Motor development, i.e., body coordination and visual-motor coordination, were assessed by a social pediatric development screening, and social circumstances by migration background (MB) and parental education (PE). Poisson regression estimated adjusted Incidence Rate Ratios  for relationships between social circumstances and participation in programs and participation and body coordination/visual-motor coordination. Children with MB  and low PE  used EXP less often. Children participating less often have a finding in body-  and visual-motor coordination . Significant effects were found for children with and without MB and higher PE. Municipalities should make EXP more attractive for families with MB and low PE. Children’s motor development is socially unevenly distributed despite many municipal exercise programs (EXP). It has not been sufficiently investigated whether and how they appeal to children from different social backgrounds. This study investigates the use of municipal EXP in preschool age and the association between participation and motor development considering social circumstances. In school entry health examinations, parents were asked about participating in various EXP (response = 65.5%;  Physical activities and the reduction of sedentary behavior are essential for successful development in children. Especially in early childhood, physical activity (PA) promotes not only the physical, but also the mental, emotional, and psychosocial development with corresponding consequences for their health ,2,3. ChiMotor skills are defined as the entirety of all control and functional processes on which posture and movement are based . PostureThe prevalence of a developmental coordination disorder in children of preschool age (3–7 years) amounts between 5–10% in studies in European countries ,10,11. WThere are many municipal exercise programs (EXP) to promote the motor development of children. Whether they succeed or not has not yet been sufficiently investigated. A review by Venetsanou et al.  shows thOverall, there is little evidence on the promotion of PA for children in the leisure setting . RethorsIn addition, there is the problem that socioeconomically disadvantaged children and children with MB, and therefore especially those with higher educational needs, take advantage of prevention and health promotion programs less often ,24. ThisFinally, there is a lack of evidence regarding the effects of social differences in interventions to promote PA. It is still unclear which groups will benefit from the measures . A more In view of the research gaps, the aim of this study is to examine whether the use of various municipal EXP in preschool age is related to the level of motor development when entering school. Special attention is paid to the social circumstances of the children, and it is examined whether EXP reach children from educationally disadvantaged families and those with MB and whether they are associated with better body- and visual-motor coordination. Representative survey data in the context of the school entry health examination allow the analysis of various EXP taking social differences into account. By that we would like to answer the following questions:How often are various municipal EXP used by children in preschool age considering their different social circumstances?Is there a connection between the use of municipal EXP during preschool age and motor development at the time of the school entry health examination for children in different social circumstances?n = 5461 subjects with whom the analyses were continued.The data were collected as part of the retrospective cohort study, “Healthy on school entrance” . BetweenThe variables underlying the analysis were measured as follows: the use of EXP was surveyed for the categories parent-baby course up to 1 year, parent-child course between 1 and 6 years, exercise and play group without parents, and daycare center with a focus on exercise and swimming course (yes/no in each case). A finding in the area of motor development was obtained using the two areas of body coordination and visual-motor coordination of a social pediatric development screening (SOPESS) . SOPESS Measuring the social situation: a migration background (MB) was assumed if at least one parent was born abroad . ParentaThe use of the various types of offers was initially determined for the total sample and then stratified by MB and PE (absolute and relative frequencies). The statistical significance of the group differences was calculated using the chi-square test. The association of MB and low PE with the use of the various offers was analyzed in multivariate models using Incidence Rate Ratios (IRR) with 95%—confidence intervals (CI) by means of Poisson regression, with the age and gender of the child and the respective other indicator of social circumstances being adjusted. The association of the use of EXP with motor development  was also determined by a multivariate basis, initially for the total sample , then stratified by MB and by PE . The analyses were carried out with the statistics program STATA 14.2 . In the sample , 2769 chOverall, 72.8% of the parents surveyed reported that their children had used an EXP. The differentiated analysis of the individual EXP shows that 52.2% of the children had taken part in swimming programs (such as baby swimming or swimming class), 45.7% in exercise and play groups without parents, and 44.2% in parent-baby courses. Of the children, 29.8% had taken part in a parent-child course. Of the parents surveyed, 6.6% stated that their children had been to a daycare center with a focus on PA .Social situation and use of municipal EXP: analyzing the social differences, it shows that both children from a family with a migrant background and children from a family with a low PE had used almost all offers significantly less than their reference group. Of the children with MB, 59.9% had used one of the offers, as compared to 86.9% of the children without it. Regarding the PE, the difference is 32% for children with low PE as compared to 77.6% for children with medium/high PE. In the multivariate model, too, the Incidence Rate Ratios (IRR) show that children with MB are less likely  to have participated in an EXP than children without MB. The same applies to children from families with lower PE compared to children with higher PE . The largest differences according to MB can be found in the parent-baby course  and in the parent-child course . The greatest differences according to the PE can be found in parent-child courses  and swimming programs . There are no significant correlations in daycare centers with a focus on PA.Municipal EXP and motor development: for the overall sample, it was shown that children who took part in EXP have a 0.76-fold (95%—CI 0.63–0.90) probability of a finding in body coordination compared to the children who did not participate . In the Taking social differences in consideration of the connection between use of a program and the level of motor development, it shows both for children with  and without MB  a lower probability of a finding in body coordination in connection with the general use of an EXP. This also applies to the individual parent-baby courses, exercise, and play groups without parents and swimming programs. In the parent-child course, an IRR 0.68 (95%—CI 0.53–0.88) only shows a significant correlation for children without MB. Daycare centers with a focus on PA are still not associated with a lower probability of a finding in either group. The stratification for the education level of parents shows that both children from families with low PE  and children from families with medium/higher PE  have a lower probability of a finding in body coordination in connection with the use of an EXP. This also applies to parent-baby courses . Daycare centers with a focus on PA are still not significantly associated with a lower probability of a finding in either group. In addition, exercise and play groups without parents  and swimming programs  are only associated with a lower likelihood of a finding in body coordination in children with medium/high PE.This is also evident when the analyses are carried out and stratified according to MB, both for general use  and for the individual types of EXP. However, if the PE is considered separately the result is different: in children from families with medium/high PE, the general use and the use of the individual types of programs were significantly associated with a lower probability of a finding. Even with children from families with low PE, the probability of a finding in visual-motor coordination is reduced with the general and individual use of programs, but the correlation is not statistically significant. The aim of this study was to investigate how often different municipal EXP are used in preschool age by children in different social circumstances. It was also examined whether there is an association between the use of municipal EXP in preschool age and motor development at the time of the school entry health examination in children considering different social circumstances. In summary, it was found that around three-quarters of the children took part in an EXP, most often in swimming programs, exercise and play groups without parents and parent-baby courses. Daycare centers with a focus on PA were rarely used. A differentiated analysis showed that children with MB participated less often and children from families with lower PE participated far less often than their respective reference group. When considering the MB, the greatest differences were found in the use of parent-baby courses and parent-child courses. The largest differences in PE were found in parent-child courses and swimming programs. The social inequalities found here correspond to the few studies on the use of PA in the leisure sector among younger children. Finger et al.  show thaWhile most studies focus on the general use of EXP, we examined the use of various municipal programs in the leisure sector in preschool age because the municipality contributes to child development and health with several offers and facilities . Two resTherefore, social barriers could be assumed in the first place. In parent-baby courses, for example, social interactions involve more intimacy than other EXP in different age groups. In addition to the physical proximity of parents and babies, it is also explicitly about parents making new social contacts. The different everyday practices, preferences, and attitudes of the sociocultural groups that are discussed in connection with the dilemma in prevention could possibly have an impact here. Franzkowiak  assumes The present study also shows that general participation in PA is associated with a lower likelihood of a finding in body coordination and visual-motor coordination. However, there are differences according to the type of program, social circumstances, and area of development. In the area of body coordination, the association applies especially to parent-baby courses, exercise and play groups without parents and swimming programs, mostly regardless of the children’s social circumstances. In the area of visual-motor skills, the association applies to almost all EXP , independent of the MB. Regarding the PE, the results are only significant for children from families with medium/higher PE. In contrast, there is no statistically significant association for children from families with low PE. This could be caused by the small sample size of children from families with low PE. However, it could also be the case that EXP are less effective in this group.The connection between the use of a program and development could be causally justified by the fact that extra movement in the first years of life is an essential component in the motor development of children because children learn “comprehensively” at the beginning and therefore open their world in a variety of ways . VariousAs a limitation of our study, it must be said that the retrospective study design, in which parents had to provide information on the past 6 years, involves methodological problems. Parents must remember which programs they have made use of with their children in the last 6 years. When interpreting the results, it must also be considered that no reliable statement can be made about causality. In addition to the problem of cause and effect described above, it was not possible to measure other factors in (early) childhood that could affect both participation in PA and motor development. Finally, measuring motor development with a focus on coordination, as is common in school entry health examinations, is limited. As mentioned in the introduction, motor development encompasses other dimensions that are difficult to describe fully in a routine examination. On the other hand, a survey within the framework of the school entry health examination has great potential: it is compulsory for all school newcomers , wherebyTaking these limitations into account, it can initially be concluded that the access routes to EXP for families with MB and those with low PE should be expanded. This includes spatial and economic access: setting approaches aim to reduce such spatial barriers to health promotion. Children and young people seldom leave their district, so sports and EXP must be implemented in their living area in order to enable low-threshold access, especially for socially disadvantaged children. It is essential to consider the interests and wishes of the people living in the respective district and to include local structures and networks such as daycare centers, schools, and sports clubs. In intervention studies, “health scouts” have proven to be extremely helpful. They assess the needs of the district’s residents and make it easier for them to access municipal EXP ,46. AlsoFurthermore, the results suggest that targeted interventions may be necessary for children with low PE. Presumably, these children have many risk factors regarding motor development, so that individual single programs are not sufficient to ensure good motor development. These risk factors depend on the individual lifestyle, such as high media usage ,50, up tIn view of the frequency of motor development delays among young children, the promotion of PA in the municipality should have a high priority. In view of the social inequalities both in motor development and in the use of EXP, new ways should be developed in which children from families with low PE and children with MB can be made aware of offers, motivated to participate, and supported by target-group-specific offers. Early childhood EXP could play an important role here.


