User fees for health care services are a frequently applied policy tool to improve efficiency by controlling demand and contain costs. It is also applied to increase resources for health care, especially when public resources are limited or the increase of income-related contributions is not feasible or not desirable. In addition, in Central and Eastern European (CEE) countries, where informal payments are widespread, the introduction of user fees is often promoted by politicians and policy makers as a potential policy tool to eradicate or “formalize” informal payments .Informal payments are unofficial cash payments or gifts in kinds directly given to the health care personnel before or after using health care services. The literature on informal payments suggests that these payments violate the idea of transparency in health care financing and the accountability of providers, which results in an inefficient use of health care resources and inequalities in access to health care Furthermore, informal payments create adverse incentives for their beneficiaries, which can be in conflict with the government’s policy objectives. .Thus, in the last decades in the CEE countries, several policies have been implemented to eradicate these payments, including the introduction of official user fees for health care services. However, there is no evidence that supports this expectation. On the contrary, there is evidence to suggest that patients continue to pay informally after the introduction of user fees –5. In thAccording to the OECD Health Statistics in Hungary, the total health expenditure accounts for 8% of the GDP in 2012, with a per capita expenditure of 1,358 USD, which is lower than the OECD average. The share of out-of-pocket payments in total health expenditure has increased considerably during the last decades, and has reached 28.3% in 2012, and accounts for about 5% of the total household expenditure. This level is one of the highest among European OECD countries. Above 80% of these payments are co-payments for pharmaceuticals (80%). There are no official co-payments for health care services, however informal payments are widespread. Hungarian health care consumers have been paying informally for medical services on a routine basis, especially in in-patient care. According to a study carried out in 2010 around one-fifth of the respondents who used physician services during the last 12 months, made informal payments, on average 60 €, and almost half of the respondents who were hospitalized during the last 12 months, paid informally on average 130 € .In 2007 in Hungary, official user fees were introduced for the use of health care services covered by the social health insurance. The introduction of these fees was one element of the reform package to contain health care cost. According to the documented policy objectives, it was expected that official fees will contribute to the eradication of informal payments .Although the amount of user fees was relatively low , the implementation met with strong political opposition and unpopularity among the public. One year later, in April 2008, the payments were abolished as a result of a population referendum initiated by the opposition party in the parliament, where more than 80% of the voters supported the abolishment of the fees  including the implementation and abolishment of user charges, Baji et al. found, that the co-payments lead to a relatively greater burden on worse-off households. [The Kakwani-index of formal household expenditure for health care services decreased from 0 to −0.1 in 2007 ]. At theDuring the 1-year period (2007) when user fees were charged for the utilization of health care services, household expenditure on informal payments decreased and became less regressive, i.e., the decrease of informal payments was higher in lower-income households . The reduction of informal payments can partly be explained by the drop in the utilization of services, which was recorded during this period. However, a higher decrease in the expenditure on informal payments among low-income households was observed, which also suggests that worse-off households tried to compensate the increase of formal payments by decreasing their expenditure on informal ones.In another study, Baji et al., analyzed the short-term changes in the probability of paying informally for in-patient and out-patient care 2 months after the implementation of user fees. The findings suggest that the probability of paying informally decreased only for hospitalization among elderly people . ElderlyOverall, the results presented above suggest that the implementation of user fees can lead to a reduction of informal payments of those health care consumers who are not able to meet the double burden. However, this finding raises questions concerning equal access to health care services. It is possible that consumers, who are not able to pay informally for health care services, may not obtain the services that other consumers obtain because they continue to pay. In this way, the reduction of informal payments can create even greater inequalities between different income groups.Nevertheless, both studies show that informal payments remain relevant. For those who are able to pay and have no budget-constraints, formal payments do not substitute for informal payments, at least at the short term, these payments rather co-exist and complement each other.Findings from a qualitative study provide some explanation for this . ConsumeAlso, attributes connected to the health care personnel  are more important for health care consumers than other service attributes, like the health care facility, equipment or even waiting time for the visits, or traveling time to the health care facility . These rFurthermore, Hungarian health care consumers are rather tolerant toward informal payments, mainly because these payments provide additional salary to the (underpaid) health care personnel . Also, sTo summarize, health care consumers doubt that user fees in 2007 had the potential to eradicate informal payments as formal fees do not substitute for informal payments. The lack of support for the stated policy objectives makes the implementation of these charges more unpopular and this might be one of the reasons why the fees were rejected by the population in the referendum. Findings suggest that the problem of informal payments remains relevant even after the implementation of user fees. However, if formal payments do not substitute for informal payments, user fees induce a double financial burden on health care consumers, and make official charges less acceptable to the public.After the implementation of user fees, informal payments remain relevant and the two payments co-exist. However, the increase of formal payments may indeed lead to a decrease in informal payments, specifically among low-income households who are not able to pay for the double  price.Regarding the policy implications, we can say that the reduction of informal payments is a desirable policy aim because of the adverse effect of these payments on the health care system, i.e., inefficient use of resources, barrier to access, and adverse financial incentives for beneficiaries. However, if the decrease of these payments only occurs among the lower-income households, among those who are not able to pay for the double burden, this mechanism can increase inequalities in access among households with different income. Those who are able to pay for the double burden may have better access to health care services compared to those who are not able to pay. Thus, the implementation of user fees is hardly sufficient and rather a controversial policy tool to diminish informal payments.The Hungarian experience with the implementation of user fees confirms that public acceptance is crucial for a successful implementation of user fees. However, in Hungary the declared policy objectives of the implementation of the user fees were not supported by the public, making the implementation of these charges more unpopular.