An increasing number of teachers are introducing animals into their class so that pupils foster cognitive, physiological, and social skills through their interaction with animals. Along with such an educational style termed animal-assisted education (AAE), Japanese formal education has also utilized animals for education. Japanese animal-rearing education is unique regarding the following two points: (1) it takes the form of “education through assisting animals” rather than “animals assisting education” and (2) animal rearing is embedded in formal education. While conventional AAE expects the benefit from the social support of animals, Japanese animal-rearing education expects benefit from nurturing and caring for animals. The present study aims to identify effective methods for using animals for education by highlighting the benefits of Japanese animal-rearing education. An overview of Japanese animal-rearing education is followed by a critical review of empirical studies of conventional AAE and Japanese animal-rearing education. Despite the differences in the educational styles, it was found that both systems commonly help children adapt to school. Additionally, conventional AAE were effective in enhancing cognitive and athletic ability of students and foster social skills, while Japanese animal-rearing education enhanced academic knowledge and skills and cultivated sympathy for animals and other people. Furthermore, it was demonstrated that the experience of raising animals affects children’s development for a long time even after children stop raising animals. In order to determine the effect of animal presence at school, however, more empirical studies with various viewpoints are necessary for both styles of education. Concerning Japanese animal-rearing education, the effects of the differences such as the amount of exposure to animals, developmental stage or character of individual children, the types of animals need to be controlled for a more sophisticated examination. Empirical studies show that preadolescence is one of the periods in which animal rearing has the greatest impact on children’s development. It is suggested that through the program of raising school animals, conventional AAE obtains more a variety of effects in their interaction with animals. Since 1980s, accumulating data has indicated the possibility that children’s relationship with companion animals has a therapeutic  as wellThe conventional style of utilizing animals for education, termed AAE, is used in many European countries. One of the most popular AAE programs is the “school dog” where teachers regularly (1–5 days/week) take their dogs into the classroom as school dogs. Beetz  reportedThe canine-assisted reading program is also a popular AAE program. The goal of the program is to support children with poor reading skills and who are reluctant to read aloud . This prInternational guidelines for AAE have been adopted , 15, whiIn such a context, the possibility and the impact of school dogs are also being investigated in Japan . The intTraditionally, but not compulsorily, Japanese kindergartens and elementary schools have had animals such as rabbits and chickens in school for education. Japanese formal education started in the late 19th century. Matsuda described how animals were introduced into formal education, explaining the kinds of animals that are appropriate to keep at a school, how to rear them, and the effective usage and impact of having animals as teaching tools . In his science-teaching plan, Matsuda , 21, andJapanese animal-rearing education takes the form of “education through assisting animals” rather than “animals assisting education.”Animal rearing is embedded in formal education.The Japanese program is unique regarding the following two points:First, “rearing of animals” is centered on the method of AAE in Japan. That is, while “children getting assisted by animals” is a popular approach in other nations and areas, Japanese schools try to foster children’s knowledge, health, and emotional intelligence through their “assisting” animals. Regarding this point, raising school animals is the means and also the goal of education. As the second point, the Japanese national government formally promotes the “rearing of school animals” as an educational tool. National guidelines for keeping animals in school also exist. According to this policy, animals are raised by pupils as an educational tool from preschool through junior high school. Schools also make an annual academic schedule that includes animal rearing, and children raise animals as an academic activity.The goal of the present study is to quest a new possibility of AAE through focusing on Japanese animal-rearing education.When we think about the bond between humans and pets, its relationship is reciprocal; pets provide us social support, and we also support pets. The presence of pets alleviates stress , 23, impMeanwhile, as the other side of the relationship with pets, we are also benefitted through raising and caring for pets. Children develop nurturance skills through the rearing of pets , 28. IntThinking through this reciprocal viewpoint, conventional AAE is benefitted mainly from the supportive nature of animals. On the other hand, Japanese animal-rearing education reflects the other side—the benefit through caring for animals.Contrasting these two educational systems—conventional AAE and Japanese animal-rearing education, the present study is to examine the merits of Japanese AAE and analyze the factors that make Japanese AAE effective and its problems. Highlighting on a Japanese animal-rearing education, the present study proposes another possibility of education through animal presence that may complement conventional AAE.First, this study presents an overview of Japanese animal-rearing education. Then, comparing the conventional AAE and Japanese animal-rearing education, the present study examines their similarities and differences. It also examines the factors that make Japanese animal-rearing education effective through the reports from school teachers and veterinarians. Finally, the issues that need to be solved for future study are discussed.Rearing school animals is incorporated into formal education in Japan, with school animals employed as teaching tools. In the course of study established by the Ministry of Education, Culture, Sports, Science and Technology (MEXT), there are guidelines for keeping and utilizing school animals for each grade and covering several subjects. The following excerpt of the course of study  indicateIn the subject living environment studies, animal rearing is included as an academic activity for first- and second-grade pupils. One of the goals of living environment studies is to “help pupils become interested in the relationship between themselves and people around them, society and nature through concrete activities and experiences .”According to this goal, the course of study for living environment studies poses the necessity of raising animals and growing plants so that pupils become interested in the habitat of animals and plants and their changes and growth. The course of study also suggests that raising animals and growing plants help pupils realize that these are living and growing entities, become familiar with living things, and cherish them. In order to meet this goal, the course of study for living environment studies recommends that schools have children keep animals for two successive years, from first through second grade. Although the course of study does not specify the kind of animals, Shimano , a schooOlder children in the third through the sixth grade learn about raising animals and having respect for their life through the course, the period for integrated studies.In Japanese education, the period for integrated studies is unique on the point that it does not have a concrete, uniform style of learning. The goal and the contents of the period for integrated studies are entrusted to each school. Schools are just required to conduct cross-synthetic learning activities in the period for integrated studies, such as international understanding, information, environment, welfare/health based on pupils’ interests and concerns.In order to reach this goal, many schools utilize school animals as learning tools, because learning respect for life is taken as one of the most important tasks for children to achieve in elementary school. As a school inspector for MEXT, Shimano  discusseIn the context of the period for integrated studies, schools formulate an annual teaching program. Schools set minute goals Figure  for the The course of study for moral education, from the first grade to the sixth grade, underscore that children should cherish animals and plants and respect the life of other people, animals, and themselves. The background to this idea is that today children have scarce opportunities to cherish and respect lives. Nakamura  investigThe course of study for science also considers observation and interaction with familiar animals as an important teaching practice. Also, the course of study for science explains that, through caring for animals, children learn about the mechanisms of animals’ bodies and the differences and commonalities between animal bodies and the human body. The course of study expects that raising animals, including fish and insects, at school can cultivate a scientific outlook in children.Interestingly, the course of study emphasizes the linkage between science and moral education. Hioki , a senioAnother popular way of rearing school animals is to join the animal-rearing committee that constitutes the student-body activity. The course of study requires that children participate in student-body so that they build good social relations and develop a self-motivated attitude. The student committee, including the animal-rearing committee, usually consists of children from upper grades. The members of the committee take care of the animals on behalf of the other pupils and report the current condition of and problems related to raising the animals to the student-body activity .Desirable Animal Rearing at School , followed by chickens (65.5%), small birds (17.0%), duck (4.3%), hamster (3.6%), and guinea pig (2.0%).The number of most of these animals was single to five . Almost all rabbits (97.7%) and chickens (98.8%) were kept in an animal house located in the schoolyard  or a committee project. Preparation of food for the animals is also included in the work of rearing at some schools. Children care for the animals before the start of the school day, during lunchtime, or after school. Children at some schools enjoy playing with the animals after taking care of them, while others just spend time tending them.Among the schools that own animals, more than 70% responded they utilize school animals for teaching living environment studies. In the event of an animal’s death, almost 80% of schools replied that they would bury the animal with the pupils taking part . TeacherHatogai  found thThe nationwide survey on animal rearing at school has not been conducted for more than a decade since Hatogai . The proThen, what kind of impact does animal-rearing education have and how do the effects differ from the one through conventional AAE? To make these points accurate, I rely on the studies that specifically cite animal utilizing education at school as their main focus.Since both the studies of animal-assisted and animal-rearing education are rather new, accumulation of empirical study of the education is not abundant. In such a situation, the first principle of inclusion was the publication of the original research in a peer-reviewed scientific journal. Mainly Educational Resource Information Center (ERIC), Teacher Reference Center, Psychology and Behavioral Science Collection, MEDLINE, and J-STAGE were used to search articles. Search terms were “animal-assisted education,” “school,” “animal,” and “pet.” The presentation abstract of academic conferences were also included. Further, the three criteria were as follows: 1) the articles in which subjects were older than university students were excluded because the review focused on the impact on children. 