Background and Objectives: Risk management is considered an integral part of laboratory medicine to assure laboratory quality and patient safety. However, the concept of risk management is philosophical, so actually performing risk management in a clinical laboratory can be challenging. Therefore, we would like to develop a sustainable, practical system for continuous total laboratory risk management. Materials and Methods: This study was composed of two phases: the development phase in 2019 and the application phase in 2020. A concept flow diagram for the computerized risk registry and management tool (RRMT) was designed using the failure mode and effects analysis (FMEA) and the failure reporting, analysis, and corrective action system (FRACAS) methods. The failure stage was divided into six according to the testing sequence. We applied laboratory errors to this system over one year in 2020. The risk priority number (RPN) score was calculated by multiplying the severity of the failure mode, frequency (or probability) of occurrence, and detection difficulty. Results: 103 cases were reported to RRMT during one year. Among them, 32 cases (31.1%) were summarized using the FMEA method, and the remaining 71 cases (68.9%) were evaluated using the FRACAS method. There was no failure in the patient registration phase. Chemistry units accounted for the highest proportion of failure with 18 cases (17.5%), while urine test units accounted for the lowest portion of failure with two cases (1.9%). Conclusion: We developed and applied a practical computerized risk-management tool based on FMEA and FRACAS methods for the entire testing process. RRMT was useful to detect, evaluate, and report failures. This system might be a great example of a risk management system optimized for clinical laboratories. Risk is defined as the effect of uncertainty on objectives . An effeRisk management in the health care sector has focused more on integrating risk management and patient safety . In the In the risk management of the clinical laboratory, it is of the utmost importance to handle patient risk due to test results error . The errRisk management-related requirements have recently been added to laboratory accreditation checklists of the Laboratory Medicine Foundation (LMF) in Korea . Risk maNevertheless, dozens of risk management methods are available, and it is recommended to select and combine them according to the type of risk . Of thesIn this study, we aimed to develop and apply a sustainable practical risk management system based on the FMEA and the FRACAS methods for the total testing process in the clinical laboratory.This study was conducted in the clinical laboratory of a 670-bed secondary care university hospital in a metropolitan area of South Korea. The hospital has almost all departments needed for patient care. The average number of outpatients was about 60,000 per month, and the average number of discharged patients was about 2000 per month. The hospital has one central laboratory staffed by four laboratory physicians and 36 laboratory technicians . At the This study was composed of two phases: the development phase in 2019 and the application phase in 2020. We designed a continuous and practical risk management system, with two branches for proactive and reactive risk management. We decided to use the FMEA method for proactive risk management as a way to reduce the risk of potential failures, so that a proactive action could be taken ,18. The Our LIS (laboratory information system) was developed in 1999 as an in-house system  . Th. Th15].  of threeThe concept flow diagram for a continuous and practical risk management system is shown in We developed RRMT in our LIS, as shown in Overall, 103 cases were reported to the RRMT in 2020. The relative proportions of failures in each testing unit are displayed in The results by failure stage and by testing unit were summarized in The risk evaluation results after corrective/preventive action were summarized in We developed and applied a sustainable practical risk management system based on the FMEA and FRACAS methods for the total testing process. As far as we know, this is the first report of an in-house-developed risk registry and management system optimized for clinical laboratories. Recent studies on ‘risk management’ in the laboratory cover a wide variety of topics, including patient safety issues caused by laboratory errors in the testing process , the appOur RRMT has the following advantages. First, it is embedded in the LIS and could be accessed anywhere in the laboratory. Therefore, we can pull up the screen, discuss the findings, and check the progress and verify them. The utilization of LIS does not require extra commercial software, making the RRMT a part of the routine daily activities in the clinical laboratory. Second, it includes the entire testing process from the preanalytical phase to the post-analytical phase, and the risk of each phase can be managed separately. The failure was reported with a significant frequency in all three phases—preanalytical, analytical, and post-analytical. It could visualize which phase should be concerned to be improved. Third, data can be stored electronically and utilized in various ways, such as training new employees or part of a laboratory quality management program. Fourth, our RRMT is compatible with the proactive FMEA and reactive FRACAS methods. The quality management systems in many laboratories usually focus on reactive work to prevent high recurrence rates. Step-by-step processed works using diagrams can help the laboratory not to miss proactive measures. Finally, we made it a system with periodic planning rather than one-time risk management. Several research papers have implemented risk management once using the FMEA method and reported their results ,18. HoweDespite these advantages, there are some limitations to our tools. Our tool focuses mainly on the risk of inaccurate test results, and we did not cover the risk management of operational, strategic, and financial parts required by ISQua . These sWe developed and applied a sustainable practical risk management system based on FMEA and FRACAS methods for the total testing process. Our new laboratory risk management system was useful to detect, evaluate, and report failures. This tool would be a great example of a risk management system optimized for clinical laboratories. We hope to expand the scope of risk management to include administrative issues in future research.