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Acid attacks committed as crimes of passion are unfortunately becoming far from infrequent occurrence. The injuries sustained in such attacks mainly involve the face and trunk, with the acid causing cutaneous and subcutaneous tissue burns that can result in permanent scarring, loss of the nose or external ear, and severe visual impairment. Different surgical solutions have been proposed for reconstruction of the auricle following loss of the ear through traumatic injury or cancer or in patients with congenital defects: surgical reconstruction may involve the insertion of an autogenous rib cartilage framework or the use of a porous polymer material inserted into an expanded postauricular flap. Reconstruction with rib cartilage has given good results but requires more than one surgical step and may be associated with adverse events involving both the donor site and the recipient site, while rejections of polymeric prostheses have been reported following their insertion into expanded postauricular flaps. The use of a titanium dowel-retained silicone prosthesis, in which the dowel is anchored to the temporal bone, is a surgical possibility, indicated particularly in cases of pinna resection due to tumour or auricular scarring following traumatic injury. Facial injuries resulting from acid burns may be sustained in situations of war; in peacetime, on the other hand, they may be the result of accidents in the workplace or home or crimes of passion. In the latter case, the attacks, intended to disfigure the victim, are inflicted as a form of punishment and can be linked to a range of different situations: lovers' disputes, financial disagreements, family feuds, robberies, vendettas, and so on , 2. AcidNitric acid, muriatic acid, and sulphuric acid, which are readily available, are agents commonly used in revenge attacks. The target is usually the face, although burns to the scalp, neck, and arms are also frequent. More superficial injuries, involving the skin and dermis, can be repaired with skin grafts. Deep lesions on the other hand, especially ones involving the nasal or auricular cartilage, usually result in severe disfigurement that is more difficult to correct. In such cases, the patients could be treated with classic plastic surgery based on the use of rib cartilage for skeletal pinna reconstruction covered by skin grafts. However, application of these solutions is often severely complicated or precluded by the conditions of the residual tissue, hence the growing use of prostheses in nasal pyramid or outer ear reconstruction. Initially, these prosthesis were held in place by adhesives which, however, gave poor results in terms of stability and were often associated with skin irritations.Now, however, there exists an excellent and innovative surgical technique that allows the fixation of ear epitheses by means of bone-anchored titanium implants , 8.The case of WP, a 38-year-old Caucasian male who, two years earlier, had been the victim of a crime-of-passion acid attack came to our attention. The attack had left him with very serious burns to the face, upper chest, and arms. In addition to suffering cutaneous and subcutaneous injuries, the patient had lost the use of his right eye (replaced with a prosthesis), while the damage to his left cornea had necessitated a transplant; he also presented with almost complete erosion of both pinnas . ImmediaSurgical procedure: before the surgical field is prepared and with the patient's face still fully and easily visible, the implant sites should be carefully marked, using methylene blue, down to the bone. Two implants are normally sufficient for satisfactory retention. These are ideally placed approximately 20 mm from the centre of the external auditory canal opening or anticipated opening. They are positioned at 8 o'clock and 10.30 on the right side and at 4 o'clock and 1.30 on the left side.We usually perform one-stage surgery, removing tags and remnants in cases of microtia and performing the necessary subcutaneous tissue reduction. In this patient, too, we removed the residual cartilaginous structures of the external ear, which were embedded in scar tissue .An incision is made 10 mm behind the anticipated implant site. Dissection is performed down to the periosteum. A cruciate incision is then performed at each implant site. The edges are raised with a raspatory.Drilling begins using the guide drill with the spacer kept on 3 mm. During drilling irrigation should be performed. The bottom of the hole is repeatedly checked for bone at the base of the site. If there is adequate bone thickness drilling continues to a depth of 4 mm. The drill indicator will facilitate correct drill orientation. The next step is to widen the hole to the exact diameter using a 3 or 4 mm drill countersink. Irrigation should be guaranteed.At this point, implant installation is performed. The low speed setting should be used for implant insertion. In compact cortical bone a torque setting of 40 Ncm is recommended, whereas in soft bone a lower torque setting of 20 Ncm should be used.The self-tapping fixture with the premounted fixture mount is seated inside the plastic ampoule in a titanium cylinder. It is then picked up with the connection to handpiece, which is placed into the drill handpiece. The implant is installed without cooling irrigation until the small grooves at the distal end of the implant are well within the canal. When the flange of the implant has seated the handpiece will automatically stop.The mount is removed using the Unigrip screwdriver and the surgical wrench. The titanium standard abutment is picked up with the abutment holder and placed into the implant. We perform manual tightening, using the abutment screw, to 25 Ncm.The skin is then repositioned over the implants. Holes are punched through the skin exactly over the abutments with a biopsy punch. The skin is then sutured. Healing caps are positioned on the abutments.A gauze dressing is applied in a figure of 8 . The healing caps are thus held in place. The patient was discharged the day after surgery and was seen again for the first dressing after seven days. The patient received a new dressing every seven days for a month.It is important to wait at least six weeks before loading the implants.Following healing and stabilisation of the surgical site, the patient was sent to the anaplastology technician who prepared the epitheses, modelling them on the father's pinna and carefully matching the patient's skin colour. The silicone epitheses were created using a wax pattern. The definitive ones have two sides: the inner one in an acrylic plate with clips that allow the attachment to a gold-platinum bar fixed to the abutments; the external one is made of soft silicone. When the process of osseointegration is complete, the prostheses, which also have clips, are easily and securely attached to or removed from the gold-platinum cylinder-and-bar system .The treatment of chemical burns of the face and body varies considerably depending on when the patient comes to clinical attention, the extent of the injury, and the presence of acid-induced erosion of the superficial and/or deep tissues. Indeed, the surgical management varies according to the time that elapses before the patient is seen. Immediately after the event it is easier to clean the lesion site and begin the work of reconstruction using skin flaps. However, patients often present several days (7–9 days) after the event when necrotic processes, possible superimposed bacterial infections, or the onset of spontaneous cicatrisation processes made the task of reconstruction more complicated .In the case of superficial tissue damage, the lesion is cleansed, also removing any dead tissue, and it may be treated with skin flaps. Deep lesions involving the nasal pyramid or auricle, possibly severe enough to result in their partial or total amputation, are instead much more difficult to treat.In these circumstances the usual techniques of plastic surgery are difficult to apply since they are procedures that require the presence of large areas of intact skin around the lesion (necessary for the preparation of sliding skin flaps or the use of tissue expanders prior to the placement of subcutaneous implants). This condition is not met by patients with extensive skin necrosis resulting in areas of atrophic scarring.n = 17) and several by traumatic mutilation of the external ear (n = 7), while the remaining ones (n = 2) required reconstruction following resection of the ear due to cancer. All the patients were completely satisfied with their reconstructions. No surgical complications, implant failures, or prosthetic failures were encountered.For this reason prostheses are being used increasingly readily. For three years, our department has been a reference centre in northern Italy for the implantation of auricular epitheses using the osseointegrated implant system, with which we have now treated 26 patients. Most of these patients were affected by microtia (Bone-anchored titanium implants provided these 26 patients with a safe, reliable, adhesive-free method of anchoring their auricular prostheses and restoration of their normal physical appearance.Basically, this approach is an evolution of the implants for dental prostheses proposed by Brånemark et al. in 1969: these have been used for 40 years in the field of odontostomatology, which the same author subsequently reproposed as percutaneous craniofacial implants for use with bone conduction hearing aids , 11.In the patient here described, who presented bilateral chemical injuries, the extent and complexity of the lesions and the considerable amount of scar tissue that had formed clearly ruled out recourse to the usual techniques of plastic surgery. We therefore opted for removal of the cartilaginous remains of the concha auriculae and tragus, followed by implantation of titanium abutments that, once properly osseointegrated, guaranteed adequate fixation of the ear epitheses. We usually treat patients with a monolateral injury and in such cases the artificial auricle is modelled on the patient's contralateral one. In this case, we decided to use the patient's father's auricle as the model. Correct osseointegration of the implants was achieved in the appropriate time and no postoperative complications occurred. The aesthetic outcome was good, as shown in It should be underlined that it is crucial, also for these patients' mental and physical well-being, to try and restore to them the sense of self-dignity conferred by a harmonious physical appearance. It would be appropriate, even prior to the surgical intervention, to work out a multidisciplinary therapeutic approach for tackling the psychological and social reintegration difficulties that face patients with injuries of this kind.


