Although found in temperate and tropical marine waters all over the world, the centre of species diversity and abundance are the shallow coastal waters of Island Southeast Asia. For at least 300 years, trepang has been a highly priced commodity in the Chinese market. Originally, its fishing and trade was a specialized business, centred on the town of Makassar in South Sulawesi (Indonesia). The rise of trepang fishing in the 17th century added valuable export merchandize to the rich shallow seas surrounding the islands of Southeast Asia. This enabled local communities to become part of large trading networks and greatly supported their economic development. In this article, we follow Makassan trepang fishing and trading from its beginning until the industrialization of the fishery and worldwide depletion of sea cucumbers in the 20th century. Thereby, we identify a number of characteristics which trepang fishing shares with the exploitation of other marine resources, including (1) a strong influence of international markets, (2) the role of patron-client relationships which heavily influence the resource selection, and (3) the roving-bandit-syndrome, where fishermen exploit local stocks of valuable resources until they are depleted, and then move to another area. We suggest that understanding the similarities and differences between historical and recent exploitation of marine resources is an important step towards effective management solutions.The Malayan term  Living in a trader's house everything is brought to me as well as to the rest–bundles of smoked tripang, or beche de mer, looking like sausages which have been rolled in mud and then thrown up the chimney… Alfred Russel Wallace [1:329]teripang and describes a range of edible holothurians commonly known as sea cucumbers. Sea cucumbers are found in temperate and tropical marine waters all over the world, but the centre of species diversity and abundance are the shallow coastal waters of Island Southeast Asia and adjacent areas. In this region, some 80–100 species are known, up to half of which have some commercial value. Along with other marine resources such as pearls, mother-of-pearl and tortoiseshells, trepang has exclusively been harvested as a high-priced commodity for the international market. Historically, trepang trade was a specialized business, almost completely in the hand of Makassarese, Bugis, and Bajau The term trepang derives from the Malayan word The consumption of trepang is almost entirely restricted to the Chinese, who consider them a culinary delicacy and an aphrodisiac. Together with similarly treasured resources such as shark fins and bird nests, trepang belongs to a group of commodities which were so valuable that “distant seaside cliffs and seemingly peripheral seas became sought-after destinations” Authors such as Macknight Makassar had long been known as a central point of seaborne commerce. Its geographic location at the southwest peninsular of Sulawesi made the town an ideal trading place, being at the crossroads of local coastal movements as well as in inter-insular traffic among Java, Kalimantan, Maluku, Nusa Tenggara and the Philippines, and in long distance trade with Europe, India and China Three ethnic groups were involved in the exploitation and trade of marine resources in this region. The Bajau people originally were sea nomads, travelling long distances in search of valuable collecting grounds and thereby opening many trading routes. Bajau have often been described as the only people engaged in commercial fishing and collecting resources along the shores in Sulawesi Similar to other products, trepang flowed through a shifting hierarchy of collecting points where cargoes were assembled. Many Bugis traders paid dues to their kings or patrons, who could also be their creditors, while the Bajau were often tied to a patron in semi-tributary relationships Gathering trepang neither required special skills nor a lot of equipment. Fishing techniques ranged from simply collecting specimens by hand to the use of single- or double-headed spears. In shallow water, trepang was located by feeling for it with bare feet and then brought to the surface. Women would also collect the specimens by hand on the reef flats at low tide, while men dived or used a weighted, three-pronged spear, which was lowered by rope from a boat to a point just above a trepang and then dropped to the bottom, the weighted spear impaling the animal Fishing and trading of trepang has a number of similarities with the more recent exploitation of other marine commodities, such as live reef food fish or ornamentals. One major factor common to all is the strong influence of an outside demand. The raise of a wealthy consumer class not only had a great influence on the Chinese desire for sea cucumbers in the late seventeenth and early eighteenth century Punggawa, the local term for patron, has already been used in the 19th century to describe elected leaders of the Bajau A second influential factor is the role of credit and debt, which is inherent in patron-client relationships. The term describes a relationship between a politically and economically powerful patron and a weaker client. Clients and their families can borrow money, equipment or goods from the patron, in order to make it through bad