Annually, 600 000 deaths are attributed to exposure of non-smokers to secondhand smoke (SHS). These include 165 000 among children, about 60% of which occur in Africa and Southeast Asia. As of 2017, only seven countries in the African region had comprehensive smoke-free legislation covering all public places. Given the increasing prevalence of smoking in many low-income countries, preventing exposure to SHS is an urgent public health priority, particularly in Sub-Saharan Africa.The objective of this study is to obtain a reliable and nationally representative estimate of the prevalence of exposure to SHS and to identify the major risk factors among young people in The Gambia.We used a two-stage cluster random sampling to select students in secondary schools throughout The Gambia and a self-administered questionnaire to collect data on demographic characteristics and detailed indicators of exposure to SHS.Of the 10 392 eligible students, 10 289  participated. The proportion of students reporting any exposure to SHS was 97.0% , with 96.4% reporting some exposure outside the home. Exposure to SHS in the home was more common in girls and among older students. Parental education, living with parents and being sent to purchase cigarettes were associated with exposure to SHS both within and outside the home. More than 50% of students supported public smoking ban in both enclosed and outdoor public places. About 35% of students were unaware of the harmful effects of exposure to SHS.Exposure to SHS is highly prevalent among students in The Gambia and occurs mostly outside of the home. Interventions to reduce SHS exposure in students are urgently needed. This study provides the first comprehensively representative data on the prevalence and determinants of exposure to secondhand smoke among young people in The Gambia.The participation rate among those sampled was extremely high, and upper basic schools and senior secondary schools were sampled from schools throughout the country.Self-administered questionnaires were used; students may have under-reported or over-reported their answers.The survey was limited to students; it may not represent the smoking prevalence of all young people in this age group.Annually, six million people die from tobacco use. Of these, an estimated 600 000 deaths are attributed to exposure of non-smokers to secondhand smoke (SHS),3In 2004, 40% of children, 33% male and 35% female non-smokers were exposed to indoor secondhand tobacco smoke worldwide.The Gambia is a West African country of 1.9 million people with a per capita gross domestic product of US$471 in 2015.This study was carried out in a sample of upper basic schools (UBS) and senior secondary schools (SSS) throughout The Gambia: Banjul and Kanifing municipalities and the rest of the country, which comprise five regions using methods described previously.Participating students completed a self-administered questionnaire adapted from the GYTS, collecting data on a range of variables including demographic details, exposure to SHS, support for public smoking regulations and knowledge of the harmful effect of SHS. The questionnaire also included series of questions on several indicators of tobacco use, smoking susceptibility, exposure to tobacco advertisements and promotion, antismoking media messages, beliefs about the danger of smoking and the perceived benefits of smoking; these data have been reported in a separate publication.10Self-reported exposure to SHS was the outcome variable and was assessed in the study by the following questions: “During the past 7 days, on how many days has anyone smoked in your presence?: inside your home, in an outdoor public place, in an indoor public place, inside any public transportation’; and ‘during the past 30 days has anyone smoked in your presence inside the school buildings or premises?”. Exposure to SHS was defined as being exposed to SHS on at least 1 day in the past 7 days in any public place and in the home or in the past 30 days at school. Exposure to SHS outside the home was defined as any exposure at outdoor and indoor public places, inside any public transportation and at school. The independent variables used in the study were gender, age and religion, school level, school funding type, school locality, parents’ educational level, tobacco use by family and friends, sent to purchase cigarettes and support for smoke-free bans.The survey was carried out between June and December 2016. The survey was approved by The Gambia Government/Medical Research Council Joint Ethics Committee and by the Ethics Committee of the Faculty of School of Medicine and Health Sciences of the University of Nottingham, UK.Data were analysed in Stata V.14. Proportions and 95% CIs were obtained as estimates of the prevalence of exposure to SHS. We adjusted associations for a priori confounders comprising age, gender and rural/urban area of schools and used multivariate logistic regression analyses to predict factors associated with exposure to SHS.A total of 50 schools throughout the country participated in the study, including 33 UBS and 17 SSS, comprising 13 private, 27 public and 10 grant-aided schools. A total of 10 395 students were registered in the selected classes, of which 10 289 (99%) students participated in the study. Detailed characteristics of the study participants are summarised in The frequency of SHS exposure at home and school is summarised in Participants’ perceptions of the risk of exposure to SHS and support for ban on public smoking are also outlined in As shown in Outside the home, lower maternal and higher paternal educational level, living with parents and being sent to purchase cigarettes for others  were significantly associated with increased risk of exposure to SHS . In addiThis is the first study to provide detailed data on exposure to SHS in a nationally representative sample of adolescent school students in The Gambia. We found a very high level of self-reported exposure to SHS among students, and, contrary to expectation, found that while around two in five respondents reported SHS exposure in the home, a large majority of young people reported exposure in public places. Older students in our sample were generally more likely to be exposed to SHS, as were children under the age of 15. Older students and girls were significantly more like to be exposed to SHS at home compared with boys. Students in our sample were also more likely to be exposed to SHS if their family members or friends smoked, if they attended UBS or grant-aided schools, smoking was allowed in the home and among those who were not Muslim. Exposure to SHS at home and outside the home were also associated with parental educational level, though in opposite ways; higher maternal and lowest paternal levels of education were associated with lower exposure. Students who were sent to purchase cigarettes for others were also more likely to be exposed to SHS. Awareness of the harm to health of SHS exposure was low; with more than a quarter of students reporting that exposure was probably or definitely not harmful. However, most students supported a smoking ban in both enclosed and outdoor public places.Our study has some limitations. This was a cross-sectional study and we used a self-administered questionnaire to measure exposure to SHS: students may have under or over reported the answers. However, students self-reports of exposure to SHS has been reported to be highly consistent with urinary cotinine level measurement.Previous studies of smoking and exposure to SHS among students in The Gambia are limited, the most recent and widely quoted being the 2008 GYTS survey. The current study estimated a lower overall prevalence of exposure to SHS than ours, but this could well reflect the restricted local sampling frame used in the GYTS.13 14In The Gambia, the Public Smoking Act, which bans smoking in all public places, came into effect in 1998. However, our observation that exposure to SHS remains high, and may even have increased since the 2008 GYTS, suggests that efforts are still needed to enhance the enforcement of this law, particularly since public places were the most frequent source of exposure to SHS among young people in The Gambia. Beyond the direct health benefit of smoke-free policies, implementing smoke-free laws, especially in public places, has been shown to change the public acceptance of smoking by the general population.17Similar to previous findings,We found that older students were more likely to be exposed to SHS both outside the home and inside the home; this is consistent with findings in previous studies among students.All of the participant schools in this study reported that they had implemented a comprehensive smoke–free campus policy, yet more than a quarter of students reported SHS exposure at school. These findings, which are consistent with previous reports of significant exposure to SHS at school,28Our results showed that parents’ educational level, family or friends’ smoking status, living with parents, home smoking rules and being sent to purchase cigarette for others were significant determinants of exposure to SHS in the home and is consistent with previous studies.This study has shown that exposure to SHS is very high among students and that despite smoke-free laws, protection against SHS exposure in public places in The Gambia is still inadequate. There is an urgent need to advocate for interventions to reduce the current level of exposure to SHS and minimise further exposure among students. This underscores the need to develop comprehensive smoke-free laws and strictly enforce these laws in all environments. Further research is required to determine whether this is a problem among students alone or reflects a wider pattern of exposure to SHS among the general population.