First initiated in 1995 to provide veterinary students with spay/neuter experience, the shelter program at the Mississippi State University College of Veterinary Medicine has grown to be comprehensive in nature incorporating spay/neuter, basic wellness care, diagnostics, medical management, disease control, shelter management and biosecurity. Junior veterinary students spend five days in shelters; senior veterinary students spend 2-weeks visiting shelters in mobile veterinary units. The program has three primary components: spay/neuter, shelter medical days and Animals in Focus. Student gain significant hands-on experience and evaluations of the program by students are overwhelmingly positive.The shelter program at the Mississippi State University College of Veterinary Medicine provides veterinary students with extensive experience in shelter animal care including spay/neuter, basic wellness care, diagnostics, medical management, disease control, shelter management and biosecurity. Students spend five days at shelters in the junior year of the curriculum and two weeks working on mobile veterinary units in their senior year. The program helps meet accreditation standards of the American Veterinary Medical Association’s Council on Education that require students to have hands-on experience and is in keeping with recommendations from the North American Veterinary Medical Education Consortium. The program responds, in part, to the challenge from the Pew Study on Future Directions for Veterinary Medicine that argued that veterinary students do not graduate with the level of knowledge and skills that is commensurate with the number of years of professional education. The American Veterinary Medical Association (AVMA) Council on Education (COE) requires veterinary schools to “provide instruction in both the theory and practice of medicine and surgery.” The accreditation standards for veterinary colleges state that “must include principles and hands-on experiences in physical and laboratory diagnostic methods and interpretation, … disease prevention, biosecurity, therapeutic intervention (including surgery)” among several other skills  The receIn 1995, in an effort to increase the hands-on clinical experience of veterinary students the College of Veterinary Medicine at Mississippi State University developed a cooperative program with a local animal shelter. Over the years the shelter program has grown in stages. Early on the program focused on spay/neuter surgery. From 1995 to 2007 the program was limited to one or two local shelters that had their own surgical suite. In 2007, the College obtained a mobile veterinary unit. No longer limited to shelters with a surgical suite the program rapidly grew to serve 14 different animal shelters. In 2013, with the addition of a second mobile veterinary unit the program expanded to 20 animal shelters and enrollment was opened as an extern experience for students from other veterinary schools. In 2014 the program was expanded to include an increased emphasis on shelter animal wellness care, medical management and shelter management as well as developing an educational component that targets elementary school children.During the early years the shelter program at the Mississippi State University College of Veterinary Medicine involved just third year veterinary students. Third year students have nine months of clinical activities in the veterinary teaching hospital. This includes a 6-week primary care rotation focused on routine small animal care. Initially every student in the primary care rotation spent one day at a local animal shelter performing spays and neuters under the supervision of a board certified surgeon. Students took turns rotating though the surgical suite performing surgeries with a faculty surgeon scrubbed in as their assistant. The role of the faculty member was to guide the student through the procedures, intervene to prevent errors, help the students when there were problems, and provide verbal and written feedback to the students after the surgeries were completed.Conducted as a “mash style” spay/neuter activity, all necessary surgical supplies were transported to the shelter along with the students and faculty member. The shelter provided the surgical suite, surgical table, anesthetic machine and, of course, the animals. Shelter personnel would select the animals they wished to present for surgery. Pending the results of a brief physical examination, patients would be anesthetized, prepped for surgery and transported to the surgical suite one at a time. Cases were assigned to give each student equal opportunity to perform each of the surgical procedures; cat spay, cat castration, dog spay, and dog castration.Initially all surgeries were performed on adult (over 6 months old) dogs and cats. Shelter management resisted the practice of early age or pediatric spay/neuter in spite of the fact that a majority of adoptions were puppies and kittens. Eventually, with a change in shelter management, pediatric spay/neuter was added to the program thereby providing students with experience in performing spays and neuters of puppies and kittens as young as six to eight weeks of age.In 2005 the shelter program doubled in size. When a local humane society built a new animal shelter that included a surgical suite, the college expanded the program to include that shelter. Rather than reduce the trips to the original shelter the approach was to simply add more trips. With this addition every third year student spent 2 days (one in each of the two shelters) performing spays and neuters.The College obtained its first mobile veterinary unit as a result of Hurricane Katrina. In 2005, Hurricane Katrina created massive destruction on the Mississippi and Louisiana gulf coast. One of the aftermaths of Hurricane Katrina was an increase in funding for animal rescue and spay/neuter along the gulf coast. A grant from the American Kennel Club Companion Area Recovery along with private donations allowed for the purchase of a mobile veterinary unit designed for disaster recovery and spay/neuter See . A grantWith the acquisition of the mobile unit the college was no longer limited to shelters that had their own surgical suite, so the program rapidly expanded to 14 shelters. The college created a senior year shelter medicine spay/neuter elective rotation. The 2-week rotation functioned year round except for Christmas and New Year’s break and could enroll two senior students at a time. Shelters would still select their patients, but with the mobile unit the program was no longer limited to just one surgery being performed at a time. The junior students still made two trips to shelters and still scrubbed in with a faculty member acting as assistant. Junior students averaged 15 sterilization surgeries in those two trips. Up to 50 senior students could enroll in the elective each year. Senior students would make seven or eight trips to shelters. On the first day of the 2-week elective a faculty member would scrub in with the senior students for each surgery, but after that first day senior students performed the surgeries unassisted. A faculty member or resident was always supervising surgeries and could scrub in to assist if necessary, but for the most part students performed the surgeries on their own. As long as the safety of the patient was not at risk, students were given the chance to handle problems/complications on their own. Senior students would average over 70 surgeries each during the 2-week rotation. With this many surgeries in a concentrated period of time, most students became efficient and confident in their surgical skills.The program still had limited enrollment during this period. Enrolling two students for 2-weeks at a time, 50 weeks of the year, kept enrollment at 50 students a year. Demand for the elective was great but with a class size of 80 to 85 students per year approximately 40% of each senior class was unable to enroll. Discontented with the situation, the freshmen Class of 2014 initiated a project to raise funds to purchase a second mobile unit. When PetSmart Charities heard of the students efforts they funded a grant to purchase a second mobile unit See .The second mobile unit was put into service in January of 2013, just in time for the Class of 2014 to be the first class in which every student who wished to take the Shelter elective could enroll. Every junior student still goes on two trips, but the capacity for senior students expanded from 50 to 120. With an enrollment of 85 students per class at Mississippi State University College of Veterinary Medicine there is room to enroll between 35 and 40 senior students from other schools in the elective. The 2-week elective is offered 48 weeks per year and can accommodate five senior students each rotation. Each mobile unit goes to seven or eight different shelters during the 2-week rotation and senior students still average nearly 70 surgeries each.Provide veterinary students extensive experience in spaying and castrating animals that will be placed for adoption;Provide veterinary students with first-hand experience in dealing with the medical behavioral and surgical problems encountered in animals confined to animal shelters;Increase veterinary students’ understanding of the issues surrounding overpopulation of unwanted pets;Prepare veterinary students to work closely with local humane societies and animal shelters to find solutions to the overpopulation of unwanted pets in the local community.The intent of the junior experience at shelters is to acquaint the students with the issues animal shelters face and to provide an opportunity to perform several sterilization surgeries. The senior elective is much more in-depth and is designed to: The surgical techniques used are similar to those used in high volume spay/neuter clinics and are consistent with the standards outlined by the Association of Shelter Veterinarians (ASV). (REF) All students who participate in the program are required to view videos of the surgical techniques prior to performing surgery See .Understanding of these surgical techniques is then reinforced by the faculty who scrub in to assist the juniors on both days that they perform surgery and for seniors and extern students on the first day of their rotation.Senior students and externs in the 2-week elective are given assigned reading to increase their understanding of the problems associated with over-population of unwanted dogs and cats, the standards of care in spay/neuter clinics, and standards of care in animal shelters See .The program has an impact both on the veterinary students and on the shelters that participate. Since the inception of the program over 55,000 sterilization surgeries have been performed at local shelters. Since the first mobile unit was acquired in 2007, over 51,000 surgeries have been performed. The adoption rate of the animals that have been sterilized are extremely high, even in shelters that have high euthanasia rates. The program has clearly saved the lives of numerous animals by increasing the adoption rates . Furthermore, the animals adopted are sterilized preventing future litters of puppies and kittens, and for some shelters reducing the intake numbers over time.The increased surgical skills and understanding of the problems of pet overpopulation by the veterinary students is, however, the true impact. Students learn high quality high volume spay/neuter techniques in both pediatric and adult dogs and cats.  