2) The study of which context was not school situation was excluded even when subjects are children. (3) The articles that targeted to assess the quality of the animals for AAE is also excluded. The reviewed articles concerning conventional AAE are summarized in Table  the arti The studGee et al.  investigGee et al.  examinedGee et al.  examinedGee et al.  examinedKotrschal and Ortbauer  investigTissen et al.  examinedBeetz et al.  examinedBeetz  investigHergovich et al.  examinedHowever, more study is needed to elucidate especially the relationship between enhanced field independence and the presence of a dog.Although empirical study was not obtained, it is reported that the presence of dogs help children with reading. Reading proficiency improves through reading practice . Poor reDue to the supportive environment that dogs provide, they are often brought into special educational classes to help children with disabilities. Anderson and Olson , for exaFujisaki  investigThese results might be partially brought by the effect of intellectual development of children. However, the participating children had reared animals continuously since they entered this kindergarten. It can be thought that such a rich experience to rear and interact with animals fostered the development of the knowledge about animals and the theory of mind. However, comparison with no rearing group should be necessary to examine the true effect of animal rearing.Nakagawa and Muto  investigThe criteria for evaluating the essays were composition elements and emotional expression. It was found that the study group wrote more words as compared to the committee group. The study group also showed higher composition ability and higher emotional expression compared to the committee group even when the number of words was controlled.Basically, the daily responsibilities of children caring for animals did not differ between the period for integrated studies group and the committee group. They both fed the animals, gave them water, and cleaned their habitat. The data showed, however, concerning emotional expression, that the study group’s scores were higher in terms of expressing animals’ emotions and of insight into those emotions, in terms of sympathy and nurturance for animals, and in terms of identifying with friends and teachers who were caring for animals together.Then, what created such difference between study group and committee group? Nakagawa and Muto  suggesteThe second was the utilization of raising animals as an educational opportunity. Nakagawa and Muto  reiteratNakagawa and Muto  hold thaMaruyama et al.  investigNakajima et al.  conducteIn the investigation, importance was attached to the following two points. First is the quality of animal rearing carried out by the children. Visiting the animal houses at several schools, the authors found that the quality of care for the animals differed by school. Some schools did not clean the animal house sufficiently; some schools did not care for the animals well during holidays or vacation; or some schools did not consult veterinarians, which resulted in a poor living environment and the death of the animals. As Vidovic et al.  reportedAfter a 1-year period in which animals were raised, it was found that appropriate-rearing group, compared to the control group, showed a lower decrease in school adaptation during T1 through T2. However, inappropriate-rearing group, as compared to appropriate-rearing group, showed a higher decrease in all five variables during T1 through T2. During T1 through T3, 1 year after the end of animal rearing, as compared to the control group, appropriate-rearing group showed a lower decrease in all variables except for knowledge of animals. However, inappropriate-rearing group showed the highest decrease in prosocial attitude in the three groups. It is reported that warmth to other people decreases as the grade in school advances and students approach puberty . The conThe second point is whether children keep animals at home. Pets are considered as family members . HaIn order to examine the effect of keeping pets at home, Nakajima et al.  divided It was found that, after 1 year of animal rearing, those who appropriately reared school animals but had no pets at home showed a lower decrease in the sympathy for animals and prosocial attitude compared to those who inappropriately reared school animals regardless of having pets at home. During T1 through T3, 1 year after the end of animal rearing, again, those who appropriately reared school animals but having no pet at home showed a lower decrease in sympathy for animals, school adaptation, and prosocial attitude as compared to those who were in control group and kept pets at home.Nakajima et al.  clarifieNakajima et al.  should bGunma Veterinary Medical Association  partiallAnother research of Gunma Veterinary Medical Association  made a cFurthermore, it has been found that such experiences in rearing and caring for school animals have an impact beyond childhood . Iwama eAs long as these empirical studies show, dogs are overwhelmingly popular in conventional AAE, while dogs are rarely kept in Japanese animal-rearing education. Also, in conventional education, dogs usually do not live in school. They are teachers’ or handlers’ pets and visit school. In order to take enough rest, most dogs do not go to school every day or multiple dogs go to school by turn , 47. AlsDespite such environmental differences, animals in both educational systems commonly have the effect to help children adapt to school including school adaptation , enhanciAnother underlying reason for animals’ impact on school adaptation would be that children feel animals do not evaluate them. Dogs, for example, provide a safe, playful, and caring learning environment . BecauseOther than school adaptation, the effect of conventional AAE can be classified into two categories. The first is enhancement of cognitive and athletic ability. This includes enhancement of field independence , fewer iMeanwhile, Japanese rearing animals has effect on two aspects other than school adaptation. The first is the enhancement of academic knowledge or skills including biological knowledge of animals , 52, theConcerning the development of individual ability, conventional AAE has impact on the development of fundamental cognitive or physical ability that support academic learning. On the other hand, Japanese animal-rearing education is effective for enhancing academic achievement. One of the reasons for such a difference would be the difference of the educational goals. Especially, Japanese education expects that the experience of animal rearing lead to the acquisition of knowledge and skills in other subjects. The results of empirical studies show that such a goal of Japanese animal-rearing education is, though partially, attained.Concerning the effects on the social relationship, conventional AAE emphasize on the change in an individual’s behavior, such as reducing aggression and hyperactivity. Meanwhile, Japanese animal-rearing education rather focuses on psychological development such as sympathy and warmth for others or prosocial attitude.There would be two reasons as to why Japanese animal-rearing education showed effect on the development of such a tender mind. One reason is the similarity of experience in keeping animals at school and pets at home. It can be thought that since rearing animals at school is a similar experience to that of keeping and caring for pets at home, the same impact that pets have on child development was also found. Empirical studies show that the relationship with animals foster prosocial mind among children , 4. InveAnother possible reason would be the cultural difference in terms of the sense of value. Markus and Kitayama  argue thHow then does rearing animals in school contributes to the development of children’s mind? Analyzing the differences in appropriate-rearing and inappropriate-rearing groups, Nakajima et al.  suggesteIt was found that the appropriate animal-rearing education often embeds animal rearing in the academic goals of the school . MaruyamTeachers’ support and guidance are also essential for children’s development through animal rearing. Fujii  reportedAnother difference between the appropriate-rearing group and inappropriate-rearing group was the lessons on the death of school animals. It is obvious that the response of the adults around the children regarding the sickness or death of animals has a significant impact on the children’s psychological development. Yarrow et al.  reportedTeachers report that holding a memorial ceremony for deceased animals, including writing letters or saying goodbye to them, soothes the sorrow of children, helps them realize the gravity of life, and aids them in understanding that the deceased will never come back Support from veterinarians is also an indispensable factor. Vets visit a school to give a class on the animal’s biology and how to raise the animal , 76, exaIt was found that Japanese animal-rearing education affects children’s academic performance as well as prosocial attitude. However, for more sophisticated examination in the future, the next four points need improvement.First, it is still unclear who benefits from raising animals at school. Some children care for the animals and some just say hello or goodbye to the animals when they see animals while arriving at or leaving school. Some pupils care for the animals eagerly and properly and some do not. The frequency of contact and intimacy with animals may therefore be different among these various groups. The effects of these differences on the amount of exposure to animals on children’s development need to be investigated. Also, children’s difference other than animal rearing such as character or scholastic aptitude need to be included into examination in order to demonstrate the impact of animal rearing on children’s psychological development more accurately.The second point is that there are developmental differences among children. Some pupils rear animals as part of living environment studies in first or second grade, some do so as the period for integrated studies study in the third or fourth grade, and some do so as an animal-rearing committee activity in fifth or sixth grade. Such differences in developmental stages should be made clear.The third point has to do with the difference in types of animals. Some schools have reported on pupils caring for fish; some on small animals kept in the school building, including the classroom; and some on chickens or rabbits kept in an animal house located outside the school building. The method of rearing or the degree of intimacy with animals may be different when the species of animals are different.The fourth point is the criteria for measuring the quality of animal rearing. Nakajima et al.  showed tThe goal of the present study was to examine a new possibility of AAE through focusing on Japanese animal-rearing education and its effect.The empirical studies revealed that the effect of conventional AAE was mainly seen in terms of the enhancement of cognitive and athletic abilities as well as that of social skills at school, such as less aggression and hyperactivity or paying more attention to the teacher. On the other hand, the effect of Japanese animal-rearing education was seen in the enhancement of academic knowledge or skills as well as consideration for others, including sympathy for animals and others or prosocial attitude. Furthermore, it was demonstrated that the experience of raising animals affects children’s development for a long time even after children stop raising animals.Such a difference in effects stems from the different relationship with animals between these two educational systems—getting assisted by animals versus assisting and caring for animals. Adopting animal-rearing education, popular in Japan, would provide a new possibility for conventional AAE. Preadolescence is one of the periods in which animal rearing has the greatest impact on children’s development , 54. EriIn order to determine the effect of animal presence at school, more empirical studies with various viewpoints and sophisticated design are needed for both of conventional AAE and Japanese animal-rearing education. Attachment to animals, for example, is one of the pivotal factors that differentiate the impact of the bond between humans and animals , 4. NakaFurther, the research on the balance between cost and effectiveness of using animals for education is necessary. Hatogai  reportedNakajima  asks wheThe author confirms being the sole contributor of this work and approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This paper explores differences in experienced environmental barriers between individuals with and without disabilities and the impact of additional factors on experienced environmental barriers. Data was collected in 2011–2012 by means of a two-stage cluster sampling and comprised 400–500 households in different sites in South Africa, Sudan Malawi and Namibia. Data were collected through self-report survey questionnaires. In addition to descriptive statistics and simple statistical tests a structural equation model was developed and tested. The combined file comprised 9,307 participants. The Craig Hospital Inventory of Environmental Factors was used to assess the level of environmental barriers. Transportation, the natural environment and access to health care services created the biggest barriers. An exploratory factor analysis yielded support for a one component solution for environmental barriers. A scale was constructed by adding the items together and dividing by number of items, yielding a range from one to five with five representing the highest level of environmental barriers and one the lowest. An overall mean value of 1.51 was found. Persons with disabilities scored 1.66 and persons without disabilities 1.36 . Bivariate regression analyses revealed environmental barriers to be higher among rural respondents, increasing with age and severity of disability, and lower for those with a higher level of education and with better physical and mental health. Gender had an impact only among persons without