, even in rural sub-village settings, it was no longer considered socially acceptable to own more than one or two dogs; prior to rabies many dog owners had two to five dogs. Hence, through both education and fear of rabies, the outbreak was believed to have altered, to varying degrees, dog management practices with long-term implications. As one male village leader noted in a FGD:banjar level, which had already been put in place in late 2010 in some villages (according to 20 % of the questionnaire respondents). There are two types of traditional Balinese laws: perarem is considered to be a trial law that has an informal amount of enforcement, while awig-awig is a law that has been sacredly encoded through religious rituals and must be followed. The awig-awig laws are considered too difficult to institute for rabies control and rather the perarem was widely discussed and implemented in some areas. These laws included: i) accepting that your dog has to be culled if it was roaming outside the household; ii) having to pay all medical costs if someone was bitten by your dog; iii) incurring a fine if you were caught discarding unwanted puppies; and iv) paying all human funeral costs (including cremation) if your dog caused a human death. Such laws, although informal, were believed to act as “drivers of responsibility” in the community, motivating people to leash their dogs and vaccinate them, although the exact impact was difficult to measure in this study. In practice, dogs are free roaming and people usually recognize their dogs. The first point of the laws described above was mainly implemented in first outbreak. In later outbreaks, this point was mainly implemented when dog bite cases caused human death, in which the owners were made responsible for both human medication and traditional ceremonies (include cremation).Although controlling rabies is believed to be the government’s responsibility, 67 % agreed that rabies control could be optimized by instituting dog ownership regulations based on traditional law at the Banjar men, women, and youth groups meet on a regular basis, i.e. monthly or by need. These social group meetings become a space in which the community can share information on new traditional laws and their implementation. In this type of community structure, traditional leaders have the responsibility to determine whether important issues should be regulated with traditional laws to ensure community awareness and responsibility, including issues on rabies and its control.Socially, Bali has a unique traditional structure and social meeting groups, with traditional laws playing an important role in daily community activities. The human-dog relationship in Bali is very unique and closely related with: (1) religion (Hindu), (2) culture, and (3) socioeconomic contexts. These aspects contribute to how intensive the human-dog relationship is and how important of a role dogs play in the daily lives of Balinese communities, i.e. to guard houses, be companions for people working in fields or plantations, as well their roles in religion or traditional ceremonies. These aspects also drive the practice of free-roaming dogs, which in the context of rabies can pose a high risk for spreading the disease.Many respondents (79 %) allow their dogs to free roam and only few could handle their dogs during mass vaccination. These dog management practices need to be improved because dog vaccination can only protect the population from rabies if an adequate level of herd immunity is achieved (>70 % coverage). Moreover, the practice of discarding unwanted (and unvaccinated) female puppies will increase the number of uncontrolled free-roaming dogs (or even lead to a higher presence of stray dogs) and decrease vaccination coverage, despite vaccination campaigns reporting 70–74 % coverage . Many reImproving dog management practices without stigmatizing community beliefs on the importance of dogs requires a better understanding of community knowledge and attitudes towards rabies and relevant control programs. Community knowledge related to rabies and the rabies control program was generally fair, but FGDs revealed that incorrect information was also circulating in the communities, i.e. rabies is curable, culling is an effective control measure for rabies, and that a fee is charged for PEP provided by the government. Hence, there is a need for more community outreach to address these information gaps and improve community knowledge.Despite the strong influence of Hindu principles in Bali (which likely contributes to the lack of community involvement in dog culling), it appears that many people passively accepted the mass culling of dogs due to a combination of fear generated by the outbreak and wanting to abide by the government. Culling, however, was not effective in reducing the number of rabies cases , 28, andWhile most questionnaire respondents understood the basics of rabies transmission, the study revealed a number of important gaps. This included: i) a lack of awareness about washing suspected rabid dog bite wounds; ii) a lack of knowledge concerning that PEP must be given prior to the development of symptoms in humans; iii) a limited knowledge that scratches could transmit rabies; and iv) a lack of emphasis on reporting rabid animals to the local livestock office to facilitate diagnostic testing and outbreak surveillance. These knowledge gaps at the local level have important public health consequences and should be included in the key messages of future campaigns. Community awareness on PEP must also be evaluated because people will want to get PEP, however, some don’t understand that the injection must be sought as soon as they are bitten (prior to symptoms) and that late treatment would be ineffective. Lack of awareness on washing dog bite wounds might be encouraged by widespread local beliefs (that existed prior to the rabies outbreak) that dog licks could heal human wounds. It might also be the reason why only 18 % of respondents answered that licks are also potential rabies transmitters. Moreover, there should be a rapid community response to dog bite cases, and this should be improved overall, not only in terms of first-aid actions and seeking medical treatment, but also ensuring reporting to the livestock office in order to prevent suspected rabid dogs from spreading the disease further. More rabies centers  should also provide free services for PEP, as some people are still not aware that free PEP services are provided for rabies outbreak areas, such as Bali.To improve community knowledge, better dog ownership should be encouraged, which involves educating people about leashing their dogs and regular feeding. If owners and communities can become closer with their dogs, then dogs can be handled more effectively during vaccination campaigns. In addition, it would also greatly improve the efficiency of mass vaccination programs. Since the economy poses a major challenge to the implementation of leashing and regular feeding in