On average each student performs 67 sterilizations during his/her 2-week rotation, See Veterinary students participating in the shelter elective at Mississippi State University College of Veterinary Medicine gain extensive surgical experience performing spays and castrations of adult and pediatric dogs and cats.Students are overwhelmingly positive about the experience. Senior students in the 2-week elective consistently rate the experience as one of the most valuable in their veterinary education.Student evaluations of the shelter elective at Mississippi State University College of Veterinary Medicine are consistently very positive See .Students appreciate the opportunity to gain extensive surgical experience during the shelter elective at the Mississippi State University College of Veterinary Medicine.Extern students frequently provide feedback as well: “This rotation is extremely valuable to my education. At my school we only get one spay and one neuter prior to graduation, which is why I came here. You guys have made me much more comfortable in surgery. For that I am so grateful.”With the elective receiving such positive reviews and with the addition of the second mobile unit enrollment in the course has steadily increased over time See .In May of 2013, a second component Shelter Medical Days was added to the program expanding the emphasis from spay/neuter and animal wellness to include shelter disease control and biosecurity. Shelter medical days are currently housed within the 6-week Community Veterinary Services junior rotation. Each student spends at least 3 days of the rotation at an animal shelter in the surrounding area, increasing the number of days spent in a shelter from 2 days on the mobile unit to a total of 5 days. Typically, a shelter medical day begins with a biosecurity walk-through of the shelter. In order to encourage students to look critically at breaks in biosecurity, they are given the task of completing a “photo scavenger hunt”. To complete the scavenger hunt they must take pictures of breaks in biosecurity, of good biosecurity practices, and signs of disease. The only rules are that all of the pictures must be taken on the camera belonging to the shelter medicine program and no employee faces can be in the photos. After all of the students have completed their 3 shelter medical days, the pictures are collated and discussed during a grand rounds session. Discussion includes explanations of why the picture was taken as well as what should be done to correct any breaks in biosecurity or prevent any transmission of disease.Following the walk through at the shelter, students spend the remainder of the shelter medical day performing physicals, basic diagnostic tests and behavior assessments. Students have access to supplies for basic fecal floats, cytology, skin scrapes or any other easily transportable tests. Students also have access to ophthalmoscopes, otoscopes, and stethoscopes. Under the supervision of a faculty member students perform exams, diagnostic tests and make diagnosis and treatment plans for the animals in the care of the shelter.Shelter Medical Days give all junior veterinary students experience in routine physical examinations and routine diagnostics. Students encounter conditions that are not commonly presented to the veterinary teaching hospital, but are commonly encountered in private veterinary practice. In addition, this program provides students with an increased understanding of disease control, disease prevention and biosecurity in the shelter environment.In 2014, a third arm, Animals in Focus (AIF), was added to the shelter program. AIF is an elementary school program direct at children in socioeconomically disadvantaged areas in Mississippi. In these areas animal neglect and abuse, such as dog fighting, tend to be more prevalent than in some other areas of the state. The intent of this program is to introduce students to the needs of animals, increase the perceived value of animal life, and to use animals as a teaching tool for individual health of both the pet and the children. AIF uses fun and interactive programs to establish relationships with the students and teachers in the schools. An imperative part of the program is using animals (most often dogs) as teachers. The children play games with the animals, learn how to safely interact with animals, and begin to place a higher value on the lives of animals in general. In addition, the hope is that teachers are able to use pets as teaching tools in the classroom. The expectation is that this will increase enthusiasm in the classroom, improve attendance, and generate higher levels of self-confidence in the students.While AIF is a great program for children in these areas across the state, it is a benefit for the veterinary students as well. Veterinary students in their third year are invited to volunteer for AIF trips. Generally, 4–5 students participate in each trip. These trips are in addition to the junior year spay neuter trips and the shelter medical days. The students lead games for the elementary school students and help them interact comfortably with animals. These trips, while being fun for the vet students, also expose them to community issues that they might not otherwise see. These trips also encourage the students to get involved in their own communities and give them the tools and experience that they need to do that.The shelter program, initiated twenty years ago, started very small with an emphasis almost exclusively on spay neuter. In the twenty year history the program has grown both in size and scope. The program now includes eighteen animal shelters/humane groups and incorporates spay/neuter, basic wellness, routine diagnostics, disease management and prevention and biosecurity in the shelter environment. Furthermore, the program is teaching elementary students the value of animal life and basic health principles for animals and people.The shelter program, while certainly benefiting the animals, the shelters, and the communities that participate, is directed towards increasing the hands-on practical skills of our veterinary graduates. Students obtain extensive experience performing surgery, performing physical examinations, conducting routine diagnostic tests, diagnosing and managing disease conditions all under direct supervision of veterinary faculty.


Advent of medical image digitalization leads to image processing and computer-aided diagnosis systems in numerous clinical applications. These technologies could be used to automatically diagnose patient or serve as second opinion to pathologists. This paper briefly reviews cervical screening techniques, advantages, and disadvantages. The digital data of the screening techniques are used as data for the computer screening system as replaced in the expert analysis. Four stages of the computer system are enhancement, features extraction, feature selection, and classification reviewed in detail. The computer system based on cytology data and electromagnetic spectra data achieved better accuracy than other data. Cervical cancer is a leading cause of mortality and morbidity, which comprises approximately 12% of all cancers in women worldwide according to World Health Organization (WHO). In fact, the annual global statistics of WHO estimated 470 600 new cases and 233 400 deaths from cervical cancer around the year 2000. As reported in National Cervical Cancer Coalition (NCCC) in 2010, cervical cancer is a cancer of the cervix which is commonly caused by a virus named Human Papillomavirus (HPV)  and generally converges on parameter estimates relatively easily . The disSVM's execution speed is very fast and there are no parameters to tune except the constant C. It is remarkably intolerant of the relative sizes of the number of training examples of the two classes. Since the technique is not directly trying to minimize the error rate, but trying to separate the patterns in high dimensional space, the result is that SVM is relatively insensitive to the relative numbers of each class. The possible disadvantages are large memory requirement  and the Meanwhile, the NN architecture is initially not structured and the learning algorithm is responsible for the extraction of the regularities present in the data by finding a suitable set of synapses during the process of observation of the examples. Thus, NNs solve problems by self-learning and self-organization . HoweverDecision tree is relatively easy to interpret and to implement. Like SVMs and NNs, many methods for decision trees do not provide a probability of class membership, although some variants, in particular, classification and regression trees, do provide such probabilities. However, performance of all decision trees is dependent on both their method of construction and the amount of pruning  performed .KNN and LDA are methods implemented in numerous programs and easy to be implemented as classification tools. Both techniques have direct analytical solution and very good at detecting global phenomena . However, they are simply defined and implemented, especially if there is insufficient data to adequately define sample means and covariance matrices. Both techniques only detect linear phenomena and are sensitive to individuals outside the norm.From As presented in The cytology combined with neural network gives the accuracy of up to 99% of accuracy to classify 400 data to be 2 classes, followed by neural network using the electromagnetic spectra features at 97.4% for classifying 780 data to be 3 classes. Greatly, the electromagnetic spectra features could achieve the higher accuracy only using discriminant analysis at 99.5% of accuracy. Therefore, based on As reviewed, the intelligent classification system for cervical precancerous cells has been attempted and developed using two types of input attributes; cervical cell/tissue images and cervical cell spectra. Therefore, the systems have employed image and signal processing techniques for extracting features as the input attributes, respectively. Both systems could classify the cervical precancerous cells with high performances. The applications of image and spectra processing and classifier for cervical precancerous classification have been developed by many researchers in the world. The screening techniques have been proven to have better performance than the manual techniques. Thus, the intelligent classification system for cervical precancerous using the image and/or optical spectra as input is believed to have better classification performance and could be used as a second opinion to pathologists.Six types of cervical precancerous data  generally can be used for the intelligent screening of cervical cancer. Computer screening system for cervical cancer based on cellular level data, namely, cytology, FISH, and electromagnetic spectroscopy, achieved better results as compared to tissue level data such as cervicography and colposcopy.Classification tools  generally can achieve good performances to classify the cervical precancerous data. The screening systems based on neural network technique are frequently applied due to the better results and potential of the technique to build a real time system.The long training time of the neural network can be reduced by using the features selection stage in the computer screening system. The dimensionality reduction popularly done by using discriminant analysis and principal component analysis can be developed using new techniques that can be proposed as future work in this research field. The developed techniques will reduce the training time and improve the classification result of the neural network.


