The application of organizational ethics in hospitals is one of the novel ways to improve medical ethics. Nowadays achieving efficient and sufficient ethical hospital indicators seems to be inevitable. In this connection, the present study aims to determine the best indicators in hospital accreditation.69 indicators in 11 fields to evaluate hospital ethics were achieved through a five-step qualitative and quantitative study including literature review, expert focus group, Likert scale survey, 3 rounded Delphi, and content validity measurement. Expert focus group meeting was conducted, employing Nominal Group Technique (NGT). After running NGT, a three rounded Delphi and parallel to Delphi and a Likert scale survey were performed to obtain objective indicators for each domain. The experts were all healthcare professionals who were also medical ethics researchers, teachers, or PhD students. Content validity measurements were computed, using the viewpoints of two different expert groups, some ethicists, and some health care professionals (n=46).After conducting NGT, Delphi, Likert survey, 11 main domains were listed including:  Informed consent, Medical confidentiality, Physician-patient economic relations, Ethics consultation policy in the hospital, Ethical charter of hospital, Breaking bad medical news protocol, Respect for the patients’ rights, Clinical ethics committee, Spiritual and palliative care unit programs in the hospitals, Healthcare professionals’ communication skills, and Equitable access to the healthcare. Also 71 objective indicators for these 11 domains were listed in 11 tables with 5 to 8 indicators per table. Content Validity Ratio (CVR) measurements were done and 69 indicators were highlighted.The domains listed in this study seem to be the most important ones for evaluating hospital ethics programs and services. Healthcare organizations’ accreditation and ranking are crucial for the improvement of healthcare services. Ethics programs would also motivate hospitals to improve their services and move towards patients’ satisfaction. In this regard, more involvement of bioethicists can help healthcare organizations to develop ethics programs and ensure ethics-based practice in hospitals. Some bioethics experts argue that the scopes of ethics in healthcare professions are divided into theoretical  and applied branches. Regarding the former, the focus is mainly on theories , norms , principEvery organization requires a clear statement of quality management. Hospitals are the organizations dealing with human beings, so ethical standards in such organizations seem to be very important. Unfortunately, many of these organizations don't usually realize the importance of setting ethical standards in their routine, quality assurance programs. Today the medical ethics community is trying to develop more effective approaches for quality improvement in medical care ethics .Without setting standards and a common focus, the achievement of significant ethical goals, which is one of proposes of the Ministry of Health and Medical Education , is nearThe study, which is both qualitative and quantitative, was conducted through 5 steps including literature review, expert focus group, Likert scale survey, three rounded Delphi study, and content validity ratio testing.ParticipantsOverall, 36 participants were invited and contributed to the study. Two of them participated only in the NGT, thirteen were present in NGT, Delphi and Likert survey and twenty one participated in Delphi and Likert study stages. The fifteen experts present in NGT included 10 Ph.D candidates  and 5 faculty members , the majority (66%) being between 31 to 50 years of age. Some of the experts had a history of management at different levels of the health care system including the presidency of the University of Medical Sciences, vice chancellery for research, vice chancellery for education, vice chancellery for treatment, vice chancellery for health, the dean of city health network, the dean of the emergency care in several provinces of the country and the manager of the hospital. One of them had a history of working in the national TV as a journalist and executive/presenter for developing people’s information about health system. They had a history of working in fifteen cities of six provinces in the country; some with a history of working in only one city and some in different cities. As mentioned, totally 36 experts participated in the Delphi and the Likert scale survey:  8 Ph.D candidates and 12 faculty members , 10 ethics educated nurses and 6 other medical and paramedical professionals who had at least a course of ethics education and had paper and research history in the field of ethics.Thirteen of the Delphi and Likert scale survey experts participated in the NGT, too. The Delphi experts were from different medical, nursing and paramedical fields such as pathology, paediatrics, ophthalmology, psychiatry, General Surgery, internal medicine, neurology, community medicine, legal medicine, medical education, nursing education, and nursing management, all affiliated to Shiraz University of Medical Sciences. Some of the experts had a history of management at different levels of the health care system including the presidency of the University of Medical Sciences, vice chancellery for research, vice chancellery for education, vice chancellery for treatment, vice chancellery for health, the dean of city health network, the dean of the emergency care in several provinces, the manager of the hospital, senior nursing officer, nursing supervisor, and dean of the nursing office. Also they had a history of working in 21 cities and 7 provinces in the country. The details of the Delphi participants’ demographics are shown in Informed consent forms were prepared and obtained from the participants in all stages of the study separately.  1. Literature review The researchers conducted an explorative literature review to find possible similar studies and the major domains for evaluating hospital ethics and health care organizational ethics. This review helped authors to make a better design for the research and also describe the different important domains in the matter from different perspectives of different experts all over the world. SAE, MA, and MS explored and reviewed the literature on the topic through search engine websites and scientific databases such as Scholar Google, Scopus and Pub Med by searching different combinations of some key words such as ethics, hospital, health care, organizational ethics and accreditation, and joined together for 7 meetings and discussed the issue to share the information aiming to propose the plan of the research after consulting SZT, step by step. Additionally, MA, and MS reviewed Pub Med and Scholar Google with the NGT and Delphi method in title and abstract and held 3 meetings by AM, and ZK to design the NGT and Delphi stages of the study.2. Expert Focus Group The approach used in this step of the study was the use of Nominal Group Technique (NGT) along with NGT since it is more structured than the focus group design. NGT was established by Andrew H. Vande Ven and Andre L. Delbecq in 1968. It is defined as a group decision making method for creating ideas and identifying problems. In this technique a prioritized list of concepts are developed through multi voting and brainstorming by team members. The leader is accountable for guiding the brainstorming sections and recording the ultimate list of concepts based on the ideas of the group members . NGT is Conducting the NGT activityThe NGT meeting was held in 2012 October, and was attended by 15 medical ethics experts in southern Iran including 10 Ph.D students who were physicians or pharmacists (MD or PharmD) and 5 faculty members of the medical school with teaching experience of medicine from 13 to 30 years and that of medical ethics from 13 to 20 years, their academic degrees ranging from instructor to full professor. Authors excluded the medical faculty members who were former medical ethics teachers, and did not have any ethical lecture for more than 1 year. All of the 15 experts were invited to the Medical Ethics department conference hall at Shiraz University of Medical Sciences (School of Medicine). At first, authors used a self-administered questionnaire. The questionnaire asked for participants’ demographic information including age, gender, position, the participants’ last academic degree, years of medical practice, years of practice as medical ethics activist , and years of other special activities in health care system, as a professional, researcher, teacher or manager. Authors ensured the participants about the confidentiality of the information they provided. Index cards were prepared for all participants. The leader explained member roles and group aims by a kind welcome, a statement of the significance of the task and importance of each member's involvement and a suggestion that how the groups' output will be used.NGT was performed through the following steps:"what are the most important domains for ethical evaluation of a hospital?" so that all members could see it. After that we had silently brainstorming ideas; members were allowed 5-10 minutes to write all their responses. So each idea was thoroughly discussed, members being encouraged to share ideas. Each person stated one idea at a time and his/ her idea was written on the board without any value judgment. For elaborating on the ideas on the board, each idea was discussed. Members, both pros and cons, were encouraged to share thoughts about each item. There was further clarification of each item so that everybody in the group might appreciate it well. In these stages, duplications were deleted. However, mixing two or more ideas into one was not done in the above mentioned stages. The participants were invited to rank order the top ten alternatives based on importance, clarity, and measurability: five as the most significant and one as the least significant. This was done by having members write the idea in the center of a card and their ranking on the right corner of the card.  The leader collected the cards and mentioned each ranking. The ranks for each item were averaged. All domains with their ranks were written on the board so that all members could see them. The ranked domains were further elaborated by the leader to guarantee that all participants had grasped what each item meant. Regarding the clarity and quantifiability of each domain, each member was again asked to rank the domains based on Likert-scale from five to one (five as the highest and one as the lowest). This was done silently and independently as in early ranking step. This ranking was limited to ten items per person. The rankings were again averaged. For the final ranking discussion, the group reviewed the ranking and discussed the outcome of the activity. In the end, all ranked priorities were listed in a table, beginning with the domain which ranked the highest. A column included the total votes for each item with the number of persons who voted for that item in front of the priority. Having gone through this, the 15 experts determined the list of priorities. Voting was based on five point Likert-scale. The meeting continued about 8 hours and it took about a week to finalize the experts’ ideas via interviews.A question was written on the board as an issue statement According to the experts’ scores, there were 3 scores for each domain which were from 1 to 5. After computing the mean of the points, the authors curved the points to the percentage. Then 15 top domains were distinguished. An advanced literature review discussion performed by SAE, MA and MS, and the domains found to be a part of the others were omitted. Finally, 11 main domains remained. Relevant indicators for these domains were listed in 11 tables with considering their face validity. The matter of the Delphi study was these 11 tables. 