some rural areas, more effective strategies need to be explored.Public awareness programs on rabies prevention and control and responsible dog ownership must be delivered regularly to ensure community knowledge improvement and to encourage behavioral changes. We found no significant relationship between gender and knowledge level or community attitudes towards rabies and its control. Based on the FGDs, men and women share equal roles and responsibilities in managing dogs. Youth and children have daily contact with dogs, for play and companionship, while adults also have contact in houses or at their workplaces. Therefore, different genders and ages have similar potential risks to contribute to the rabies spread, but could also provide valuable assistance to rabies control programs if their knowledge and attitudes are improved.While community knowledge was generally fair and attitudes were mostly positive, the community in general still maintains free-roaming dogs. While there was a significant relationship observed between knowledge and educational level, and also between knowledge and the role in the community, there was no significant relationship observed between community knowledge, attitudes, and dog keeping practices. Dogs were generally free roaming, regardless of these variables. Therefore, campaigns should target people of all genders, ages, religions, educational backgrounds, occupations, and roles in the community, regardless of their rabies experience, to ensure appropriate information dissemination.Once active rabies cases have been significantly reduced , elimination efforts must focus heavily on strengthening surveillance capacity and rapid response, as well as maintaining vaccination coverage . Cognizaahimsa (non-violence). Such culturally embedded logics could be used to frame education efforts targeting compliance to vaccination as well as more responsible dog ownership practices. This could include more physical contact with dogs from a young age, leashing, regular feeding, and animal healthcare. Additionally, a major emphasis on education should address the practice of discarding unwanted female puppies (due to their maintenance of the stray dog population) and the reporting of rabies cases in dogs. The principle of ahimsa could also be used to promote a sterilization program, to explore animal welfare issues, to stop culling, to promote regular vaccination of puppies, as well as to emphasize the importance of reporting dog rabies cases to livestock officers in order to curtail further spread to dogs and humans.First, the Balinese have a local belief that has a strong emphasis on banjar or village-based volunteers , and working with banjar leaders through, for example, a “trainer-of-trainee” model would offer a useful pathway in raising local awareness and engaging communities in rabies control and animal health more generally. Moreover, the head of banjar is usually also on the board of directors for schools in the area and this means that schools can also help disseminate knowledge about rabies.Second, our research has shown unique community structures and regular social meetings  that could be engaged to facilitate increased public awareness of rabies elimination and a community’s capacity for supporting rabies control programs. Training for banjar level, and responding to any rabies outbreaks quickly. With the employment of dog-catchers, dogs were believed to have shown more “resistance” (i.e. aggressive and harder to catch) with each passing campaign and some reported to “hide” and avoid the teams as well as villagers in general. However, dog-catchers were useful for vaccinating dogs that were not owned dogs (stray dogs) or free-roaming dogs that could not be handled by their owners. Door-to-door vaccination is still relevant since not all owners can handle their dogs or bring them to vaccination points in banjars due to owning a large number of dogs. At this point, volunteers can assist vaccination teams in handling the dogs or by providing baseline data of dogs registered at the banjar level. Formal acknowledgement and institution of community volunteers in rabies control programs needs to be considered. Volunteers may feel more appreciated and be encouraged to work harder. Moreover, volunteers will need technical assistance from the government to improve their capacity in supporting the programs to combat rabies.Lessons can be learnt from other similar campaigns, such as the Bohol Rabies Prevention and Elimination Project in the Philippines, which generated considerable village level involvement through thousands of volunteers, dog registration efforts, school-based education modules, and engaging legislative enforcement . Bali catanggung renteng), legal codes have important social punishment dimensions and are used for a range of daily activities in Bali. Although there are certainly problems with coercive public health measures, some of which arise from community inequities [Lastly, our study reveals people’s endogenous attempts to use traditional legal structures in order to increase local compliance with rabies control, which has also been reported in Tanzania . With thequities , these aAs a sociocultural study that also included an analysis of risk factors of a disease, this research had number of limitations that need to be acknowledged. There was a high proportion of male respondents, determined by the convenience sampling and analysis based on village groups, and this could have biased our results, even though the study tried to complement the questionnaire data by the findings elucidated by the FGDs. Moreover, the research involved a small number of selected villages in regencies and therefore extrapolation to other areas should be made with caution. Despite the weaknesses of this research, study results and recommendations should be considered and implemented as potential pathways to optimize the rabies control program in Bali.banjar and village levels were identified as potential ways for supporting the ongoing rabies control program in Bali. These include public awareness activities, vaccination, dog registration, dog population management, and rapid response to dog bites. The program also needs some recognition or acknowledgement from the governments, especially from local government as well as regular mentoring to improve and sustain community participation.The human-dog relationship in Bali is multifaceted. With the uniqueness of culture and local beliefs and encouraged by a socioeconomic aspect, a number of local practices were found to constitute risk factors for continued rabies spread. Community knowledge and attitudes to encourage gradual behavior changes need to be improved across different genders, age groups, educational backgrounds, religions, and roles in the community, regardless of the villages’ experiences with rabies. Community-driven activities based on sociocultural conditions and community capacity at the