The project has been formulated as a “randomized before-and-after controlled study” targeting small-scale poultry farms in the Mekong Delta region of Vietnam. It aims to provide farmers with a locally-adapted veterinary support service to help them reduce their reliance on antimicrobials. ViParc has been developed in the backdrop of efforts by the Government of Vietnam to develop a National Action Plan to reduce Antimicrobials in Livestock and Aquaculture. Crucially, the project integrates socio-economic analyses that will provide insights into the drivers of antimicrobial usage, as well as an assessment of the cost-effectiveness of the proposed intervention. Information generated from ViParc should help the Government of Vietnam refine its policies to curb excessive antimicrobial usage in poultry production, while lessons from ViParc will help tackle excessive antimicrobial usage in other productions systems in Vietnam and in the broader Southeast Asian region.Antimicrobial usage and antimicrobial resistance (AMR) in animal production is now recognized to be an important contributor to the global problem of AMR. Initiatives to curb indiscriminate antimicrobial use in animal production are currently being discussed in many low- and middle-income countries. Well-designed, scientifically sound interventions aimed to tackle excessive antimicrobial usage should provide scientists and policy makers with evidence of the highest quality to guide changes in policy and to formulate better targeted research initiatives. However, since large-scale interventions are costly, they require careful planning in order not to waste valuable resources. Here, we describe the components of the ViParc project ( Antimicrobial resistance (AMR) in food animal production systems has recently become the focus of considerable scientific attention. There is now a consensus that AMR represents a “One Health”/“Ecohealth” challenge that urgently needs to be tackled by the international community. A number of high-level reports have indicated the urgency to formulate and conduct interventions to curb antimicrobial usage and AMR, both in human medicine as well as in animal production. Potential interventions may involve education campaigns, improved awareness and farmer training, the provision of antimicrobial replacements, changes in the antimicrobial supply system, or changes in policy and legislation Anon, ,b.Initiatives to curb antimicrobial usage and to monitor AMR in food animal production systems have been on-going for over a decade in many developed countries, and in some cases  for even longer. However, in developing countries such initiatives are still embryonic. This is quickly changing, and momentum is building through the support of international organizations and donors such as FAO, OIE, European Union, Wellcome Trust, Bill & Melinda Gates Foundation, the Fleming Fund, etc., This interest is providing impetus and funding for researchers to develop and implement scientific approaches that help fill existing knowledge gaps on antimicrobial usage and AMR, to design interventions, and to assist policy-making at all levels.However, examples of scientifically sound large-scale interventions to curb antimicrobial usage in animal production are still rare. Given the complexity and diversity of animal production systems worldwide, their variable antimicrobial usage practices, the baseline levels of AMR, as well as the cultural and legal frameworks in which they operate, it is unlikely that “one-size interventions” would fit all. In order to be meaningful for policy makers and producers, well-designed interventions need to reflect such complexity and diversity. Typically intervention studies are costly since they require a considerably large number of study units  to be truly representative, and to be carried out over a long period (no less than a year). Maintaining producer interest over such a long period is likely to represent an additional challenge. With these considerations, careful design and planning is crucial in order to optimize limited resources. On the benefit side, well-planned and conducted interventions may produce results that may be of benefit to sectors beyond the specific target production system. A crucial step is the development of adequate tools and processes that meet the criteria of feasibility, sensitivity, relevance, flexibility, and cost-effectiveness within a specific context , although the Ministry of Industry and Trade has also some competences. The MoA regularly publishes and updates a list of approved as well as a list of banned veterinary drugs and antimicrobial growth promoters following the submission of technical dossiers by commercial companies. Currently there are ~2,000 veterinary drugs containing antimicrobial ingredients currently licensed for sale in Vietnam. A number of antimicrobials have added to the banned list over recent years, but the current approved list includes a large number of antimicrobials of families that are currently classified as of critical importance by WHO. Once the supplier has obtained official government approval, there are no further sale restrictions, and countries are not require to report on sales of antimicrobials. Most antimicrobial sales are done through veterinary pharmacies, which are licensed by the local veterinary authority. Purchasing of antimicrobial drugs for animal use require no veterinary prescription. There is an on-going Government-funded programme to monitor residues in meat, fish, and shrimp, as well as the quality of the antimicrobial and feed supply chain.A considerable body of evidence has been accumulating on levels of current antimicrobial usage in poultry production systems in Vietnam. This includes high levels of usage of antimicrobials as growth promoters , funded by the Wellcome Trust, is one of the first scientifically-based intervention trials of its kind aiming to tackle antimicrobial usage in food animal systems in the Southeast Asian region. The project targets the small poultry sector which is currently prevalent in Vietnam. It involves the recruitment and follow-up of 120 randomly selected meat chicken farms from the Mekong Delta. The study has been designed as a “randomized before-and-after controlled trial” in order to achieve the greatest level of scientific evidence. The project will be delivered in two phases, a “baseline” phase (12 months), followed by an intervention phase (18 months). The “intervention” will consists of the provision to randomly selected farmers in the intervention group with a cost-free, locally-adapted advisory system backed by diagnostics to identify the most common diseases affecting poultry in the area (See later). A control arm will not receive any veterinary support. Because about 50% of the chicken feeds are medicated  is different and the prevalence of antimicrobial resistant bacteria and residues in meat before and after the intervention. Data from the project will also capture whether the productivity and profitability of the poultry systems is altered by changes in veterinary advice, antimicrobial usage, and potentially AMR levels.Crucially, the ViParc project is concerned with the collection of high quality data. This has been a challenge in many previous projects that involved unannounced visits to farms. This is due to the fact that in most cases smallholder farmers do not keep adequate records, and the farmer typically has little recollection of previous practices. In addition, there is often a certain mistrust often precludes the provision of accurate data to the interviewers. The ViParc project involves repeated visits to the farms (three per cycle) by well-trained animal health workers. Farmers are required to keep a project log-book where all relevant data  is weekly annotated. Farmers are also asked to keep containers of all medicines and commercial feed products used. An economic report will be generated from the data on real time. A summary of this will be fed-back to the farmer to maintain their interest and commitment to the project. In addition, fecal samples are collected from the flocks at each production phase to investigate AMR in commensal enteric flora. This information will be used to describe changes in prevalence of resistance over time and elucidate the relationship between antimicrobial usage and AMR. Finally, chicken meat is investigated for residues at the end of each production cycle.The ViParc project takes place in a context of high-level activity aiming to curb and monitor AMR in animal productions systems in Vietnam. With the support of the Food and Agriculture Organization of the United Nations (FAO), the Ministry of Agriculture of Vietnam is currently developing its “National Action Plan for the Reduction of Antimicrobial Use and Antimicrobial Resistance in Livestock Production and Aquaculture.” The plan has been structured around four specific objectives: (1) to revise and enforce policy and governance related to AMR and AMU in livestock production and aquaculture; (2) to increase awareness on AMU and the risk of AMR occurrence among livestock and aquaculture professionals, producers and consumers; (3) to promote responsible AMU and husbandry practices among livestock and aquaculture producers; and (4) to monitor AMR, AMU, and antimicrobial residues in livestock production and aquaculture. It is expected that the ViParc project will contribute to outputs within objectives (1), (2), and (3). Given the commitment of the Government of Vietnam, it is highly likely that during the implementation of ViParc restrictions will be implemented related to the availability of certain antimicrobials . The continued monitoring of “control farms” as part as the ViParc project, will allow to measure the impact of some of these changes.An intervention “package,” provided free of charge to farms randomized to the two intervention arms, will consist of the provision of a locally-adapted veterinary support system. The components of this support system are:A Farmer Training (FT) module. The FT module consisting of three workshops where farmers will be trained by poultry specialists on: (i) Good farming practices: record keeping, chick procurement, water and feed quality, farm biosecurity, cleaning and disinfection, and pest control; (ii) Control of poultry diseases, including responsible use of antimicrobials, vaccines, and probiotics; and (iii) Waste management and environmentally-sustainable practices.A Farm Health Plan (FHP). Each farm will be allocated to one poultry vet at the beginning of the intervention who will draft a tailor-made Farm Health Plan (FHP). The FHP document will include specific recommendations to improve the flocks' health, likely to include advice on vaccination schedules, detailed plans for terminal C&D and improvements in biosecurity. The poultry vet will visit each farm once during each production cycle to inspect the flocks, review records, and update the FHP document. In addition, and with the help of international experts, the project is developing and Auditing Tool in order to score each farm on a number of key variables, and to measure potential take up of the advice given by the poultry vets.A Diagnostic Support programme. The ViParc project will set up a basic diagnostic laboratory that will cover the most common poultry bacterial, viral and parasitic diseases. Farmers in the intervention arm will be instructed to alert their project vet should they observe signs of disease in their flocks. Poultry vets will carry out cost-free diagnostic investigations aimed at establishing the cause of disease, focused on identifying the most common bacterial, parasitic, and viral diseases known to be present in the area. The information generated during the project will be used to improve the advice given on vaccination in the area. However, setting up diagnostics is costly and complex. It is envisaged that the project will focus only