3. and 4. Delphi and Likert scale surveyAfter identifying the domains, the research team applied another qualitative method to develop some objective indicators from these general and vague domains. In spite of some common members, the expert group members were not identical to the NGT experts. All NGT experts were invited to the Delphi. In addition, some other clinical professionals, especially doctors and nurses who had passed at least one course about nursing or medical ethics and had a history of hospital management experience or had publications in the field, were added to the experts. As Sinead Keeney et al. argue, individuals with only some knowledge in a specific field cannot be considered experts. Furthermore, the experts’ commitment to participating makes them more involved in the matter . For the5. Content validity measuremente – N/2)/(N/2), in which the Ne shows the number of panelists pointed “essential” and N shows the total number of panelists. The CVR value was computed for each indicator. A minimum CVR of 0.49 was required to retain an indicator in the final form of the instrument  was computed through Lawshe formula which is: CVR = .The authors think organizational standards could focus on patient rights or patient safety or improvement of the quality of care doctors or nurses provide, even if these standards don’t meet organizational behaviour in the specific field of medical ethics. In other words, a hospital is an organization similar to other organizations and has clients known as “patients”, so hospitals have ethical responsibility to their clients. It is, in fact, the general ethical responsibility of all organizations against their clients. We tried to focus on purely ethical standards to improve hospital bioethical behaviour in addition to the general organizational behaviour. So the authors think that there are some additional bioethical indicators to transform accreditation into ethical accreditation.Potter  holds thBeauchamp and Childress believe the concept of autonomy belongs to individuals’ decision making in health care and research as patients and research cases ; howeverAlthough experts made a distinction between Informed consent and the principle of autonomy, some think Informed consent is the doctrine of the principle of autonomy and has a central role in the physician-patient relationship , 42. Victhdomain. In fact, the matter of equity and the justice is one of the 4 principles of Beauchamp and Childress (Economic relationship between medical care providers and patients is, in fact, at the top of the list. The clarity of the economic decisions, knowing conflict of interest, avoiding or disclosing that to the patients are some important issues in the biomedical ethics literature , 45. Alshildress . Resourchildress . Gonzalehildress . One of hildress . Suhonenhildress .Methodological considerationsNGT is a structured qualitative research; this method plus three round Delphi could reveal the experts’ opinion in the best way, and it can be an excellent example or role model for the other medical universities and hospital managers in Iran and other countries.Regarding the limitations and weaknesses, performing NGT and three round Delphi was a huge work and we couldn’t design any needs assessment before the beginning of the study. Maybe the study would have led to more significant findings if it was based on needs assessment rather than opinion survey. Although opinion survey is valuable, it has some limitations. For example, it is possible that we had some subjectivity in the results; however, the experts were the best participants we could have access to and we tried to do the best results by giving appropriate feedback to the experts. Other organizational ethics researchers in medical and nursing care services also use Delphi and NGT to explore ideas, and even producing instruments and evaluation tools -70.The way in which the standards are applied and checked is also very important. For example, we can ask which organization is responsible for doing an internal evaluation, the hospital or health care managers or the Ministry of Health. Or it could be done as an external evaluation by NGOs or international organizations such as human right watching organizations to decrease conflict of interests between the providers of care and the ethical creditors. On the other hand, could we have a unique questionnaire in different countries with different cultures and different ethical norms? Can we say the main domains in the entire world are comparable but the standards arising from the domains can be somehow different according to the regional differences? What are the optimum questions to accredit ethics in the hospital? The listed domains in the study seem to be the most important domains in evaluating hospital ethics and could be generalized to other medical settings. However, they could be enriched through further studies, considering needs analysis and cultural issues. Accrediting and/or ranking hospitals by such criterion could appreciate hospitals which are more ethical than the other, inform the patients about them, and make a move to improve medical ethics in the hospitals. National and international accreditation/ranking organizations can prepare annual ethical hospital ranking list and it could serve as a help devise for the patients to select their hospitals for common treatments or medical tourism.


The visible corona revealed by the natural phenomenon of solar eclipses has been studied for 150 years. A turning point has been the discovery that the true spatial distribution of coronal brightness can neither be seen nor imaged on account of its unprecedented dynamic range. Howard Russell Butler (1856–1934), the painter of solar eclipses in the early 20th century, possessed the extraordinary skill of painting from memory what he saw for only a brief time. His remarkable but forgotten eclipse paintings are, therefore, ideal for capturing and representing best the perceptual experience of the visible corona. Explained here is how by bridging the eras of visual (late 19th century) and imaging investigations , Butler’s paintings reveal why white-light images misled researching and understanding the Sun’s atmosphere, the solar wind. The closure in understanding solar eclipses through the convergence of perception, art, imaging, science and the history of science promises to enrich the experience of viewing and photographing the first solar eclipse of the 21st century in the United States on 21st August 2017. Shown in That Butler’s paintings capture best the perceptual experience of the visible corona is not surprising, given that he studied physics and graduated before becoming a successful landscape and portrait artist, the most well known of his portraits being those of Andrew Carnegie. Although he had never seen a total eclipse, he drew up meticulous scientific plans to prepare for the 1918 eclipse , and exeStreaming charged particles from the Sun are known as the solar wind. Scientists studying the solar wind turned to eclipse images for clues to its source at the Sun. One difference sets Butler’s paintings apart from the imaged corona. As seen in Coronal images informed first on the process of visual perception  through “In the broadest sense, every act of representation is purposefully selective, just as our acts of seeing. With even the most basic of photographs, depth of field, focus, point of view, lighting, and exposure all serve advertently or inadvertently to include or emphasize some features to exclude or downplay others. This is to say nothing of its subsequent printing and transmission. The scientist, even more than the casual maker of family snapshots, is in the business of selective visual pointing. And the scientist makes sure that the look of the image manifests all the signs of authenticity that are current at the time of its making and reception.The essential nature of the issue of visual trust in representations has not changed over time, even if the scope for convincing deception has increased in ways that increasingly defy ready detection. We have in practice to work with levels of visual trust, otherwise we could not realistically proceed. Visually, we are trusting beings. As such, our current vulnerability is not essentially different in kind from our predecessors’; it is just far greater in extent.”In conclusion, the trust of coronal imaging in solar wind research reflects the comments by


Previous research demonstrates that the processing of spatial information and numerical magnitude are strictly interwoven. Recent studies also provide converging evidence that number processing is influenced by body movements. In the present study we further investigate this issue by focusing on whether and how motions experienced with the whole body can influence arithmetical calculations. We asked participants to make additions or subtractions while experiencing leftward and rightward motions. Data revealed the emergence of a congruency effect between the orientation inferred by the type of arithmetical calculations and the type of motions experienced along an horizontal axis. The first evidence of an influence of number magnitude on space is the so-called spatial-numerical association of response codes (SNARC) effect. During an odd–even classification task on numbers from 1 to 9, responses are faster and more accurate in left space following small numbers , and in right space following large numbers , compared to the opposite instructions. This number–response compatibility effect e.g.,  suggestsRecently, and more relevant to our aims, spatial biases have been reported even at level of arithmetic operations. For example, Crucially, the influence of performing movements with the body  on number processing has received growing attention. For example, random number generation tasks seem to be influenced both by actively and passively experienced movements. More specifically, Furthermore, recent studies have proved the influence of whole body movements, and not only of single body parts, on number generation. For instance, Of particular relevance is a study by The present study aims to broaden the findings obtained by Lugli and co-authors. In particular, we investigate whether movements executed with the whole body along the horizontal axis  can influence the processing of numerical magnitude when calculations had to be performed. To the best of our knowledge, so far only the study by We hypothesized a congruency effect between the spatial orientation related to the type of calculation performed  and the direction of the motion contemporary experienced . More specifically, we predicted a facilitation when participants were required to make subtractions while moving toward the left and additions while moving toward the right (congruent condition) with respect to the reverse assignment .Fifty-two undergraduate students from the University of Bologna  took part in the experiment for course credit. All had a background in humanities, were naïve as to the purpose of the experiment, and gave written informed consent. Four participants who made three or more calculation errors  were eliminated, so that the final sample consisted of 48 participants.The study was approved by the Psychology Department’s ethical committee of the University of Bologna.Data collection took place in an open space, in a secluded and shaded area of a municipal park. We chose a natural setting for the experiment in order to reproduce, the