Sharing of sanitation is common in low-income settlements in Sub-Saharan Africa. However, shared (limited) sanitation facilities have been thought to pose health risks due to poor hygiene levels. Interventions to improve user behavior and cleanliness of shared sanitation are few, both in literature and in practice. This study details the codesign and testing of strategies to improve the cleanliness of shared sanitation facilities in low-income areas of Kisumu City in Kenya. The strategies included a cleaning plan, monitoring system, and discussions among users, and were codesigned through workshops with stakeholders and group discussions with landlords and tenants. These strategies were tested in 38 compound houses through the Trials of Improved Practices approach over a 5-month period. Field staff visited the compounds, observed the cleanliness of the shared toilets, and through discussions, encouraged users to develop a formal cleaning system and a monitoring plan. The discussions built social capital and collective action and facilitated uptake of the cleaning plan with notable improvements in cleanliness of shared toilets. The results support the acceptability of shared sanitation in low-income settlements, the importance of codesigning and coproducing solutions with users, and the need to evaluate the effects of these strategies on cleanliness of shared sanitation. It is estimated that between 2000 and 2017, the population using “limited” sanitation facilities increased from 5% to 8% globally.––Health risks from sharing of sanitation facilities arise mainly because of the possibility of human contact with excreta due to poor hygiene levels. There are mixed results concerning shared sanitation in literature. A number of studies have confirmed that shared sanitation facilities are a health risk as they often contain fecal matter due to poor user behavior, lack of cleaning, and a general lack of responsibility and initiative among users to clean the facilities.,Since shared sanitation facilities are an interim solution especially for households in low-income areas, few interventions have been implemented to improve their hygiene levels. The few interventions have adopted a number of approaches, including education and the provision of cleaning materials,,Our work focuses on the management of shared sanitation facilities in the low-income settlements of Kisumu in Kenya and Kumasi in Ghana. Initial results highlighted the barriers and opportunities for improving the cleanliness of shared sanitation in the two cities.The study was guided by the Behavior Change Wheel, a theoretical approach for designing behavior change interventions.,For development and testing of the interventions, we adopted the Trials of Improved Practices (TIPs) approach. The TIPs approach uses a participatory methodology and aims to design feasible interventions and then test whether these interventions are acceptable.,,,This study was conducted in Kisumu, Kenya’s third largest city after Nairobi and Mombasa. The city has a population of approximately 500,000 residents as per the 2019 population and housing census.An initial qualitative phase of the study provided insights on opportunities, barriers, and motivations for improving the hygiene conditions of the shared facilities. These have been summarized in an earlier manuscript.In development of the strategies, we aimed to develop and test strategies that were driven by the compound members, that could be easily implemented by community leaders and resource persons—such as Community Health Volunteers (CHVs)—and which could be sustained beyond the study period. The strategies were identified through workshops with the research team and stakeholders, and validated through group discussions with community members.One workshop was held with the research team, and another with stakeholders. The purpose of these workshops was mainly to confirm the findings from the previous qualitative phase and to identify and prioritize possible strategies. The workshop with the research team sought to identify possible strategies for implementation at the compound-level as revealed by qualitative data. Team members read through the qualitative transcripts and identified the challenges as well as possible strategies. From this workshop, several strategies were identified, mainly:a. Introduction of a cleaning schedule b. Hiring of community-based groups or external individuals to clean compound-level shared toilets c. Compound-level discussions with compound members d. Monitoring the usage and cleanliness of the shared toilets e. Locking toilets to keep other users away f. A “reward” system, such as praising members who voluntarily clean toilets, or warning/disciplining members who do not participate in cleaning toilets g. Awareness creation/health education and sensitizationA second workshop was held with stakeholders who had been part of the study from the beginning, and who were drawn from the public and private sectors, as well as from the community. In addition to identifying possible strategies, the workshop aimed to share results from the initial study phases with the stakeholders. After sharing results from the qualitative and quantitative phases, stakeholders were grouped in five heterogeneous teams, which consisted of representatives from the different stakeholder categories who attended the workshop. The teams were each asked to propose possible intervention strategies for improving the cleanliness of the shared sanitation facilities. Results from the five groups were consolidated and summarized into main themes representing the various proposed strategies.•Mobilization and sensitization. Health and behavior change education, as well as communication and dialogue were recommended as strategies to increase awareness among community members on the need for improved behavior.•Strategies at the compound-level. Stakeholders recommended strategies such as landlords taking responsibility for the provision and maintenance of sanitation facilities; landlords and tenants holding regular meetings; development of regulations and agreements among users (both landlords and tenants) on the maintenance of the sanitation facilities; locking toilets so that they are not used and soiled by people who are not involved in their upkeep; developing cleaning schedules/timetables that involve all users; and ensuring cooperation among compound members in overall management of their sanitation facilities.Overall, stakeholders noted the inadequacy of toilets in the settlements, which led to tenants sharing sanitation facilities and others sneaking into and soiling their neighbors’ toilets. It was also highlighted that shared toilets were unclean as their users were less motivated to clean them if the toilets were constantly soiled and when cleaning was not done by all users. A number of solutions were suggested, includingAside from these compound-level strategies, stakeholders proposed other strategies, including increasing access to reliable water supply; increasing the number of secure, private, and easy to clean sanitation facilities; and improvement of sanitation technologies such as pour-flush or sewer systems. Where pit latrines are used, it was noted that their design should allow for emptying and they should be constructed with a consideration of the topography, water table levels, and soil types found in the area. It was emphasized that county-level standards and guidelines on construction of sanitation facilities as well as the number of users per toilet were needed, which landlords would have to comply with. Finally, stakeholders proposed financing models such as including the cost of sanitation services in the cost of water and/or rent, and engaging community-based groups in provision of cleaning services.A comparison of recommendations from both workshops showed similar proposed strategies, especially at the compound-level, with a focus on education and sensitization of community members, meetings and discussions among landlords and tenants, and regulations on use of shared toilet facilities. Strategies beyond the compound-level such as financing provisions, development of standards and guidelines, and technological improvements were noted as recommendations for further research since their testing was beyond the time frame and scope of the study.Group discussions were conducted with community members with the aim of selecting a combination of feasible strategies that could be tested at the compound-level. Community Health Volunteers from the four villages were engaged to identify participants from their villages. These participants had to be users of shared sanitation facilities who had been resident in the settlement for at least 3 months. To account for participants who may not attend, we aimed to recruit the maximum recommended number of 6–12 participants,The first set of discussions was held separately with landlords and tenants, and these provided somewhat similar results. To confirm the results, two more discussions were conducted, which also gave similar results, and it was felt that there was no need for more discussions. Overall, two discussions were held with tenants and another two were held with landlords. The first discussion with landlords had a total of eight  participants while the second had nine  participants. The first discussion with tenants had 11  participants, while the second had nine  participants. These discussions were held over 2 days, with each day having separate group discussions for landlords and tenants. Each group had one research assistant who facilitated the discussion and another assistant who took notes and made observations.Before the discussions began, participants were briefed about the study, and the research team presented the strategies for improving the hygiene conditions of shared toilets that had been identified during the workshops. The discussion then followed, and participants were asked to propose additional strategies. Tenants in the two group discussions proposed an additional strategy of provision of cleaning materials, while landlords in both discussions proposed the addition of rules and regulations. After inclusion of these strategies, participants were asked to vote for the three most important and feasible strategies. The voting was done secretly to prevent participants from influencing each other. These votes were then collected by the research team and tallied to provide the total number of votes for each strategy.“ . . . A cleaning plan will help to encourage everyone to participate. All users should be assigned the responsibility of cleaning . . . ” Both landlords and tenants agreed that a cleaning plan was necessary to encourage all users to take responsibility in cleaning their shared toilets.“ . . . Some neighbors do not know each other, and some do not know how the toilets in their compounds are cleaned. We need to first have the discussions, to make sure that we all understand the importance of having clean toilets . . . ” Tenants clarified that the cleaning plan would work best when the users have a common understanding, highlighting that there could be neighbors who do not know each other and do not participate in any common activities.“ . . . How shall we clean the toilets? We need to have soap, water, and a broom. Otherwise the toilets will not be clean . . . ” As earlier stated, landlords suggested the inclusion of rules and regulations, noting that some tenants may not be cooperative, therefore cleaning of shared toilets should be part of communal living regulations. Tenants on the other hand felt that cleaning materials, including cleaning brushes and soap are an important component of having the toilets clean.Testing of the intervention strategies was conducted from January to May 2020. The identified strategies were compared with the theoretical approach guiding the study. Previously identified strategies from the qualitative stage included use of restrictions, environmental restructuring, enablement, enhancing education and training, and improving sanitation technologies.To qualify for selection to test the identified strategies, compounds needed to have at least two households and at least one toilet that was shared by the households. All the households in the compound had to be users of the toilet. The toilets needed to have a superstructure that offered privacy, a door that held in place, and a roof. Using these criteria, a CHV from each of the four units within Nyalenda A, together with the research assistants walked through the units and identified eligible compounds that met these criteria. In line with the TIPS recommendation for a small sample size, CHVs and the field staff were asked to recruit a minimum of 10 compounds from each of the units, thus making a total of 40 compounds . During the enrolment, two compounds refused to continue with the study, therefore reducing the sample size to 38 compounds that agreed to participate in testing the strategies. Community Health Volunteers and the research assistants visited the selected compounds to introduce the intervention strategies and encourage the compound members to participate, clarifying that the testing would entail attending meetings and discussions. Data collection during the first three meetings and discussions was done physically in the compounds over a period of 1.5 months. The next three follow-up sessions were done through phone calls to the compound leaders over a period of 2.5 months.During the first visit and meeting with the compound members, CHVs introduced the research assistants, and the compound members introduced themselves. Once introductions were complete, the research assistant led the discussions by focusing on the use of their sanitation facility, prevailing cleaning practices, availability of a cleaning schedule, challenges faced in keeping the toilets clean, ways of improvement, and the importance of keeping shared sanitation facilities clean. The assistants proposed the strategies, and encouraged compound members to draft a cleaning plan (if they did not have any) and to propose a representative within the compound who would oversee the whole process. Members were encouraged to work together by mobilizing each other, identifying how best the strategies would work for them, and participating in implementing the strategies. At the end of the meeting, the members suggested a convenient date for the next meeting.The second follow-up visit was held 1 week after the first visit. The CHV team and research assistants visited the