disabilities, where women report more barriers than men. Structural equation model analysis showed that socioeconomic status was significantly and negatively associated with environmental barriers. Activity limitation is significantly associated with environmental barriers when controlling for a number of other individual characteristics. Reducing barriers for the general population would go some way to reduce the impact of these for persons with activity limitations, but additional and specific adaptations will be required to ensure an inclusive society. The International Classification of Functioning, Disability and Health (ICF) provides a framework for disability that incorporates environmental factors, i.e. those factors that “make up the physical, social and attitudinal environment in which people live and conduct their lives” 1:10]. Following the ICF, environmental factors can enhance participation or act as barriers and decrease participation, either increasing functioning opportunities in the former case, or restricting participation in the latter –7. While. FollowiExploring the interaction of environmental barriers with ICF functioning components  may contribute to identifying both equitable policy initiatives and development of individualized and appropriate public goods and services that can improve the quality of life of people with disabilities. The models utilized in the analysis draws on the ICF model and incorporates factor that represent the component of health, individual factors, environmental factors and activity limitations, and may thus contribute to further understanding the application of the ICF model. This is concurrent with the invitation from WHO to use the components in the ICF to create models that allows for analyses of different aspects of the disablement process (1:18).This article will analyse differences in experienced environmental barriers between individuals with and without disability, and the impact of additional factors, in four different African contexts, as well as comparing the association between environmental barriers and disability across the four study settings.The ICF classifies environmental factors into five main domains. The first domain, products and technology, includes access to food, assistive devices, technology, adapted and otherwise, medication, finances and other assets. Research has shown a lack of assets ,14,15, lThe natural environment and human-made changes to the environment  constitutes the second domain and has been identified as creating barriers to participation for persons with disabilities ,15,16,18The fourth domain, attitudes of others, has also been identified as a barrier to participation of person with disabilities ,7,21. ThThe ICF  presentsEnvironmental factors can further be categorised into those affecting everyone, both disabled and non-disabled, and those that are specifically related to various disabilities. For example, poor accessibility of public transport and difficult terrain in rural areas with poor infrastructure affect all people, but the extent to which it affects people with disabilities may be qualitatively different in increasing exclusion. Other barriers, such as access to assistive technology and stigma are specifically related to disability. Thus, and supported by the literature on disability and environmental barriers, our hypothesis is that the presence of disability/activity limitations is directly associated with environmental barriers–also when controlling for individual and contextual characteristics that are known to differ between persons with and without disabilities. Health variables, SES and Personal factors included in our model are all known to vary between persons with and without disability and may potentially influence the relationship between disability and environmental barriers.The study was carried out in 2011–2012 in four different sites in each of South Africa, Sudan and Malawi, and five sites in Namibia, as part of an EU funded collaborative research project on access to health care for vulnerable people in resource poor settings (Equitable). As described elsewhere , the selData were collected through self-report survey questionnaires –S3 FilesThe study population included all people living in the various study sites. As described previously , ta sampThree different questionnaires were used, in addition to the screening questions: A household questionnaire  and two Of the variables in the model, Environmental barriers and Activity limitations were validated prior to the study, Possession scale was drawn from similar battery of indicators in use by Central Statistical Offices in the participating countries, while the remaining variables were straightforward and easy to understand (e.g. gender). The Research Team worked extensively in several rounds on the questionnaires in order to ensure that they were relevant for the contexts, and in all countries small-scale trial data collections were carried out prior to the main data collection to ensure comprehension.To measure environmental barriers, the questionnaire included the Craig Hospital Inventory of Environmental Factors (CHIEF) . The scaThe initial part of the analysis consist of descriptive statistics and bivariate regressions. Based on these results, we subsequently developed a structural equation model (SEM) , which sAs described elsewhere , ethicalThe dataset used for the present analysis combines household and individual level data. The combined file comprises a total of 9,307 individuals. A small number of missing values, particularly in Sudan, leads to minor variations in N between different variables. The gender balance varied significantly between the four country samples. Some of these differences, and the particularly skewed gender balance in SA, are assumed to be due to characteristics of the selected sites, with a high proportion of migrating workforce. Age did also vary significantly between the countries, and between men and women. Mean age for men and women in the total sample was 34∙7 and 37∙9 years respectively, and the gender difference in age varied somewhat between the four countries from 3∙8 years higher mean age among females in South Africa, 1∙5 years higher among females in Malawi, and 1 year higher among males in Namibia and Sudan.extent of the barriers revealed that the three largest barriers were transport, the natural environment and access to health care .Overall, An exploratory factor analysis was conducted to assess the appropriateness of constructing an Environmental Barriers Scale of the eight items in CHIEF . This yiIn order to develop a model explaining the relationship between activity limitations  and environmental barriers, bivariate linear regressions were carried out . The anaAccording to the bivariate regression analyses, perceived environmental barriers are higher among rural respondents, increase with age and severity of disability, and lower for those with a higher level of education and with better physical and mental health. Gender has an impact only among persons without disabilities, where women report more barriers than men. Higher socioeconomic status, on the other hand, is associated with more barriers only among people with disabilities.Based on the bivariate regressions reported above, we included all the variables from Initially, we controlled for the different country contexts by including dichotomous variables for each country (Model 1). Subsequently, we estimated a group-wise model where estimates were allowed to vary with country, testing whether the estimates are invariant across country (Model 2). Starting with Model 1, Finally, the model shows that respondents in Namibia report of the highest level of barriers, followed by South Africa, Sudan and Malawi. Since the model controls for individual level characteristics in the respective populations, these differences reflect the actual frequency of experienced obstacles that exist; they are not a product of, e.g., higher levels of disability or a more unhealthy population. Hence, of the country characteristics outlined initially (see description of study context above), dispersion and long distances appear to be the most detrimental for access.2 test). Even so, some associations are fairly similar across country. Notably, activity limitation is positively associated with environmental barriers in all four settings. As illustrated in Turning to Model 2, there appears to be several differences between countries in individual-level determinants of environmental barriers. According to Model 2, all the variables but age varies significantly with country  show that this result is not robust to different model specifications. The mean number of possessions per inhabitant is much lower in Malawi than in the other contexts, which could potentially explain this result in the group-wise model.The goodness of fit statistics reported at the bottom of The present study found that individuals with disabilities face more severe environmental barriers than non-disabled individuals in each of the four country subsamples. Both persons with and persons without disabilities experienced transportation, the natural environment, and accessing health care services, as being the most severe and the most frequent barriers. The rank order among the different barriers is largely the same for persons with and without disabilities. Environmental barriers were found to increase with reduced SES status and increased activity limitations. With less predictive strength, rural residence, poor mental health and physical health also predicted experiences/perceptions of greater environmental barriers. While statistically significant in the initial, bivariate analyses, education was not associated with environmental barriers in subsequent analyses, which also included disability, health and socioeconomic status. One interpretation of this is that education reduces barriers only insofar as it improves livelihood.The association between activity limitations and environmental barriers was consistently positive across countries. The effect was strongest in Malawi and Namibia, and somewhat weaker in Sudan and South Africa. Transportation and natural environment are well documented as main barriers in the daily life of individuals in the current contexts. Transport is often challenging in Africa due to a number of reasons such as rough terrain, flooding, poor road infrastructure, huge distances; expensive, inadequate or non-existent public transport; and fewer people owning motorised vehicles . The natOverall, the study confirmed the expected association between activity limitations and environmental barriers that was also described by Reinhardt et al ; while aWhile this study offers unique data from sub-Saharan Africa, the four country samples are not representative at a country level, and sampling was directed by bringing forth the uniqueness of each context, with variation in rationale for selecting study sites. Any interpretation and use of results should take this into consideration. The self-report nature of the research should also be acknowledged. It should further be noted that the data collection was complex and undertaken under demanding circumstances by different teams in each country and in populations, which may have influenced the quality and introduced bias in the data. We have countered such problems through a series of workshops to ensure a joint understanding of the research process among the country teams, including active participation of the project lead as well as the work package leader in all training at country level. While the limitations still need to be acknowledged, the main aim of the article was not to present representative estimates at country level but to analyse a theoretically based model. Nonetheless, our results indicate that the experience of increased frequency and intensity of experienced barriers is strongly associated with reported activity limitations across the four country samples; albeit to different extents in different countries. This finding suggests that that this is a general mechanism that is at work in different contexts and different countries and should be a primary target for policy to address.The study has confirmed that individuals with and without disability experience the same type of environmental barriers, but that disability  exacerbates the experience of these barriers. A broad approach to reduce barriers and implement measures to provide necessary support and adaptation to individuals with disability is necessary to achieve full inclusion is society among vulnerable groups. Reducing barriers for the general population would go some way to reducing the impact of these for persons with activity limitations, but additional and specific adaptations will be required to ensure full reduction of their impact and promoting equitable access, inclusion and participation in society.S1 FilePdf. Household questionnaire.(PDF)Click here for additional data file.S2 FilePdf. Individual questionnaire.(PDF)Click here for additional data file.S3 FilePdf. Control questionnaire.(PDF)Click here for additional data file.S4 File(ZIP)Click here for additional data file.