most closely as possible, everyday processes and actions, such as basic calculations and walking.Participants were asked to keep subtracting or adding three to a starting number  for 22 seconds and to say the result of each calculation aloud . We made sure that the starting numbers: (a) were always composed by three digits ; (b) started with two different digits .Figure 1). If an error occurred, the trial was repeated giving to the participant a new starting number.At the beginning of each trial, the experimenter and the participant walked close to each other along a straight path for 20 seconds. Then, the experimenter spoke the starting number aloud , informed the participant about the type of calculation to be executed , the direction of the movement to perform , and then she gave the go signal. Immediately after the go signal, participants turned left or right and then continued walking for 22 seconds. At the same time, each participant was required to repeat the starting number and then to keep saying the result of each calculation aloud, until the experimenter gave the stop signal  and the two types of motion . The type of calculations were always alternated . Throughout the task, the experimenter was in charge of: (a) walking close to the participant , so that the number of steps taken was held constant across participants. Hence, the spatial point where each trial started and ended were held constant among participants; (b) recording the start and final numbers of each trial; and (c) keeping track of the calculation errors. No feedback was given during the calculation process and the importance of accuracy over speed was stressed. It is worth noting that two of the authors served as experimenters for this study and that data entry was always double checked before running the analyses. In other words, the experimenter took note of the starting and final number for each trial. At the end of the task, two experimenters computed how many calculations were made for each trial and then entered this value for analyses.Overall, the experiment lasted about 10/15 min.We considered the number of correct calculations as our dependent variable, whereas calculation errors were excluded from analyses.We hypothesized a congruency effect between the type of motion performed and the type of calculation made. Hence, we divided the trials in congruent  and incongruent . Then we averaged the number of correct calculations separately for each group of pairings.Congruency (congruent vs. incongruent) as the within-subject factor. The magnitude of size effect was expressed by The number of correct calculations were entered into a repeated-measures ANOVA with Congruency  was significant. The number of calculations was higher when participants performed congruent pairings (M = 10.1) with respect to incongruent ones .The main effect of Congruency  was significant. The number of calculations was higher when participants performed congruent pairings (M = 11.1) with respect to incongruent ones (M = 10.2). As to subtractions, the Congruency factor  was not significant, since the number of calculations did not differ between congruent (M = 9.1) and incongruent pairings (M = 9).We also conducted a congruency analysis separately for additions and subtractions. As far as additions are concerned, the main effect of On the whole, results revealed the emergence of a congruency effect between the type of motion performed and the type of calculation made. A facilitation effect was indeed obtained when participants performed calculations in response to congruent pairings , instead of incongruent ones . The reasons why the congruency effect we found was mainly triggered by additions will be discussed in the further section.In the present study we explored the link between space and numbers, and in particular whether and how active motions experienced with the whole body influenced the calculation processes. Results showed a facilitation, in terms of higher number of calculations, when additions and subtractions were executed in a congruent pairing  rather than in an incongruent one . Thus, in line with our hypothesis, data revealed a congruency effect between the direction of the whole body motions and the orientation inferred by the type of calculation processes .Overall, our data support a bidirectional influence between conceptual and motor activation, and add new evidence to the studies about the influence of the motor processes over semantic ones . Two main causes could underlie this result: the differences between the two arithmetic processes and the differences between the two axes on which the two studies focused, i.e., the horizontal (present study) and the vertical axis .Finally, it is worth mentioning another difference between the present work and that of Table 1). On the contrary, while performing subtractions participants might have been more focused on the calculation process with respect to their body movements. One possible further reason of the asymmetry we found between subtractions and additions could be due to the fact that participants walked in an horizontal and facial space. One could indeed speculate that walking in front of me improves addition, while walking backward improves subtraction. On the other hand, a recent study of On one hand, some evidence spokes in favor of a distinction between additions and subtractions which appear to draw on different strategies. Solving simple addition problems may rely more on declarative memory and less on quantity understanding e.g., , whereasThe issue addressed in this study can have interesting implications for an embodied and grounded perspective. This recent view of cognition postulates a link between perception and action , and claOur study adds to previous evidence in favor of an embodied nature of number processing by showing that numbers representation is influenced by whole body motions . InteresHence, the present findings confirm the existence of a connection among numbers, space, and motor processes, by showing the emergence of a congruency effect when subtractions and additions were calculated while moving also along an horizontal axis, and provide further evidence on the reliability of the real-life condition task that the present study and the work by Conceived and designed the experiments: Filomena Anelli, Luisa Lugli, Giulia Baroni, Anna M. Borghi, and Roberto Nicoletti. Performed the experiments: Filomena Anelli and Luisa Lugli. Analyzed the data: Filomena Anelli, Luisa Lugli, and Giulia Baroni. Contributed reagents/materials/analysis tools: Filomena Anelli, Luisa Lugli, and Giulia Baroni. Drafted the paper: Filomena Anelli. Provided critical revisions: Luisa Lugli, Giulia Baroni, Anna M. Borghi, and Roberto Nicoletti.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


As designated points of entry (PoEs) play a critical role in preventing the transmission of international public health risks, huge efforts have been invested in Taiwan to improve the core capacities specified in the International Health Regulations 2005 (IHR 2005). This article reviews how Taiwan strengthened the core capacities at the Taoyuan International Airport (TIA) and the Port of Kaohsiung (PoK) by applying a new, practicable model.An IHR PoE program was initiated for implementing the IHR core capacities at designated PoEs. The main methods of this program were 1) identifying the designated PoEs according to the pre-determined criteria, 2) identifying the competent authority for each health measure, 3) building a close collaborative relationship between stakeholders from the central and PoE level, 4) designing three stages of systematic assessment using the assessment tool published by the World Health Organization (WHO), and 5) undertaking action plans targeting the gaps identified by the assessments.Results of the self-assessment, preliminary external assessment, and follow-up external assessment revealed a continuous progressive trend at the TIA , and at the PoK . The results of the follow-up external assessment indicated that both these designated PoEs already conformed to the IHR requirements. These achievements were highly associated with strong collaboration, continuous empowerment, efficient resource integration, and sustained commitments.Considering that many countries had requested for an extension on the deadline to fulfill the IHR 2005 core capacity requirements, Taiwan's experiences can be a source of learning for countries striving to fully implement these requirements. Further, in order to broaden the scope of public health protection into promoting global security, Taiwan will keep its commitments on multisectoral cooperation, human resource capacity building, and maintaining routine and emergency capacities. Taiwan, an island situated in the subtropical zone, economically relies on international trade and has long been aware about preventing the import of communicable diseases through the thriving international traffic. The point of entry (PoE) plays a critical role for early detection of disease risks and the mitigation of the impact of the rapid spread of infections. Therefore, border health measures have been applied at all international airports and seaports by the Taiwan Centers for Disease Control (TCDC). However, the emergence of new import infections urged Taiwan to ensure the capability of responding to the pandemic at PoEs. As it has always been a challenge to ensure prompt mobilization of various stakeholders at PoEs for jointly battling a threat of an epidemic, TCDC invested substantial efforts to seek a systematic and focused approach that can develop PoE capacities with the strong collaboration of stakeholders.Meanwhile, as the severe acute respiratory syndrome (SARS) epidemic had challenged the traditional rationale of global health protection –3, the IAssessment Tool for Core Capacity Requirements at Designated Airports, Ports and Ground Crossings  the designation of the PoEs should be based on consensus; 2) the stakeholders with the responsibility of implementing the core capacities should be brought together, not only from the health sector, but also from other public and private sectors; 3) the successful implementation of this program requires strong support from the cabinet and its subordinate organizations; 4) a coordination mechanism, with clear functions and structure, is necessary; 5) an agreed protocol, which clarifies the strategies, timeline, and multidisciplinary/multisectoral duties, is essential, and 6) all strategies should be harmonized with the currently available resources, national administrative structure, and consensus made by the participants.In accordance with important conclusions drawn from the preparatory analysis, the TCDC submitted a protocol for a new program  to the Executive Yuan. Subsequently, through extensive review and discussion, the protocol was formally approved to be implemented in January 2011.After consulting various authorities, four criteria were taken into consideration while identifying designated PoEs: 1) the number of international conveyances, 2) the number of international travelers, 3) the geographical distribution, and 4) the existing facilities and logistic capabilities. Thus, one airport  and one seaport  were consensually designated at the first stage.Every year, over 70% of the travelers enter Taiwan through the TIA. The airport has experienced a remarkable annual increase in the number of international travelers and aircraft during recent years, and an additional terminal is being planned. The PoK, which is the largest seaport in Taiwan, traditionally dealt with freight transportation. However, in the past few years, it is also being used to harbor cruise