seasons. This can be regarded as benevolent, but also creates debts and dependency. Patron-client relationships have a significant influence on the exploitation of marine resources in certain parts of Island Southeast Asia. In South Sulawesi, they developed from (1) local systems of land tenure and agricultural production Patrons react to market signals such as the desire for a new resource by providing their clients with the necessary equipment and announcing their will to buy a certain item. Clients–depending on the credits provided and often socially tied to a patron–will change to a different target resource, if their patron demands them to do so. Thus, patron-client relationships influence the choice of fishing strategies of individual fishermen th century th century in the Americas Opportunistic behaviour is also quite common in the exploitation of open-access marine resources. Fishermen exploit local stocks of valuable resources until they are depleted, and then move to another area, a pattern Berkes et al. A current study by the FAO claims sea cucumber overexploitation to be a recent problem Therefore, the aim of this paper is to follow the trepang fishing and trade as an example for the historical and current exploitation of marine resources in Island Southeast Asia. Our focus is on the trade which was started and is still handled by people from Makassar, and which had historically accounted for the largest amount of this economically important activity.haishen (sea ginseng) in a book called Miscellanies of Five Items in 1602. It was described as an aphrodisiac. More frequent references began to emerge in the late seventeenth century and indicate that trepang must have already been a common food at this time. According to Chinese literature, trepang was found along most of Chinas coastal areas, but the local production soon failed to meet the demand. It was therefore first imported from Japan, and later from Southeast Asia daghregister) of Makassar from June 1710 that refers to trepang collection off Buton (I) in Southeast Sulawesi Vereenigde Oost-Indische Compagnie or VOC). However, from the mid-eighteenth century on, there are frequent references to the collection and processing of trepang all over Island Southeast Asia, with Makassar in South Sulawesi as the centre of trade.While some authors stated that sea cucumbers have been harvested for over 1000 years in the Indo-Pacific region [26 and references therein], documented evidence is only available for the last 400 years. In China, written references to trepang appeared for the first time under its Mandarin name Bugis had probably been visiting the Moluccas–namely the islands of the Kei group (II) –since the sixteenth century Both Kei and Aru soon developed into major fishing grounds. While it seemed that Aru islanders originally sailed to Ambon in order to sell their commodities, after the 1820s traders started to visit people directly in their villages sasi. Sasi encompasses fishery-related rights and rules, and is therefore commonly referred to as a traditional resource management institution, even though it also has other functions and its focus has changed through time kewang. At least since the 18th century, a specific form of sasi was applied to trepang, the sasi teripang. Some areas of the Aru Islands employed sasi teripang until recently sasi thus is a local institution, it has been suggested that Dutch colonial administrators did assist local elites in recrafting and deploying sasi practices to control access to marine commodities The importance of trepang for the livelihoods of many people in the Moluccas is also documented by the fact that institutions which governed the right to capture marine animals were developed pikul  to the north and west of Makassar. Although many of the Spermonde islands were not yet inhabited, some already were settled, such as the island of Barrang Lompo In 1717–1718, 11 tons of trepang were exported from Makassar. In the following years, the trepang trade started to grow. In 1725–1726, the amount rose to 79 tons, in 1766–1767 to 301 tons, and in 1787–1788 to 512 tons, respectively see . At the trepang pasir, was obtained from sandy banks around the island of Kuding Aring, today known as Kodingareng Other important trepang collection areas during the eighteenth and nineteenth century were West-Papua (VII), Sumbawa (VIII), Timor (IX) and Selayar (X), as well as two regions in Northern Australia, namely Marege (XI) and Kayu Jawa (XII) see . The SpeThe commercial fishing reached a peak in the mid-eighteenth century. Around 1850, the annual export of dried trepang from the Kei Islands was estimated at 36 tons, between 600,000 and 1,200,200 specimens It is difficult to determine how many species of trepang were fished. Koningsberger trepang pasir from the Spermonde Archipelago near Makassar. Part of its high quality was due to the skilful way in which the product was prepared by the Bajau there th century one pikul of this variety was worth 77.5 rixdollars, while the cheapest kind (black trepang) sold for 10 rixdollars. At the same time, a pikul of rice cost about 1.5 rixdollars While the species definitely played a role in determining the locally distinguished variety, the size of the animal and the skills used in processing were also important The most