compound members again to further discuss their experiences with trying out the strategies. During the meeting, compound members reported challenges encountered, progress made, and suggestions for improvement. Research assistants noted those cases where progress had been made and encouraged the members to work together in improving the cleanliness of the toilets. Where little or no progress had been made, the research assistants still encouraged the compound members to work together and try out the proposed strategies. Again, the members proposed the most convenient date for the next visit.The third follow-up visit and discussion was done approximately 2 weeks after the second visit, to allow compound members to continue with the strategies without solely relying on the research team. This visit followed a similar format as the second visit, focusing on progress made, challenges experienced, and any outcomes from the discussions and strategies.During these three visits, assistants collected quantitative information such as the number of compound members who attended, the type of toilets, and the number of cubicles being shared. They also collected qualitative data including the strategies that had been implemented by the compound members, challenges faced, and benefits experienced. Where possible, the assistants observed the cleanliness of the toilets. Compound meetings were only held if a minimum of 50% of all compound members who used the toilet were available. If the members were not available or the numbers were not enough, the meetings were postponed to a time that was convenient for all members.Three more follow-up sessions were conducted remotely through phone calls due to restrictions in fieldwork activities as a result of the COVID-19 pandemic. The fourth and fifth follow-up visits were held approximately 3 weeks after the preceding visits while the sixth and final follow-up was held 1 month later. Data was collected through phone calls to the compound representatives, and to at least two other compound members. Discussions during the phone calls focused on the progress made and challenges faced.Ethical approval for the study was obtained from the ethics committee of the Great Lakes University of Kisumu GLUK (Ref: GREC/001/285/2018). A research permit was further obtained from the Kenya National Commission of science and Technology (Ref: NACOSTI/P/18/5546/24979) and from the Kisumu County government. Permission to conduct the study was sought from administrative heads at the local level in the study area.During the group discussions, field assistants detailed the purpose of the study, progress and findings from previous phases, the purpose of the group discussions, duration of the discussions, actions that would be taken to ensure anonymity and confidentiality such as not using names, and the next steps after the discussions. They were also informed that they were free not to continue with the discussions if they chose to. Discussions began after all questions from the participants had been answered satisfactorily, and participants had given their signed consent to participate in the discussion.During the first household visits, field assistants provided detailed information sheets to the participants. The assistants explained the details of the information sheet, including the purpose of the study, reasons why the compounds were selected, the study procedures including community dissemination plans, duration of the discussions, expected requirements from the participants, steps to ensure confidentiality, how the data would be used, and contact information of the researchers. They were allowed to ask questions after which they were given a copy of the information sheet to keep. The participants signed two copies of the consent form in the presence of the CHVs. They retained one copy of the consent form, and another was kept by the study team.Quantitative data from the compound visits was analyzed through descriptive statistics such as means, frequencies, and percentages. Qualitative findings from the group discussions were analyzed the matically using already predefined themes, that is, the intervention strategies. Quantitative and qualitative data were combined during analysis and presented together to provide meaningful explanations for the uptake of the strategies.N = 2), requests for compensation for attending meetings (N = 2), difficult/uncooperative members (N = 1), and filled-up pit latrines which made it difficult to implement the strategies (N = 1). Three other compounds dropped out during the third visit because they were not willing to participate in the strategies (N = 1), or due to unwilling or uncooperative members (N = 2). A total of 29 compounds completed all the follow-up visits  had tenants as the main occupants. Over 90% of the toilets were pit latrines which had one to four cubicles that were shared by the households .N = 12), we encountered new compound members who had not attended the first meeting participating in the second and third follow-up meetings. This increase was because compound members and the compound representatives shared the information with their neighbors, encouraging them to attend the meetings. A tenant in one of the compounds gave reasons why she encouraged her neighbors to attend the meetings . . .“because cleanliness of the toilet affects us all, and we need to discuss together as a team” Most members of the compounds attended the three group meetings and discussions. One compound in particular recorded 100% attendance in all the meetings, while all the other compounds had a minimum of half the number of households attending. As noted in “We know that Sunday is a day for the meeting and discussions” In addition, members selected a convenient time and date, and in doing so, they prioritized the meetings, as noted by a participant who confirmed that,Furthermore, compound members often reported that they held subsequent meetings (in addition to the meetings we held with them), where they further discussed implementation of the strategies and other matters affecting them. Members who did not attend the discussions were away due to work, travel, or social functions. Whereas both men and women attended the discussions, women were the majority, partly because they were always at home, or were usually involved in cleaning of the toilets.During the first visit, almost all the compounds reported that they did not have any form of cleaning plan. Similar to results from the earlier qualitative phase,By the end of our visits, approximately 66% of the compounds had adopted a cleaning plan . This plno need for a formally written cleaning plan. Households from such compounds organized themselves and often assigned households to specific days of the week to clean the toilets. Such households frequently reported that they were few in number and each household knew when they were to clean the toilet.Informal plans were agreed upon by members, after they discussed and organized themselves. For example, participants in several compounds reported making verbal agreements during the meetings and assigning each household a specific day to clean the toilet. Two compounds in particular felt that they did not need to write down a formal plan and have it pasted on the toilet because it would be plucked out. In other compounds, especially those with few households, members reported Adoption of the discussions and the cleaning plan led to over 80% of the compounds implementing some form of organized cleaning, compared with the pre-intervention stage where households volunteered to clean toilets (74%). Notably, 47% of compounds had all households involved in the overall management of their sanitation facility. With regards to gender, men were directly involved in cleaning in most of the compounds. When men were not directly involved, compound members agreed to have women clean the toilets while men purchased cleaning materials. In such arrangements, although all households were involved in the overall management of the sanitation facilities, only specific households  cleaned the toilets, hence the increase from 13% in the pre-intervention stage, to 44% of cases where specific households were involved in cleaning. Before implementation of the intervention strategies, the specific households that were involved in cleaning were those with younger children, with little or no participation by other households.“I am uncomfortable asking him [a male neighbor] to clean the toilet” The plan to have men purchase cleaning materials and have women clean the toilets was acceptable to compound members, as it was noted that some women were not comfortable with asking men to clean the toilets. In one compound for example, a female tenant confessed that:“It is women who need to clean the toilets, and not men” Another female tenant in the same unit felt that:In such compounds, men were involved in purchasing the cleaning items while women cleaned the toilets. Men were also exempted from cleaning in cases where they were unmarried and/or not always at home. In instances where individuals were not available to clean the toilets, they agreed to exchange their cleaning days with their neighbors, or they asked their neighbors to clean the toilets on their behalf. In one compound for example, a man opted to pay his neighbor to clean the toilet.N = 3). Lack of materials to paste the written schedule on the toilet door was also a common challenge. Other challenges arose from the movement of tenants out of the compounds, or their movement to rural areas especially during the COVID-19 pandemic. Consequently, the available households cleaned the toilets on the days when their neighbors were to clean, or they had to rewrite the cleaning plan and only involve the available households.Compounds experienced various challenges with the cleaning schedule, mainly its getting torn or plucked from the toilet door , landowner (34%), or one of the tenants (42%) to be responsible for monitoring the progress of the strategies that were being implemented in their compounds. In compounds where the landowners were resident, members selected them to oversee and be responsible for the initiatives, while in compounds without a resident landowner, members selected the caretaker or one of the tenants. Besides being our contact persons within the compound, the selected individuals also followed up with members and reminded them of meetings, they organized the compound members and drafted the cleaning plan, they followed up on any individuals who missed the discussions, and reminded members to clean the toilets. In a handful of the compounds (16%), the members felt that they did not need anyone to act as a monitor, since “N = 14); purchase of a padlock and locking of the toilets (N = 9); cleaning and slashing grass next to the toilet (N = 1); emptying of filled up pit latrines (N = 1); accompanying young children to the toilet to avoid misuse (N = 1); installing handwashing containers (N = 5); cleaning the bathrooms in addition to the toilets (N = 4); and instituting rules for use of the toilet  (N = 4).In addition to the proposed strategies, compounds implemented additional strategies, which included individual or collective contribution of resources for purchase of cleaning materials and agents Compound members reported various benefits as a result of the strategies. The most evident benefits were greater cooperation/teamwork among members, unity, and improved relationships among households. For instance, compound members in all the units reported that ““Households remind each other when it was their turn to clean” A tenant from another compound also confirmed that the improved relationship led to households reminding each other to clean the toilets.The improved relationships made it easier for compound members to organize themselves and participate in other compound-level activities such as cleaning the compound and barring outsiders from sneaking into and using their toilets. Individuals who previously cleaned the toilets voluntarily without help from their neighbors reported satisfaction and relief from everyday cleaning and from division of work among all households.“My toilet is the cleanest in the area” .Participants also reported that their toilets were cleaner because they were locked to prevent use by non-compound members who soiled them, and due to regular cleaning. One landlord for example, proudly stated thatN = 10) showed improvement in the hygiene levels of their toilets from a soiled and smelly state during the first visit, to the reduction or total elimination of the odor and fecal matter around the toilet by the third visit. In terms of health benefits, one respondent reported that an infection that was suspected to have arisen from using a dirty toilet had cleared.“Since we started cleaning the toilet, the infection has disappeared, and this has encouraged us to continue cleaning the toilet” Participants also reported that the toilets were cleaner because of improved behavior. Households used the toilets responsibly since they understood the effort involved in cleaning the toilet. Compounds that collectively bought cleaning soap expressed satisfaction by stating that the odor from the toilet had reduced. The cleanliness of the toilets was confirmed by observations from the research assistants, as some compounds . This challenge may need to be addressed at a wider level, such as the city level, by the planning, environment and public health departments to determine appropriate sanitation interventions in low-income settlements.Although shared sanitation facilities are perceived as posing health risks to users, they are a common phenomenon in low-income settlements where residents may not be able to afford individual household sanitation facilities. This study details the development and testing of strategies to improve the cleanliness of shared sanitation facilities. Results highlight that if users of shared sanitation facilities are empowered, they are able to collaboratively work together to improve the cleanliness of their facilities, and thus reduce their health risks. Social capital and collective action are important prerequisites for behavior change and their development should be examined within each context. Possible interventions for large-scale implementation should incorporate aspects that enable users to build social capital and improve community behavior, while stakeholders such as local government should define minimum criteria and guidelines for provision of sanitation facilities.