vessels and has shown a rising trend in the number of arriving travelers. In addition, a new travel center is currently being constructed. It is noted that, to upgrade competencies and promote the development of the TIA and PoK, during 2010–2012, the responsibility of operation and management of both the PoEs was shifted from the government authority to the state-run corporations. Since then, these state-run corporations have been responsible for the coordination and consolidation of various agencies stationed in the designated PoEs, under the supervision of the Ministry of Transportation and Communications (MOTC) of the central government.Since the beginning of the implementation of the IHR PoE program, there has been an interesting discussion on the competent authority at the designated PoEs. According to the IHR 2005 definition, a competent authority means ‘an authority responsible for the implementation and application of “health measures”’. Originally, it was perceived that the TCDC shall serve this role. However, when the core capacity requirements were examined in detail, it was realized that some of the health measures mentioned in IHR 2005 were being conducted by other government authorities in reality. For example, if an ill traveler with symptoms of a possible communicable disease was reported in the PoK, the TCDC will be responsible for the assessment of the traveler. If the TCDC decided to refer the traveler to a hospital for further diagnosis and treatment, the PoK fire brigade would be responsible for transporting the traveler to the hospital (with their trained personnel and equipment). Thus, in order to cater to the practical situation in Taiwan, it was consensually decided that the competent authority shall vary according to the different health measures.After the SARS outbreak in 2003, the importance of enhancing the cross-sectoral involvement through an integrated coordinative structure at PoE level was highlighted. Subsequently, while implementing the IHR 2005, each PoE in Taiwan established a ‘port sanitary group’ as a network of various stakeholders. The group comprised authorities from departments responsible for customs, immigration, quarantine, security and port management, and conveyance operators, as well as the local health authorities. It has successfully served as a coordinating platform at PoE level, targeted to the preparedness and the effective contingency arrangement of port health matters. During the H1N1 pandemic in 2009, the port sanitary group functioned very well on efficient information sharing, policy declaration, and coordination about any public health measures carried out at the PoEs.Based on the positive coordination experiences, a specific taskforce  was established under the port sanitary group at the TIA and PoK to facilitate the fulfillment of the core capacity requirements. In addition to members of the port sanitary group, this taskforce also involved private sectors such as sky catering, ground handling, and cargo terminal services. The PoE Taskforce coordinated with members 1) to conduct core capacity self-assessment, 2) to develop PoE action plans that address gaps identified from the assessment, 3) to monitor the progress of the action plans, and 4) to provide feedback to the central governments on difficulties that have been identified regarding core capacity development.The competent authorities at the PoE level in Taiwan are mainly under the supervision of central governments that are in charge of national policy making, budget, and legislation. Therefore, it is believed that while developing the PoE core capacities, it would be more efficient if any important consensus and resource integration can be achieved in advance, at the central level, especially in terms of jurisdiction clarification and financial support. Furthermore, problems that universally exist among various PoEs are often related to issues in general structure, which can never be resolved by the individual PoEs alone. In this case, problem solving must highly rely on the mobilization of resources/support from the central government to the PoEs. For example, initially, both TIA and PoK felt that they lacked the expertise/capability to cope with radiological events, or plan their response to them because the central Atomic Energy Council commissioned no affiliated units at the PoEs. Consequently, the council dispatched experts directly to the TIA and PoK, to assist them in formulating radiological emergency planning, and provided necessary training for the early detection, operation of equipment, and approach to seek external support from the national radiological response team.An inter-ministerial central government task force  has subsequently been constituted. Under the successive leadership of Ministers without Portfolio,Additionally, authorities stationed in designated PoEs can seek immediate assistance from their superiors at the central governments, to solve problems or to arbitrate the disagreements. For instance, the TIA Co. Ltd, the government-owned company responsible for the operation and management of the airport, would like to clarify and improve current procedures related to security checks of postal parcels transported through the airport. Therefore, apart from police and custom authorities, the company also requested its superior MOTC to collaborate with the National Postal Services  in the discussion. Thus, the MOTC acted as the intermediary as well as the final decision maker (in case of any disagreements), and it was very helpful in facilitating improvement work.The IHR PoE program designed three systematic assessments , together with the implementation of action plans that addressed the identified gaps. Each assessment applied the 95 assessment indicators and scoring system provided in the WHO tool .Before investing resources for establishing core capacities, the PoEs must have an overall idea of its present status. Therefore, the TIA and PoK had respectively completed self-assessments during March 2011, by a PoE Taskforce. At the first stage, the secretariat of the taskforce led the introduction of the 95 assessment indicators, so that members could thoroughly understand the implication of the IHR core capacity requirements. Following this, members were asked to report their field activities concerning the IHR core capacities. In addition, a field visit was arranged for, if necessary. For instance, the TIA taskforce visited the airport cargo terminal services to understand the operation of the transportation of dangerous goods according to International Air Transport Association (IATA) regulations. Finally, members worked together to complete the WHO assessment tool, by describing any measures, facilities, and approaches available at the PoE, and listed documents which can provide evidence on the compliance of the core capacity requirements. Based on the information collected, the taskforce jointly decided the perceived stage of implementation .Through the self-assessment, both the TIA and PoK obtained the baseline information of their existing core capacities, and then implemented some improvements to address the identified gaps. Yet, in order to avoid bias due to subjective judgments, an external expert was invited from Japan to conduct an in-depth review of the designated PoEs, from an international perspective, in August 2011. During the preliminary external assessment, the reviewer carefully verified the documents that evidenced the compliance of assessment indicators. Sites were visited to investigate facilities, equipment, and practices implemented in the field. In addition, the reviewer interviewed key personnel, raised inquiries, and obtained feedback during the assessment.To facilitate the assessment, a pre-designed assessment protocol was provided to the reviewer and the PoEs to prepare them for the same. In addition, background materials such as self-assessment reports and a brief introduction of both the PoEs, were provided to the reviewer in advance. The reviewer was requested to pre-designate the document and the potential sites to be assessed.In order to ensure the PoE's efforts for improvement were already consistent with the IHR requirements, two experts were invited from the Australia Government's Department of Health and Ageing to undertake a follow-up external assessment in mid-March 2013. Similar assessment procedures (document reviews and on-site visits) were applied in the two external assessments to ensure that their results were comparable.Based on findings discovered from the self and the preliminary external assessment, a series of activities were identified to improve the designated PoEs in Taiwan. Firstly, both the PoE Taskforces respectively prioritized the identified gaps, while taking into account factors such as urgency, resource availability, and achievability. Subsequently, action plans that described practicable approaches and resource investments, and which set a defined timeline with checking points, were developed. As improvement is always a dynamic process, regular monitoring and feedback is crucial to ensure progress and that outcomes are in line with expectations. The PoE Taskforces were allowed to adjust the scope and timeline of the plans according to current need and performance .The WHO assessment tool also provided an MS Excel spreadsheet file model, which enabled reviewers to choose their response  to each indicator. When the performance of each indicator is determined, the model automatically generates numerical results with graphic representations of the same. According to the WHO, a PoE with a final score of above 80% is defined as fairly consistent with the requirements of the IHR Annex 1.The TIA taskforce reported a self-assessment score of 86%. Among 89 assessment indicators (six indicators specific to seaports/ground crossing were excluded), 73.1% were assessed as ‘fully implemented’, while 26.9% were reported to be ‘partially implemented’ in the airport. It was found that the TIA owns a communication network among various stakeholders for communicable diseases or biological events, while the reporting system for radiological and chemical events had not yet been established. The airport exhibited routine capacities of adequate on-site medical services for ill travelers, and an inspection/surveillance program of the terminal environment and aircraft. However, the response plans toward radiological, chemical, and biological emergencies were not in place.The external reviewer of the preliminary external assessment reported that 77.5% of the assessment indicators had been ‘fully implemented’, while 22.5% had been ‘partially implemented’. The total score of the TIA was 91%, which showed a fair progress as compared to the self-assessment. From the reviewer's viewpoint, the TIA had already or nearly fulfilled Part A (Communication & Coordination) and Part BI (Routine) requirements, and suggested that further efforts need to be invested in developing its capabilities to respond to PHEIC. It was noted that all the competent authorities in the TIA answered that if they encountered a problem that was difficult to address, they would consult their headquarters. However, the horizontal communication between agencies at the TIA was rarely mentioned.Based on the learning from the previous two assessments, the TIA applied its action plans on the following areas: 1) Reconstructing the communication flow to ensure that event information is notified by and disseminated to stakeholders including outsourcing companies and service providers; 2) formulating/updating emergency plans with the consideration of the surge response. Contents of the plans, along with the communication link with various