E-cigarette initiation (behaviour) was facilitated by: capability ; opportunity ; and motivation . The application of the COM-B model identified multiple factors that may lead to e-cigarette initiation, including those that could be influenced by policy, such as price relative to cigarettes and use in smoke-free environments. The effects of these policies on initiation should be further investigated along with the possible moderating/mediating effects of social support.The aims of the study were to (1) describe how and why smokers start to vape and what products they use; (2) relate findings to the COM-B theory of behaviour change (three conditions are necessary for behaviour change (B): capability (C), opportunity (O), and motivation (M)); and (3) to consider implications for e-cigarette policy research. Semi-structured interviews ( E-cigarettes are electronic devices that use a battery powered heating element to disperse liquid, usually a solution of glycerine and/or propylene glycol containing nicotine, into an aerosol that can be inhaled . E-cigarStudies from the U.S. have shown that smokers initiate e-cigarette use after learning about them from advertising (including on the Internet) and through family and friends ,6,7. OthTo date, there has been no qualitative study using individual interviews of adult current and former vapers to understand the reasons for initiation. Additionally, no studies have used a theoretical framework to understand the factors the might lead smokers to initiate vaping. This paper, therefore, has the following three aims: (i) to describe how and why smokers start to vape, and what products they choose to initiate; (ii) to relate the findings to an established theory of behaviour change, the COM-B model ; and  and involved semi-structured interviews (conducted between June and September 2014) with 30 current and ex-smokers who were using or who had used e-cigarettes at least weekly for a month in the past year. Participants included 13 males and 17 females; age range: 18–60 years. Further details relating to their smoking and e-cigarette (vaping) status are reported in n = 14), a university mailbase of research volunteers (n = 13), word of mouth (n = 2), and posters in local newsagents (n = 1). Our study aimed to recruit 30 individuals (maximum variation sampling) as the research team considered this to be both feasible and sufficient to generate new insights into e-cigarette trajectories of use. Interested individuals were invited to contact one of the study researchers by phone or email for further details. Those making contact were assured that all the information they provided would be kept confidential to the research team. They were also told that their participation was voluntary and they could remove themselves from the study at any time. After hearing more about the research, those who were still interested and eligible were offered an interview time of their choice and sent an information package, which contained written details about the study and a consent form.Participants were recruited via Gumtree, a UK website for free classified advertisements  were exported from MaxQDA into a Microsoft Word  document and analysed inductively line-by-line via iterative categorisation . IteratiParticipants all indicated that they had had the physical capability/motor skills to enact the behaviour of vaping for the first time. Indeed, nobody stated that they had been unable to make the product work initially. Most participants initiated with a cigalike product, which were bought ready to use and easier than tank or modular devices, as most participants found these types to be ‘bulky’ and “scary”. Some individuals explained that they had observed their friends or family vaping cigalikes and then, because use was simple, had been able to replicate the action successfully.“It was hard to tell if, you know, you wanted the equivalent of one cigarette’s worth of nicotine, (yeah) it was hard to gauge how much of that you had to take in, so I wasn’t sure if it was more concentrated or not. Obviously, you can easily inhale, you know, and I think you usually get like a flash of light on the end.” Overall, most participants reported that (1) they should quit smoking because it is harmful to their health; (2) recognised that e-cigarettes were comparatively better for them than cigarettes; (3) that they were a potentially useful smoking cessation aid; and (4) an alternative source of nicotine.“I almost use the e-cigarette to relieve myself from the dirt I’m putting into my system, to give myself a break, almost. So that way I’m still getting my nicotine… The problem with cigarettes, obviously, is that you see it’s not only the nicotine, it’s the other stuff and I’m very aware of that.” However, a small number of participants acknowledged that they were not very knowledgeable about e-cigarettes, either explaining that they had heard conflicting messages or referring to the current lack of evidence on their safety and effectiveness:“One of the biggest negatives is the sort of constant, um, uneducated debate about it… even almost to the point of… I don’t actually know anything about them. I just use them and then you get, like, there’s a newspaper article or something (reporting that) these things are killing our kids.” Only a few participants used the internet to search for information about e-cigarettes prior to initiation. They described how they acquired the knowledge to choose an e-cigarette that might most effectively help them quit by searching for, and looking at, vaping and vaping products online. Several said that they had used social media, such as internet fora or Reddit, to increase their knowledge of product types before initiating. Thus, it seemed that, in addition to having the knowledge that e-cigarettes could be used to quit, some participants had more in-depth knowledge about e-cigarette product types, and knew to buy online or to go to specialty vape shops .Most participants reported that cigalike e-cigarettes were readily available from shops  and this had facilitated their first use. For the most part, individuals did not need to go to specialist e-cigarette shops to make their initial purchases; but those that did purchased tank e-cigarettes. Some individuals said that it was the prominent position of an e-cigarette display at the shop counter that had persuaded them to buy their first product. A few participants who were already curious explained that the salesperson inside the shop had prompted them to buy their first e-cigarette:“He (shop assistant) was just, “Have you smoked or do you smoke?” and I was like, “Yeah” and (he) was like, “Try this”. He didn’t have to do much. I was curious about the product.” According to a small number of participants, the increased presence of e-cigarettes both in shops and online had opened their eyes to the possibility of vaping. The availability of low cost cigalike e-cigarettes had facilitated first use because they were cheap enough for experimentation without financial commitment:“The local pound shop