Rapid rural-urban migration of people to cities is a reality around the globe that has increased city slum dwellers. Sodom and Gomorrah is a city slum located in the heart of Accra, Ghana. Like other slums, it lacks basic amenities necessary for dwellers’ quality of life. This study describes residents’ access to health and factors associated with the use of healthcare facilities.Questionnaires were administered in systematically selected shacks across the entire slum. Data on demographic characteristics, existent health facilities and number of users, health-insured residents and knowledge of common diseases were collected.p < 0.05) associated with the use of healthcare facilities. Younger residents and those without National Health Insurance Scheme membership, formal education, no knowledge of common illnesses and regular income were significantly less likely to use a healthcare facility. For most residents, neither distance (73.2%) nor transportation to health facilities was a problem (74.1%).Majority of the residents were from the northern parts of Ghana, relative to the south and a few of them come from other parts of West Africa. Seventy-one percent of residents had never visited a health facility in the last 5 years. When necessary, they access health care from drug stores (61.1%) or hospitals (33.1%). Residents’ age, educational status, income, health knowledge and membership of National Health Insurance Scheme were significantly (Conditions of profound environmental hazards, overcrowding, poor-quality housing and lack of health care in Sodom and Gomorrah pose grave threats to the health of the inhabitants. Multisectoral interventions and resource mobilisation championed by the Ministry of Local Government and Rural Development are needed to alter the trend. Stack poverty makes it difficult for them to afford many essentials of life; they experience grave deprivation pushing them into a state of despondency.3A slum, according to the United Nations and UN-Habitat, is a run-down area of a city characterised by poor substandard structural quality of housing, insecure residential status, squalor, overcrowding and lack of basic amenities.7 The overcrowding and poor housing coupled with the dirt and squalor and lack of financial resources contribute to the presence and spread of varied infectious diseases in slums, affecting women and children mainly.10 Maternal mortality, high vulnerability to HIV infection, high unmet need for family planning and developmental challenges in children and adolescents are just a few of the many negative results of poor access to health in city slums.15City slums may geographically be close to healthcare facilities, yet residents are deprived of access to needed health care resulting in negative economic and health consequences.8 Three of the MDGs − 4, 5, and 6 − specifically focus on health and seek to reduce infant and maternal mortality and combat diseases such as HIV and malaria, conditions which are unfortunately rampant in slums.16 To be effective, interventions aimed at making lasting changes must be context-specific, empowering and evidence-based. It is in this regard that research in this area is essential if strategies are to produce the desired outcomes.Improving living conditions and access to quality health care for all, particularly for slums dwellers, is central to development and speedy realization of the Millennium Development Goals (MDGs) in any country. Efforts towards achieving the first MDG goal, eradication of extreme poverty, through cross-cutting appears more urgent in slums where poverty is demonstrably present.19 it is expected that findings from this study can provide insights into some of the health issues of other city slums within the country and sub-Saharan Africa for appropriate and targeted interventions.The purpose of the study was to examine health issues in Sodom and Gomorrah in Accra, Ghana, and factors that may be associated with accessing healthcare facilities in the last year. This study is timely in the light of the fact that even though a plethora of studies on slums exist, very few have looked at the situation in sub-Saharan Africa and studies on Ghana are practically nonexistent. Because slums around the globe share similar characteristics of poverty and deprivations in many spheres of life, including health care,20 The study population consisted of adults in the Sodom and Gomorrah community who were heads of their respective dwellings or households.The survey was conducted in Sodom and Gomorrah, a slum within Accra city, near the Korle Bu Teaching Hospital (KBTH). It stretches across 146 hectares and houses an estimated 25 000 to 40 000 residents. Residents are ethnically diverse, mostly poor, barely educated and generally unemployed or engaged in odd, nonpermanent jobs. Sodom and Gomorrah is characterised by poor housing, dirt and squalor, overcrowding and inadequate access to safe and clean water, sanitation and other infrastructure. It is one of the world’s digital dumping grounds, where millions of electronic waste products from the West are crudely processed each year.21 by 5 percentage points and accounting for 10% nonresponse. For convenience and with the aim of covering all parts of the slum, the slum was divided into four areas and in each of these areas, the first household was selected and entered and subsequently every third household were entered till the required sample size was achieved.This was a cross-sectional study. We conceptualised that access to health care in the slum was low and influenced by factors such as availability of health facilities, pattern of health facility use, based in part on knowledge of common illnesses, and on acquisition of health insurance to facilitate use of available health services. Based on this, we selected a total of 465 adults in the community who were heads of their respective dwellings or households. This sample size was deemed sufficient to estimate with 95% confidence that the proportion of Sodom and Gomorrah dwellers who used a healthcare facility in the last 1 year prior to this survey will not differ from 55% A structured questionnaire with close-ended questions on respondent demographics, use of health facility in the last 1 year, membership of National Health Insurance Scheme (NHIS) and knowledge of causes, signs and symptoms, treatment and prevention of common illnesses in the community was used for data collection. Other data collected on potential barriers to the access and use of healthcare facilities included attitude of healthcare providers, distance to nearest health facility and access to transportation. The questionnaire was independently reviewed and edited by the investigators to ensure quality control and appropriateness for study. The questionnaire was pretested in Makola in the central business district of Accra amongst 50 head porters and truck pushers at the close of day when they were readily available. Pretesting of the questionnaire was done in this group because the investigators perceived that they are similar to the slum residents in demographic characteristics and hassled life styles. Pretesting of the questionnaire did not reveal any need for changes.A research assistant and her team were trained on the administration of the questionnaire to ensure uniformity and consistency in their approach. The questionnaire was administered individually to participants by a team led by the research assistant moving from dwelling to dwelling within the slum over a 2-week period in December 2011.22 was used for data processing and analysis. Chi-squared test was used to assess statistical differences between independent categorical variables in the levels of use of formal health care.Respondents were approached by the research assistant and her team who explained in detail the purpose of the study and solicited participation. Data were entered in Microsoft Office Excel, 2007. A composite indicator for health knowledge based on knowledge of causes, signs and symptoms, and prevention of malaria and cholera and common illnesses mentioned was constructed. Questions assessing knowledge were grouped under six blocks, which are causes of malaria, signs and symptoms of malaria, prevention of malaria, signs and symptoms of cholera, prevention of cholera and knowledge of other illnesses in the slum. Respondents’ knowledge was graded as good if they provided at least one correct response for each block. Respondents’ knowledge was graded as fair if they provided at least one correct response for only four or five blocks. Respondents’ knowledge was graded as poor if they provided at least one correct response for only three or less blocks. Stata 12.1p-value of ≤ 0.05 is considered statistically significant.Risk ratio (RR) estimates and their confidence intervals were estimated by using the modified Poisson regression with a robust error variance. Adjusting the RR for other predictors or potential confounders was done by adding them to the model statement. A Ethical approval for this study was granted by the Committee on Human Research, Publications and Ethics, Kwame Nkrumah University of Science and Technology, School of Medical Sciences, Kumasi, Ghana. Written informed consent was sought from all participants and consent obtained before questionnaires were administered. Illiterate participants thumb printed and/or gave verbal consent after they had been provided with adequate information about the study and had all their concerns and/or questions answered.We sampled a total of 465 slum dwellers. Two were excluded from the analysis because of nonresponses. The Sodom and Gomorrah community has no hospitals or clinics. The residents said they mostly accessed health care from two drug stores in the slum and from herbalists. A few attended the Cathedral Clinic nearby in the past and only one respondent had ever attended the KBTH, which is a tertiary health facility in the city of Accra. Some demographic characteristics of the participants are presented in Majority of them (80.6%) were not registered members of the NHIS at the time of the survey. They cited lack of money (45.5%) for the initial registration as the main reason for not having a national health insurance membership. Other reasons included inconvenience (13.4%), no need for it (9.1%) and other unexplained reasons (14.7%). The respondents were predominantly from the northern parts of Ghana, relative to the south. A few of them were from the West African subregion.According to the residents, malaria and diarrhoeal diseases were the most prevalent illnesses in the slum because of the prevailing poor sanitation conditions. They also mentioned mental illness, HIV and convulsion in the young, though these were less