targets, were validated by table exercises or scenario drills; 3) developing regular and irregular inspection mechanisms to ensure the quality of outsourcing services, and specifying all requirements in contracts; 4) designating a specific location for the decontamination of PHEIC; 5) replacing personal protective equipments (PPEs) that had passed their expiry date, or purchasing required ones; and  updatingThe reviewers of the follow-up external assessment reported that 100% of the indicators had been ‘fully implemented’ . In geneIn the self-assessment, the PoK taskforce reported that 39.8% of the 88 assessment indicators (seven indicators were not applicable for seaports) had been ‘fully implemented’, 53.4% had been ‘partially implemented’, while 6.8% were evaluated as ‘not implemented’. The total score of the PoK was 77%. It was found that the communication link with senior health officials and SOPs for assessing urgent reports and disseminating information from the WHO were to be established. In addition, inspectors found a lack of knowledge about water management, swimming pool/spa, and air quality management on ships and terminal facilities. Emergency planning and PPEs toward radiological and chemical events were either absent or out of date, and a place had not been designated for decontamination.Concerning the preliminary external assessment, the total score of the PoK was 97%. Among the 88 assessing indicators, 76.7% were assessed as ‘fully implemented’, 22.2% as ‘partially implemented’, and 1.1% as ‘not implemented’. The reviewer observed that, similar to the problems identified at the TIA, agencies in the PoK sometimes omitted the dissemination of the information to their partners in the PoEs. On the other hand, since the inspection of conveyances are sometimes closely linked with the management and the inspection of the port facilities , it was appreciated that the PoK improved cross-sectional capacities by holding joint training programs for both ship and facility inspectors. In terms of emergencies, the reviewer perceived that the response system in the PoK has been improved since the self-assessment. It was also highly valued that the PoK planned ‘cross-unit human resources support programs’, which aimed to seek personnel belonging to other PoEs to support large-scale events immediately. It might help the surge capacity at the port in total.The previous two assessments provided the PoK with clear clues to identify their action plan, which was as follows: 1) Re-examining the communication flow, taking into account private sectors such as shipping agents; 2) completing the emergency response protocols toward PHEIC. Protocols shall not only be approved by both PoE stakeholders and central authorities, but also tested by drill exercises; and 3) taking the IHR core capacity requirements into consideration while planning the new travel center, especially for terminal facilities such as water supply system, waste management, toilets, food/beverage services.External reviewers of the follow-up assessment scored the PoK 99.9% , which iBased on reviewers’ suggestions, the TCDC implemented inspection and control measures for recreational swimming and spa activities on ships into the annual training program for ship sanitation inspectors. In addition, the port management authority is increasing the number of trained inspectors, and arranging for provision of training, to increase staff knowledge.In this section, we have discussed the main issues that originated from the implementation of ‘IHR PoE program’.Results of the self-assessment, preliminary external assessment, and follow-up external assessment revealed continuously progressive trends in the TIA and PoK . The folAs the upcoming PoK travel center, and a new TIA terminal are expected to increase passenger numbers in the next few years, existing core capacities  may not be enough to handle the magnitude of travelers. It is therefore necessary to be attentive to the needs of further improvement in the core capacities through an analysis of the potential impact of the rising numbers of passengers.The first two assessments found that capabilities to respond to radiological and chemical events effectively were underdeveloped or nonexistent in both, the TIA and the PoK; however, the response planning for a large-scale outbreak/pandemic had been established after the SARS epidemic. These findings corroborated the evidence generated from the general review of global IHR implementation, specifically indicating that, ‘The chemical, nuclear, and radiological threats encompassed in the IHR 2005 presents a unique challenge to the surveillance and response community in both developed and developing countries’ .Since the beginning of the implementation of the IHR PoE program, there was a discussion on whether radiological and chemical capacities were needed to be involved in the assessments, as the WHO ambiguously described in one of the assessment indicators (Part BI d.2.3) that ‘Harmful contamination, other than microbial contamination, such as from radionuclear sources, could also be found on ships, but is outside the scope of this guidance’. Further, due to the lack of international guidance, it seemed easier and less complicated to restrict the assessments to communicable diseases. However, it was subsequently determined that Taiwan should not ignore radiological and chemical hazards because the type of accidents that may occur at the PoEs cannot be predicted or selected. Sometimes, an accidental or deliberate release of chemical, biological, and radiological agents on arriving conveyances would have the potential to cause adverse health and financial consequences . In thisThrough understanding the risk profile of the TIA and PoK as well as in consultation with technical experts dispatched by the central governments and national disaster response authorities, it was determined that the emergency response at PoEs level should meet the following six basic criteria: 1) PoE response protocols are aligned with those at the national and local level to ensure the seamless flow of information from the various response systems; 2) clear identification of duties and responsibilities of each stakeholder; 3) knowledge and equipment for early detection and personal protection; 4) communication mechanisms to disseminate information to relevant stakeholders at the PoEs; 5) access to external assistance from the local or central disaster response system; and 6) clear command and control system before the arrival of external assistance, and the process of command transfer.According to the criteria defined above, the TIA and PoK updated their emergency plans, and integrated them into protocols for various types of PHEICs , 20. TheThe advocacy of the IHR PoE program was very challenging initially. Due to a lack of understanding of the IHR 2005, key stakeholders at central ministries and PoEs perceived that the regulations were only under the jurisdiction of the health ministries. Therefore, the TCDC invested considerable effort in advocating the aim and concepts of the IHR 2005. Despite these efforts, the IHR PoE program was not implemented very smoothly, due to the resistance and complaints from the field, until the Japan Fukushima nuclear disaster occurred in 2011. Fearing the impact of nuclear contaminations (as traffic and trade are very frequent between Japan and Taiwan), people working at the PoEs were keenly aware of the importance of protecting themselves by enhancing the surveillance and response system. They found a self-motivated actor  to partiIt was also observed that the process of preparing for each assessment brought the stakeholders closer. As they shared the same objective of obtaining better results for the next assessment, partners involved in the PoE met frequently to discuss matters. This extensive participation of various professionals led to a robust unity and mutual understanding. The reviewers observed that all the relevant units at each PoE were united with a well-organized structure, and the contribution of the staff toward the implementation of the IHR was a major strength in the implementation of core capacities at PoEs in Taiwan. It is believed that this solidarity shaped through the IHR PoE program will continue even after the core capacity requirements have been fulfilled. It shall be continuously beneficial, not only for the daily operation of the PoEs, but also in co-confronting future crises.Strong national efforts throughout all the governmental agencies, to achieve the core capacity requirements at the PoE, were noted by the reviewers of the preliminary and follow-up external assessments. Sometimes the application of the program was affected by bureaucracy and sectionalism, especially with reference to jurisdiction and expenditure allocation. The solution was the continuous communication and strong commitment of the higher-level authorities to carry through the program and to arbitrate contentions. Thus, Taiwan was inspired by the reviewers’ conclusions that the progress achieved is testament to the strong commitment, professionalism, and enthusiasm demonstrated by the staff, in their respective roles.This article introduced a new, but applicable, model that Taiwan developed for developing IHR core capacities at designated PoEs. The IHR PoE program focused on 1) designating two PoEs according to the pre-determined criteria, 2) identifying the competent authority for each health measure, 3) building a close collaborative relationship with stakeholders from the central and PoE levels, 4) designing and implementing three stages of systematic assessment, and 5) undertaking action plans targeting the gaps identified by the assessments. With incessant efforts invested in the ‘learning by doing’ process, the designated PoEs of TIA and PoK were assessed as highly consistent with the capacity requirements of the IHR 2005. As many countries had requested extensions to fulfill the IHR 2005 core capacity requirements , it is eNevertheless, the achievements of the IHR PoE program do not imply an end, of a process, but are a starting point to address the increase in international traffic, and to respond to future challenges at airports and seaports effectively. As the reviewers suggested, it is necessary to continue to maintain core capacities in the designated PoEs and flexibly adjust the overall strategy in the face of new diseases (such as Middle East Respiratory Syndrome Coronavirus infection or new strains of avian flu), new terms of emergencies, new international guidance, as well as new transporting routes and destinations. For this purpose, the Taiwanese government will remain committed toward implementing and reviewing the content of the IHR PoE program. So far, the coordination and collaboration at PoEs functioned well in response to the H7N9 outbreak that began in China at the end of March 2013. The emergency of a new disease reminded Taiwan that the collaborative mechanism and the partnership, which were already successfully triggered or shaped, should be continuously maintained to ensure the sustainability of the core capacities.Currently, Taiwanese government has launched the second stage of the IHR PoE program. Five more PoEs (three airports and two seaports) have been identified as designated PoEs to develop their core capacities. The new task will rely highly on the experiences from the development undertaken at the TIA and PoK. In addition, it will adapt to the characteristics of the specific PoEs and the ever-changing environment. These efforts are expected to extend the safety of the lives and property of Taiwanese people extensively and to bolster the competitive advantages of PoEs in Taiwan.