on the most common bacterial and parasitic diseases circulating in the area. The diagnostic methods that will become available to the laboratory are likely to include bacterial culture for bacterial pathogens, testing of viral pathogens , and quantification of helminths. Bacterial pathogens isolated from diagnostic specimens will be investigated for their antimicrobial susceptibility against commonly used antimicrobials. Although, it is unlikely that this may influence treatment of specific disease incidents, since farmers will normally not wait until laboratory confirmation. However, this will allow build up a basis of knowledge on AMR among poultry bacterial pathogens in the area, which will be extremely valuable to inform treatment guidelines.An important consideration is that the ViParc intervention will follow a “persuasive” rather than a “restrictive” approach, with no formal enforcement of restrictions to the farmer on antimicrobial usage. It is expected that through on-going advice a considerable amount of disease will be averted on farms, and it is expected that positive changes in productivity will be detectable in the intervention group.Since poultry farms, however small, operate on a business rationale, the use of antimicrobials, and other health-enhancement practices are likely to respond to economic drivers. However, these behaviors are often based on existing perceptions of risk and cultural attitudes. Because of this, a component of the ViParc project includes the investigation of the socio-economic context. An essential pre-requisite for the project is the understanding of the supply chain context  it will be essential to measure these costs in relation to the benefits  and its market fluctuations.Long term sustainable AMU-reducing interventions require the integration of solid economic data with in-depth knowledge of farmers' beliefs and motivating factors for antimicrobial usage. However, little is known about these in the Vietnamese context. From an economic perspective, a rational farmer would balance the cost of antimicrobials against the avoidance of losses due to disease. However, non-economic factors such as the desire to maintain a particular self-image or social identity, the compliance with social or institutional rules, and cognitive biases in the perception of risk and uncertainty can all influence the perceived cost-benefit balance. Farmers may seek to mitigate this uncertainty by seeking information from sources they believe are better informed  that have a vested interest in the sale of antimicrobials.An economic assessment based on the estimate of the gross margin  of the batches of chickens raised will be performed with data generated from the ViParc project. The marginal costs and benefits will be examined using a partial budget analysis framework before and after the intervention. The data to feed these analyses will include: (1) potential changes in costs due to disease and productivity; (2) reduced costs in antimicrobials; (3) costs of the intervention; (4) potential for behavior change; and (5) potential AMR reductions. Crucially the ViParc project aims to understand to what extent the proposed intervention  is taken up by the farmer. This will be measured as far as possible using several tools, since it is a crucial variable in terms of the formulation of a potential cost-effective package.A potential limitation of ViParc is its focus on “full time” dedicated farmers. A large fraction of farmers in the area raise “backyard” flocks with <100 birds, and these farmers are not eligible for the study. In addition, an unknown percentage of poultry farmers only raise chickens depending on the economic and market conditions, and therefore may not be in the official farm census. However, we believe that these farmers are very much unlikely to request veterinary support, and simply cull their birds whenever there is disease in their flocks and move on to another business. The project is implemented through the official provincial veterinary system, since there are no private poultry advisors other than commercial companies and veterinary pharmacists in the area. The level of trust between farmers and the veterinary system at present is quite low, although we expect to see an improvement in this relationship as a result of the ViParc project.The ViParc project is expected to provide evidence to the Government of Vietnam on whether the proposed intervention will have a behavioral and economic impact, both at farm-level and across the food production chain. Analyses from ViParc will allow the formulation of pricing mechanisms and those components within the intervention package with the highest likelihood of being sustainable in the long term in the Vietnamese context. The development of a cadre of well-trained poultry advisors and an upgrade of existing diagnostic systems are likely outcomes from the project. Where the interventions are not economically profitable at farm-level, yet generate positive externalities in terms of reducing AMR levels on farms, it will be possible to propose modifications for the antimicrobials and chicken meat market. Alongside the formal testing of interventions, the ViParc project will develop of methods and metrics for the assessment in the smallholder farm context, and will shed light on the need for upgrading of existing production systems.The ViParc project has been granted ethics approval by the Oxford Tropical Research Ethics Committee (OXTREC) (Ref. 5121/16).JC wrote the initial draft and conceived the idea of the intervention study. JR contributed to write the socio-economics and policy components.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.


There is an assumption in current landscape preference theory of universal consensus in human preferences for moderate to high openness in a natural landscape. This premise is largely based on empirical studies of urban Western populations. Here we examine for the first time landscape preference across a number of geographically, ecologically and culturally diverse indigenous populations. Included in the study were two urban Western samples of university students (from southern Sweden) and five non-Western, indigenous and primarily rural communities: Jahai , Lokono (Suriname), Makalero (Timor), Makasae (Timor), and Wayuu (Colombia). Preference judgements were obtained using pairwise forced choice assessments of digital visualizations of a natural landscape varied systematically on three different levels of topography and vegetation density. The results show differences between the Western and non-Western samples, with interaction effects between topography and vegetation being present for the two Swedish student samples but not for the other five samples. The theoretical claim of human preferences for half-open landscapes was only significantly confirmed for the student sample comprising landscape architects. The five non Western indigenous groups all preferred the highest level of vegetation density. Results show there are internal similarities between the two Western samples on the one hand, and between the five non-Western samples on the other. To some extent this supports the idea of consensus in preference, not universally but within those categories respectively. Understanding human preferences for landscape, and particularly to what degree preferences differ between populations is of importance both from a basic research perspective and from a practical landscape and environmental management perspective. A high consensus in preference across populations would enable general theoretical models of landscape appraisal and justify the application of general models of landscape management across cultures.Since the mid-1970s, several well-established and oft-cited paradigms in environmental psychology have advocated a universal consensus in human preferences for certain types of natural environments. Such paradigms include the Prospect-Refuge theory  in order for us to compare how more conventional sample populations respond to the stimulus across experts and non-experts. In addition to this sampling of an unprecedented cross-section of humanity, our approach breaks new ground in that it represents an interdisciplinary collaboration between landscape studies and field linguistics. Thus, language experts with established field sites provide practical and communicative access to the diverse sample and enable a culturally and linguistically attuned experimental protocol in each of our sample populations.in-situ choice experiment for landscape preference using computer generated visualizations. Within landscape preference research the use of ranking or rating of images on a Likert scale has been the dominant method for establishing preference  resulting in 9 different scenarios for the same base landscape. In order to develop images of these scenarios, a neutral landscape was created in the form of a virtual model using the software Virtual Nature Studio, based on the methodology presented in Ode Sang et al. . The neuOur study includes five non-Western, indigenous and primarily rural communities: Jahai , Lokono (Suriname), Makalero (Timor), Makasae (Timor), and Wayuu (Colombia), whose landscape preference has not previously been investigated. We also included two Western (Swedish) university student samples, i.e., common samples on which much landscape preference work is based. There are conflicting results on whether experts and non-experts differ or agree on landscape preferences. However, in some studies where university students from landscape architecture and landscape oriented fields were used, results showed that they differed in preference from students of other disciplines , linguistic affiliation  and primary subsistence mode . Habitats vary topographically and vegetationally, but all populations except the Swedish ones are found in tropical regions. However, the samples also offers opportunities for comparison of closely connected populations speaking related languages and inhabiting similar environments: the Lokono and the Wayuu, the Makalero and the Makasae, and the two Swedish groups.The study included a total of 140 respondents, and the sample size for each of the seven groups varied between 15 and 25 participants  on the plateau above the old town, at an altitude of approximately 500 m. It is separated from the old town by a distinct rock escarpment and is rather arid. Unemployment is high, and small-scale farming, fishing, as well as small livestock form an important part of the inhabitants' subsistence. Like the Makalero, the Makasae are Catholic, but retain animist traditions in which parts of the landscape associated with clan history are considered sacred.rancherias, usually quite distanced from one another to prevent herd mixing. The Wayuu adopted this pastoralist lifestyle shortly after contact with the Westerners. Though the Wayuu are quite a numerous indigenous group  with a thriving culture, their language (which belongs to the Arawakan language family) is today endangered, as it is not being transmitted to children.The Wayuu inhabit the Guajira Peninsula, a border area between Colombia and Venezuela on the Caribbean coast. The territory is dominated by arid, semi-desertic landscapes with scarce xerophytic vegetation and hardly any permanent water features. Topographically, the northern and central parts of the peninsula are mostly flat  but the terrain rises in the south, toward the Sierra Neveda de Santa Marta  and Serranía del Perijá  ranges. This part of La Guajira is also more humid and occasional wetlands appear. The majority of the Wayuu practice goat herding and live in small settlements called mawkili “lit. empty area” or sawkili “good area.” Today, many Lokono have partly given up the traditional slash-and-burn agriculture and adapted to the cash economy. Hunting, fishing and gathering have lost their status as subsistence