started selling like, er, disposable e-cigarettes with the promise that buying one was equivalent to like a pack of twenty. So £1 versus £6, £7, £8. So you know, it seemed like a good deal.” A small number of individuals also reported that having the opportunity to vape in public places or private homes had prompted them to initiate e-cigarette use. For example, one woman explained how she had starting using an e-cigarette because she could use it inside the pub without having to go outside. In addition, one man reported that he had first used an e-cigarette in the home of a friend because he had not wanted to go outside to smoke when visiting. Overall, the opportunity of vaping indoors seemed attractive to participants, although this was sometimes accompanied by uncertainty about the social acceptability; indeed one participant described searching online for information on vaping etiquette because they were unsure of the appropriateness of vaping in public places.The majority of participants reported that they had heard about e-cigarettes from family or friends who were already vaping or who had vaped in the past. These individuals had often promoted the use of e-cigarettes to, or purchased products for, the participants because they wanted them to stop smoking. For example, Holly had first started vaping after her friend had physically gone to a specialist shop and bought her a tank e-cigarette:“I think it was my friend [who] encouraged it… She went and got it for me. She said, “I’ll go to the shop and get you one, give me the money”, and then she went and got it. She encouraged me…” ’ intentions and decisions about vaping negatively. This had occurred either because participants had felt too much pressure or because family or friends had promoted aspects of e-cigarette use that did not interest the participant; for example, the brother of one participant had advocated e-cigarettes on the grounds that they could be used indoors, but smoking outdoors did not concern the participant.Furthermore, one participant had no intention of quitting smoking but the persistence of their partner convinced them to quit and start vaping, as a compromise in the relationship. Sometimes, however, the encouragement of friends and relatives had inadvertently influenced participantsParticipants also sometimes reported that the first e-cigarette they had used had actually belonged to another person, usually a friend or a colleague. In this situation, the participant either reported that they had been in an indoor environment, such as a pub, and had not wanted to go outside to smoke or that they were with a vaper who had spontaneously offered them their e-cigarette to try. A few individuals also clarified that they had experimented with e-cigarettes with friends or had planned to quit smoking using e-cigarettes with a friend:“When they tried those e-cigarettes a year or so ago, a mate goes to me, “It works”. So I was like, “I have to give it a try”. Then my brother, as well, my brother smokes, or used to smoke as well and he’s the one that got me on e-cigarettes as well recently.” Lastly, a few participants explained how seeing strangers vaping had initiated their interest. For example, one man said that an increase in the visibility of e-cigarettes in his surroundings in Italy had encouraged him to try a product.Participants often spoke about “curiosity”, or their “desire” to try an e-cigarette, as being the main driver for initiation. Additionally, a few spoke of being attracted to e-cigarettes because they were “cool” or “fun”; for example, one participant described e-cigarettes as aesthetically “cool”, whereas another felt they were appealing because they were novel. In contrast, others explained how they had been reluctant to try e-cigarettes because they felt they were “silly” or “a fad”:“I remember thinking it was a fad, like the herbal cigarettes my Mum used to smoke. I just remember thinking they were silly, so I never really thought anything of it, and then I tried them and realised it was actually quite effective.” ‘enjoyment’ of smoking tobacco cigarettes—particularly the smell and taste—that had, for a long time, deterred her from starting to vape (before her boyfriend’s persistence and love of exercise triggered her to try e-cigarettes):One individual also noted how it was the “I love the smell of cigarettes. I love the way they taste, the disgusting taste that’s perfect, the smoke that burns. That’s something that I really enjoy... My boyfriend tried to convince me (to try an e-cigarette)… and I said… “I don’t want to do it. Just leave me alone so I can smoke my cigarettes”.” In addition to feelings and impulses, many participants gave considered reasons that motivated them to initiate vaping. For example, some reported that they had been happy to try e-cigarettes because they had wanted to improve their health:“If I’m gonna be an addict to an e-cigarette, it’s gotta be better. I mean, if all I’m gonna go do is swap my addiction over to an e-cigarette then, I think it’s worth doing.” ‘tactile’ similarities between an e-cigarette and a cigarette had motivated them to initiate vaping. These attributes made vaping more attractive to them than nicotine patches or gum:Others explained that they had initiated vaping because they believed that e-cigarettes would alleviate their cravings and help them to stop smoking. In particular, some reflected on how the hand-to-mouth actions of smoking and vaping were very similar, with both satisfying a psychological need to put something in the mouth. A few individuals also explained that the “Just chewing gum or putting a patch on, it’s not the same. You need to have your cigarette, like light up and everything… So… it’s either you have your normal cigarettes and like cut down or go for the e-cigarette. So obviously I decided to go for the e-cigarette.” Conversely, a number of participants reported that they were initially not motivated to try e-cigarettes because they had felt that they would not work or did not replicate the process of smoking. Still, others lacked motivation to vape initially because they were using e-cigarettes as a quit aid and felt that e-cigarettes replicated the hand-to-mouth action of a cigarette too closely and, therefore, did not break the psychological habit of smoking.A summary of the COM-B model categories can be found in Using the COM-B model , our stuAspects of our findings are consistent with previous research. E-cigarette initiation was facilitated by the influence of family or friends ,7, the aIn terms of capability, we found that few individuals performed any prior research on how to use an e-cigarette or what type would be most effective to help them quit; most purchased on impulse. Cigalikes were the most common type of product first used, reflecting their greater availability in general shops. There was also evidence that those who started vaping thought that, despite safety concerns, e-cigarettes were less harmful than tobacco smoking; in other words, they