To investigate and compare the trends in incidence and mortality of penile cancer between Australia, England and Wales, and the US, and provide hypotheses for these trends.Cancer registry data from 1982 to 2005 inclusive were obtained from Australia, England and Wales, and the United States. From these data, age-specific, -standardised and mortality:incidence ratios were calculated, and compared.The overall incidence of penile cancer in England and Wales  was higher than in Australia , and the US . Incidence of penile cancer in all three countries has remained relatively stable over time. Similarly, although the mortality rates were also higher in England and Wales  compared to Australia  and the US , the mortality/incidence ratios were similar for all three countries.Penile cancer incidence is low, affecting mainly older men. Rates differ between the three countries, being twice as common in England and Wales as in the other studied regions. Circumcision rates have a potential influence on these rates but are not the sole explanation for the variation. Invasive squamous cell carcinoma of the penis (hereafter referred to as penile cancer) is a rare disease, the reported rates of which vary widely between countries  Registries in the US. The penile cancer diagnoses for the UK were available only from 1995 to 2003, however mortality data was available from 1982–2005. Nine registries were used when analysing the SEER database .The Australian Institute of Health and Welfare (AIHW) database is the central cancer registry for all cancer incidence and deaths and collates data by all state-based cancer registries in Australia and is a validated and reputable source of data .To investigate the prevalence of circumcision, a literature search was performed using the pubmed database with the MeSH terms “circumcision” and “prevalence” AND/OR “incidence”. Papers relevant to the 3 countries being studied were selected and reviewed. Twenty-three articles were reviewed. To ensure relevant papers were not missed, the references of the papers were also reviewed. Ten articles met the search criteria. Non-English articles were excluded.The incidence of penile cancer increases with age. Fig.  In EnglaData on incidence of penile cancer were available between 1982 and 2005 in Australia and the US, but only for 1995 to 2003 in England and Wales  Table .The data we present here clearly show a significant difference between the incidence of penile cancer in the US, England and Wales, and Australia. While the US and Australian incidences are similar, the incidence in England and Wales is considerably higher. The rates in England and Wales correlate with other published European data; rates in Denmark are similarly high   reporting of only a subset of circumcisions , and discounting religious/cultural circumcisions that occur outside hospital, as well as adult circumcisions, and, (2) falling rates of circumcision. Infant and adult circumcision typically occur for different reasons. There is good inter-study correlation for each of the three countries. However, the studies cannot be aggregated in their results as different methods have been used to obtain values for incidence and prevalence.As has been previously noted, infant circumcision has been posited to have a protective role in penile cancer (Maden et al. The circumcision rates in the US are much higher than the rates in the other two countries. Although the population demographics and rates of other cancers in the US differ from the other two countries, the incidence of penile cancer is similar to that in Australia (Parkin and Muir Although we see only a tiny rise in penile cancer rates in Australia, and no statistically significant change in incidence in England and Wales as the rate of circumcision has fallen, it is entirely possible that this is due to the long lag between infant circumcision and the peak incidence of penile cancer. Over time, mortality from penile cancer has marginally reduced, presumably with improved treatment, possibly in assessing for and managing early nodal disease. With a generally noted decline in circumcision rates beginning in 1950 and continuing until the present, were a distinct correlation in penile cancer incidence to emerge, it would be likely to begin to be observed in 2020 and trend upwards until 2060.Limitations from this study include the fact that the use of cancer registry databases, which, while widely accepted, relies on reporting of cancer, either when diagnosed or on a death certificate. This may result in under-reporting of disease rates.Penile cancer is a rare disease, the burden of which falls predominantly on older males. The rates have remained fairly stable between 1982 and 2005 in all three regions. In addition, mortality/incidence ratios were similar across all three regions, suggesting similar treatment outcomes.England and Wales had the highest incidence and mortality rates of penile cancer compared to Australia and US and also the lowest infant circumcision rates and overall circumcision prevalence. This offers some support to previous data suggesting infant circumcision may reduce risk of penile cancer. However, despite having higher circumcision rates in the US, the incidence of penile cancer in Australia and the US were similar, suggesting that the penile cancer incidence is not solely attributable to circumcision rates.It will be interesting to observe the trends in the incidence of penile cancer over the years to come, as the time interval between change in infant circumcision rates and development of penile cancer grows.


Primary eye care (PEC) in sub-Saharan Africa usually means the diagnosis, treatment, and referral of eye conditions at the most basic level of the health system by primary health care workers (PHCWs), who receive minimal training in eye care as part of their curricula. We undertook this study with the aim to evaluate basic PEC knowledge and ophthalmologic skills of PHCWs, as well as the factors associated with these in selected districts in Kenya, Malawi, and Tanzania.A standardized (26 items) questionnaire was administered to PHCWs in all primary health care (PHC) facilities of 2 districts in each country. Demographic information was collected and an examination aimed to measure competency in 5 key areas  was administered.Three-hundred-forty-three PHCWs were enrolled . The competency scores of PHCW varied by area, with 55.7%, 61.2%, 31.2%, and 66.1% scoring at the competency level in advanced cataract, conjunctivitis, presbyopia, and trauma, respectively. Only 8.2% could measure visual acuity. Combining all scores, only 9 (2.6%) demonstrated competence in all areas.The current skills of health workers in PEC are low, with a large per cent below the basic competency level. There is an urgent need to reconsider the expectations of PEC and the content of training. There is a growing body of literature documenting problems in the quality of care in primary health care (PHC) systems in eastern Africa. Murray and Frenk state that most deficiencies in quality of care result from gaps in knowledge or the inappropriate applications of available technology rather than a lack of resources . Gilson In spite of this, there is persistent enthusiasm for the concept of providing eye services  at the most basic level of the health system by general PHCW in Africa . PEC mayThe concept of PEC was born after Alma Ata when it was noted that some of the tenets of primary health care could have an impact on reducing two important causes of blindness in developing countries: vitamin A deficiency-related corneal disease and trachoma. Tetracycline eye ointment was included in the basic medicines recommended at the PHC facility to treat the latter. The scope of PEC started to expand when it was noted that general PHCW, with minimal or no equipment, could probably be taught to recognize a white pupil (advanced cataract) and a red eye  . With thThe curricula for PHCW in many African countries include PEC. The exact content varies, even within countries, and some non-governmental organizations have provided supplementary training. The intent of PEC training is to prepare PHCWs to manage  anyone who comes to a health centre with an eye complaint. Management of eye conditions by a PHCW is based on history taking, examination of the eye, and knowledge of likely causes. Treatment options usually include antibiotic eye