Background: Global health partnerships have grown rapidly in number and scope, yet there has been less emphasis on their evaluation. Gavi, the Vaccine Alliance, is one such public-private partnership; in Gavi-eligible countries partnerships are dynamic networks of immunization actors who work together to support all stages and aspects of Gavi support. This paper describes a conceptual framework – the partnership framework – and analytic approach for evaluating the perceptions of partnerships’ added value as well as the results from an application to one case in Uganda.Methods: We used a mixed-methods case study design embedded in the Gavi Full Country Evaluations (FCE) to test the partnership framework on Uganda’s human papillomavirus (HPV) vaccine application partnership. Data from document review, interviews, and social network surveys enabled the testing of the relationships between partnership framework domains . Topic guides were based on the framework domains and network surveys identified working together relationships, professional trust, and perceptions of the effectiveness, efficiency, and legitimacy of the partnership’s role in this process.Results: Data from seven in-depth interviews, 11 network surveys and document review were analyzed according to the partnership framework, confirming relationships between the framework domains. Trust was an important contributor to the perceived effectiveness of the process. The network was structured around the EPI program, who was considered the leader of this process. While the structure and composition of the network was largely viewed as supporting an effective and legitimate process, the absence of the Ministry of Education (MoE) may have had downstream consequences if this study’s results had not been shared with the Ministry of Health (MoH) and acted upon. The partnership was not perceived to have increased the efficiency of the process, perhaps as a result of unclear or absent guidelines around roles and responsibilities.Conclusion: The health and functioning of global health partnerships can be evaluated using the framework and approach presented here. Network theory and methods added value to the conceptual and analytic processes and we recommend applying this approach to other global health partnerships to ensure that they are meeting the complex challenges they were designed to address. The first independent evaluation of the Alliance highlighted the issue of unclear roles and responsibilities but contrasted this with the partnership’s ability to “allow quick decision-making, innovation and flexibility, and open debate and self-assessment.”9 The second Gavi evaluation reported the benefits of a lean organizational structure on efficiency and effectiveness.10 Yet, Naimoli6 reported that in the case of gavi’s health systems strengthening (HSS) grants, inadequate explication of roles and responsibilities, a lack of transparency and trust, and differing ideologies were some challenges noted by participants at all levels of the Alliance.Gavi, the Vaccine Alliance, formerly known as the Global Alliance for Vaccines and Immunizations is an example of an early adopter of the global health partnership governance and business model. Founded in 1999 as a public-private partnership, the Alliance brings together country governments, UN agencies, vaccine manufacturers, philanthropic foundations, non-governmental organizations (NGOs) and research institutes to achieve the Alliance’s mission of saving lives and protecting people’s health by increasing access to immunization in poor countries. Each partners’ activities are mutually agreed upon at the global level and outlined in an annual business plan,10 so too has the recognition that partners must bring a growing diversity of skills and approaches to the partnership.12 This is certainly true for the case of Uganda, whose immunization system performance is gradually improving following the re-introduction of Gavi support in 2012 and thus the reorganization of its immunization program and partnership, and where the efficient allocation and coordination of partners’ comparative advantages will be essential to supporting national and global goals.13 Gavi’s 2015 announcement of a new structure for coordinating and managing Gavi Alliance partners — the Partners’ Engagement Framework14— will replace the Gavi Business Plan in an effort to ensure country-centric processes and increase the relevance of partners’ activities; it is also a reflection of the broader growth in the diversity and decentralization of partnerships and networks for global health.14 This paper presents a case study of an Alliance partnership in Uganda prior to the introduction of the Partners’ Engagement Framework, but which may serve as a useful baseline.As the Gavi strategy has evolved to include strategic goals related to coverage and equity as opposed to simply new vaccine introductions,15 A key evaluation question is centered on the role and effect of the Alliance partnership on decision-making, planning, and implementation of financial and technical support. This study builds on existing evaluations of the Alliance partnership10 by introducing a framework that illustrates the theoretical linkages from inputs to outcomes — effectiveness, efficiency, and country ownership — of partnership-led processes through the application of mixed-methods data collection and analysis. The results of this study will be of particular salience as the Partners’ Engagement Framework is implemented and may serve as a baseline description of the state of Gavi partnership in one priority country.This paper outlines an approach to evaluating the effectiveness, efficiency, and legitimacy of global health partnerships with an illustration from the Full Country Evaluations (FCE) commissioned by the Alliance. The FCE is a 4-year prospective evaluation of Alliance support in four countries which ultimately aims to connect inputs, outputs, outcomes and the impact of Gavi support while learning lessons about the process and areas for improvement.The aims of this paper are two-fold. First, we describe in detail how to design and implement an evaluation of health partnerships, drawing on a specific theoretical framework (the ‘partnership framework’) and social network analysis (SNA). Second, we apply the partnership framework to a specific national level case of an immunization partnership to demonstrate how the framework can be used to describe and relate partnership domains to perceptions of outcomes in the process, and to assess the feasibility and usefulness of this approach. The case study is the process surrounding the Government of Uganda’s application for Gavi funding for national introduction of the vaccine against human papillomavirus (HPV). The paper closes with a discussion of the implications of the partnership evaluation approach for other global health partnerships and partnerships more generally.22 The FCE evaluation team integrated these concepts to develop and apply a new conceptual framework to measure the partnership approach’s contribution to national immunization processes. In doing so, the evaluation responds to two gaps in current partnership evaluation practice: the tendency to ignore the inner workings of partnership relationships, and limited use of available analytic tools to measure and describe partnership structure. Partnerships are composed of individuals and the relationships between them, making it essential to understand the inner workings of a partnership to influence the overall functioning of the partnership. Despite the availability of SNA tools and methods, the increasing number of global health partnerships has not been matched by a corresponding increase in measurement of these networks. This paper provides a framework whereby stakeholders or decision-makers can evaluate their own partnerships to ensure that there is an added value of the existing partnership in terms of efficiency, effectiveness, and country ownership.A broad range of literature addresses partnership definition, practice, and measurement, including concepts from public administration, organizational science, and network analysis.24 Measurable characteristics of partnerships can be contrasted with other governance or organizational structures such as contractual or direct implementation models,25 which have been the historic norm in global health and still constitute the vast majority of decision-making and implementation processes , centralization , and diversity .33 The systematic measurement of these metrics and their linkage through the framework to the Alliance objectives is a methodological innovation which will hopefully support efforts to evaluate the Alliance partnership model in order to enable it to achieve its intended outcomes moving forward.Social network theory, broadly, suggests that the behaviors and decisions of nodes — individuals, organizations, or any other unit — are determined by those nodes’ relationships with other nodes, as well as the larger structure created by the entirety of the relationships.In this section, we elaborate on the evaluation design and implementation so that it can be easily replicated. We provide sample data collection tools in 37 embedded in an ongoing prospective evaluation of Alliance support (the FCE).15 Among the four FCE countries, Uganda was chosen as the initial case country to implement the partnership analysis because of local interest and the recent completion of a potential case – the development of the funding application to the Alliance for HPV vaccine introduction at the national level. In the partnership analysis approach, the ‘case’ can be defined as a process with a specified outcome of the process, for example an application for new vaccine support, resulting in a submission to the Alliance; or the planning process culminating in the launch of a new vaccine. Defining the case as process facilitates cross-country comparisons and encourages empirical identification of the network of actors who have participated. It ensures that the outcomes  involved partners spanning administrative levels and jurisdictions, a national level process was chosen for ease of access to potential respondents and data collection.The HPV vaccine application process was chosen as a suitable case because of its timeliness in relation to planned data collection and the potential of applying lessons learned to both the ongoing implementation of HPV vaccine in Uganda as well as to other new vaccine applications in Uganda and elsewhere. In addition, it was of theoretic and programmatic interest to understand how a partnership around HPV vaccine, which targets adolescent girls to prevent cervical cancer, might involve a different group of stakeholders than traditional childhood vaccines. As the Partners’ Engagement Framework moves to include ‘expanded’ partners,38 minutes of application meetings, the application submission to Gavi,39 and Gavi’s decision letter.Data collection included document review and in-depth interviews, including a structured network survey, with key informants. The document review component informed the development of topic guides and supported the identification of initial interview respondents. Documents included the final report of Uganda’s HPV vaccine demonstration project,In-depth semi-structured interviews were conducted with individuals