understood and made decisions based on the concept of relative harm. However, some participants were confused about the safety of e-cigarettes. There was a clear desire for information about e-cigarettes, including research evidence on what is known about their harmfulness compared to smoking . How to In terms of opportunity, there seemed to be a strong interaction between social and physical opportunities to vape, such that family and friends often facilitated vaping, but in specific places, such as pubs, where smoking was not allowed. Allowing vaping where smoking is not allowed enabled some smokers to take advantage of the environmental opportunity to try e-cigarettes . Such policies are, however, not uncontroversial. Concerns have been expressed that allowing e-cigarette use in public places may encourage initiation among some youth and young adults, thus, further research is needed in these areas . FamilieIn terms of motivation, the hand-to-mouth action of e-cigarettes appeared to encourage some smokers to vape as it resembled smoking but deterred others as it was too similar. Additionally, similar to studies showing that enjoyment of smoking predicts quit attempts , deep enThis study used the qualitative study design of self-selection, which creates a non-representative sample of e-cigarette users. In addition, this study focused on smokers and ex-smokers recruited and interviewed in London. As such, our findings cannot be generalized empirically to other populations or settings, but consistency with some other research suggests our findings are not atypical. The COM-B model enabled us to identify factors that both facilitated and impeded the initiation of vaping amongst smokers. However, we experienced some difficulty in isolating several components of the model. For example, understanding that smoking is bad for health (capability) is difficult to separate from the resultant desire to quit (motivation). In addition, it is possible that alternative factors that enable or prompt initiation of e-cigarette use, such as additional environmental or social factors, were not considered by participants. We experienced difficulty in separating the three components into their respective subcategories . These are the first qualitative data on e-cigarette initiation to be applied to the COM-B model, therefore, a strength of the study is that it provides a new way that qualitative data could be analysed for informing intervention design and policy research. The diversity of individuals interviewed was a key strength of the study. Participants reported a wide age range (18–60 years), many ethnic backgrounds and nationalities, and varied patterns of e-cigarette usage. The study was exploratory and numbers were too small for meaningful subgroup analyses, however, the sample size of 30 was small enough not to require excess time and money, yet large enough to collect rich and in-depth data on a new phenomenon. Additionally, most research to-date has tended to rely on quantitative data and available qualitative studies (mainly U.S) have largely used focus groups or not focused on initiation. Future research could explore past initiation to what factors influence vapers to continue or stop use, and what policies influence the transition between cigarettes and e-cigarettes.To conclude, we return to our original three aims. First, a range of factors influenced e-cigarette initiation amongst smokers. Most importantly, these included an understanding of the concept of harm reduction, easy access to cheap cigalikes in shops, particularly where sales staff talked to customers about them, encouragement from social network members, ability to vape in public places, and belief in their effectiveness; second, the COM-B model of behaviour change provided a useful heuristic for exploring e-cigarette initiation, and enabled us to identify a number of factors not previously reported in the literature; third, a co-ordinated approach to policy research on e-cigarettes could encompass tailored information for smokers, promotion at point of sale, a sensible price/taxation policy relative to smoking, and a strategy and clear guidance on where vaping is permitted and permissive vaping policies where appropriate. Nonetheless, it is also important to recognise that e-cigarettes are only one of a range of quit smoking aids ,29 and a


Prolonged sedentary time is linked with poor health, independent of physical activity levels. Workplace sitting significantly contributes to sedentary time, but there is limited research evaluating low-cost interventions targeting reductions in workplace sitting. Current evidence supports the use of multi-modal interventions developed using participative approaches. This study aimed to explore the acceptability and feasibility of a low-cost, co-produced, multi-modal intervention to reduce workplace sitting.n = 317) were invited to take part. Seventeen participated in all aspects of the evaluation, completing pre- and post-intervention sitting logs and questionnaires. The intervention was delivered over four weeks from 7th July to 3rd August 2014.The intervention was developed with eleven volunteers from a large university department in the UK using participative approaches and “brainstorming” techniques. Main components of the intervention included: emails suggesting ways to “sit less” e.g. walking and standing meetings; free reminder software to install onto computers; social media to increase awareness; workplace champions; management support; and point-of-decision prompts e.g. by lifts encouraging stair use. All staff . All participants were aware of the intervention as a whole, although there was a range of awareness for individual elements of the intervention. The intervention was generally felt to be both acceptable and feasible. Management support was perceived to be a strength, whilst specific strategies that were encouraged, including walking and standing meetings, received mixed feedback.Mean baseline sitting time of 440 min/workday was reported with a mean reduction of 26 ± 54 min/workday post-intervention (This small-scale pilot provides encouragement for the acceptability and feasibility of low-cost, multi-modal interventions to reduce workplace sitting in UK settings. Evaluation of this intervention provides useful information to support participatory approaches during intervention development and the potential for more sustainable low-cost interventions. Findings may be limited in terms of generalisability as this pilot was carried out within a health-related academic setting. In recent years, a new research paradigm has emerged, highlighting the potential deleterious health impacts of sustained sedentary behaviour , indepenSedentary behaviour is defined as any waking behaviour characterised by an energy expenditure ≤1.5 Metabolic Equivalents (METs) while in a sitting or reclining posture , and is Prolonged workplace sitting is especially significant when considering interventions to reduce sitting time due