drops or ointment and sometimes steroid drops. Referral options usually include specialised mid-level ophthalmologic personnel  at the district level.Guided by our pilot study results, we undertook a more comprehensive study that involved more PHCW, extending the evaluation program to another district in Tanzania and to two districts each in Kenya and Malawi. Specifically, we evaluated the knowledge and skills of PHCW to recognize and manage four common eye conditions  and to perform one skill . The four conditions are generally considered to be within the scope of PEC in Africa . CataracTwo districts in each country were selected based on proximity to the lead investigator in the country. All government health centres (known as “dispensaries” in Tanzania) in each district were included and visited by interviewers. On the day of the visit all the PHCW present within these health centres were interviewed. There are sometimes “attendants” and other unofficial cadres of workers at the health centres, and we intended to limit the interviews to officially recognized and trained cadres; this was realistic in Kenya and Tanzania where “unofficial” cadres were infrequent. In Malawi, however, a significant proportion of workers fit this category and we included them since they are regularly providing health care there.An interview questionnaire for the PHCW was designed and pre-tested in the pilot study . Part 1 The questionnaire was administered by two different interviewers in Tanzania and one each in Malawi and Kenya. The form was translated into Swahili then back into English to ensure accuracy. A Swahili form was used in Tanzania and an English form was used in Malawi and Kenya. The interviewers were trained by the lead investigator in each country, who met together to agree on protocol. A detailed set of instructions for completing the form was prepared.Data were entered into Microsoft Excel, and then transferred into Stata for analysis. We compared scores among PHCW from each country for each component using chi-square; total scores for health workers were compared among countries by t-test. Mean total scores were used to test associations between competency and other variables, including gender and prior training. Odds ratios for prior training being associated with competency were also calculated.This study was approved by the Tumaini University ethics committee in Tanzania and by the Ministries of Health in Malawi and Kenya.Three-hundred-forty-three PHCW from 137 PHC facilities were studied; these included 59 facilities in Tanzania (100 PHCW), 40 in Kenya (107 PHCW), and 38 in Malawi (136 PHCW). These included all health workers who were present on the day of the interview.The average number of patients recorded in log books who presented with eye complaints among the centres in 2010 was 52, 108, and 278 in Tanzania, Kenya, and Malawi, respectively. These differences are consistent with the fact that in Tanzania the PHC facility has a catchment population of 2,000-5,000; in Kenya it serves around 10,000, and in Malawi it serves around 8,000-20,000. On average there were 2.7 PHCW per PHC facility . Basic descriptors of the PHCW in each country are provided in Table Table Table Table This study is one of few attempting to evaluate the skills in PEC of PHCW in low income countries. PHCW in the study are clinical officers and nurses for the most part, although about half of the PHCW in Malawi had neither of these qualifications. Females comprise at least half and closer to two-thirds in Kenya and Tanzania; PHCW in Tanzania are generally older than in the other countries.While almost all PHCW said that they provided eye care, not all had been trained to do so. The percentage that received PEC training in Tanzania, Kenya, and Malawi, respectively was 34%, 97%, and 48%. The fact that one-third of those who provide eye treatment have not had any eye training is an example of the overstepping of competence noted by Walter [It is interesting that only 28 (41%) of those who were trained in PEC said that testing of VA was part of their training. This is an important skill and often a critical determinant of management of eye conditions; the fact that it was not included in some PEC training requires investigation of the curricula being utilised in each country.Overall, the scores were low, especially considering that the test was designed only to measure basic competence in common conditions. Presbyopia is likely to be the most common condition in the population , but only 30% of PHCW could recognize and manage this. Severe trauma is a condition whose mismanagement can have devastating consequences; it was the condition most readily recognized and managed but even so only 66% of PHCWs were able to do this. Untreated cataract is a major cause of avoidable blindness; the photo showed a white pupil (advanced cataract) but only 56% of PHCW recognized the condition and knew what its management entailed . Conjunctivitis is a common self-limited condition without visual sequelae and was recognized and managed appropriately by 61%. Ability to measure visual acuity was uniformly low, with fewer than 10% able to demonstrate this critical skill, consistent with the fact that it was not included in PEC training.Higher scores were significantly associated with having had previous PEC training and with gender . However, the actual differences in mean scores between those with and without training was not large Table  and a laThere are several limitations to this study. We could not verify the accuracy of the PHCW information on whether they actually had PEC training and what was included in it; some may have said they had no training in the hope that it would be offered and others may have said they did have training since they were providing eye care. We did not attempt to evaluate the quality of training in any of the countries and we believe it to be highly variable. In Malawi, the results must be interpreted in light of the fact that health workers who are not officially part of the system were included; however, they comprise a significant part of the workforce on the ground. It was beyond the scope of this study to determine what constitutes proper training in PEC, but we focused on elements that are generally considered within the scope of PEC in Africa .In spite of the above limitations, these findings raise a number of issues that should be of concern to those who advocate for this form of “task shifting.” First, the training curricula for PEC need to be investigated. Although numerous manuals have been written on PEC, to our knowledge none have been tested in terms of whether they provide the basic skills required to “recognize and manage” eye complaints at the frontline. In a companion paper we provide the first attempt to test the sensitivity and specificity of simple ocular signs and symptoms at identifying eye conditions requiring referral and this area needs more work . A seconIn summary, the current skills of PHCW in PEC in Kenya, Malawi, and Tanzania are low, with a large percent below the basic competence level. There are many challenges in training PHCW to provide an acceptable quality of eye care. There is an urgent need to reconsider the concept of PEC before committing more resources to PEC as it is understood in most African countries. This does not mean the concept should be abandoned; rather, we think that the aim of PEC should be to help reduce avoidable blindness and visual impairment. Thus, it must address the major causes of blindness and visual impairment today; there are likely to be skills that PHCW can contribute in this regard. However, additional research is required to better define the role as well as the most effective mechanisms to support this cadre of health care workers.DFATD: Foreign Affairs, Trade and Development Canada; GHRI: Global Health Research Initiative; IDRC: International Development Research Centre; MCH: Maternal and Child Health; PEC: Primary eye care; PHC: primary health care; PHCWs: primary health care workers; SD: standard deviation; VA: visual acuityThe authors declare that they have no competing interests.PC, SL, and EE conceived the research project. All authors contributed to the drafting of the study design and EE, MG, EB, and KK conducted field staff trainings. KK led manuscript writing with assistance from PC and SL. All authors approved the final manuscript.