practices. With most villages being reachable by road, traditional transport by water has disappeared in most places. The Lokono language  is spoken today only by a few elders in each village.The Lokono people inhabit the northern parts of French Guiana, Suriname and Guyana. The landscape of the area where the data were collected is characterized by higher lying savannahs dissected by gently sloping creek valleys, whose vegetation consists mostly of dense tropical rainforest. The many local watercourses are characterized by tidal and seasonal differences in water height and flow, frequent meanders and anastomosing channels. The differences in elevation rarely exceed 50 m. The Lokono villages are located on the edge of the forest and the savannah, on cleared areas called The phrasing of the preference question was given special consideration in this study, due to the linguistic and cultural diversity of the sample populations, as well as the practical aspects of administering the task in the field settings. Rather than asking for a general preference, which leaves undesirably large room for interpretation, we decided to put preference in a context that would be more expressible and understandable across field sites. Thus we chose to focus our question on habitation preference. This approach was also used in relevant previous studies  makes a lexical distinction between the two: leva “to be alive, to exist” and bo “to dwell, to have one's home.” Translation into some other languages requires a paraphrase like “to build one's house,” in order to specifically express habitation .A further consideration concerned the translatability and cultural appropriateness of the preference question. The English phrasing “Where would you prefer to live?” presents several potential translational difficulties. The most apparent one is how to understand and convey the indigenous notion of habitation. For example, the English term live encodes permanent habitation , whereas Swedish bo is unspecified as to permanence. In our sample, permanence also has a cultural twist: one population is traditionally nomadic (Jahai) and until recently erected only temporary camps, intended for habitation for a few months, at the most. Inevitably, any notion of permanence in such a setting will be appraised differently from one in which more sedentary dwellings are the norm. Drawing on our linguistic expertise from the sample settings and taking the indigenous notions of habitation into full account, we have aimed to design the linguistically and culturally most attuned preference question for each setting. The questions are presented orthographically, glossed and translated in Table An additional challenge here is the notion of permanence. For example, English The study also includes an assessment of the respondents' familiarity with the presented landscapes, operationalized by respondents indicating which single image in the whole set was most similar to the landscape in which they grew up. This is further explained in the procedure section.Participants at both Swedish universities were recruited by the researcher, who visited classes and gave information about the study and instructions on how to sign up. Participation was voluntary and gave no course credits but a cinema ticket was offered to all who participated. Among the other populations volunteers were recruited following oral presentation of the study at informal community gatherings organized for the purpose by the respective researcher together with community representatives. The researchers have long-term experience of working in the respective communities. The research was explained as a picture task involving pictures of the land. Participants were offered a small incentive according to locally established practices. Sessions typically lasted 5–10 min.Each of the nine images was paired with the others, resulting in 36 unique image pairs. For an example, see Figure Respondents were tested individually with a researcher present the whole time. Swedish respondents performed the study indoors while for the other sites the environments in which the test was done varied due to practical conditions, see Table The answers from most of the respondents were not consistent in the sense that the pictures could not be uniquely ranked from the 36 preferences from one person. For example, if picture 1 is preferred when it is compared with picture 2 and if picture 2 is preferred when it is compared with picture 3, it is not necessarily true that picture 1 is preferred when it is compared to picture 3.ij, i = 1,2,3, j = 1,2,3, that the picture with density i and topography j is chosen as the one to be preferred. According to this assumption the preferences in the pairwise comparisons use the Bradley-Terry model  in favor of picture  is given byTo model this situation, as well as the factorial design with the pictures described by density of vegetation and topography, we imagine that if a person is shown all the pictures simultaneously, the probability is πR as reference and a factorial design with density, topography and the interaction between density and topography. HenceTo estimate the parameters in this model, a generalized logit model is used with a picture Based on this model, a logit model in PROC GENMOD in SASp ≤ 0.05 was considered significant).Contrasts were created to test for main effects and interactions in this model  groups. For the five non-Western groups — Jahai, Lokono, Makalero, Makasae and Wayuu — there were no significant interactions between topography and density of vegetation  groups. For the Jahai, Lokono, Makalero, Makasae, and Wayuu, the general pattern is that the most preferred images are those in the bottom left corner of the matrix  samples, whose preferences were influenced by interactions between topography and vegetation density. On the other hand no such interaction effects were present for the other five populations. For the non-Western, population main effects of topography and vegetation density were found. This indicates that strategies for how judgements are made, at least when using photographically controlled representations of landscape, might differ between Western urbanized schooled respondents and the indigenous populations who still have a close relationship to the land. The Swedish groups displayed interaction effects between topography and vegetation which suggests that the respondents from this group were not separating these variables when they perceived and evaluated the landscape. In contrast, the other groups considered the variables separately in their evaluation and therefore appear to respond more directly to topography and density as separate properties of the landscape.The result could also reflect that the Swedish student respondents are more affected and tuned to the test situations. This would suggest that they try to understand the parameters of the task and respond accordingly rather than responding and choosing images based on preference.Furthermore, the pattern of preference for openness differed between the non-Western and the Swedish samples. For the two Swedish samples, their overall highest preference was for the image with medium density and medium variation of topography. This tendency was particularly strong in the students of landscape architecture, who can be considered to be experts trained in landscape evaluation. The students of landscape architecture thus demonstrate the preference for a moderate openness asserted by theory  showed quite a strong tendency to prefer their landscape of origin (50–60%, see Table An important purpose of this study was to include small-scale indigenous communities. This however is associated with limitations to our ability to control for or test the impact of factors like age, gender, and educational status. Similarly, obtaining comparable conditions concerning rural or urban residence or education level within all samples has not been possible. Rather, in this study the difference in residence and education occur between the Western and non-Western samples, as a result of the diverse conditions in which these samples can be found. These limitations must be taken into account when interpreting the results. Education and urban vs. rural residence would be factors of interest to further elaborate on in future studies since these factors have been suggested to explain differences between groups in cross cultural visual landscape preference studies Yu, . ConcernOur results bear evidence to clear differences between Western student samples and indigenous communities in the way landscapes are evaluated, what landscapes contain, and the impact of previous experiences. The non-Western groups responded more directly to topography and density of vegetation as specific properties of the landscape when evaluating preference. In contrast, the Western student groups, did not separate the properties out to the same extent but showed interaction effects between topography and vegetation. This could be because this sample might evaluate the landscape more as a whole. Alternatively, it might reflect a greater understanding of the type of survey and the parameters tested and a production of responses accordingly.The study did show that there were internal similarities between the two Western samples on the one hand, and between the five non-Western samples on the other. To some extent this supports the idea of consensus in preference, not universally but within those categories respectively.Our study shows that strong universal consensus with preferences for moderate to high openness—asserted by current theory mostly on the basis of studies drawing on Western and/or urbanized sample populations—can be contested if the empirical venture is expanded to include diverse and small-scale indigenous communities living in non-urban environments. Thus, claims of innate preferences, driven by evolution, for semi-open savannah-style environments are not supported by our cross-cultural sample. Our results rather point to strong consensus in preference for densely forested environments for the non-Western samples. However, in order for any generalizations to be made in this regard, additional preference studies from an even broader sample of communities in a wider range of ecologies will be necessary.The research program of which this study was part was approved by the Regional Ethical Review Board in Lund and determined by the Board not to fall under the Ethical Review Act due to the non-sensitive and non-invasive nature of the research. All subjects in the literate sample populations gave written informed consent in accordance with the Declaration of Helsinki. All subjects in the non-literate sample populations gave informed consent according to a protocol of oral approval developed in full accordance with the standards and guidelines of the European Commission's Seventh Framework Program as well as the CODEX of the Swedish Research Council, and the recommendations of the Code of Conduct of the Volkswagen Foundation's Documentation of Endangered Languages program and the Code of Ethics of the International Society of Ethnobiology.CH co-desinged the survey in collaboration with ÅOS. Took part in the analysis and intepretation of the results and the writing of the paper. ÅOS co-designed the survey in collaboration with CH. Developed the imagery. Took part in the analysis of the results and the writing of the paper. J-EE developed and carried out the statistical analysis of the survey. Contributed to the writing of method and result section. FA, KR, JH, and NB carried out the survey in field and provided guidance for local adaptation of the questions and intepretation of results for local areas. Contributed to the writing of the paper, particularly regarding description of local groups. NB co-ordinated the project and the carrying out of the survey.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.