fascinating and also comparatively well-known part of the Makassarese trepang fishery is its extension towards the northern coasts of Australia. Due to the extensive work of Charles Campbell Macknight, we have a relatively complete picture of the size and sophistication of what he has called “Australia's first modern industry” The two major trepang fishing areas were Marege, also known as Arnhem Land and today a part of the Northern Territory, and Kayu Jawa, the so-called Kimberley Coast in Western Australia see . Lion [4The British hydrogeographer Alexander Dalrymple was the first who, in 1768, reported about Bugis in Australia “After clearing the narrow passage between Cape Wilberforce and Bromley's Isles, we followed the main coast to the S.W. having on the starboard hand some high and large islands, which closed in towards the coast a-head so as to make it doubtful weather there is any passage between them. Under the nearest island was perceived a canoe full of men; and in a sort of roadsted, at the south of the same island, there were six vessels covered over like hulks, as if laid up for the bad season.” As is turned out, the vessels came from Makassar. They were part of a fleet which each year-using the north-west monsoon starting in December–travelled along the coast of northern Australia in search for trepang. They were equipped with all necessities to build small camps close to the shore, where they also erected smokehouses for the preparation of trepang. The majorities of supplies were brought from Makassar; including tobacco and other commodities for Aboriginal people who were to a small extent also employed. Only firewood for smoke-drying was gathered from mangroves in the area.grey trepang, also described as chalk fish or white trepang. While this variety was not the most valuable, it still fetched a reasonable price and was available in great quantities. According to contemporary sources, trepang Marege and trepang Kayu Jawa became distinguished varieties in the market, and the commercial success of the trepangers depended on their ability to transform the abundant chalk fish into trepang Marege or trepang Kayu JawaDepending on the wind, about 10–15 days were needed for the 1,600 km from Makassar to Marege. Each year, up to 2000 men made the journey and were temporarily scattered in processing camps between the Cobourg Peninsula and the bottom of the Golf of Carpentaria. They mainly gathered th and early 20th century aboriginal Australians According to Macknight When considering the amounts of sea cucumbers that were collected, it seems implausible that overfishing did not take place at least in some locations. As a matter of fact, a number of sources do contain descriptions which can be interpreted as more or less obvious signs of early overfishing.Knaap and Sutherland An explicit account of local overfishing was given by Bosscher Shortly afterwards, a new harvesting technique was adopted along the Australian coasts: dredging. Searcy Fishing for sea cucumbers became more effective. However, the more or less stable level of trepang exported from the region over a long time seems to confirm that overfishing, if it occurred, was probably a temporary problem of a limited area that was fished out for the year, but replenished before the next From the few sources available, it seems fair to assume that some overfishing did occur, but was restricted to certain locations and limited periods of time. Sufficient recruitment was obviously still possible, and species which occurred in greater depths were yet out of reach. The scattered information does not allow more detailed reasoning including an answer to the question if the changing spatial exploitation patterns were indeed a result of stock depletion or rather driven by competition. However, it should be kept in mind that historical overfishing could have gone largely unnoticed, especially for resources which had virtually no value outside the Asian markets.th century, when populations collapsed in many places because so many people took part in collecting. The age-old movement of certain groups of collectors from reef to reef accelerated as prices rose and stocks of certain species were quickly depleted in one area after another As discussed above, although considerable amounts of sea cucumbers have been harvested for centuries in some localities, ecological overfishing historically did not appear to pose a major threat since harvest was confined to comparatively shallow depths. Larger individuals occurring at greater depths possibly provided a pool of individuals that could replenish the population once it was depleted in shallow waters Holothuria nobilis, H. scabra, Stichopus spp., Thelenota spp., and Bohadschia spp.”