The current approaches in identifying the characteristics of ethical leadership proceed mainly from a Western perspective based on virtue-driven moral philosophy  and frequently ignoring the Asian perspective of morality based on idealism. This study aimed to conduct parallel analysis in convergent design by using qualitative and quantitative methods to extract person-driven ethical leadership themes by considering the Asian context. Using the hypothetico-deductive method, 13 themes were extracted altogether, out of which 4 are new context-driven themes . In recent literature, a considerable debate is going on to define the approaches of ethical leadership. There are two schools of thought that includes relativism and absolutism perspective of ethical leadership. Most of the researchers rely on a relativism-based Western perspective derived through a pragmatic approach. Realism is the reality about the world around us, and we need to deconstruct the learned philosophy and reconstruct it according to our cultural realities. In contrast, the absolutism  based Eastern approach derived ethics from religious and social-based values that have been completely ignored in the ethical leadership literature . EthicalThe most important theoretical contribution of this study is developing and validating the person-driven ethical leadership themes from an Eastern perspective. The aim of this study was to fulfill the gap by analyzing the personal characteristics of ethical leadership as suggested by Another worthwhile contribution of this study is can be highlighted by relating it with three dimensions of data integration analytics suggested by As A deductive approach is used to identify and logically classify themes present in existing literature . It demaFairness, as suggested by Accountability, as explained by People orientation and consideration, as coined by Moral identity was coined by Internal locus of control, as developed by Role modeling, as explained by Personality traits, as presented by Moral reasoning/ethical critique, as developed by Following the deductive approach, an inductive approach was used, involving the researchers inquiring the respondents to explain the constituents defining the construct under study . QualitaThis inductive approach for item generation is based on the following procedures:ISurvey technique for an inductive approachIIPopulation and sample (Study 1)IIIData interpretation and codingIVInstrumental approachVSemantic validityQuestionnaires and interviews are some of the most accepted and commonly used techniques in survey research for data collection in social science research . The surAnother reason for selecting this technique in this study is explained by This study was based on four demographic questions , the details are shown in The sampling design of this qualitative research is of a single stage as the researcher has access to the population and can directly sample the target .In qualitative research, the idea is to purposefully and carefully choose the participants or the sites , which will aid the researcher in understanding the research question or the problem. Similarly, qualitative research does not require any specific sampling technique or selection of a large group of participants, unlike quantitative research. Apart from the sampling technique, there lies another ambiguity in qualitative research. Researchers provide no specific answer to address how many participants and sites are involved in the study. However, Keeping in view the above points, the open-ended questionnaire was circulated through Email among 25 working professionals in the middle management level having more than 10 years of working experience either in the corporate sector or academia. Out of which 14 respondents replied. The informants included seven from the corporate sector  and seveThe reason for including the corporate and academia respondents was to generalize the scale validity in the service sector. Similarly, the reason for selecting middle management with 10 years of experience was to target informants who have worked not only in subordination but also as supervisors or in leadership roles in their organizations so that they could comprehend their perspective and envisioned ethical leadership from the perspective of both roles.The responses to the open-ended questions are usually provided descriptively. Respondents sometimes present their descriptions in the form of listings that demonstrate their knowledge regarding the phenomenon, explanation, or sometimes motivation. These descriptions are based on facts, but sometimes their attitudes or evaluations are also represented in their feedback. Similarly, the arguments sometimes are mentioned explicitly, and conversely, sometimes the researcher has to read and analyze between the lines due to the subjectivity of data. To get specific, meaningful, and interpretable data from the open-ended questionnaire, the key lies in the formulation of the right and relevant question. They are keeping in view that the formulation of the question should be neutral and inviting to answer. Similarly, questions should be specific, short, and contain the right questioning word .In the current scenario, some of the respondents specifically stated the characteristics of an ethical leader. Some respondents explained the characteristics that an ethical leader should possess. Altogether, the respondents clearly understood the question as they communicated adequate answers to define the characteristics of an ethical leader.The open-ended question contains a set of codes. Coding means the process through which the raw data are transformed systematically and combined into themes or units containing the detailed description of the relevant matter characteristics . The resIn this study, data coding was made by recording and combining the phrases or words similar in meaning into similar themes. In this step, the data were systematically coded into 13 themes that are listed as follows:1.Agreeable/respect/respectful/well-mannered/humble2.Conscientious/conformity/dutiful/dedicated/devotion with organizational values3.Fairness/justice/unbiased/transparent4.Honesty and integrity/truthfulness/not betraying5.Team oriented/collective good/common good6.Accountability/no tolerance for values7.Humane/people centric/positive/empathy/forgiving/tolerance/approachable/caring8.Locus of control/responsible9.Role modeling/credibility/trustworthy/trust building/upright10.Altruism/selfless/sincerity11.Give credit/confident/secure/appreciative/skill building/encourage initiative12.Ethical critique/brave/strong will power/understanding/flexibility/analytic ability13.Wisdom/faith/charisma/vision/preaching/personal knowledge/mission-oriented/sense of connecting with the purpose of lifeThe instrumental approach involves the researcher’s theory to interpret the texts according to it. In this approach, the researchers develop the themes’ dictionaries that reflect how these themes will be interpreted before data coding. Here, the researchers must use sympathetic understanding for encoding the text according to their sources’ meaning. This representational way requires the researcher to manually code the fragmented text into the assigned theme so that the coder could capture the latent meaning prevailing in the text according to the theme, which cannot be captured if a computer program is being used .In this study, the instrumental approach was followed, because, through the deductive method, the themes were already generated from past literature that explained the concept of ethical leadership. However, by following the inductive method, some new themes also emerged from the respondent’s descriptions and feedback, which were not considered part of ethical leadership in previous literature in the Western context, such as altruism, collective good, encouragement, and transcendence spirituality. In contrast, some researchers  in crossAfter the respondent’s response or answer is coded down by a coder (or the computer program) into themes, it leads toward semantic validity. A meaning category, theme, or the code semantic validity means that the researcher who already has familiarity with the texts underneath the study has the consensus among the categorization of the phrases or words collected through responses and combined or recorded into a particular category or theme do reflect and quantify that categories or theme meaning .The assurance of the semantic validity is more required than the face validity, which is based on checking similarities among words and phrases with themes but extended toward making the justifiable inferences relied upon the collection of reliable and valid data .In this study, semantic validity was performed  by carefFor data triangulation and analysis, the convergent mixed method design was applied in this study to merge or converge the themes/dimensions extracted from deductive and inductive approaches. In this design, the two databases  are separately analyzed and then merged. For merging the two databases, several ways are identified by This study follows the side-by-side comparison approach. In this approach, the researcher presented the comparison within the discussion by first explaining one set of the findings; in this study, themes/dimensions were first extracted using the deductive method, followed by the themes/dimension extracted using the inductive method. The final procedure was to merge and to integrate these two forms of data into the graphic form or the table form, which is also known as the joint display of the data, and this can be displayed into many different forms . Using mIn contrast, four additional context-based themes  emerged from the inductive method. However, among these new themes, This study contributes to a mixed methodology by using convergent parallel track analysis of two data  strands simultaneously. The novelty of this methodology is highlighted by Another worthwhile contribution of this study can be highlighted by relating it with the three dimensions of data integration analytics explained by This study follows the parallel comparison approach by first extracting the themes of personal-driven ethical leadership characteristics through the deductive method followed by the inductive technique. Furthermore, the final procedure was based on integrating and merging the two sets of data (deductive and inductive) in a joint display. The purpose of using mixed-method design specifically in this study was to explore the eastern