When a definitive aesthetic treatment is determined, it is crucial to grant the patient's wish with the necessary dental treatment. Thus, conservative treatments that are the solution to aesthetic problems involving morphologic modifications and provide the result that the patient expects should always be the first therapeutic option. In this context, ceramic laminate veneers, also known as “contact lens,” are capable of providing an extremely faithful reproduction of the natural teeth with great color stability and periodontal biocompatibility. Minimal or no preparation veneers are heavily advertised as the answer to our patients' cosmetic needs, which they can be if they are used correctly in the appropriate case. This report is about ultraconservative restorations to achieve functional and aesthetic rehabilitation through treatment planning. Thus, clinicians should be aware that the preparation for laminate veneers remains within enamel, to ensure the bond strength and avoid or minimize the occurrence of postoperative sensitivity. One of patients' greatest desires when seeking dental treatment is the aesthetic transformation of their smiles to include healthy and harmonious dentition. Because of this, conservative treatments that are able to modify the shape, size, and color of the teeth and that provide the result that the patient expects should always be the first therapeutic option –3.Contrary to what many clinicians think, the concept of ceramic laminates without tooth surface wear is not new. Historically, during the 1930s, a California dentist Charles Leland Pincus  worked iDuring the 1980s, after the development of techniques for adhesive cementation, ultrathin laminates were relaunched. However, at the time, the practice did not spread as quickly as expected, due mainly to professionals' fears regarding the strength of the very thin porcelain veneers in resisting masticatory forces . Due to In this context, laminate veneer, also known as contact lenses, emerged. This extremely aesthetic solution uses nothing more than thin ceramic fragments but presents excellent optical properties. It is considered one of the most conservative treatments for oral rehabilitation, as it requires minimal or no tooth preparation , 7. WithPatients undergoing this type of treatment require that the ceramic laminates offer clinical longevity. However, planning is a crucial step in successful aesthetic rehabilitation treatment. Planning each clinical case using a photographic protocol provides better predictability in the final outcome. In addition to photos and videos, wax-up/mock-up binomial important tools to establish correct values and to ensure the symmetry and proportion to the new smile , 11, 12.A female patient (23 years old) with high aesthetic requirements sought dental care in private practice, complaining about the color and size of her anterior teeth because talking does not reveal her upper incisors.A male patient (25 years old) sought dental care in private practice due to a fracture in his maxillary central incisors after hitting the bottom of a pool while diving.An intraoral clinical examination revealed that the anterior teeth had a small axial inclination and asymmetric gingival margins , and theIn clinical practice, especially in prosthetic restorative procedures, there is often a need for prior corrections of the contours and the gingival anatomy due to the goals of achieving facial aesthetics and ensuring harmony between the gum tissue and the dental anatomy.An intraoral clinical examination revealed Class IV fracture in tooth 21 and small fractures in the incisal edge of tooth 11. The patient also presented with a diastema between the canines and the maxillary lateral incisors . A dentaRegarding minimally invasive restorations, planning should not be restricted to the steps of forming and cementing. Other essential steps in the planning process for laminated ceramics include photographic and video analysis, Digital Smile Design (DSD), and mock-ups.The photographic protocols were performed  to assisWith a photographic protocol, it was feasible to plan both cases using DSD. This process involves adding lines and digital designs to face photos in a specific sequence to better assess the aesthetic relationship between teeth, gums, smile, and face; this allows for a better understanding of the problems and can lead to possible solutions Figures  and 5. FFor the case study, DSD was used to create a diagnostic wax additive that shows the individual anatomical features of the teeth. Case 1 involved an increase in mesiodistal dimensions, the cervical alignment of the incisor edges, and buccal volumes of teeth 13–23 . Case 2 Once the wax-up was completed, a silicone guide  was made and put under 2 atm of pressure to increase detail reproduction. This silicone guide was partially filled with a bis-acryl resin material  and placed in the patient's mouth . Before In Case 1, after the diagnostic wax-up was fabricated, gingivoplasty was performed on the predetermined elements. A period of 45 days was expected for perfect healing and maturation of the gingival tissue. In this treatment, multidisciplinary dentistry, represented by the relationship between periodontics and prosthodontics, is not restricted only to the need to observe periodontal health for the completion of a restorative treatment; it also extends to the indication of gingivoplasty to improve the treatment's final result.The color selection was made, while the teeth were hydrated at the beginning of the consultation. Furthermore, a mapping of the colors was conducted to facilitate communication with the dental laboratory.In the case of the ultrathin ceramic restorations for the diastema closure, the insertion axis will begin in the cervical incisal direction, involving the mesial and distal surfaces . TherefoMinimally invasive preparations were performed using diamond burs and sanding discs, which were oriented with silicone guides  Figures  and 12. In Case 1, the impression was carried out in two steps, with heavy and light addition silicone  to obtain an accurate copy of the entire tooth and the gingival structures. Gingival retraction cord was used, as the terms of the preparations were all supragingival. In the first step, the dense addition silicone  was manipulated and placed on the previously selected tray. It was placed in the patient's mouth, and internal relief was carried out simultaneous with the movements of the “strip and set.” The second step involved the use of a small amount of the same silicone rubber that was applied to the dental preparations and the first mold. The tray assembly and the dense silicone portion were placed into position on the light mixture and allowed to set.In Case 2, the impression was performed in two steps with heavy and light bases of addition silicone  to obtain an accurate copy of the entire tooth and the gingival structure, following the same sequence as in Case 1. The retractor cord was not used, as the preparations were strictly supragingival. The lower jaw of each patient was molded with the same material that was used to form the antagonist of the upper jaw in the production model.The feldspathic porcelain laminate veneers were manufactured with IPS d.SIGN (Ivoclar Vivadent) to maintain the teeth's naturalness .To minimize the chances of errors during the cementation stage, such as possible fractures in the ceramics, two types of tests were done in the mouth: dry proof and damp proof using try-in paste  . The venThe cementation of the ceramic laminates is fundamental, as it will be the last step in the work; it should be done with extreme caution. It is important to remember that, unlike conventional crowns, which use dual-type resin cements, ceramic laminates should use a purely light-cured luting agent to prevent the color shifts that can occur due to chemical changes in the curing process. Furthermore, due to thin restorations such as contact lenses, which most allow photoactivation through them, there is no guarantee that the resin cement will be effectively cured.For minimally invasive restorations, the choice was acid-sensitive ceramics, those that experience surface changes when conditioned with 10% hydrofluoric acid, because this process increases the adhesion between the restoration and the tooth.The essential difference in the internal etching processes of ceramics is the duration of hydrofluoric acid exposure . The intIn the dental substrate, a total etching technique was carried out using 37% phosphoric acid for 30 seconds. The acid was subsequently removed with water before the total drying of the enamel surface and the application of a two-step adhesive system  . The surThe luting agents used in these cases  were applied in the internal surface of the veneer, and then the veneer was positioned with light and continuous digital pressure. It is important for cement extravasation to occur on all sides so that the entire inner surface is filled. The excess cement was removed with a brush, and the veneer was light-cured for 10 seconds. Resin cement residues were removed with manual tools and the veneer was once more light-cured at the facial and lingual sides for 90 seconds.  .The finishing and polishing of the cement line were performed with flexible aluminum oxide disks . The laminate ceramic contact lens is a restoration that requires no finishing after cementation—only polishing with a scalpel and abrasive rubbers to remove excess cement. That is, the surface of the restoration is not changed by a glaze performed in a laboratory, thus ensuring the stability of the restoration over its years in the patient's mouth. The occlusion was assessed to make sure the anterior guidance and the lateral excursions were correct, while obtaining even occlusal contacts throughout the restorations. Finally, the patients were pleased with the aesthetics and function of the restorations. Furthermore, all prosthetic questions , dentofacial harmony, and relationship dentolabial and maxillomandibular were conferred Figures –20.Aesthetic rehabilitation with ceramic laminates is being increasingly used as a way to preserve tooth structure, especially in young patients. The diagnostic wax mock-up allows for individualized planning and a predictable outcome in cases where a certain shape and position are expected. These procedures require a refined knowledge of tooth anatomy and insight into each patient's personality . The man Case 1 was a thin tissue biotype. Furthermore, a mock-up was used to allow the surgeon to visualize the final gingival margin and guide the incision shape [The first step is to assess the need for periodontal plastic surgery, gingival biotype, and obtain dimensions for the biologic width for each tooth involved in the treatment to determine whether an osteotomy would be needed . By undeon shape . Case 1, the patient would not want to remake orthodontic treatment, because this was done in childhood and looking for immediate results.Another factor to be considered in the planning is the previous orthodontic treatment to minimize the amount of wear of the tooth structure and provide options for dental alignment problems. Aesthetics is often a primary concern among those seeking treatment through short orthodontic treatment and there are several other factors relating to this that need to be borne in mind when treating the adult patient . However Case 2, a minimal and calculated enamel proximal recontouring might be necessary to remove undercuts or to minimize the influence of the proximal height of contour (crest of convexity) [The great advantages of consolidating membership in the enamel increase the indications of ceramic restorations with minimal or no preparation . The majnvexity) . Similarnvexity) . In thisThe decision regarding the most appropriate material for these types of situations always leads to questions, as dentists often have difficulty choosing between the use of direct composite resins and the production of ceramic laminates. Dental ceramics can both improve teeth's aesthetic appearance and reestablish their strength and function , 27. WheTo achieve better clinical outcomes in the long term and improve the properties of restorative materials, various studies have been conducted. Improvements in the coefficient of thermal expansion and in the size and distribution of particles have led to abrasive ceramic restorations that are more resistant to fracture, giving an improved prognosis and making the ceramic dental restorative material superior to composite resin .The clincher, however, is that ceramics, both feldspathic and lithium disilicate-reinforced, have almost equal resistance after cementation. The explanation for this is the principle of the adhesive bond, which ensures resistance and bond strength through the transfer of one substrate to another. Thus, there is no advantage to using ceramic lithium disilicate-reinforced ceramics, as they will not result in more resilient restorations relative to pure ceramics, such as feldspar or fluorapatite . By usinProper selection of luting material is critical to the clinical longevity of ceramic restorations. Using light-cured resin cements is recommended because they have a variety of colors and different degrees of opacity. In addition, the light-cured luting agent has greater color stability than the dual-curing luting agent . FurtherThe brush technique seems to be the best option for removing excess resin cement in the clinical routine due to this method's good results and technical simplicity; brushing promotes dental and periodontal health and increases the longevity of aesthetic results . In thesThe margin placement of the restorations was located at the supragingival or equigingival (even with the tissue) for all restored teeth . This chThe available literature shows that ceramic laminates have performed well over the years. Studies show results ranging from 5 to 20 years of clinical outcomes after the procedure , 37, 38.These clinical reports describe the laminate veneers as an excellent option for effective, conservative, and aesthetic treatment. Therefore, all of the treatment sequences are ruled by the same plan, taking into consideration the adhesive systems, ceramics, ceramic etching, light curing, resin cements, and the correct photographic protocol. As a result, the aesthetics and function expected by the patients were achieved. The use of ceramic veneers enabled a conservative and aesthetic successful rehabilitation treatment. Thus, for the clinical longevity of restorations with laminate veneers, it is necessary for professionals to carefully follow all clinical steps.