involved in the HPV vaccine application process. Respondents were identified based on the local research team’s in-depth knowledge of the process, and augmented by document review. Interviewers, who were members of the local FCE research teams, followed topic guides based on the partnership framework domains  were also included  when a round of names elicited fewer new names than the previous round. This is a common decision point for dispersed networks, such as policy networks, as it suitably limits bias while not overtaxing resources.The research team read the qualitative interview notes together and coded text segments by hand according to a pre-determined coding structure based on the framework categories. Additional codes included codes for interactions between categories, and the application process for inactivated poliovirus vaccine (IPV) which had occurred more recently than the HPV vaccine application process and was mentioned often during interviews. The team read the coded text segments and wrote a memo for each theme summarizing key interpretations and findings.Immediately following interviews, network data were entered in matrix form in a MS Excel workbook. Names were entered in rows and columns and the existence of a working relationship was entered in each node-alter cell, weighted by the reported trust score. A second matrix recorded information exchange ties, entered as binary . Respondent attributes and perceived outcomes were entered in a third worksheet, and descriptive analyses performed in Stata.41 where the maximum value of two ties was taken in cases of asymmetry. Density, centralization, and degree centrality were computed based on existing algorithms; a dichotomized version of the working relationship network was also analyzed. Network maps were produced for the networks using NetDraw.42The two resulting network sociomatrices were imported into UCINET software43 UNEPI links with other MoH departments and divisions through Technical Working Groups as well as Senior and Top Management committees. EPI activities are organized during monthly technical committee meetings consisting of EPI country partners led by the EPI manager.Uganda National Expanded Program on Immunization (UNEPI) is responsible for immunization under the Ministry of Health (MoH) in Uganda and is headed by the Assistant Commissioner of Health Services also known as the Expanded Program on Immunization manager (EPI manager). UNEPI is situated in the Department of National Communicable Diseases Control (NDC) within the Directorate of Clinical and Community Services. The UNEPI program is responsible for policy, standards and priority setting, capacity building, coordinating with other stakeholders and partners, resource mobilization, monitoring, and technical support supervision to districts.EPI has various partners including (1) Public partners such as National Medical Stores (NMS), district administrations and health facilities; (2) Development partners such as United Nations Children’s Fund (UNICEF), the WHO, and bilateral donors; (3) International non-governmental organizations (INGOs) such as PATH, SABIN Vaccine Institute, African Field Epidemiology Network (AFENET), and Maternal and Child Health Integrated Program (MCHIP).Haemophilus influenzae (Hib) vaccine and pneumococcal conjugate vaccine (PCV), and utilized cash support for injection safety (INS) and HSS windows, receiving a total of $190.6M in Alliance funds to date. Gavi support to Uganda was suspended in 2006 following financial irregularities and was re-commenced in 2012 when those irregularities were resolved.Uganda has benefited from Alliance support since 2001 with the introduction of hepatitis B vaccine and immunization services support (ISS); since that time it has introduced 44 Cervical cancer is caused by HPV which is a sexually transmitted infection. In Uganda, the annual age-standardized incidence of cervical cancer is estimated at 44.4 per 100 000 women per year and age-standardized mortality rate estimated at 27.2 per 100 000 women per year (2012 estimates).45 From WHO projections, deaths are predicted to increase by nearly 80% by 2030 in mostly low- and middle-income countries, Uganda inclusive.44 Fortunately, the disease can easily be prevented through HPV vaccinations, screening and treatment. A vaccine to prevent cervical cancer was approved and licensed in the United States in 2004 and in Uganda in 2007.In Uganda, cervical cancer accounts for 40% of all cancers recorded by the cancer registry, and over 80% of women with cervical cancer are diagnosed with advanced disease.HPV Vaccines project along with India, Peru, and Vietnam. The project in Uganda was implemented by UNEPI of the MoH with technical support from PATH, and operations research was conducted by the Child Health and Development Centre (CHDC) and PATH. The demonstration project aimed at assessing the feasibility, acceptability and cost of delivering HPV vaccine. The demonstration project was initially implemented in two selected districts in 2008, each testing a different approach, but later scaled up to 12 additional districts in 2009. In Nakasongola district, delivery of HPV vaccine was tested through the biannual Child Days Plus (CDP) approach and the target population was girls 10 years of age. In Ibanda district, a school-based approach was used and the target population was based on school grade (Primary 5) or 10 years of age for girls who were not attending school.In order to benefit from Alliance support for HPV vaccine, countries are required to demonstrate their ability to deliver HPV vaccines to adolescent girls prior to application for national rollout. Uganda was among the countries selected by PATH to undertake an 38 A coverage survey in 2009 showed 88.9% coverage with the school-based delivery strategy and 60.7% coverage with the CDP delivery strategy.38 Based on the success in the two districts, the demonstration project shifted to using a combined approach of integrating the CDP with school-based immunization, and HPV vaccine immunization was extended to 12 additional districts in 2012. The new combined approach targeted all girls in Primary 4, regardless of age, and 10-year-old girls who were not in school. Vaccination of the first cohort of girls in the 12 new districts began in September 2012, the second dose was administered in November 2012, and the third dose between March and August 2013.The demonstration was considered successful and the accompanying report indicated that the HPV vaccine was highly acceptable in communities and that implementation was feasible.Its success provided evidence to the Government of Uganda about when and how best to introduce the HPV vaccine country wide prior to application for national rollout as this was a Gavi requirement. The HPV vaccine delivery model decided upon then however, has changed due to its feasibility and financial sustainability. Following the successful demonstration, Uganda then made a decision to apply to Gavi for national introduction of HPV vaccine. The application for national introduction of HPV vaccine was prepared between May and September 2013. The initial application was submitted by the Government of Uganda in September 2013 and was approved by Gavi in March 2014.The team conducted key informant interviews (KIIs) with seven individuals involved in the HPV vaccine application process between August and October 2014. An additional four network surveys were administered without an in-depth interview, totaling 11 surveys. Respondents were all based at the national level and represented the MoH and partner organizations see .Through the snowball sampling approach we identified a total of 39 individuals who participated in the HPV vaccine application process. Actors in this network had an average of 2.8 ties and reported moderate-high levels of trust for each other . The lowWe found that the partnership framework was useful in drawing out relationships between variables. We note three key findings relating the HPV vaccine application partnership to observed outcomes. First, trust was identified in qualitative and quantitative findings as being an important contributor to the perceived effectiveness of the process. Second, network mapping identified the absence of the ministries of education and finance during the application meetings, which may explain observed delays in the planning process after the HPV vaccine grant had been received. Third, respondents perceived the partnership to be only moderately efficient, which might be explained by the lack of clear guidelines or terms of reference around roles and responsibilities. The sections that follow describe these major findings, as well as other findings, according to each domain of the partnership framework.Contextual factors such as critical events, existing relationships among potential partners, or politics, can facilitate or block the ability for a partnership to form and function effectively. When describing the HPV vaccine application partnership’s underlying context and history, respondents consistently mentioned past immunization partnership experiences, including that of the HPV demonstration project, the existence of champions, political priority around cervical cancer, and high levels of trust.Respondents noted that the partnership observed through this study started to form in 2013 with the application and introduction of PCV – the first engagement with Gavi since 2005. A new team of UNEPI managers were appointed in 2013, which respondents identified as having a positive influence in functioning of the partnership and on the timely submission of the HPV vaccine application.“Originally, WHO and UNICEF were the major players but in recent years many more partners have come on board. The new EPI management has rejuvenated the partnership and all the partners come together under the EPI technical committee” .This nascent partnership further evolved and strengthened through the HPV demonstration project, which resulted in positive working relationships between many of the stakeholders.HPV vaccine project and as a result, respondents identified PATH as championing the application process and working behind the scenes to move the process along:Another contextual factor that strengthened the partnership was having a “champion” organization. As mentioned earlier, Uganda was one of the countries chosen by PATH to undertake the “PATH played a critical role. PATH continued reminding MoH of the need to prioritize the HPV [vaccine] introduction” .Qualitative data confirmed the survey finding related to high levels of trust in the network. Respondents typically reported trusting others they worked with, particularly if they had a history of working together. Trust was not always synonymous with perceptions of professional competence and low trust scores are clustered around technical assistance providers who were new to the Ugandan context. The trusting environment was also associated in interviews with country ownership, which was in contrast to the rushed process and lack of ownership in the subsequent IPV application process.“The HPV partnership functioned in an environment of trust as mentioned in the survey. There was accountability, honesty and shared goals. If this trust did not exist, then the application process would not be successful” .