frequent. Using malaria and cholera, we gauged residents’ health awareness by asking about the causes, symptoms and signs, and methods of prevention of the two diseases. Majority of the respondents (47.7%) had good knowledge about the causes, symptoms and signs of these illnesses and measures to prevent their occurrence .Factors associated with the use of formal healthcare facilities amongst the slum dwellers are presented in 16 suggest that this is not always the case. They argued that if health authorities appropriately respond, proximity to formal healthcare facilities leads to improved health awareness, which positively influences healthcare use and health-seeking behaviour.16In this study, we assessed utilisation of formal healthcare services by residents of Sodom and Gomorrah as a measure of access to and use of health care. We found that the majority of those sampled were youthful but unskilled, often jobless, and paid less attention to their health and general welfare. Majority of respondents had at least a primary-level education and a good overall knowledge about prevalent illnesses amongst residents of the slum. Just about 2 out of 10 respondents had an NHIS membership. A resident with NHIS membership was more than twice as likely to use a formal healthcare facility. Sodom and Gomorrah is centrally located in Accra and just about 300 m from the KBTH and even closer to other smaller health facilities. Indeed, the respondents indicated that neither distance nor access to transportation hindered them from using a health facility. Despite the central location of the slum and its proximity to healthcare facilities, it was interesting to note that less than 3 out of 10 used formal health care when they had need for it. They chose instead to seek from other sources. However, Agarwal and colleagues23 Living in slums under deprived conditions is a major cause of ill-health and slum dwellers suffer disproportionately from ill-health throughout their life course.27The main health problems prevalent in this slum were malaria and diarrhoeal diseases. This is not surprising as the community has no pipe-borne water or good sanitary facilities. Sanitation is generally poor. There are no well-constructed gutters or drainage systems to allow easy flow of water. The few open gutters are choked with debris, resulting in dirty stagnant ponds and flooding during the rainy season. Houses are overcrowded and all-purpose. This is typical of slums as was observed in other studies conducted in slums.28 However, it is difficult to explain why residents ‘feel’ at home under such profound deprivation prevailing in Sodom and Gomorrah. It is also needless to argue the circumstances leading to the creation of this slum as the demographic and socio-economic indicators are similar to those found in slums worldwide.2 However, the existence of such slums may be an expression of social exclusion. Slums appear to have intergenerational negative effects because children born in the slum have a slim chance of breaking through the poverty cycle. The significance of this study is its novelty and the information gleaned about the lives of slum dwellers within the city of Accra thus providing clues for effective interventions to improve the quality of their lives.It was observed that residents of Sodom and Gomorrah live in poor shacks primarily built or held together with old roofing sheets, plywood and/or cardboard papers. Children appeared neglected and malnourished, whilst adults loiter around smoking marijuana, sometimes with young children looking on. These conditions characterise Sodom and Gomorrah as a slum as defined operationally by the UN.32 This study, however, did not include a qualitative component to help understand the complex social phenomenon of the health-seeking behaviours of the slum residents. Inclusion of such data could have informed findings and targeted interventions. Future studies need to include these psycho-social measures for greater understanding of the health-seeking behaviours of slum dwellers.These results suggest that proximity of Sodom and Gomorrah to a tertiary health facility and many others in the centre of Accra did not necessarily encourage their patronage amongst the residents. However, just as it is the case for most Ghanaians, health-seeking behaviour is influenced by cultural and religious beliefs and practices.Increasing urbanisation is a major factor in the creation and continued existence of the Sodom and Gomorrah slum. The slum reveals a ‘theatre of social exclusion’ where prevailing poor economic, educational and sociocultural conditions conspire as if to perpetuate each other’s reign. Conditions of profound environmental hazards, overcrowding and poor-quality housing and lack of health care or other essential services in Sodom and Gomorrah pose grave threats to the health of the inhabitants and probably to the rest of the city of Accra. Interventions requiring significant multisectoral effort and resource mobilisation championed by the Ministry of Local Government and Rural Development are needed to attempt a resolution of this crisis.


Operational research is currently one of the pillars of the global strategy to control tuberculosis. Indonesia initiated capacity building for operational research on tuberculosis over the last decade. Although publication of the research in peer-reviewed journals is an important indicator for measuring the success of this endeavor, the influence of operational research on policy and practices is considered even more important. However, little is known about the process by which operational research influences tuberculosis control policy and practices.We aimed to investigate the influence of operational research on tuberculosis control policy and practice in Indonesia between 2004 and 2014.Using a qualitative study design, we conducted in-depth interviews of 50 researchers and 30 policy makers/program managers and performed document reviews. Transcripts of these interviews were evaluated while applying content analysis.Operational research contributed to tuberculosis control policy and practice improvements, including development of new policies, introduction of new practices, and reinforcement of current program policies and practices. However, most of these developments had limited sustainability. The path from the dissemination of research results and recommendations to policy and practice changes was long and complex. The skills, interests, and political power of researchers and policy makers, as well as health system response, could influence the process.Operational research contributed to improving tuberculosis control policy and practices. A systematic approach to improve the sustainability of the impact of operational research should be explored. Operational research (OR) can be defined as ‘the search for knowledge on interventions, strategies, or tools that can enhance the quality, effectiveness, or coverage of programs in which the research is being done’ , formed by the National Tuberculosis Control Program (NTP) in collaboration with partners , has been conducting OR capacity-building trainings in Indonesia since 2004. Details on the TORG's OR capacity-building activities and outputs have been published previously  and one to two TB program staff (‘program-based researchers’). The process of capacity building has been described previously .This was a qualitative study conducted between March 2014 and December 2014. Data were collected by thorough in-depth interviews and document reviews.By February 2014, 33 provincial OR groups had participated in the TORG proposal development workshop. The newest province, which was established in late 2012, was not involved in the TORG when this study was conducted. Only 31 groups conducted a field study. Two OR groups experienced teamwork problems and did not continue with the field study. Four OR groups were still in the data analysis phase and had not completed the project. Therefore, we included 27 OR groups in this study .We obtained a list of researchers who had participated in any of the TORG proposal development workshops held between 2004 and 2014 from the NTP. We selected the principal researcher and/or another co-researcher from each OR group. Relevant policy makers or program managers  at the provincial health offices, district level TB program staff, and NTP focal points) were selected by snowball sampling based on information from the researchers.Results and recommendations of the ORFollow-up actions after results were disseminatedInfluence of OR upon policy and/or practice changes, as well as means of support and impedimentsWe developed the guidelines of in-depth interviews according to the framework of Hanney et al. . The intWe collected OR project reports and harvested information on the recommendations from the study projects. This information was used for triangulation of data from interviews to assess the implementation of the OR project recommendations.We excluded the OR projects of two provinces from the analysis since we were unable to obtain information from the policy makers’ perspective. Ultimately, we included interview data from 50 researchers and 30 policy makers in the analysis. The researchers consisted of 28 academics, 17 provincial health office staff members, 2 district health office staff members, and 3 hospital staff members. Policy makers included 4 national TB programmers, 21 provincial CDC/TB programmers, 3 district CDC/TB programmers, and 2 TB health service coordinators.To improve accuracy , this stThis study received ethical clearance from the Committee of Research Ethics of the Faculty of Medicine of Universitas Sebelas Maret, Indonesia. The interviewers provided information about the study via emails and phone calls before conducting the interviews, and the informants provided verbal informed consent before the interviews. The interviews were taped, and informed consent was recorded. Transcripts of the interviews were anonymized, as were analyses and data interpretation/presentation.Content analysis , 9 was uThe 25 OR projects included in the analysis varied in topics and study designs . Twenty-The analysis revealed a ‘path to impact’ theme that consisted of three categories: the impact, path, and keys. The impact described issues pertaining to the contribution of OR projects to relevant TB policies and practices. The path revealed the processes from the end of the OR field study to the success/failure of OR projects in contributing to TB policies and practices. The keys represented relevant factors that supported or hindered the implementation of the OR projects’ recommendations.Descriptions of OR impact are presented in Thirteen OR projects related to the first domain of