Despite the introduction of the Millennium Development Goal to reduce maternal deaths from 400 to 100 per 100,000 live births, the proportion of maternal deaths is still much higher in most developing countries like Ghana. Various interventions have been implemented in Ghana that focus on increasing skilled maternal care. These are especially needed in rural areas. EHealth has the potential to contribute to reducing the challenges in maternal healthcare (MHC) that poor areas suffer. This paper analyzes the potential of eHealth solutions to improve maternal health in rural Ghana as well as the challenges to their implementation. The work was carried out in cooperation with the local health directorate of Kpando Municipality, one of the administrative areas in the Volta Region.context, community, capacity, connectivity, and content.The study is focused on remote peninsulas and islands in Kpando Municipality. Data was gathered through triangulated research methods. Maternal health challenges were identified using the Three Delays Model for MHC. The three delays are delay in seeking care, delay accessing health facilities, and delay receiving adequate care. Challenges to the implementation of eHealth solutions in remote communities were analyzed using the Drury’s 5C eHealth model for developing countries. The 5Cs correspond to The results show that financial dependence of women, a decision-making process based on previous experiences and traditional beliefs, competitiveness between facilities, organizational loopholes, lack of equipment, and geographical situations directly influence MHC outcomes. EHealth solutions, thanks to the high number of health workers with basic IT skills, have high potential to reduce MHC delays. However, poverty, cultural beliefs, organizational issues, connectivity, and lack of human resources were identified as main challenges to the implementation of eHealth solutions.In Ghana’s rural areas the three delays proposed in the model affect the outcomes of MHC. These delays are influenced by socio-economic status, access to facilities, and quality of care. EHealth solutions show great potential to reduce the delays. Based on the 5C model, a mHealth solution aiming to improve guidance during pregnancy was outlined. MDG 5 focused on reducing the maternal mortality ratio (MMR) from 400 to 100 maternal deaths per 100,000 live births in the period between 1990 and 2015 . As MDG Ghana is one of the countries that has adopted the draft 2030 agenda. This West African country has a population of 27 million (estimated in 2015). Ghana is divided into ten administrative regions, 138 districts, and 58 councils . The preHealthcare in Ghana is decentralized. The Ghana Health Service (GHS) is responsible for the implementation of policies. Strategies and interventions in maternal health are based on the Safe Motherhood Initiative (SMI), a worldwide effort that was launched in 1987. This initiative consists of five pillars: antenatal care (ANC), delivery care, postnatal care (PNC), emergency obstetric care (EmOC), and family planning. The aim of the initiatives is to increase the number of deliveries supervised by skilled birth attendants (SBA) and increase the number of ANC and PNC attendants 15] authoBesides financial factors, we found cultural factors and social stigma key findings to explain low ANC attendance. ANC visits are important to early detection and prevention of pregnancy related complications. Thus, patient reluctance to seek treatment greatly increase the risk of complications. On the supply side, the most important challenge identified might be the lack of information about previous complications and patient history, which directly affects the standar of care provided and might lead to high risk pregnancies being treated in facilities that are not prepared to treat high risk cases.Implementing eHealth solutions for rural communities in developing countries requires different approaches and strategies than in the developed world. There is much literature available with recommendations and guidance for eHealth implementation in developing countries. Their findings are consistent with the ones in this work , 19–21. One of the challenges an eHealth solution field implementation could face is lack of trained personnel to use it. Thus there is a need for continuous and effective training, as well as planning ahead for the possibility of staff rotations. On the other hand, the fact that 80% of interviewed health workers own smartphones is a facilitator for mHealth solutions. Moreover, it is likely that eHealth solutions will face technical problems. Difficulties with the replacement and/or repair of broken equipment need as well to be accounted for. Addressing this issues cloud services can provide remote management. Another solution is to use technology from companies that have technical support across the country. These findings are in line with the ones of , 21.Finally, results might indicate that an eHealth solution will have the highest impact by providing accurate clinical information. Clinical information is crucial for the prevention and early detection of pregnancy complications. By this logic, a potential mHealth solution has been proposed that takes into consideration all the findings of this study. If the proposed solution is able to surmount these obstacles, it could have a high impact in the area, as well as on other areas of similar characteristics.Among the strengths of the research, are its qualitative design and the inclusion of many communities and stakeholders. The latter adds to the conceptual generalizability of the results to other remote areas in Ghana and neighboring countries. The qualitative setup of the study permitted the research objective to be examined in depth and comprehensively, allowing subtleties and complexities to be discovered.On the other hand, one limitation is the cultural differences (including language barrier) between participants and researchers. These differences could have created response bias towards socially desirable answers; some participants may have been reserved towards the researcher in some aspects of their answers. Culture differences may also have led to misapprehension of sensitive and subtle topics during analysis. Further, interviews were not recorded since participants did not feel comfortable to be recorded due to personal and professional issues. Consequently, misinterpretation of questions and answers may have altered the true meaning of some discussed subjects.Triangulation of different research methods and data, with the inclusion of different stakeholders, was used to increase the validity of this study. Moreover, the incorporated member checks and the active seeking of negative cases increased understanding of the stakeholders.Maternal healthcare in rural areas in Ghana is affected by three delays that influence the outcomes of care. These delays are influenced by socio-economic factors, accessibility of the facilities, and quality of care provided. One of the factors that lower quality of care is that health workers in remote areas are not trained to monitor high-risk pregnancies. Socio-economic factors include social stigma and traditional beliefs, which are strongly embedded in Ghana. These factors, along with deficient transportation means, influence maternal skilled care attendance.Ehealth solutions show great potential to improve the factors that influence the delays. This is partially thanks to the high number of health workers with basic IT skills. However, identified challenges according to the 5C model need to be taken into account when designing an eHealth solution. Main challenges are the lack of infrastructure and technical support, the decision making process of patients based in cultural beliefs and previous experiences, poor mobile connectivity, environmental challenges and the poverty context in general. Based on the 5C model, an eHealth solution was outlined aiming to make the highest impact on improving guidance during the pregnancy.The challenges and facts presented in this research can be used as background guidelines for other eHealth solutions to improve maternal health in Ghana. Furthermore, the conclusions of this article can be extrapolated—with caution—to other rural areas and remote communities in Africa.A mHealth solution has been outlined, based on health workers’ needs as identified during the research. In the next steps, the solution will be prototyped and re-designed following a human-centered approach. The aim is to create a solution that health workers will be willing to use.In a following publication the mHealth solution will be described including aspects such as networking, security specifications, backup systems, and privacy protocols. These aspects will be assessed and incorporated into the design of the solution.