“Yes, the HPV application partnership facilitated country ownership of the process, especially when compared to IPV [application process]” .47 and the issue  was considered by respondents a reason for high partner involvement.Buy-in and ownership was also attributed to the high levels of political will and priority surrounding HPV vaccine and cervical cancer. The First Lady of Uganda was a champion for HPV vaccine,48 However, network mapping also uncovered ‘missing’ actors.Our analysis of the network data, confirmed by data from interviews and observation, indicates that the network structure displayed structural attributes consistent with other partnerships: relative decentralization; moderate density in the network core; and high average levels of trust see .20,21,48The network centralization score (0.40) indicates that there was no single leader in this network; although there is some tendency towards UNEPI, followed by WHO and UNICEF. This is illustrated in “The MoH took a lead in HPV application process… The government is currently taking the leading role in these processes unlike the past. However, PATH played a critical role. PATH continued reminding MoH of the need to prioritize the HPV [vaccine] introduction” (Development partner).The network survey helped to identify who was involved, as well as who was not. Given that HPV vaccine is targeted to adolescent girls, and that UNEPI proposed to deliver the vaccine through school-based channels, the involvement of the Ministry of Education (MoE) should have been a necessary condition for application. Some respondents noted that the MoE did not attend application meetings, although their signature was on the application submitted to Gavi:“I didn’t see MoE during the application process. They participated in demonstration project but not the application process. We could have actually involved them much more but we just didn’t” .The absence of the MoE was an issue also raised by the Gavi Independent Review Committee (IRC) in their initial review of the application, but the Alliance Board ultimately approved the application. The absence of the MoE was also raised to the EPI program by the FCE team in Uganda, who acted to include the MoE in planning meetings once the application had been approved. As Uganda ultimately decided to deliver HPV vaccine through schools, their participation in the planning process was necessary. This study may have been one contributing factor to their involvement during planning, thus, mitigating potential consequences of their absence.49 Participation of finance ministries in decision-making is recommended as a means of ensuring financial sustainability. As Gavi-eligible countries begin to take on a larger share of vaccine co-financing and transition from Gavi support, there are concerns over the long-term financial sustainability of immunization programs.51The Gavi Senior Country Manager was not named. While on one hand their strong engagement is considered essential for Gavi’s success, it is also true that they are meant to provide support for effective implementation of, and not applications for, Gavi support. Only one individual from the Ministry of Finance (MoF) was named, once. The lack of participation from the finance ministry is consistent with other network-based studies of new vaccine decision-making; a finding that is not always apparent from reviewing application documents alone.So far we have described a partnership that is based on trust and mutual understanding and structured to allow for shared decision-making across a wide range of actors. Yet supportive context and structure are not sufficient to lead to positive outcomes; how the partnership is managed in practice, and whether individuals fulfill their responsibilities and expectations will determine its ultimate effectiveness, efficiency, and country ownership.Numerous respondents noted that the HPV vaccine application partnership was not formalized in writing; no terms of reference existed to outline composition, roles, and responsibilities. Interviewers probed further on specific mechanisms intended to manage and coordinate immunization partnerships – the Gavi Business Plan and the Inter-agency Coordinating Committee (ICC) – but found they had not played their intended roles. The Gavi Business Plan outlined Alliance partners’ roles and responsibilities for Gavi activities in each country but few respondents were aware of its existence, and thus, which partners were assigned to which specific activities supporting HPV vaccine introduction. The ICC is a national policy advisory committee for immunization that is meant to coordinate partner roles and endorse all Gavi-related decisions, but it was implicated as a final decision-taking body as opposed to one coordinating work processes, roles, or responsibilities across partners.Respondents differed on the consequences of this for the process; some spoke favorably of the way in which roles were assigned on an as-needed basis. Others found that the process would have been improved if roles were assigned at the beginning. As a result, some respondents noted that some partners were more involved than others.The consequences of the management issues are perhaps best reflected by whether respondents considered the partnership to have benefitted effectiveness, efficiency, or country ownership. As noted above, the statements that were met with the highest level of agreement were on average related to country ownership and effectiveness, and then efficiency see .While the country ownership outcome scored high overall, only 35% of respondents thought the partnership improved the overall sustainability of the immunization program. A highly functioning HPV vaccine application partnership should add value not only to the HPV vaccine application process, but also to Uganda’s broader EPI program.As expected, an immunization partnership existed around the HPV vaccine application process for Gavi support, and the partnership was perceived positively in terms of perceived country ownership and effectiveness but slightly less so for efficiency. This study suggests three key drivers of partnership added value: trust; a diverse and inclusive network; and a clear governance mandate.A key finding was the importance of trust in facilitating the effective functioning of this partnership. Trust existed because of underlying relationships among the network actors, built in part by previous new vaccine introductions and through the HPV vaccine demonstration project. Trust matters; as the Alliance moves forward with the implementation of new forms of country-targeted technical assistance through the Partners’ Engagement Framework, they should remain sensitive to the need to build trust between and within all Alliance partners, including governments.Our second major finding is related to inclusiveness. On one hand, the absence of the education and finance ministries had the potential to lead to inefficiencies during implementation as their specific knowledge was and is necessary for effective, efficient, and sustainable implementation of the HPV vaccine. In part due to this study and the broader FCE, the MoH ensured the participation of the MoE during the vaccine introduction planning process, ensuring a smooth roll-out of a school-based delivery program. The under-representation of finance ministry staff in vaccine policy decision-making is a persistent issue which must be systematically addressed if long-term programmatic and financial sustainability is to be achieved.On the other hand, the network was otherwise diverse and inclusive. The composition of the network extended far beyond the Alliance’s ‘core partners’ and demonstrates the utility of empirically mapping such networks. Consistent with partnership principles and network theory, diverse actors ultimately improve the innovativeness and resilience of a network through their ability to access new ideas and resources. In this case, an NGO partner was instrumental in maintaining momentum during the process. However, despite the relative diversity of this network, we note that the network sub-core consists of relatively few individuals, and that the departure of even one could cause major delays or inefficiencies.20 such as the Alliance and most other global health partnerships.Our third driver of partnership added value is clear governance and management structure and processes. Compared to the other outcomes, respondents did not find the partnership efficient. Eighty-four percent of respondents perceived the partnership increased country ownership, compared to 79% considering it to have improved effectiveness, and 63% thought it improved efficiency. The principles that define partnerships, namely shared goals, and decentralized, diverse actors, simultaneously create governance and management challenges. This is particularly true in mandated, versus emergent, networks,Perceived efficiency and overall governance of the partnership could be improved while retaining its legitimacy. Specifically, this partnership did not report many standardized or formalized procedures or management mechanisms. While the relative lack of formalized rules and procedures enabled flexibility on one hand, we recommend that national immunization partnerships be strengthened to provide a clear governance and management structure and to clarify and coordinate partner roles and responsibilities. Reaffirming the central leadership roles of the EPI program — and strengthening their capacity to govern and manage — will ensure that good governance occurs while also strengthening country ownership.18 We see tremendous added value of applying a theoretical framework to inform study design, data collection, and data analysis and to contribute to theory-driven health policy and systems research.53 The partnership framework domains  were highly sensitive and specific to the data we collected, and this framework could be applicable to a variety of cases unrelated to Gavi support. We built on the framework’s intended qualitative data collection approach with the use of social network mapping in order to empirically measure who truly worked in the partnership, and the measurable structure and strength of their relationships. Without the network survey, we might not have realized the extent to which the ministries of education and finance were absent from the process, which has had mid-range consequences on the ongoing HPV vaccine planning process. Conversely, the network survey identified key non-traditional Gavi partners who were not named on the application, but yet played an important role in Uganda’s process. This finding may help Uganda’s EPI program as it considers partnership needs and ideal partners for ongoing and future immunization activities.This case study was driven by the partnership analytic framework.Our findings also highlight the benefits of the prospective evaluation approach to identify downstream consequences of partnership processes. However, and particularly in an ongoing, prospective evaluation where respondent burden and fatigue is of particular concern, the data-heavy needs of SNA are difficult to achieve. We recommend ongoing experimentation with secondary sources of network data, including meeting attendance, to reduce respondent burden while simultaneously leveraging the power of network science.The new Partners’ Engagement Framework will potentially improve the transparency