The predictive model was developed based on prescription patterns indicative of chronic diseases, using a random sample of 50% of the population. Multivariate Cox proportional hazards regression was used to assess weights of different prescription patterns and drug classes. The predictive properties of the DDCI were confirmed in the validation cohort, represented by the other half of the population. The performance of DDCI was compared to the CCI in terms of calibration, discrimination and reclassification.6 local health authorities with 2.0 million citizens aged 40 years or above.One year and overall mortality rates, unplanned hospitalization rates and hospital readmission rates progressively increased with increasing DDCI score. In the overall population, the model including age, gender and DDCI showed a high performance. DDCI predicted 1-year mortality, overall mortality and unplanned hospitalization with an accuracy of 0.851, 0.835, and 0.584, respectively. If compared to CCI, DDCI showed discrimination and reclassification properties very similar to the CCI, and improved prediction when used in combination with the CCI.DDCI is a reliable prognostic index, able to stratify the entire population into homogeneous risk groups. DDCI can represent an useful tool for risk-adjustment, policy planning, and the identification of patients needing a focused approach in everyday practice. Administrative health databases can be used to obtain algorithms useful to forecast readmission and reduce in-care cost. Validated comorbidity indexes (such as Charlson Comorbility Index) have been applied on hospitalization data to predict the risk of death or readmission, but these models do not permit to define the out-patient risk profile. More complex predictive models were obtained to overcome this limitation through the integration of several data-sources, including outpatients, accident and emergency, electronic clinical data from general practitioners, socio-economic data, and community dispensed prescriptions. Unfortunately, the different data-bases required are not always available and/or standardized. Our data show that a much simpler scoring system, solely based on drug prescriptions, can accurately predict one-year and long-term mortality, as well as the risk of unplanned hospitalization and hospital readmission.Healthcare utilization, unnecessary care and health care spending increase linearly with the number of chronic conditions affecting an individual. In U.S., 25% of the population with multiple chronic conditions account for two-thirds of total health care spending,2.An accurate prediction of the risk of poor outcomes in individuals with multiple comorbidities would allow health care professionals to focus on patients who are at highest risk of hospital readmissions, inappropriate care, elevated healthcare costs, and mortality. Stratifying patients according to risk can help identifying individuals candidate to an appropriate intervention in order to improve health outcomes, allocate resources more efficiently, reduce costs and facilitate better planning. As an example, several studies have shown that focused care after discharge can decrease the risk of readmission to hospital–8. SeverAn alternative approach can be represented by the use of drug prescription data, using the chronic use of specific classes of drugs as a proxy of chronic diseases and an expression of healthcare complexity. The possibility to use prescription data as indicators of underlying diseases was experienced in many clinical contexts–15, and The aim of the study was to develop and validate the Drug Derived Complexity Index (DDCI), a predictive model derived from drug prescriptions. In particular, we evaluated whether DDCI was able to stratify the general population according to the risk of death, unplanned hospital admission, and readmission, and compared it with the Charlson Comorbidity Index in terms of discrimination and reclassification.We conducted a population-based retrospective cohort study, using a record-linkage analysis of prescription databases, hospital discharge records, and the civil registry, including data on the population aged 40 years or over of the Puglia region in Italy .All Italian citizens have equal access to health care services and are cared for by a general practitioner as part of the National Health System (NHS). With the only exception of some drugs delivered directly by hospital pharmacy , prescription databases provide information on all community prescriptions reimbursed by the NHS with drugs coded according to the Anatomical Therapeutic Chemical (ATC) classification system. HospitaThe reliability of data sources and their linkage to produce epidemiological information have been previously described,19. All st 2003 to December 31st 2010 were used to develop and validate the DDCI. A fixed cohort of all residents at 01/01/2004 and aged 40 years or above was identified from the civil registry of the Puglia region. Index date was represented by January 1st 2004 for all citizens registered at the local health authority and alive at that time. The year of observation prior to the index date was used to define baseline characteristics. Patients were followed up from their index date to the earliest of death, migration, or the end of the study period. Prescription patterns indicative of chronic diseases (PPCD) and chronic exposure to drugs were derived from prescription databases.Data from January 1Charlson Comorbidity Index (CCI) was calculated based on the diagnoses contained in hospital discharge databases.The main outcome was overall mortality. The first unplanned hospital admission occurred after the index date, hospital readmissions, and 1-year mortality were considered as secondary outcomes. Overall survival was defined as the time between index date and death. For subjects who did not die, survival time was censored at the end of follow-up period or the date of leaving the region. The time horizon for risk prediction was set at 7 years.To control the accuracy of predictions and to increase the reliability of all statistical analyses, the whole population was divided into 2 random samples :Training set, including 50% of subjects, in which different PPCDs and drug classes were included in a predictive model to develop the DDCI;Validation set, including the other half of the population, in which the predictive properties of the in DDCI were confirmed.In addition, two cohorts were selected from the validation set:a first cohort of randomly selected residents, in which the discrimination and reclassification power of DDCI were assessed;a second cohort of all subjects hospitalized during 2003, in which the performance of DDCI was compared to that of the Charlson Comorbidity Index.Patients’ baseline characteristics are reported as frequency (percentage) and mean±standard deviation (SD). A multivariate Cox proportional hazard regression model including all the PPCDs and drugs to which patients were chronically exposed at baseline was performed to identify predictors of overall mortality. All drug classes significantly associated with mortality risk were included in the final model. A weight assigned to each drug class was derived from regression coefficient value divided by 0.3; the value obtained was rounded to the nearest integer, as proposed by Gagne et al. . The ove22. The reclassification extends the concept of discrimination by evaluating separately the subjects with and without outcome. The interpretation is opposite for subjects with and without the outcome. The proportion of events correctly reclassified and not-events correctly reclassified are summed. This sum was labeled as Net Reclassification Improvement (NRI) [Overall mortality and time-to-first unplanned hospitalization analyses were performed using multivariate Cox proportional hazards regression models, and risks were reported as hazard ratios (HRs) with their 95% confidence interval (95% CI). Survival curves and probabilities were reported according to the Kaplan-Meier method. We evaluated the performance of the score in terms of discrimination and reclassification, with mortality and first unplanned hospitalization as outcomes. A model including age and sex was considered the reference model to which DDCI was added. In hospitalized subjects selected from the validation sample the same age and sex based reference model was used. Models adding separately the Charlson Comorbidity (CCI) index or the DDCI were tested. The final model included age, sex and both CCI and DDCI. Accurate predictions discriminate between those with and those without the outcome. Discrimination power was assessed by estimating survival C index with their 95% CInt (NRI) . SubsequOverall, a cohort of 1,998,948 subjects aged > = 40 years  was identified. The mean follow-up period was of 6.62±1.28 years, 12.53% had experienced at least 1 hospitalization for any cause and 76.25% had at least one drug prescription in the 12 months prior the index date. The training and the validation data sets included 999,391 and 999,557 subjects, respectively . During In the training set, time-to-death analysis was used to assess weights of different PPCDs and drug classes. All the classes of drugs not significantly associated with overall mortality were excluded from the final model. Among the drug classes included in the final model, some  showed a poor contribution to mortality risk, totalizing a score of 0. Opioids appeared to be the drugs more related to mortality risk. The use of lipid modifying agents and immunosuppressants was associated with a risk of death lower than the reference category, represented by individuals not taking any of the drugs considered, and therefore a negative score was assigned to them. The regression coefficient values calculated on overall mortality and the weight assigned to each drug class of the best-in-class model are shown in A statistically significant increase in hazard ratios values with the increase in DDCI score was documented in the validation cohort, closely reproducing the results obtained in the training sample . In partDDCI was also able to predict time to first unplanned hospitalization; Kaplan-Meier curve showed a progressive increase in unplanned hospital admission risk with increasing DDCI score , Panel BThe evaluation of accuracy, discrimination and reclassification capacity of DDCI was performed for the residents of the largest local health authority  , Model AIn the validation data set, 125,094 citizens had had at least one hospitalization during the 12 months prior the index-date. The clinical risk for these subjects was assessed through the application of the Charlson Comorbidity Index and the DDCI. When compared to the reference model (age and sex), both DDCI , the DDThe availability of a tool capable to capture the level of clinical complexity of patients could assist physician in their everyday practice, allowing to make more objective their clinical judgments. The possibility of an uniform assessment of the complexity of the patients could also facilitate the definition of guidelines and care models centered on patients with multiple morbidities and carrying a high risk of unfavorable outcomes.Moreover, since the last year of life is characterized by high healthcare costs, the identification of individuals at high risk of short-term death can be of great significance to health providers and insurers.The major strength of the DDCI score is its reliance on a single source of administrative data based on the ATC coding system, widely utilized in many countries. For this reasons the DDCI can be applied in all the healthcare contexts in which there is a lack of clinical data; it can be easily applicable at population level, requiring only the availability of data on drug prescriptions.The study also has limitations. First the application of DDCI at the population level is not generalizable outside of comprehensive health networks or all-payer administrative datasets. Nevertheless, the score can be used in any database containing drug prescriptions  or within studies to stratify the clinical risk profile of specific cohorts. It can be also used as a case-mix adjustment measure whenever clinical data needed to calculate CCI are not available.Second, in our cohort, the use of lipid modifying agents and immunosuppressants was associated with a risk of death lower than the reference category. These results could appear counterintuitive. However, the use of lipid lowering drugs was very limited (6.7% of the population). We can thus hypothesize that within the reference group represented by individuals not treated with any of the drug classes considered there were also individuals candidate to lipid lowering treatment but not receiving the drug. This can be responsible for a higher risk of death in the reference category as compared to people treated with statins. As for immunosuppressants, we do not have an obvious explanation. Nevertheless, it should be noted that this class represented less than 0.2% of the whole cohort, making its contribution to the scoring almost irrelevant. Third, it should be emphasized that the scoring system can underestimate the risk in some individuals, due to the lack of information on those drugs, particularly cancer drugs, dispensed at the hospital. Furthermore, it reflects the risk of the Italian population, and its testing in other healthcare systems is warranted.Finally, DDCI was not externally validated, but the random split in 2 equally large dataset  of a whole regional population of approximately 2 million of people constitutes a reliable methodology for the validation. Anyway, further studies are needed to evaluate the performance of DDCI as compared to CCI on an external outpatients population.We developed and validated a prognostic index derived from prescription data, able to stratify the entire population into homogeneous risk groups. DDCI can represent a useful tool for risk-adjustment and for policy planning, as well as an instrument for the identification of patients needing a focused approach in the everyday practice. Its use can thus help improving the quality of care and optimize resource allocation.