impact. For example, the OR project in Bali Province led to the development of reward systems for private practitioners’ contributions to TB suspect referrals. Additionally, the OR project on TB–HIV collaboration at a teaching hospital in West Java Province triggered the development of standard operating procedures for TB–HIV collaboration at the hospital level.The multidrug-resistant TB program was very dynamic. Because our OR project had a long duration, the recommendations from our OR could not keep up with the continuously shifting dynamics of the program. Nine OR projects involved strengthening current TB control policies and practices upon evaluating the strengths and weaknesses of the activities of TB control programs. Some OR projects produced recommendations that the TB control program had already implemented, although the studies were not yet completed. For instance, the OR project on pediatric TB was initiated concurrently with the development of the national pediatric TB guideline. However, the guideline was finalized while the OR project was still ongoing. The OR duration and the dynamics of the TB control program activities were important factors, as expressed in the following quotation:The recommendations of most OR projects included in our study resulted in changes to policies or practices that lasted for various lengths of time. For example, the recommendation from the OR project in Jambi Province that the work of the TB program staff and laboratory staff be integrated at the primary care level was only maintained for less than a year after the results dissemination seminar. The recommendation of involving community members in active TB case detection in Aceh Province was maintained for approximately 1 year. The recommendation to award accreditation points to private practitioners involved in TB case detection in Bali Province was maintained for a longer period. OR recommendations were less sustainable when they concerned innovations of policies or practices instead of recommendations to strengthen existing policies and practices.The overall process of translating knowledge obtained through OR into influence on TB program policy and practice is presented in Some OR groups informally shared preliminary findings before the official dissemination seminar to raise interest among relevant policy makers. Some OR groups also created policy-brief documents.Approximately 1 year after commencing field work, all OR groups conducted an official dissemination seminar for stakeholders from multiple disciplines who may have had the capacity to implement, or catalyze implementation of, the study recommendations. There were three types of policy makers invited: health facility level program managers ; provincial or district level managers ; and national level managers . During the dissemination seminars, the OR group typically presented the results and recommendations of the study; discussions with stakeholders then followed.I think the results [of OR] are useful. Other [district] TB program coordinators could accept them [the results and recommendations]. Yes, these [the recommendations] are feasible … In general, the policy makers accepted the OR results and recommendations, since these were regarded as relevant, practical, and having the potential to improve TB program performance.It was common for policy makers to develop preliminary policy documents (e.g. a letter of commitment to support the OR recommendations) as a follow-up to the dissemination seminar. However, the preliminary policy documents did not guarantee that the policy makers would deploy the recommendations of the OR projects . Only a For some projects, researchers or/and policy makers conducted additional advocacy activities to obtain supporting policy papers and funding, thereby ensuring the application of the OR recommendations. In general, the policy makers/program managers requested that the researchers conduct additional presentations about the OR results and recommendations in a formal meeting . Otherwise, the policy makers/program managers promoted the recommendations of the OR projects to all relevant facilities under their authority. Some researchers highlighted evidence from the OR project in their presentations at various forums.The time between the dissemination seminars and the deployment of the recommendations ranged from months to years . ComplexResearchers, policy makers/program managers, and health system personnel form the keys to translating knowledge from OR projects into changes to TB program policy or practices. The roles of these individuals in OR contributions and achievement of milestones in TB policy or practices are presented in Good collaboration and cohesion existed in the OR groups that impacted TB program policy or practices. In contrast, a group member leaving for a new job could impede follow-up on the OR recommendations . One acaOR projects that led to program or policy changes tended to have program-based researchers with sufficient power and confidence to approach and persuade the policy makers and/or program managers. Conversely, program-based researchers who had no relevant authority felt less capable of persuading TB program policy makers.We coordinated and tried to work with the local Indonesian Medical Association. We had conducted activities [to involve private medical practitioners] together [with the Indonesian Medical Association]. However, the results did not satisfy our expectations, as most private practitioners did not attend the meeting. Therefore, we changed our strategy the following year. Communication and advocacy skills, as well as contingency planning, were also key to the successful influence of an OR project on policy and practice  as exempA combination of enthusiasm and political power on the part of the policy makers was shown to be an important facilitator of achieving impact . Those pChanges of high level policy makers/program managers  or middle level policy makers/program managers  were often mentioned as obstacles to implementing recommendations for policy or practice changes. After a change of policy maker, it was more difficult for the researchers to ensure that the OR recommendations were implemented. Hence, such changes were also barriers to the sustainability of the impact of the OR.When we disseminated our study results to other districts, they [the district TB program staff] were questioning how they could implement the recommendations [of community-based active case finding] … Until now, the national TB control guideline [has] only [included] the passive case detection approach … Availability of a relevant national policy document or guideline was another key factor regarding implementation of innovative recommendations from the OR projects . Some ofAvailability of financial support was another key to facilitating the impact of OR projects . Some stThe preparedness of the Ministry of Health to respond to logistical provisions related to enabling application of OR project recommendations was another challenge. For example, the recommendation to implement active TB case detection by so-called community champions in Aceh was followed, and the numbers of TB cases reported by primary health centers increased. This consequently required additional drugs and laboratory supplies, something the logistics planners had not anticipated.Finally, staffing changes hampered the sustainability of the OR-recommended actions that involved TB program field staff. For example, the impact of the integrative work of the staff from the TB program and the laboratory in Jambi Province was diluted mostly due to the turnover of the TB program staff at the primary health centers.Our study provides empirical evidence regarding the impact of OR projects on changes of policies and practices; similar impacts have been described previously for other areas of focus , 12. TheThe mechanisms of the influences of OR projects on TB control policies and practices are complex and nonlinear , as has The recommendations from some OR projects in our study could not be maintained. This was sometimes due to the irrelevance of the recommendations to existing policies; at the time study results were disseminated, there would already be a new and better policy. Therefore, process dynamics and policy relevance should be taken into account when the researchers plan for OR; as Ioannidis argued, fine-tuning between research and existing policy should be considered .Our study found that the implementation of OR project recommendations may require a broader health system response, such as the availability of overarching policies and additional resources. Others have also shown that financial and human resource constraints impede the use of research evidence in decision-making . Again, Our study evaluated OR projects facilitated by the TORG in the context of decentralized health systems; this limits the generalization of our findings. Nevertheless, we believe that our study provides evidence for the impact of the OR projects on policies and practices. Moreover, the lessons shared in this paper could be of use to ongoing initiatives involving OR capacity building in other countries.Our study concluded that OR contributed to the development of new policies, introduction of new practices, and strengthening of current TB control policies and practices in Indonesia. However, the sustainability of these changes was often limited. The process of translating OR outcomes was complex. Even though OR findings are useful for TB control program improvement, the deployment of recommendations can be influenced by other factors. The skills and political power of researchers, interests and political power of policy makers, and health system response could all influence the process.Therefore, we recommend the following. First, the OR initiative should be intensified and promoted. The curriculum of OR capacity building should include skills of knowledge translation and communication for advocacy. Second, the OR group should include health staff with sufficient power to achieve changes in the TB control program. Researchers with sufficient influence will contribute heavily to translating knowledge into policy. Third, the timing of advocacy actions should be carefully planned in order to increase the possibility of sustainable deployment of the recommendations. Fourth, short communication lines between the OR groups and policy makers or program managers during and after executing the OR projects ought to be established to ensure that the results and recommendations of the research are properly implemented. Finally, ‘OR on OR’ studies are required, particularly to explore potential mechanisms to sustain the impact of OR on policies and practices.