context-based characteristics/themes of the personality-driven, ethical leadership domain through the convergence of 13 themes. Among them, nine themes were based on both inductive and deductive techniques, whereas this study identified four additional context-driven themes through the inductive method  in the domain of ethical leadership from the eastern perspective. However, This study deconstructs the reality and reconstructs it according to the cultural realities of our respective societies. Ethical leadership literature is based on Western culture and completely ignores the Eastern cultural realities. This study explores the ethical leadership phenomenon from the lens of ethical positioning theory, which explains that ethics defined in Western cultures are different from the ethics perceived in Eastern cultures. The ethical positioning of the eastern cultures is based on idealistic cultural values, whereas the western societies rely on relativism based ethical positioning. In the line with the above theoretical arguments, this study investigates the ethical positioning of a leader within the collectivist, high power distance, and high uncertainty avoidance culture.This study is based on the realism approach that is based on the eastern perspective of ethical leadership. As our culture is deeply rooted in spiritual and social values that have been ignored by the west, norms and expectations of employees in our culture are different as they are embedded in spiritual aspects. This study explored the characteristics of ethical leadership from the cultural lens that will benefit managers and practitioners to cater to the needs of their followers such as enhancing their innovative work behavior for gaining competitive advantage. It will also help managers to overcome the organization’s dehumanization and will increase the job commitment and performance of the employees. Managers need to be honest, truthful, and fair for developing an ethical identity that will reduce the prevalence of negative behaviors within the organization.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Research Ethics Approval Committee, Faculty of Management Sciences, National University of Modern Languages, Islamabad. The patients/participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Given the rapid recent trend of urbanization, a better understanding of how urban infrastructure mediates socioeconomic interactions and economic systems is of vital importance. While the accessibility of location-enabled devices as well as large-scale datasets of human activities, has fueled significant advances in our understanding, there is little agreement on the linkage between socioeconomic status and its influence on movement patterns, in particular, the role of inequality. Here, we analyze a heavily aggregated and anonymized summary of global mobility and investigate the relationships between socioeconomic status and mobility across a hundred cities in the US and Brazil. We uncover two types of relationships, finding either a clear connection or little-to-no interdependencies. The former tend to be characterized by low levels of public transportation usage, inequitable access to basic amenities and services, and segregated clusters of communities in terms of income, with the latter class showing the opposite trends. Our findings provide useful lessons in designing urban habitats that serve the larger interests of all inhabitants irrespective of their economic status. Added to this, rising economic inequality jeopardizes the health and livelihoods of many urban residents. Indeed, the percentage of Americans living in middle-income neighborhoods has decreased from 65 to 42% in the last 40 years, while the inhabitants of neighborhoods at the lower and higher ends of the income spectrum have grown5. Much of the urban growth has been driven by the less wealthy who have progressively moved from the rural areas to cities6. While the rise in economic inequality is a global phenomenon, different patterns are observed between countries and cultures. For instance, while low-income households are typically located in the outskirts in Paris, they live downtown in Detroit7. Such patterns of economic segregation and inequalities are connected as well to racial segregation, urban decay8 and gentrification9. In fact, over the course of history, many policies and resulting infrastructure changes were put in place in ways that hurt minority communities and already vulnerable portions of cities. This has been thoroughly documented in10 for the case of New York and similar instances have been occurring around the world. Understanding the factors behind this and developing public policy to alleviate these trends is therefore crucial to enhance social mobility and economic progress, as well as positively impact the health of citizens14.The recent trend of rapid global urbanization15. These cities follow a distinct pattern of urbanization, transitioning from strong industrial centers to a decentralized manufacturing pattern16. Additionally, the layout of a city’s natural resources and amenities can bias a population to concentrate in locations other than the expected city center, although urban layout is by no means static. Development induces change in residential patterns change, even more so, during periods of gentrification, causing shifts in the income profile of neighborhoods over time17. Varying welfare policies and housing market conditions affects cities differently across locations; the decline of neighborhoods into poorly maintained areas is more strongly felt in American cites than European ones8.To understand the unique sociodemographic and economic context of a city, one needs to take into account a number of factors. For instance, some cities in developing countries concentrate industry in city centers, leading to unfavorable urban conditions such as pollution22. Underlying these intra-city mechanics are the people, and their mobility patterns23. Indeed, the increasing accessibility of location-enabled devices and large-scale datasets of human activities, such as credit-card purchases, taxi rides and mobile phone usage are fueling significant advances in our understanding of human mobility behavior32. Yet, the connection of these observed mobility patterns with socioeconomic status is surprisingly unclear and in many cases contradictory.Residential inequality is only a partial view of the whole picture, given that cities are a product of several interconnected systems. City infrastructure and dynamics are significantly connected to their underlying social systems, in particular influencing development and productivity indicators33, a similar study in Louisville, KY, revealed that low-income residents tended to travel further on average than those in affluent ones34. On the other hand, analysis of cell phone data from an emerging Latin American economy revealed that wealthier citizens traveled to more locations and longer distances35. An analysis of mobility in Bogotá, Colombia found the most mobile population to be the upper-middle class instead of the wealthiest36. Employment status played a role in movement patterns in both Riyadh and Spain, where the unemployed tended to travel less and spend more time at home38. Two studies in French municipalities found a connection between the diversity of location visits with income, but no connection to the distance traveled40.For instance, while mobility patterns across different socioeconomic classes exhibit very similar characteristics in Boston and SingaporeThe variance in the results, indicate that the observed diversity in trends are the result of a complex interplay between urban infrastructure and socioeconomic processes. However, these were conducted in a relatively small set of cities, with different underlying datasets and methodologies. Greater clarity and insight may be uncovered by conducting the studies at scale, globally, and with a uniform methodology. To that effect, here, we explore the multiple facets connecting human travel behavior in a city to its socioeconomic landscape, through a country-wide analysis encompassing one hundred cities in the United States and Brazil. The two countries were selected due to their similarity in total population and the number of large cities, with one being a developed economy, while the other an emerging economy with markedly different socioeconomic characteristics. We find differences within and between the two countries, with two distinct classes of cities; one where there is a strong connection between the socioeconomic status of the residents and their movement patterns, and another class where there appears little-to-no connection. The latter class of cities are characterized by wider use of public transportation, equitable access to amenities and services as well as greater mixing among neighborhoods in terms of income profiles. The former class of cities show the opposite trends. We conclude with a discussion of the implications of our findings, including possible policy directions as it relates to urban planning.sub-areas (SAs).The Google Aggregated Mobility Research Dataset contains anonymized mobility flows aggregated over 300 million users who have turned on the Location History setting, which is off by default. This is similar to the data used to show how busy certain types of places are in Google Maps, helping identify, for instance, when a local business tends to be the most crowded. The dataset aggregates flows of people between regions, specifically ZIP Code Tabulation Areas (ZCTAs) for the United States, and the comparable census Weighting Area (WA) for Brazil, both of which we generically refer to as 4. To provide strong privacy guarantees, all trips were anonymized and aggregated using a differentially private mechanism to aggregate the flows41. This research is done on the resulting heavily aggregated and differentially private data. No individual user data was ever manually inspected, only heavily aggregated flows of large populations were handled. As a result, the data is represented as a flow matrix i to j for the year 2016. For the purposes of our analysis we consider the 50 largest cities in the United States and analogously in Brazil ranked according to their population. In Fig. To produce this dataset, machine learning is applied to logs data to automatically segment it into semantic trips42, and analogously the 2010 decennial census for Brazil43. Among the metrics collected were age, race, level