to the increase in desk-based jobs over recent decades  and the This paper describes the development and mixed methods evaluation of an intervention to reduce workplace sitting time, drawn from a four week uncontrolled study, which is intended to be a precursor to a larger controlled trial. The main aim of this study was to explore intervention acceptability and feasibility, which was addressed by documenting: pre- and post-intervention changes in daily sitting time; participants’ awareness of the various elements of the intervention; and participants’ views of the intervention. It also provides initial evidence on effectiveness of low-cost interventions, which could be used to inform future workplace studies.The development of the intervention was based on three stages as highlighted by Neuhaus et al. : conceptMany of the interventions that have been developed to reduce workplace sitting have focused on a single-level of influence, such as the provision of educational sessions/behaviour change support  or envirTheoretical support has been identified as an essential element in the development of complex interventions , 35. A tMany of the studies that aimed to reduce workplace sitting time included the use of ergonomic adaptations such as treadmill workstations , 45, cycPotentially low-cost elements of an intervention may include the use of reminders, prompts and weekly emails. The installation of free computer software reminding staff to take regular breaks, has been shown to produce a significant reduction in workplace sitting when compared to controls . In addiEleven staff from the School of Health and Related Research (ScHARR), an academic school focusing on health-related research in the University of Sheffield, UK, volunteered to be part of an intervention development focus group, of which seven were able to attend a one-hour session. The framework for this session was taken from previous work by Dunstan et al.  and invoAn uncontrolled pre-post intervention design was used with a single sample and two data collection time points over the five week study period. All study procedures were undertaken by a student undertaking a Masters in Public Health. Ethical approval was provided by the ScHARR Ethics Committee (reference number 0745/KW 30). Intervention development focus group participants provided informed written consent, for other participants, informed consent was implied by completion and return of questionnaires and sitting logs.n = 317) of ScHARR were eligible to participate in this study. Employees come from four Sections within the school: Public Health (PH), Health Services Research (HSR), Health Economics and Decision Science (HEDS) and Design, Trials and Statistics (DTS) and are based across two sites in Sheffield City Centre.All employees . The intervention began at week one (week beginning 7th July 2014) and ran over four weeks. At week five, a questionnaire of both quantitative and qualitative study measures and a post-intervention seven-day prospective sitting log were completed by participants.All quantitative data were self-reported. Demographic information , lifestyle factors , and physical activity   relatingAwareness of the various elements of the intervention was assessed at week five via the post-intervention questionnaire. Only participants who had not been involved in the intervention development were included in the subsequent analysis. Awareness was reported using the items: ‘were you aware that the intervention was running?’ (required a yes/no response); and ‘which elements of the intervention were you aware of?’ , posters, emails, video links, links to reminder software, Twitter™ updates, information on the department homepage, workplace champions, management ‘leading by example’, I was not aware of the intervention, other).Qualitative data were obtained via open-ended questions as part of the post-intervention questionnaire in week five. The topics covered were: appropriateness of the intervention; effectiveness of the intervention; barriers to reducing workplace sitting not addressed by the intervention; other benefits of the intervention; and suggested improvements to the intervention.Statistical analyses were performed using Statistical Package for the Social Sciences  version 22. Demographic, lifestyle and physical activity data were presented as descriptive statistics  for both the participants who completed all four elements of the data collection (the pre-intervention questionnaire and sitting log and post-intervention questionnaire and sitting log), i.e. “the completers”, and for those who only completed three or less elements of the data collection, i.e. “the non-completers”. Participation rates and rates of awareness of the intervention were also reported using descriptive statistics. Within group differences in daily workplace sitting time from baseline to post-intervention were presented using the mean ± standard deviation and confidence intervals.The qualitative data obtained from post-intervention questionnaires were thematically analysed. The themes were based on pre-determined categories: acceptability and feasibility of the intervention; impact; helpful elements; unhelpful elements; barriers that were not addressed by the intervention; other benefits that were realised; and suggested improvements to the intervention. The data were coded into raw data themes, which were allocated to the pre-determined categories for analysis.The intervention was drawn from the conceptualisation process and formative research and hence consisted of individual-, social-, organisational- and environmental-levels of influence. Table Of 317 staff, 26 (8.2 %) volunteered to participate in the evaluation of the intervention, two of whom withdrew due to sickness prior to data collection , statistical differences to "completers" were not assessed, but overall there appeared to be no substantial differences between the two groups."Completers" and "non-completers" were of similar gender, ethnicity, educational attainment, base building, and smoking status (see Table p = .411 and .782). Mean workplace sitting time was reported at 440 ± 79 min/day pre-intervention and 414 ± 80 min/day post-intervention  were aware of the intervention as a whole and also the posters and emails, but there was a range of awareness for the other elements of the intervention from 69 % for the branding to 0 % for the workplace champions , which were analysed under the pre-determined categories. Selective and representative quotations to illustrate the categories are presented below.The responses to the intervention were generally positive and it was felt that the various elements of the intervention were practical. One participant stated that, “the suggestions made for [the intervention] fitted with what would be possible within a work environment like [this department]”.An element where there was mixed feedback about the acceptability and feasibility was the standing/walking meeting. One participant felt that, “standing/walking