Emerging infectious diseases (EIDs), the majority of which are zoonotic, represent a tremendous challenge for public health and biosurveillance infrastructure across the globe. Due to the complexity of zoonotic pathogens, it is essential that research and response to EIDs be a transdisciplinary effort. And while crisis and circumstance may be the initial catalyst for responding to an outbreak, we provide examples of how transdisciplinary scientific collectives, which are organized and solidified in advance of crises, can transform the way the world responds to outbreaks and in some cases could even prevent one from occurring . Current Understanding the complex interactions inherent in zoonotic disease requires the union of medical doctors, veterinarians, virologists, wildlife biologists, epidemiologists, and geographers, to name a few. But the very diversity and breadth of a multidisciplinary team can present challenges to communication and teamwork, particularly in the midst of crisis, when it may be too late to build trust and establish communication mechanisms (Emerging infectious diseases (EIDs) represent a tremendous challenge for public health and biosurveillance infrastructure across the globe and are primarily zoonotic . Becausechanisms . While tchanisms  revealedchanisms , 6. HoweBoth the time scale and the qualitative nature of long-term scientific collaborations pose a challenge to traditional methods of measuring their value and impact. Every event, from trainings, workshops, and conferences to the activities surrounding an outbreak response, requires an investment of both time and monetary resources. And the scientific process necessary to understand the complex systems of zoonotic diseases within the environment requires an investment of years, if not decades, to review what is known, develop ideas and hypotheses, collect and analyze data, and continuously build upon a body of knowledge as new data emerge But assessing the value provided by long-term collaborations, whether those partnerships lead to research outputs, training activities, or simply the sharing of information and best practices, needs to occur within a shorter time scale, if the recognized value to be realized is to inform programmatic and resource allocation decisions. In order to assess the value in that time frame, we need to have a measurement of both the collaborative effort as well as its impact on current disease threat reduction systems. Current indicators that a cooperative engagement or a single event or workshop will produce outputs that are valuable and sustainable are based the measurement of return on investment (ROI) using metrics, such as the number of people trained or number of presentations. In an effort to respond to shrinking scientific budgets, more emphasis is being placed on ROI metrics for applied scientific programs, such as cooperative engagement programs. But the existing ROI metrics, which do not take into consideration the importance of relationships, are not suited for measurement of such intangibles. And how do we demonstrate that investment into the creation and fostering of relationships which are long-lasting, creative, and committed to solving problems can produce truly transformational outcomes which reduce the threat of infectious disease?The need to develop a framework that captures the impact and benefit from scientific engagements is clear. Policymakers and Program Managers alike need to be able to evaluate when research and training activities are an efficient and effective use of federal dollars, and whether these activities help meet program objectives. But there are challenges to defining the appropriate metrics, including aligning long project timelines with shorter programmatic milestones. Traditionally, the focus has been on reporting research results rather than measuring broader benefits and the synergy of those metrics across different types of activities.the long-term net outcome emerging for all parties resulting from the establishment and mutual maintenance of a relational engagement  and propose a method for measuring ROR using a systems dynamics modeling framework. We modify the definition of ROR commonly used in business, as gagement . It is igagement . Like buUsing the scientific collaborations that emerged from the training workshop for biosurveillance of pathogens in bats held in Singapore in 2014, we apply a methodology for visualizing and measuring the resulting relationship networks and outcomes . Participants were from the Philippines, Taiwan, the Republic of Georgia, Thailand, Jordan, and the USA and were country partners with the U.S.-based Cooperative Biological Engagement Program (CBEP), a component of the Defense Threat Reduction Agency’s Cooperative Threat Reduction program. The training, which was initiated and funded by CBEP, leveraged the expertise from the Program in Emerging Infectious Disease at Duke-NUS Medical School, to provide a comprehensive course that covered a wide variety of topics on EIDs in bats. While the primary goal for the bat-borne pathogen training was to increase the capacity and capabilities for biosurveillance in partner countries, a secondary and ultimately perhaps more important goal was to develop a sustainable network for researchers interested in One Health. The participants were able to build on the relationships forged at during the training support and leverage these into research collaborations.field to phylogenies). The final day of the training focused on molecular evolution, sequence alignment, selecting evolutionary models, and phylogenetic tree reconstruction with both lectures and laboratory practicals. All participants were vaccinated for potential zoonotic pathogens, such as rabies, and all animal work was approved by the NUS IACUC (B01/12). A day-long, interactive workshop demonstrated the necessity of a cohesive approach to zoonotic pathogens.Participants were primarily virologists and laboratory-based scientists, and we provided a course that captured the basics of bat biology, ecology, field surveillance, laboratory screening, and phylogenetic analysis. Thirteen individual lectures were given over the course of 2 weeks. Also included were four field trips to trap and process bats in the field and gain an understanding of the work flow from field to laboratory to analysis  outbreak, which originated in Saudi Arabia but is currently presenting cases worldwide. The goal of the session was to utilize the historic Hantavirus outbreak case study to illustrate how a collaborative approach to problem solving can lead to transformative science. Building upon this example, participants were guided through an exercise where they applied that concept to developing mechanisms (and relationships) to answer questions about the transmission of MERS CoV that remain unanswered today. Finally, the relationships and potential collaborations identified that day and forged during an intensive 2-week training course in which they lived, worked, and learned together were then tracked and monitored over the next year as the participants returned to their respective countries and institutes.The eight researchers who came together for this training and workshop represented eight countries in three regions. Like the original, multidisciplinary group of scientists who solved the mystery of Hantavirus transmission in 1993  as a resource-limited, finite capacity system operating under control constraints. The scientific social network or “system” that started with the Bat Borne Pathogen Surveillance Workshop were modeled as ordinary differential equations and evaluated in the system dynamics software tool, Vensim™. Mathematically, the basic structure of a system dynamics computer simulation model in Vensim™ is a system of coupled, non-linear, first-order differential  equations. The Bat Borne Pathogen Surveillance Workshop was modeled as a single starting event that evolved outwards as additional relationships unfolded. The system dynamics model, in this case, is only used to weight the different outcomes that came from a particular relationship and keep track of the endpoints with an overall index. The system dynamics model developed would be considered one of the simplest ways to weight, calculate, and visualize a scientific social network stemming from an event.Relationships were identified by connections made at the initial training event that led, sometimes by multiple steps or subsequent connections to specific deliverables or outcomes, such as collaboration on a proposal, a paper, or a training event Table . WeightsThe eight researchers from the Philippines, Taiwan, the Republic of Georgia, Thailand, United States, and Jordan who participated in the workshop each brought unique relationships with institutes, universities, and government offices that could be leveraged for collaborations as deemed appropriate and useful. Each participant had different background and experience in the laboratory and field experience working with animals. We identified a total of 23 measurable deliverables that were the outcomes of the workshop. Nine separate proposals were developed between the participants in the workshop, with smaller project development grants (PDG) being weighted lower than full 3-year proposals for research. Four publications or poster presentations at conferences were developed from the workshop and longer, more developed publications or larger scientific conferences were weighed higher. Even though the original cohort was from seven countries, including Singapore, 12 countries were represented in the outcomes, illustrating the immediate and rapid expansion of the initial collaborative network. One educational curriculum was developed from the workshop, which covered the lessons learned from the Hantavirus outbreak and discovery in 1993  networks can be identified and measured, emphasis on objectives to increase the metrics can increase. For example, motivation to improve measured results can lead to an increased emphasis in the quality of resulting and differentially weighted deliverables.For the initial Bat Borne Pathogen Surveillance Workshop, the value of the index or metric was 115, which in the same way as other indices, is not useful without comparison to other events calculated in the same manner. The usefulness of this social network metric lies in the comparison to relevant events to help discern the relative value of the time and resources to organizations. In market-driven business engagements, there are primarily two sides to a value proposition, namely value for the supplier and value for the customer . In coopThe One Health initiative explicitly states that interdisciplinary and cross-sectional approaches are required for the prevention, surveillance, monitoring, control, and mitigation of EIDs. The terms multi- and interdisciplinary describe research efforts that incorporate a variety of disciplinary perspectives with varying degrees of integration across perspectives . CollaboPeromyscus maniculatus) populations, and Sin Nombre Virus , increased precipitation, vegetation primary productivity, deer mouse  along the way for each party.Providing an infrastructure either in funding for additional meetings or an online social site for the group to help strengthen and forge the sustainability of the relationships.Finding and giving examples of funding opportunities or supporting scientific collaborations and highlighting deadlines for application.Allowing for social activities as part of the event helps foster connections and helping maintain potential future opportunities to meet or connect. Providing opportunities to maintain the relationships over time only builds on the initial connection.Not doing any of the above suggestions can impede the success of a research collaborative network, but also forcing participation can backfire. Presenting the data on the positive application of professional networks and continuing to provide opportunities for strengthening the network can invigorate the group to be enthusiastic for working together in the future.Here, we show that visualizing and quantifying scientific social networks that develop from a specific event can be useful in estimating the impact of collaborations on a field or mission, such as reducing the threat of infectious diseases. A primary goal for cooperative engagement programs is to advance a field together in research or education by supporting groups of investigators to communicate and coordinate their research and training and educational activities across disciplinary, organizational, geographic, and international boundaries. Established relationships may be paramount in preventing the next pandemic.All authors listed, have made substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.