Universal Health Coverage (UHC) has emerged as a major goal for health care delivery in the post-2015 development agenda. It is viewed as a solution to health care needs in low and middle countries with growing enthusiasm at both national and global levels. Throughout the world, however, the paths of countries to UHC have differed. South Africa is currently reforming its health system with UHC through developing a national health insurance (NHI) program. This will be practically achieved through a decentralized approach, the district health system, the main vehicle for delivering services since democracy.We utilize a review of relevant documents, conducted between September 2014 and December 2015 of district health systems (DHS) and UHC and their ideological underpinnings, to explore the opportunities and challenges, of the district health system in achieving UHC in South Africa.Review of data from the NHI pilot districts suggests that as South Africa embarks on reforms toward UHC, there is a need for a minimal universal coverage and emphasis on district particularity and positive discrimination so as to bridge health inequities. The disparities across districts in relation to health profiles/demographics, health delivery performance, management of health institutions or district management capacity, income levels/socio-economic status and social determinants of health, compliance with quality standards and above all the burden of disease can only be minimised through positive discrimination by paying more attention to underserved and disadavantaged communities.We conclude that in South Africa the DHS is pivotal to health reform and UHC may be best achieved through minimal universal coverage with positive discrimination to ensure disparities across districts in relation to disease burden, human resources, financing and investment, administration and management capacity, service readiness and availability and the health access inequalities are consciously implicated. Yet ideological and practical issues make its achievement problematic. There is a growing enthusiasm for universal health coverage (UHC) at global and national levels. It has emerged as a silver bullet solution to health care needs in low and middle income countries . CurrentBeyond generating attention globally and nationally, UHC has also been set as a possible umbrella goal for health in the post-2015 development agenda , 4. But As a health financing system, the NHI is designed to pool funds to provide access to quality, affordable personal health services for all South Africans based on their health needs, irrespective of their socioeconomic status. Thus, the NHI is intended to ensure that the use of health services does not result in financial hardships for individuals and their families . AccordiDespite the global and national momentum, however, the paths of countries to UHC have differed with varying health systems  and refoIn Africa, the DHSs’ strategy has become the backbone of nearly every national health system. Countries are covered by health facilities-organized in a tiered system . Even whThere is confusion as to what UHC actually is . BroadlyMeanwhile, it is instructive to mention that UHC comprises two main components: quality, i.e. essential health service coverage, and financial coverage – both extended to the whole population. Three dimensions underlie countries’ efforts in progressing towards UHC as identified by the World Health Organization. These are population coverage, service coverage and cost/financial coverage . This reequity of access and financial risk protection. Its defining feature is a prescription of a clear split between health financing and health provision, allowing for the entry of private insurance companies, private health providers and private health management organizations [In other words, UHC is defined in terms of rights to health care, financial protection, and utilization of health care services on an equitable basis . Universizations . Does thIn terms of population coverage, NHI will extend coverage to all South Africans irrespective of their socio-economic status. Coverage will also extend to legally permanent residents. In extending effective population coverage , priority will be given to the population that is in greatest need and must include those experiencing the greatest difficulty in obtaining care. The identification of the population with the greatest need will be based on criteria consistent with the principles of NHI. Vulnerable groups will be prioritized .NHI will have a single-payer mandatory prepayment mechanism where resources are pooled in a single fund to cater for the health needs of the entire population via a strategic purchaser. By this, the NHI will ensure that individuals and households do not suffer financial hardship and/or are not deterred from accessing and utilizing needed health services. It involves eliminating various forms of direct payments such as user charges, co-payments and direct out-of-pocket payments to accredited health service providers. In effect, the NHI aims at providing a comprehensive package of health services to all South Africans according to need and not ability to pay . The WhiSo given this background, how is UHC evolving within a district-based system? An extensive literature review conducted to gather relevant descriptive and quantitative data on UHC and the DHS formed the main methodological approach for investigating this. The main focus was on UHC and its ideology, the link between UHC and service availability, service availability and districts and the focus on districts using the case of the NHI pilots in South Africa. As part of the literature review process, an assessment of relevant publications including government policies, Department of Health (DoH) reports, District Health Barometer (DHB), South African Health Review, working papers and academic articles concerning the topic were also made use of.Thus materials were collected from different and multiple sources including documents, policy briefs, reports, bulletins and academic papers as a way of triangulation so as to give credibility and dependability  to the sReviewing national and international documents as well as the academic literature on DHS and UHC and their ideologies, we explore the prospects for UHC in South Africa.Ideologically, the goal of UHC, whether tax- (likely NHI route) or insurance-based is deeply ingrained in a broadly-defined politics, ethics and international law . While UIndeed evidence shows that all countries that have achieved UHC have done so with an increase government role in the financing, regulation, and sometimes direct provision of health care services , 23–27. If the main goal of universal health coverage is to ensure good quality care for all then universal access to services is a precondition to achieving universal coverage , 28. ButBut with these differences emerging more clearly, there needs, therefore, to be differential improvements in services. Can this be through UHC and what is the relationship between UHC and service availability? O’Neill et al. identify two types of service availability-general and service-specific. General Service availability is concerned with the physical presence of items required for the delivery of services and encompasses health infrastructure, core health personnel and aspects of service utilization. On the other hand, service-specific availability is concerned with whether a specific type of health intervention is offered. Intervention may be defined by target population, for example, pregnant women, infants, children, the poor, HIV positive patients, and by specific programme . AlthougDistrict health systems comprising primary health care and first referral hospitals, are key  to the dThe link between service availability and the district cannot be overemphasized as the DHS model applies to the whole health system and at all levels of healthcare delivery. For example, although about 90 % of South Africans live within seven kilometers of a public sector clinic and two thirds within two kilometers, monetary and time-related costs associated with travel to a local clinic can pose considerable barriers to vulnerable populations . AssessmIn the Free State, staff shortages, infrastructure, and budget constraints were identified as impacting negatively on effective and efficient delivery at the inspected facilities as well as the service readiness of those facilities . In one In the other provinces  similar issues were present. At the Ellisras Hospital in Limpopo, the report indicated the lack of sufficient doctors as there is poor infrastructure and a poor living environment. In the North West, it was reported that at the Brits Hospital, there was no doctors’ quarters. Other issues noted included infrastructure, generally poor emergency medical services in all the districts due to insufficient ambulances, where response times often range between one and four hours. Sometimes ambulances never arrived after repeated calls placing the lives of affected persons at risk . The WesHealth human resources vary enormously between provinces. For example, Limpopo and North West have the smallest proportions of health professionals except for registered nurses. In Northern Cape and Mpumalanga, over half of medical practitioner posts are vacant , 39. At Variations in readiness for service delivery are mirrored by management challenges. Overall, there is variable expenditure on district management. In Eastern Cape, for example, Cacadu district expenditure on management was 10.8 %, while Nelson Mandela Bay spent 5.0 %. In KZN, the percentage of district health services expenditure on district management was lowest in Zululand in KwaZulu-Natal (0.8 %) and highest in Northern Cape in ZF Mgcawu (14.2 %). Eight out of the 10 districts with the lowest percentage expenditure on management were from KwaZulu-Natal, which may point to a lean effective system or lack of capacity.Yet despite these differences between districts , the ideAs seen in the preceding section, the focus on districts is underpinned by the fact that in order to achieve equity, the organization of healthcare should be according to geographic sub-divisions of a country, managed through decentralized management structures: a normative statement. Ideologically, the district is related to the need for decentralization and community involvement; and the integration of health programmes. It thus emphasizes the specific characteristics of an area, its particularity. According to the World Bank, decentralization can reduce administrative bottlenecks in decision making and increase the efficiency of government and its responsiveness to local needs. It can also enhance the accountability of public institutions, improve service delivery, and allow greater political representation and participation of diverse groups in decision making . Yet theA conscious change in policy direction in favor of pursuing UHC in South Africa can be seen in the development and piloting of the NHI in eleven districts since 2012. The aim is to roll out nationwide in a fifteen year period. This can be situated within the context of global trends on desirable health system reforms . The pilThe pilot districts selected are situated in the nine provinces and specifically in areas with high levels of underserved communities. According to Nkosi, selection