and accountability of partners and increase country ownership by involving countries in the identification of their technical assistance needs from partners. However, this study showed that the existence of many capable partners does not ensure clear expectations and management of activities and processes. Ongoing evaluations should track the impact of PEF on partnership networks and their outcomes.Our choice of the HPV vaccine application case was for pragmatic and theoretical reasons. The fact that HPV vaccine is likely to require new or different partners as compared to childhood vaccines may limit the external generalizability of our findings. On the other hand, this same particularity makes it a very relevant case study to inform the implementation and evaluation of the Partners’ Engagement Framework, which will likely bring many new partners into established partnerships. This study was cross-sectional, which means that the network data do not represent the partnership dynamics that certainly exist.36 This study’s low response rate limits the internal and external validity of the reported SNA measures; however, we have taken great care to present quantitative network findings which were supported by data from qualitative interviews and participant observation. While our data likely provide a more accurate representation of the structure of the network core, we caution that the periphery structure, particularly its density, will be underestimated based on missing ties between non-interviewed nodes. While we measured respondents’ perceptions of the partnership’s effectiveness, efficiency, and country ownership during the study, the prospective nature of the Gavi Full Country Evaluation enabled the inclusion of evidence on the mid-term outcomes of the HPV application process and the national implementation of HPV vaccine.Only 11 network surveys were administered, in part to mitigate respondent burden within the context of a 4-year prospective evaluation. Network data collection is notoriously difficult due to the need to survey the census of the network, but not impossible with adequate time commitment and a supportive context.Despite the particularities of an HPV vaccine partnership, these data and findings can serve as a baseline from which to compare the effects of the new Partners’ Engagement Framework and whether that policy change increases effectiveness, efficiency and country ownership. This study offers a number of important lessons for the design and implementation of the Partners’ Engagement Framework; notably that the quality of relationships matters when considering new partners, and that without clear roles, responsibilities, and terms of references, adding new partners is only likely to decrease efficiency further. Further efforts to test the partnership framework should ultimately lead to clear recommendations for governments and partners outlining how to best structure and manage partnerships to achieve critical global health goals.The partnership framework and approach presented here can be applied to measure the health and performance of other global health partnerships to ensure that they are meeting the complex challenges they are designed to address. As partnerships become an increasingly common approach to health and development, it is important to ensure they are performing optimally and intervene when they are not. The partnership framework combines SNA and partnership theory into a single useful and adaptable framework that evaluators or policy-makers can apply to understand and intervene to strengthen networks, to ultimately improve global health more effectively, efficiently, and legitimately.We would like to acknowledge the support and assistance of other team members on this project: Faith Namugaya and Moses Kamya from IDRC, Kampala, Uganda; Julie Rajaratnam, Ashwin Budden, and Jeff Bernson from PATH, Seattle, WA, USA; and Steve Lim from the Institute of Health Metrics and Evaluation at the University of Washington, Seattle, WA, USA. Most of all we are grateful to the study participants in Uganda and particularly the Ugandan MoH for the time and knowledge they gave to this study. This work was supported by Gavi, the Vaccine Alliance as part of the Gavi FCE. The funder played no role in the work including design and conduct of the study, data collection, data management, data analysis and interpretation, preparation, review, and approval of the manuscript.Ethical approval for the Gavi FCE, which includes this study, was secured from the University of Washington Institutional Review Board and the Makerere University School of Biomedical Sciences Higher Degrees Research and Ethics Committee.Authors declare that they have no competing interests.JS, NS, PW, DH, and JB were involved in the conception and design of the study; CK, GA, JS were involved in the acquisition of data; CK, PW, GA, JS, and EC analysed the data; CK, JS, EC, NS, and PW drafted the manuscript with critical revisions from JS, DH, and JB.1Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda. 2PATH Seattle, WA, USA. 3Makerere University School of Public Health, Kampala, Uganda. 4Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. 5The INDEPTH Network, Maternal, Newborn and Child Health Working Group, Accra, Ghana. 6George Washington University, Washington, DC, USA. 7Management Sciences for Health, Arlington, VA, USA.Supplementary Files 1Click here for additional data file.Supplementary Files 2Supplementary Files 1 and 2 contain sample data collection tools.Click here for additional data file.Policy-makers can use the partnership framework and network mapping to understand the actors in the partnerships that affect their work.Based on an understanding of the relevant stakeholders, policy-makers, and those who support them can work to ensure that all relevant government and non-government stakeholders are represented in the process.Policy-makers and those who support them can strengthen partnerships and processes by ensuring sufficient coordination mechanisms, including the existence of terms of reference or a partnership coordinator. As partnerships grow they require additional investment in coordination.The public, and particularly the health of the public, is shaped by policies that are developed and implemented by networks of actors, where the ability to work together to develop or implement a government policy depends on who is involved and how they are connected. This study shows that the structure and quality of connections between people involved in immunization policy in Uganda affected their ability to work together effectively, efficiently, and with a sense of legitimacy. By improving the evaluation of partnerships using the partnership framework and approach, this research can help policy-makers make better policies by ensuring that the right people are involved, and better policies will ultimately improve the quality of life for all citizens.


Analyzing the disease-related web searches of Internet users provides insight into the interests of the general population as well as the healthcare industry, which can be used to shape health care policies.We analyzed the searches related to neurological diseases and drugs used in neurology using the most popular search engines in the US, Google and Bing/Yahoo.We found that the most frequently searched diseases were common diseases such as dementia or Attention Deficit/Hyperactivity Disorder (ADHD), as well as medium frequency diseases with high social impact such as Parkinson’s disease, MS and ALS. The most frequently searched CNS drugs were generic drugs used for pain, followed by sleep disorders, dementia, ADHD, stroke and Parkinson’s disease. Regarding the interests of the healthcare industry, ADHD, Alzheimer’s disease, MS, ALS, meningitis, and hypersomnia received the higher advertising bids for neurological diseases, while painkillers and drugs for neuropathic pain, drugs for dementia or insomnia, and triptans had the highest advertising bidding prices.Web searches reflect the interest of people and the healthcare industry, and are based either on the frequency or social impact of the disease. The burden of neurological diseases is prominent around the world, contributing to 2–6% in the World Health Organization’s analysis “Global Burden of Diseases 2010”[An approach to get additional information directly from the general population is analyzing Web searches, known as the infodemiology approach. Even ifIn this study, we aimed to analyze the searches related to neurological diseases and drugs for neurological diseases in the US. We enhance previous web search methodology with analysis of bid prices in web search advertising, allowing us to infer the interests of the healthcare industry.Considering differences in the use of search engines, languages and organization of health systems between countries, we only analyzed searches done in English from the US, using aggregated data for 2015. By focusing in only in the US we were able to obtain more homogenous results at the prize of losing generalization to other Western countries and assuming the bias to higher-educated population. All data used in this study was obtained from public advertising interfaces (APIs) available in the two major search engines, Google and Bing/Yahoo. No user identification procedure was performed at any time. Therefore, informed consent was not requested from users as we used aggregated results. For the same reason, we could not do session analysis, in which we would track the sequence of requests of each user . For this reason, we focused in more precise terminology such as disease diagnosis and did not performed more general, common or vague terms such as “pain”, which prevented the analysis by symptoms. The ethical committee of Hospital Clinic of Barcelona, Spain, approved this study.http://www.ninds.nih.gov/disorders), which provided a list of 448 neurological diseases and enriched the list with its common disease abbreviations.We used the list of diseases from the National Institute of Neurological Disorders and Stroke (https://www.centerwatch.com) and Medilexicom (http://www.medilexicon.com) including the generic and brand name. Because some commonly used drugs in Neurology are old  or may have not been approved for these indications (off label use), we enriched the list of drugs with the list of drugs reimbursed by Medicare for neurological diseases as described in[In addition, we created the list of FDA approved drugs for neurological diseases (including pain) from Centerwatch . For our analysis, we use the standard advertising APIs of Google and Bing/Yahoo restricted to the US market, as they are the major search engines nowadays. For the case of Google, we also include a competition factor that estimates the competitiveness for the market of each query, or in other words the number of companies interested in a given term (https://support.google.com/adwords/answer/3022575?hl=en).We evaluated people’s interest in brain diseases by using the volume of search terms related to neurology, either disease diagnosis or CNS drugs. That is, we considered the frequency or volume of a query (or group of queries that have the same meaning) as a good proxy for the interest of people. Similarly, we used the real-time bids for web queries by advertisers to evaluate the interests of the healthcare industry. In search