meetings were less appropriate as most of the work I do involves leafing through results or looking at computer screens which works better with a desk and chair”. However, another participant stated that, “[this department] is quite a flexible work environment and so things like walking meetings would be acceptable”.Awareness raising: “It made me more aware of the issue and made me think about how much time I spend sitting at work”.Reminders to sit less: “It kept the idea in my consciousness. It gave me ideas about things to try”.One regular staff meeting was converted to a standing meeting.It was felt that the intervention made a positive impact on workplace sitting time due to:There was a feeling that the intervention as a whole provided some generic positive changes within the department. One participant felt that the intervention resulted in “people talking about it - colleagues proposing walking meetings” and another felt that, “many people are receptive to the idea of moving more at the moment”.Specific elements of the intervention, such as emails from management, were felt to provide a supportive culture to changing behaviour with one participant commenting that, “emails from the Dean showed support and reminded us that we should not feel guilty taking a break”.Standing/walking meetings: “Walking meetings both reduced sitting time and felt more efficient in terms of use of time”.Posters: “Posters created a feeling of community”.Reminder software/timers: “Using a timer to remind me to get up and move, walking a further distance to get a drink/photocopy etc.”.Other helpful elements highlighted included:One participant did not find any elements of the intervention helpful, stating, “I get uncomfortable sat down anyway, so I already do many of the suggestions”.Reminders: “I didn't want to put a reminder on my computer because I don't want to be distracted if I am in the middle of something that needs concentration”.Twitter™: “I don't use Twitter so this did not help for me”.Posters: “Posters - I was already up and about when I saw them!”.Elements that were felt to be unhelpful for some participants included:The desk-based nature of work: “So much of my work relies on being sat at a computer which is unable to be addressed in a zero cost intervention”.Workload/time: “I was working to tight deadlines, so when engrossed with work, getting up and moving around weren't a priority”.Workplace environment: “Workspace not designed to promote reduced sitting time”.Views of peers: “Sometimes it looks like you're not working if you're not at your desk”.Barriers that the intervention did not fully overcome included:Improved productivity/concentration: “Increased attention, if I got distracted I would move and then be able to concentrate fully again”.Reduced stress: “I found that leaving my desk for a short time reduced stress levels when working on difficult tasks”.Increased awareness of the associated health benefits: “Being more mindful and better informed of the health benefits of sitting less”.Improved workplace culture/changing social norms: “The intervention appears to have strengthened/increased the culture of working in more flexible and creative ways “.Improved physical health: “More energy from moving around more” and “less back ache”.Additional benefits of the intervention identified by participants included:The most commonly suggested improvement was to include ergonomic adaptations. Of particular note was the suggestion to utilise standing/treadmill desks which would allow a more substantial reduction in sitting time without disrupting workflow and productivity. One participant stated, “I guess for there to be a major improvement in sitting less there needs to be some workplace changes to really make sitting less possible”.To integrate with other initiatives: “Perhaps it [the intervention] could have also been linked to #sitlessmovemore for more effective dissemination/reach and wider conversations”.More “leading by example”: “Senior staff/Meeting Chairs asked to introduce standing breaks in meetings”.Effective use of workplace champions: “Champions more visible. I didn't attend any meetings where people suggested standing, I think this should have been done more across the school”.Financial investment: “More money invested into practical solutions to encourage us to sit less yet maintaining productivity”.More scheduled activities: “If there was Tai Chi or yoga one-lunchtime a week in, say, [location close to their office], I'd definitely go”.Demonstrate elements are evidence-based: “Perhaps include sources on posters as someone mentioned on Twitter, to give them more credibility in an academic environment”.Other suggestions for improvement included:This uncontrolled trial explored the acceptability and feasibility of a low-cost, co-produced, multi-modal intervention in reducing daily workplace sitting time amongst university desk-based workers. Three sources of information were used: pre-post behavioural responses; awareness of the various elements of the intervention; and views on the intervention.Baseline sitting time of 440 min/day amongst study participants was higher than sitting time data for professional/managerial staff obtained in a previous study by Miller et al.  which loOn the whole, studies that evaluated multi-modal interventions that demonstrated statistically significant changes, reported a 10-25 % reduction in workplace sitting –43, 57. The studies conducted by Neuhaus et al.  and CarrParticipants (not involved in the intervention development) were all aware of the intervention, but with some variation in the awareness of the different elements. There was a lack of awareness of some elements of the intervention such as the Twitter™ updates and the presence of workplace champions, which therefore rendered them unhelpful to those participants. The intervention as a whole was generally well-received by participants and was felt to be acceptable and feasible due to the ability of the different elements to be easily incorporated into the working day. It was felt that the intervention had a positive impact on workplace sitting as a result of awareness raising, reminders and support from management. Management support in particular was valued by participants in previous studies that evaluated similar interventions as a means of validating changes to health behaviour , 51. TheAside from the reduction in workplace sitting, further benefits that were also described by participants, included: increased productivity, improved workplace culture, decreased stress, increased awareness of the health benefits of sitting less, and improved physical health. There is currently uncertainty in the literature regarding what the clinically important difference in sitting time needs to be in order to positively affect health. In a large population study , it was Since the completion of this pilot, a review by Gardner at el.  was publThe main strength of this pilot was the adoption of a systematic and evidence-based intervention