of the districts was based on health profiles/demographics, health delivery performance, management of health institutions or district management capacity, income levels/socio-economic status and social determinants of health, compliance with quality standards and above all the burden of disease . So can Furthermore, will improving access to quality health services, particularly, in the rural and previously disadvantaged areas require mechanisms for introducing a district health system of funding for health services; and what are the costs of introducing a fully-developed district health authority and implications for scaling up? –54. But Approximately 12 months after their inception, the Strengthening South Africa’s Response to HIV and Health (SARRAH) conducted an independent review of the current status of the eleven NHI pilot districts and some progress has been made. NHI teams are in post (in nine districts), but only four districts have nationally appointed full-time NHI Project Managers with the other districts making efforts to fill up the various posts. Overall, a significant proportion (about 60 %) of the NHI conditional grant funds has been disbursed by the districts in the last quarter of the year. This has primarily been on procuring equipment and refurbishing health facilities . There has been progress with District Health Management Teams (DHMTs). Claims of NHI activities being coordinated on a regular basis are also reported. Clinic committees have been established, and most are now functioning. The report further notes progress in hospital reforms with re-designation of district hospitals. Thus full-time CEOs are in post in 60 % of all hospitals. Quality improvement mechanisms have been introduced in 10 of the 11 districts; Facility Improvement Teams (FIT) are said to be functioning, quality assurance plans are being monitored, and Office of Standards Compliance (OSC) assessments are taking place in all the districts. Private GPs were to be contracted in the 2013/14 financial year , 54. YetAgain, contracting of general practitioners to provide PHC services at clinics located within the pilot districts was implemented in the 2013/14 financial year. It has been estimated that over 302 general practitioners have been contracted since. Available data indicates that 152 contracted general practitioners are providing services in 260 PHC facilities in eight pilot districts. Preliminary data indicates that for the 2014/15 financial year, approximately 34,330 patients received services delivered through these general practitioners contributing to the reduction in waiting times and improving access to needed services for the catchment populations served .There remain key challenges in the NHI pilot phase. Overall, there are reports of uneven progress across the districts. The report notes for, instance, that achievements in the Eden (Western Cape), Pixley ka Seme (Northern Cape), Tshwane (Gauteng) and uMgungundlovu Districts  were far higher than in the OR Tambo (Eastern Cape) and Vhembe Districts (Limpopo Province). For example, only 2 % of primary healthcare facilities in the OR Tambo and 15 % in the Vhembe Districts were able to provide the full package of primary healthcare services. In contrast, it is claimed that more than 80 % of the facilities in the Eden, 76 % uMgungundlovu, and 65 % in the Pixley ka Seme Districts had sufficient capacity . This siThere has also been a lack of adequate infrastructural improvement in the pilot districts. Progress has been slow due to poor coordination between the National Department of Health (NDoH) and the Department of Public Works. Preparations for the new NHI services and innovations necessarily depend on improvements to the standard of the available facilities and the coordination of functions between the DoH and the Department of Public Works .Inadequate budget spending guidance from the NDoH was also noted. By the end of the 2012/13 financial year, it was reported that only 77 % of the budget allocated to the pilot districts through conditional grants had been spent. And 90 % of the available funds were used only in the fourth quarter of the financial year . This, aThere is also the lack of progress in establishing the structures for community participation in primary healthcare service delivery- clinic committees and hospital boards. While all the districts were reported to have hospital boards and clinic committees, there is little detail about how these bodies function and the extent to which they facilitated meaningful community participation. Furthermore, variations in the quality of the structures meant to facilitate public participation were evident. In the Pixley ka Seme District in the Northern Cape, for example, four out of thirty-six clinic committees are described as “functioning optimally” in the report. In contrast, in the OR Tambo District, all the hospitals have boards “but functionality is an issue”. The Gert Sibande District has no protocol for the establishment of clinic committees, and has used the provincial protocol for Hospital Boards instead . In sum,The question of whether UHC reduces health inequity remains a question at the present. However, to the extent that UHC removes financial barriers to health care access through the pooling of funds to provide a basic package via health insurance to those who otherwise could not have paid at the point of service, UHC enhances the population access to appropriate promotive, preventive, curative and rehabilitative health care without any catastrophic financial cost. In this regard and in light of state DoH policy, UHC through NHI implies a move towards equity of access and financial risk protection, especially, by which the most excluded and vulnerable populations rise to the same standards of health enjoyed by the more privileged in society. The introduction of community health workers, improvements to monitoring the health of children and decongesting clinics by new modes of chronic illness medication distribution are significant positives.But as the WHO and Scheil-Adlung et al. note, ‘coverage’ denotes access that is realised, i.e. going beyond legislative entitlement to effective coverage. It also includes the quality of health services received , social equity, and the financial risk protection that has been obtained –60. But Evidence from the pilot districts demonstrated that out of 301 (49 % of 609) PHC clinics across nine districts assessed in relation to their readiness to deliver comprehensive health care services, one third of them were considered to be ready overall  with conHuman resource distribution across the districts is perhaps the outstanding constraint. In the Amajuba district in the KwaZulu Natal Province, the recruitment of the District Clinical Specialist Team (DCST) has proved daunting with the district only being able to recruit the advanced midwife and PHC nurse out of a total membership of seven by the end of 2013. Even with the availability of facilities, UHC might not ensure equity in healthcare access without the required health professionals to deliver services.Considered in the context of the disparities across districts in relation to disease burden, human resources, financing and investment, administration and management capacity, service readiness and availability and the inequalities that still exists in the pilot districts, this commentary suggests a need for a minimal universal coverage and for positive discrimination. In line with Brearley et al. contention, financial risk protection, which is at the heart of UHC, has the potential of reducing the vulnerabilities of poor people and strengthening household resilience if the overall system is adequately funded and sufficiently redistributive . Yet theFrom the results presented above, positive discrimination is already taking place in the pilot districts. Based on principles of solidarity and communitarianism, the worst districts, that were underserved and understaffed, benefit most as South Africa moves towards UHC over a fifteen year period. While discriminating against other districts, bridging the health availability and access gaps between the underserved and better- resourced districts could only lead to improvements in health availability, access and health status outcomes in South Africa. We argue, therefore, that such an approach can be replicated nationwide when NHI is finally implemented. This will ensure resources are freed up in areas that less need them for use in areas that need them- pro-poor, rural and other underserved areas based on health profiles, socio-economic status and service readiness and capability. Such an approach requires dedicated and committed political leadership over the long term, found in the UHC reforms in Brazil and Thailand .Evidence from the data also supports the need for positive discrimination while upholding minimal universal coverage for all South Africans. Yet in a resource-constrained setting, positive discrimination may be resented by those seen as not entitled to these resources, as was found in attracting new staff to underserved areas through a rural allowance. Existing staff felt that they were discriminated against . ResourcFurthermore, results from the data support the view that positive discrimination for minimal universal coverage at the district level works but sick individuals and communities may not be best served by the geographical approach as there are illnesses in richer areas and healthy people in poorer ones. This scale problem is difficult whatever the UHC implementation solution. For the present there is encouragement and, financially, it is acknowledged that socio-economically deprived districts in South Africa have been receiving more resources than those less deprived ones as a way of ensuring equity and bridging the inequality gaps as “much more is spent on DHS per capita uninsured in deprived areas”  than in The paper set out to explore the extent to which the DHS can serve as a catalyst to UHC in South Africa. It noted the differences in population health status and service delivery between districts and noted the possible tensions between the ideologies of UHC and decentralization. Yet there is mixed but largely positive news from the NHI pilots, selected because of poor health conditions and services. Yet there is a concern for the future, financially, ideologically and practically. But in order to ensure no district lags behind in health policy reforms towards UHC, there should be priority setting driven mainly by the objective to achieve equity in access to health and wellbeing outcomes. Service availability and readiness have to be based on the unique conditions of each district, according to the principles of DHS. By emphasizing district particularity, more resources can be committed to those districts that are underserved and in dire need of health facilities and personnel in the country. Nationally, financial sustainability of UHC must be ensured.Thus in South Africa the DHS is pivotal to health reform and correctly UHC, as defined by WHO, which emphasizes the well-functioning of the entire health system of which the DHS is a part. Whether the financial and ideological challenges will undermine this intent is not known. But as the roll-out of the NHI program to all districts may require a rethinking of the salience of the DHS or a scaling down of UHC developments.