of education, population, median income, sex composition, among others. A representative sample of the data, aggregated at the level of ZCTA’s is shown for Rochester, NY in Supplementary Table S3, and at the level of WA’s for Campinas in Supplementary Table To represent socioeconomic status we collected data from the most recent 2016 5-year American Community Survey (ACS) for the United Stateshigh and low income sub-areas as the top and bottom median income quintiles within their city. This metric is useful for simply categorizing the income of different sub-areas in a city. Our second metric, In Supplementary Figs. 44, that contains geo-referenced information for a broad array of urban amenities, including schools, banks, libraries, groceries and universities, to name a few. The OSM data contains 691 different types of urban facilities belonging to eight main classes: healthcare , sustenance , financial , education , art-culture , entertainment , transportation (bicycle parking and bus station) and others .Mobility patterns of urban residents are not only influenced by considerations of cost or income constraints, but also by the number and diversity of amenities and services accessible to them. To collect this information, we query the OpenStreetMap (OSM) databaseFor the purposes of our analysis, we consider basic amenities related to food, healthcare, education and finance. A representative list of such amenities is shown for four different cities in the United States in Supplementary Table i it can be computed asi to a different area j and i, computed asi. The city-level values are then computed by summing over all locations i within the city. The measure serves as a proxy for trip frequency which is a useful complement to trip distance, as it represents an activity rate. Activity patterns, which are connected to employment status38, combined with average distance traveled, indicate the distance and frequency of travel for residents in a given location. These factors are potentially influenced by the socioeconomic resources of the residents as well as their proximity to opportunities, and enables targeted ways of understanding the influence of city infrastructure and services on its residents.We characterize the mobility patterns of an area based on two representative quantities. The first metric is the average travel distance, or weighted average out-flow length, which is intended to capture the mobility-related costs that are directly proportional to travel distances. For each location https://www.pewresearch.org/global/2016/02/22/smartphone-ownership-and-internet-usage-continues-to-climb-in-emerging-economies/).We begin with a country-wide analysis of the mobility patterns of the lower and upper 20% of SA’s by median income. The choice of income range enables a first look at the trends for residents at the opposite end of the socioeconomic spectrum, that is those with the most and least potential constraints on their traveling behavior. In Fig. n income intervals, we construct for each urban area, n income distribution vectors m positions each m denotes the number of SAs in that city. Here, n lives in SA m. We compute the Spearman rank correlation coefficient between each m. For the results reported here, Given the observed country-level signal between the mobility metrics at the opposite ends of the income scale, we next conduct a more granular analysis across all census-determined income breaks In Fig. ist Fig. A and a preq Fig. B, indicaThe Brazilian cities, on the other hand display markedly distinct trends. While there are a few cities with relatively little correlations such as Caxias do Sul, Campinas and Blumenau, the majority of cities display high positive correlations across metrics and income ranges, with the strongest signal being in the middle-income range Fig. C,D. Wher45, finding a clear partition of the cities in the United States into two different groups, color-coded in teal and orange as shown in Fig. The results from Fig. In Fig. 4, that those cities that are in the orange cluster tend to be more hierarchical and centralized in terms of mobility-flows as compared to those in the teal cluster that are sprawled and decentralized. Hierarchical cities have higher levels of infrastructure for public transit, and the observed higher usage of public transit is not just a behavioral feature but also reflects wider availability.We next investigate the factors behind this difference in correlations. A way to mitigate the disadvantages due to income is having efficient and cheap public transportation systems. In Fig. As mentioned earlier, another feature that might influence mobility patterns is the availability of amenities and services. Correspondingly, we check the typical distance residents of a particular location have to travel before they come across a number of basic amenities . For ease of display, instead of using all eight income breaks, we split the income groups into five categories  and plot the fraction of amenities accessible up to 10km from the resident location .Taken together our results shed greater clarity on the connection between socioeconomic features and movement patterns as compared to previous studies, given the scale of our investigation. A study of a hundred cities in two large countries comparable in size and population but differing in levels of economic development, revealed that cities can be broadly classified into two categories; those where resident’s movements are influenced by their income profile (with varying degrees of influence), and those where mobility is largely independent of their socioeconomic condition. This classification of course applies in an averaged sense, given the differences in cities both between and within the countries.The two categories find their clearest manifestation in the United States, with a roughly even split between the 50 cities, that was uncovered with a clustering approach, with cities in the income-correlated cluster labeled teal and those in the weakly-correlated cluster, orange. The wider availability of public transportation in the orange cluster appears to be a feature that mitigates the correlation between income and movement, perhaps playing the role of an equalizing feature for those in the lower income brackets. Another key aspect is the availability and diversity of basic services. While lower-income residents in the teal cluster are on average closer to basic amenities, this appears to be a function of them living in the city-center, with the higher-income groups concentrated in suburbs. When it comes to the diversity of services available, there is a clear advantage to those in the higher-income bracket. These cities are also segregated by income, whereby high-income and low-income residents tend to be concentrated in specific areas. This is also manifested in the parts of the cities that they visit, with relatively little mixing between the income groups. Indeed, given the connection with income and race Figs. , S2 thisIn Brazil, we also find two categories, however unlike in the United States, movement in both clusters is correlated with socioeconomic features, with the difference being one cluster (blue) displays even stronger correlations then the other (yellow). While public transportation usage is comparable across cities, the accessibility to services in terms of proximity and quality is strongly skewed towards the highest income brackets in the blue cluster, although the income advantage is also found to a lesser extent in the yellow cluster. Additionally cities in the blue cluster have a more segregated residential profile than those in the yellow one. Both clusters, however display, a sharp divide between rich and poor in terms of which parts of the city is visited, with the rich being concentrated in the city-center and the poor primarily moving in the periphery. In some sense, the Brazilian cities mirror the teal cluster from the United States, with stronger differences in mobility in terms of the socioeconomic characteristics.To validate our results, we also conducted our analysis on a different dataset; the commuting patterns extracted from the United States census. The qualitative results are essentially identical, with some differences in the clustering of the cities, stemming from the fact that the census does not accurately capture the frequency of travel. This resulted in a few cities changing clusters, but by and large the differences in terms of transportation usage, accessibility of services and residential segregation were preserved, attesting to the robustness of our analysis. A similar analysis could not be conducted for Brazil given that such data is not available in that country’s census. This points to another strength of this new approach: its applicability globally by leveraging aggregate signals such as mobility that are inexpensive to compute and available in a timely fashion. Methods relying on traditional census data do not generalize to many regions where census is unavailable, unreliable, or considerably delayed in time.48, although the extent of its efficacy may vary from region to region, given the observed differences between the United States and Brazil. Certainly more efforts must be made in terms of improving the quality of services in low-income areas. Given that this disparity might arise from the residential patterns seen in both countries, inclusive zoning and incentives to foster mixed-income neighborhoods may well be an effective policy50. Indeed, such initiatives have been tried in cities such as New York, Boston and Chicago, which all incidentally lie in the orange cluster.To the extent that it is undesirable to have cities with residents whose ability to navigate and access resources is dependent on their socioeconomic status, public policy measures to mitigate this phenomenon are the need of the hour. While it is difficult to disentangle the causal mechanisms behind the observed disparities, investment in affordable and robust public transportation may enhance equality of accessNevertheless, much remains to be uncovered, in particular whether the reported trends here exist in countries in different regions and varying degrees of economic development. Effective strategies and measures will also vary from region to region and more tailored studies would be required to identify the contextual causes of different socio-mobility profiles. We anticipate many more studies along this direction in the near future.Supplementary Information.