development process, incorporating conceptualisation and formative research. The fact that the intervention was grounded within a theoretical model (SEM) allowed the multiple levels of influence to be targeted, thereby ensuring that: individuals' autonomy and knowledge were increased; social networks were developed; and organisational support was obtained. The only element that this intervention unsatisfactorily addressed was the presence of true environmental changes. In addition, the use of a participatory approach has been demonstrated as an effective mechanism to reduce workplace sitting, which ensured a match between the needs of the staff and the suggested strategies . The parThe major limitations of this pilot were the subjective nature of the data collection tool and the small number who provided individual data, relative to the number of staff invited to participate in data collection. The measurements of sitting time were based on self-report only, which may have introduced reporting and recall bias, although the prospective nature of the completion of the log may have minimised some of the bias.The convenience sampling techniques used may have introduced selection bias. Participants may have been largely those already aware of the detrimental effects of prolonged workplace sitting or those who felt they might benefit the most from the intervention and hence were more committed to participating. Furthermore, the comparison between the “completers” and “non-completers” shows that, although there were no obvious differences between the two groups, it is unclear how representative the two groups were of the entire workforce. In addition, nothing was known about change in sitting time amongst the “non-completers”, so it is possible that “completers” were those who had a strong view about /were more aware of the intervention, which could have introduced further bias.The small sample size and the nature of the intervention (such as posters and changes to meetings) made individual randomisation impossible and even cluster randomisation very difficult with likely contamination of any control group, meaning it was not possible to control for confounders. The lack of a control group, small sample size and probable selection bias may mean that the findings of this study are not widely representative of all ScHARR staff and hence are limited to the population studied and setting in which the study was conducted.The lack of long-term monitoring of the effects of this pilot intervention along with the short intervention duration means that the potential for sustained reductions in workplace sitting have not been determined.Further limitations included:This study has demonstrated the acceptability of low-cost interventions to reduce workplace sitting. The implications of such interventions on productivity at work requires further research, but the present evidence suggests that there is at least no decline in productivity or other work-related outcomes and it is possible that a reduction in sitting may improve productivity according to the findings from this study. Therefore, UK workplaces could consider pragmatic methods for reducing workplace sitting, which address multiple levels of influence and includes a participatory approach to ensure that the strategy is tailored to the needs of the workplace.The findings of this pilot contribute to this emerging research paradigm and could be used to inform the development of a larger, cluster-randomised control trial. This more robust study design would allow for control of confounding and selection bias and has the ability to explore effect modification, whilst also producing a more precise estimate of effects. Furthermore, interventions tested over a greater duration including longer-term follow-up and objective monitoring techniques, to determine accurate and sustainable effects, are required. Any negative implications of such intervention and suggestions for intervention improvements should be incorporated into any further intervention development and evaluation ensuring the iterative nature of such a process. Including an environmental/ergonomic element within such multi-modal interventions is likely to yield more successful results, although will be more costly and hence may be a significant barrier to uptake amongst some employers.Establishing whether there were differences between “completers”, “non-completers” and those who did not participate at all, may have provided further insight into the findings of this pilot and maximise the generalisability. Future research should ensure that everyone who is to be exposed to an intervention is recruited to participate in the study, not simply a self-selected sample as in this pilot. To support this, providing an incentive in return for participants’ time spent during the data collection process, in the form of either a financial incentive or simply feedback on how their sitting time compares with their peers, could be beneficial. In addition, conducting similar pilots in a variety of different sedentary workplaces  may provide a greater understanding of the steps that need to be taken to develop and evaluate successful interventions aiming to reduce workplace sitting, and hence also increase the generalisability of the findings.This pilot has highlighted the importance of a systematic, evidence-based intervention development process, which should include a pilot study, so further research into interventions to reduce workplace sitting need to ensure a similar process is adopted. Furthermore, there is a requirement for future research to focus not only on whether an intervention successfully reduced workplace sitting, but on the impact such interventions could have on both health- and work-related outcomes. It is these findings which will allow a full assessment of the cost-effectiveness and hence sustainability of such interventions in UK workplaces.This study has reported findings relating to the acceptability and feasibility of an intervention to reduce daily workplace sitting of desk-based staff in an academic institution. It has provided support for using a participatory approach to inform intervention development, which is tailored to the individual workplace; the use of an evidence-based theoretical model such as SEM, which ensured multiple levels of influence were addressed; and the use of mixed methods to effectively evaluate such interventions. This pilot has provided a basis for future research and it is intended that this pilot be a pre-cursor to a larger controlled trial.


In statistics, tools have been developed to estimate individual change over time. Also, the existence of latent trajectories, where individuals are captured by trajectories that are unobserved (latent), can be evaluated (Muthén & Muthén, To ease the use of LGMM/LCGA step by step in this symposium (Van de Schoot, When applying LGMM/LCGA models for the first time, the guidelines presented can be used to guide what models to run and what to report.