advertising, a second price auction is performed for each query, where for each click the advertiser pays what the next advertiser is willing to pay. Therefore, the bid value is a good proxy for the interest of the industry (advertiser) for a given query. Hence, the total value of the market for that query, We evaluated the interest of people in neurological diseases by using the volume of search terms related to neurological diseases (full name or common abbreviations) in the two most important search engines Google and Bing/Yahoo . We founMoreover, highly ranked searches included polysemic terms such as “whiplash” or “shingles”. Both engines handle polysemic terms in a different way, which can explain some differences in the frequency of searches. In our queries, we included the name of the disease as well as common disease abbreviations. However, abbreviations can refer to different terms. Nevertheless, the effects of such abbreviations were not significant because they did not modify the ranking of a given condition, with three exceptions: IBM (Inflammatory Body Myositis vs IBM corporation), PSP  and TM (Transverse Myelitis vs Trademark) .Second, we analyzed the bids for queries by advertisers to evaluate the interest of the healthcare industry in neurological diseases . AlthougWe evaluated the searches for drugs for neurological indications . The mosWe analyzed the relation between query volume and query bid  for drugs and diseases for both search engines . ADHD, Acompetition factor and suggested bid, and the correlation of Google’s volume and spend (competition factor depends on the number of advertisers for each query. The spend (volume * bid) correlated in both search engines , the most commonly searched drugs were generic drugs (OTC) such as painkillers, or drugs for sleep disorders, dementia, ADHD, stroke or PD. Therefore, web searches provide an overview of the interests of the general population regarding neurological diseases. We must take in consideration that the results from web searches would not match results from epidemiological studies because they always involve the bias for the most educated population having better access to the Internet.In addition, we evaluated the market value of such drugs for the healthcare industry, which is mainly based on direct advertisement to users and therefore differs from marketing strategies for addressing health care professionals such as neurologists (e.g. recently approved drugs for CNS diseases). This infodemiology analysis can be useful for defining the health policies for neurological diseases as well as understanding the interest of the pharmaceutical industry.Previous studies regarding web searches about neurological diseases have shown that patients with several neurological diseases such as MS, Parkinson disease or epilepsy search extensively the web –14. For Several limitations should be considered for the interpretation of this data. First, while these web searches cover the US population, they cannot be considered representative of the overall population interests because of differential access to the internet and computer literacy between ethnicities, ages and socio-economic status. We decided to focus only in the US in order to avoid other sources of bias. The US population is the most populated country of all developed countries plus they use a single language  with a common health system. We have considered analyzing other populous developed countries together (European Union and the Far East—Japan and South Korea-), but the language and the health systems diversity would decrease the accuracy of the results and would not solve the bias versus wealthy and well educated populations having better access to Internet. Moreover, we discarded underdeveloped countries in our study because they would introduce the bias of having different frequencies of diseases  and less access to therapies. In summary, our US study can be considered a good proxy to the frequency of neurological diseases and use of CNS drugs in developed countries and a baseline for future studies in other countries.Second, search strategies can differ between people due to use of abbreviations, synonyms or colloquial expressions and here we have only analyzed disease terms and their abbreviations, but not other search strategies. We have explored the use of less specific terms in web searches such as symptoms and common complaints, but the specificity of such searches was low and the fact that the search engines do not allow to obtain user sessions, this prevents us to develop a strategy of linking concepts in order to increase sensitivity. That said, for drugs we used both the generic and brand names and therefore any variability due to polysemy or semantic strategies is less relevant. Our results may be influenced by media and news releases , which can significantly drive the searches, 18. FinS1 FileList of search terms used in this study.(XLS)Click here for additional data file.S2 FileResults for brain disease searches.(XLS)Click here for additional data file.S3 FileResults for CNS drug searches.(XLS)Click here for additional data file.


Human trafficking is a serious violation of human rights, with numerous consequences for health and wellbeing. Recent law and policy reforms mean that clinicians now hold a crucial role in national strategies. 2015 research, however, indicates a serious shortfall in knowledge and confidence among healthcare professionals in the UK, leading potentially to failures in safeguarding and appropriate referral. Medical education is a central point for trafficking training. We ascertain the extent of such training in UK Medical Schools, and current curricular design.We sent Freedom of Information requests to the 34 public UK medical schools, which included a preliminary question on education provision, supplemented with follow-up questions exploring the nature, delivery and format of any education, as well as future curriculum development.There was a response rate of 97%. A majority (72%) of the schools did not provide trafficking education. 13% of these did, however, offer opportunities outside the formal curriculum. 70% had no plans to implement any education opportunities. Among the 28% of schools providing teaching, 56% integrated this within the core curriculum. 56% only delivered this within a single year of the degree. 67% provided some form of teaching in-person, while 78% used a combination of methods.Medical education on trafficking in the UK is variable and often absent. To produce future clinicians who are competent and capable, there is a need for expanded education on trafficking and research into optimal curriculum design. The UK’s new Independent Anti-Slavery Commissioner should work with medical schools to develop an educational strategy urgently to fulfil the UK Government’s plans and commitments. Both in the UK and around the world, human trafficking education presents a critical opportunity to address human rights and safeguarding to a generation of new doctors. For over two decades now, trafficking in persons—also referred to by the broader moniker of modern slavery—has attracted extensive international attention. A reprehensible violation of human rights, this crime involves the recruitment and movement of individuals, both domestically and internationally, into conditions of exploitation . EstimatCentrally, the new Act stresses the need for public authorities to better cooperate in the assistance of trafficked people, identification of victims, and provision of support . The newHowever, a 2015 study conducted by Ross and colleagues found that 87% of NHS professionals reported a lack of knowledge in identifying trafficked people, and 78% reported insufficient training limiting their ability to assist these individuals , 10. HowSuch a lack of awareness and training are not, however, the consequence of low prioritisation or perceived irrelevance. Existing research indicates that clinicians would welcome training on human trafficking, specifically on how to identify and respond to human trafficking , 11. StuTomorrow’s Doctors requiring medical schools to provide the appropriate education and training that enables its students to ‘[i]dentify the signs that suggest children or other vulnerable people may be suffering from abuse or neglect and know what action to take to safeguard their welfare’ here is not a specific learning objective about human trafficking”. Such a response indicates the over-simplification of trafficking to sex trafficking in the minds of educators, which should be explored, as this is out of alignment with UK law. It may also leave students with an incomplete understanding of non-sexual forms of exploitation and drive inadequate or unsafe responses in later clinical practice, as the methods for identification and initial contact, the referral procedures, and the guidelines surrounding informing law enforcement agencies can vastly differ between different forms of abuse [In the minority of medical schools providing trafficking education (of abuse , 25. TraCritically, our results also indicate a student demand for education on the issue. Three institutions provide opportunities outside the formal curriculum to learn about human trafficking, evidencing that medical students are keen to learn about the subject and are taking up options to obtain the relevant education when it is not in the core curriculum. These results confirm those identified in the Canadian study which identified that 85% of students felt it was important or very important to learn about the identification and healthcare needs of trafficked individuals . In lighHowever, curriculum development should be undertaken in light of greater research and findings on good practice, both in the UK and abroad. We identified great variations in the context and format of teaching when it was delivered, which affirms general research on medical education . It is tHowever, just as modern slavery is not an issue confined to one country, its responses require international cooperation and cross-national learning. It is essential that innovations in teaching and learning are shared both within countries and between countries, as school-based and national curriculum developments may inform better educational practice around the world. Responses to encourage collaboration and cross-learning globally, and to facilitate the creation of broader and more effective approaches in the educational and clinical settings, must be implemented.In sum, medical students, as future clinicians, have a crucial and strategic need for education that allows them to perform a critical role in intervening, identifying, assessing and referring trafficked individuals. The safety and quality of care delivered to trafficked persons requires clinicians to have a good knowledge both of trafficking, including clinical indicators, and appropriate responses both within the clinic and to the relevant referral bodies. Despite a renewed focus on this subject in recent decades, there are serious shortcomings within the health sector in meeting and addressing the needs of modern slaves, leading to behaviours that can jeopardise the well-being of these already vulnerable adults and children. We recommend expanding education on modern slavery within UK medical schools to establish the foundation for best practice in future clinicians.