This study highlighted that transitional care interventions are complex and multifaceted. However, the presence of a peer to support system navigation, advocacy and individual and family education was considered the most ideal intervention addressing the current gap in care. Future research, which aims to engage patients and families in a co-design approach, is recommended to further develop this intervention.Transitional care interventions have the potential to optimize continuity of care, improve health outcomes and enhance quality of life for adolescents and young adults living with chronic childhood-onset disabilities, including neurodevelopmental disorders, as they transition to adult health and social care services. The paucity of research in this area poses challenges in identifying and implementing interventions for research, evaluation and implementation. The purpose of this project was to advance this research agenda by identifying the transitional care interventions from the scientific literature and prioritize interventions for study. A modified-Delphi approach involving two rounds of online surveys followed by a face-to-face consensus meeting with knowledge users, researchers and clinician experts in transitional care (n = 19) was used. A subsequent virtual meeting concluded the formulation of next steps. Experts rated 16 categories of interventions, derived from a systematic review, on importance, impact, and feasibility. Seven of the 16 interventions categories received a mean score rating of ≥7 (out of 10) on all three rating categories. Participants then rank ordered the reduced list of seven interventions in order of priority and the top four ranked interventions advanced for further discussion at a consensus meeting. Using the Template for Intervention Description and Replication (TIDieR) checklist as a guide, the participants identified that a study of a  Youth living with childhood-onset disabilities may experience challenges during the transition process from pediatric to adult health and social services. Adolescence in itself is an important period of transition involving multiple changes and choices related to identity, sexuality, education and work . Living Transitional care interventions (TCIs) are a wide range of services and interventions known to promote continuity of care, reduce significant detrimental physical and mental health outcomes, and improve the quality of life of adolescents and young adults living with childhood-onset disabilities as they age. Examples of TCIs include preparing patients and families for transition readiness, promoting information continuity amongst health professionals or case management services through the transition process . The pauWe conducted a modified Delphi  with knoA snowball sampling approach  was usedmodified Delphi mirrors the regular Delphi in using repeated surveys to arrive at consensus. Where it differs from convention is that it begins the process with pre-selected items drawn from earlier work, rather than using the experts to brainstorm on a particular subject (The Delphi method is a process whereby multiple rounds of feedback from a group of experts are solicited . Repeate subject . In our  subject . The facHosted in Canada Surveys (https://www.hostedincanadasurveys.ca). Consistent with healthcare-oriented modified-Delphi processes, the multi-round surveys employed rating and ranking exercises  checklist and guide  was usedLastly, with a priority TCI identified, a virtual meeting was held amongst experts who indicated an interest in further discussing and refining the proposed research including study focus and methods. The experts were provided with a summary of the consensus meeting and then participated in a consensus discussion around next steps for a study of the prioritized intervention.In total, 19 out of 29 invited experts in TCIs consented to participate in the modified Delphi process. This included individuals working within pediatric and adult specialty care medicine, psychology, social work, occupational therapy, physical therapy, kinesiology, therapeutic recreation and nursing; individuals working in appropriate health, social, and non-governmental organizations; and, researchers with expertise in transitional care for adolescents and young adults with childhood-onset disabilities, health services research and knowledge translation. The majority of experts were female (84%) and included healthcare professionals, researchers, and those with a combined role of researcher and healthcare professional. More than half of the experts (63%) indicated 20 or more years of experience in their area of expertise, with over one third of respondents (42%) specifying expertise in pediatrics.In the Round 1 rating survey, all interventions received a mean score rating of ≥7 on importance and impact; however, only seven of the interventions received a mean score rating of ≥7 on the third rating category related to feasibility. See In the Round 2 ranking survey, participants were asked to rank and prioritize the 7 TCIs identified in Round 1. See The experts indicated that it was important to focus on the top four TCIs identified in the surveys. See After in-depth consultation and facilitated discussion, it became apparent that “case management” continued to arise as the most significant construct, as it was represented in all of the top four TCIs. While this was an intervention that scored low on the feasibility criteria in Round 1, after discussion, the participants agreed that the presence of a “coach,” “peer” or “system navigator” should be the key intervention of a future research study. Specifically, participants agreed that evaluating the impact of “a person” who would act as an educator, advocate and system navigator to support patients and families through the transition into the adult system would best serve the population. Issues of concern remained about comparison groups, population, geography and identity of the case manager.Although not initially planned as part of the modified Delphi process, we added a final, brief virtual meeting with interested participants who held research roles and expertise to build a more focused evaluation plan. While the consensus meeting was successful at prioritizing one TCI for future research, a focused research discussion to plan an optimal future evaluation was warranted.It was agreed upon by all the researchers that a targeted intervention using peers with lived experience of transitioning into the adult system as peer navigators offered a promising approach and a unique future evaluation opportunity. A proposed intervention described using the TIDieR checklist, was developed during this discussion see .The researchers also determined that this research agenda would benefit from input and participation from patients and families. This notion initially arose during the consensus meeting; however, was reinforced in the final research discussion. It was determined that the next steps in the research development plan would require a co-design approach with these partners.Using the modified Delphi approach, we sought the opinions of experts on TCIs for adolescents and young adults with childhood-onset disabilities, including neurodevelopmental disorders, with the intention of prioritizing key components for future implementation and evaluation. The results of our previous systemic review identified a list of 16 interventions  that werCollaborative discussions with experts highlighted that TCIs for adolescents and young adults with childhood-onset disabilities are complex and multifaceted. Using the TIDieR framework to focus the discussions, experts indicated that the presence of an individual playing the role of system navigator, educator, advocate, coach and case manager would be an ideal intervention for further evaluation. More specifically, a focused evaluation of trained peer transitional coaches is needed to advance the evidence in TCIs for youth and young adults with childhood-onset disabilities. The notion of a peer system navigator is still unique to this population.Our findings are consistent with other researchers in the field of pediatric TCIs. Dimitropoulos et al.  previousOur study had many strengths. First, to our knowledge, there are no studies assessing the impact of a peer transition coach to assist the population of youth with childhood-onset disabilities as they transition to the adult system. The role of a “peer” has gained increasing recognition in the literature and practice amongst other populations. The literature on peer support suggests that peers can help patients develop improved well-being while decreasing symptoms and hospitalizations . FurtherBased on these findings, we propose that peers could potentially fulfill an important role as transitional care coaches within the population of youth with childhood-onset disabilities transitioning to the adult care system and community. The collective results of the systematic review, modified Delphi process and consensus meetings have culminated in an emergent understanding that system navigation lead by peers is a potential impactful intervention worthy of further investigation for this population, and that there is a unique opportunity to train adults who have successfully transitioned to the adult system to support patients and their families with this same process. We anticipate that peers may be well-suited for the provision of “health system navigation” and “post-transfer support” , yet furBefore proceeding to such an investigation, key considerations seem warranted. Firstly, prior to potentially considering specific activities, processes and competencies to be integrated in the role of peer navigator, the perspectives and preferences of patients and families need to be sought. As such, a co-design approach is needed to elicit the perspectives of patients' and families' and ensure that they inform the nuanced elements of the implementation and evaluation protocols. Additionally, the need to create core competencies of a peer system navigator has been emphasized in the literature , 32, andWith a concrete construct identified, and clear vision on the next steps of building the research protocol with a co-designed approach, we are confident that a solid evaluation structure is being established. Both quantitative and qualitative approaches will be necessary to evaluate the efficacy/effectiveness of such a targeted intervention. We are optimistic that this essential evaluation will be attractive to future granting agencies.We acknowledge study limitations. Although we followed modified Delphi practices based on the precedent of previous authors , real tiThis study commenced with 16 potential TCIs for adolescents and young adults who have a childhood-onset disability and are transitioning to the adult healthcare system. Using a modified Delphi process, we were able to prioritize one key intervention and research agenda which involves the development and evaluation of a peer transitional coach. The next steps of our research agenda will be to engage patients and families in a co-design approach to optimize its function in the lives of the individuals it will endeavor to enable.The original contributions presented in the study are included in the article/This study involved human participants and was reviewed and approved by University Health Network Research Ethics Board (REB 19-5746). The patients/participants provided their written informed consent to participate in this study.AD and DL: led the creation of this manuscript. SM: research project and manuscript creation. All authors contributed to the creation of the grant, study methodology, data analysis, and review and feedback of the manuscript.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.