. Nowadays, most of the fishermen in Spermonde report that they travel large distances, e.g. to the coasts of Kalimantan, to collect trepang (unpublished data from own interviews in June and November 2009).In the 1980s and 1990s, increasing demand from China and other parts of the world revived the trepang fishing activities A study recently published by FAO H. nobilis, a highly sought-after species, showed that overfished stocks may take decades to recover While the social systems linked to trepang fishing and trade have intensively been researched, the ecological effects of removing a large number of bioturbating organisms from shallow tropical ecosystems for the most part are still unknown In 1825, Kolff gave the following description from the Tanimbar Islands: “… we… passed through a number of small islands … and trepang lay on the banks in the greatest abundance.” Certain regions in maritime Southeast Asia still largely depend on resources taken from the sea. Besides traditionally harvested commodities such as pearls, mother-of-pearl or shark fins, a number of new products have entered the market over the last decades, such as live food fish or ornamentals. While the exploitation of sea cucumbers is quite unique in its magnitude and in the role which certain ethnicities used to play in the trade, it also shares a number of similarities with more recent exploitation patterns of other resources.A common feature is their exclusive destination for markets outside the country of origin. Thus, utilization changes according to international demands, and the goods flow through a shifting hierarchy of middlemen and other traders.punggawas is central in the market chain. Patrons react to market signals by providing their clients with credits and/or the necessary equipment for fishing activities. Primary resource collectors can therefore hardly choose what to fish. They are bound to their punggawa by debts and have to adapt their exploitation strategies accordingly. While punggawas specialize in certain commodities, their clients do so as well. This has led to spatially differing exploitation patterns between locations: In the Spermonde Archipelago, some islands are known for their live food fishing activities, while others utilize ornamental fish and corals or trepang (own observations).In regions such as South Sulawesi, the role of patrons or de facto open access nature of marine resources in many areas, where property rights are not defined or secured. Such roving collectors are thought to have no incentive for the local conservation of resources. The proposed remedy is the so-called “stationary bandit”, which simply means that fishermen stay in one place. As they are dependent on the future existence of their local resources, stationary users are hypothesized to have a vested interest in the maintenance of these resources A pattern common to marine resource exploitation is the spatially expanding depletion of harvested species known as the “roving bandit syndrome”. Roving bandits profit from the For centuries, trepang has played an important role in the economic development of maritime Southeast Asia. It laid the foundations for a complex web of relationships, integrating scattered seafaring populations into long distance trade, and intensifying the commercial possibilities of outlying regions.While trepang fishing shares a number of similarities with the exploitation of other marine resources, such as (1) a strong influence of international markets, (2) the role of patron-client-relationships and (3) the roving bandit syndrome, there is also a major difference: its longevity. For 300 years, trepang remained a major export commodity in island Southeast Asia. Fishing for live food fish such as grouper has a history of less than 30 years. After half of that time, some waters including Riau and the Spermonde Archipelago were already fished out. In order to obtain reasonable catches, divers based in these islands must now roam further away, e.g., to Take Bone Rate Atoll and through the Moluccas and Raja Ampat in West Papua. Additionally, fashion is extremely important and plays a major role in determining a fish's desirability. Like any fashion-driven preference, preferred species of live reef fish tend to change with time sasi teripang, and local overexploitation was avoided by travelling to other areas. Such institutions are completely absent for more recently exploited resources, and also for trepanging in its modern way. Alternative management forms have to be created, such as pro-active management plans beyond the periphery of presently exploited areas Another major difference is the existence of certain management structures. Trepang fishing in some areas led to the development of property rights which determined the right to capture sea cucumbers. Harvest restrictions were implemented by temporal closures of collection areas, the so-called Thus, understanding the similarities and differences between historical and recent exploitation of marine resources, as is currently being attempted by several authors in the frame of the History of Marine Animal Populations (HMAP) project, constitutes an important step towards finding sustainable solutions for the emerging problems.This article draws on an extensive analysis of historical documents and a number of secondary sources. Research for this article was initiated by a systematic search of digitalized documents available in the online repository of the Royal Netherlands Institute of Southeast Asian and Caribbean Studies (KITLV) in Leiden, The Netherlands and through google books. Data was then augmented by original documents derived mainly from two archives: the KITLV in Leiden, and the National Archives of the Republic of Indonesia (ANRI) in Jakarta, Indonesia. The historical information was complemented with empirical findings from field visits to Makassar and the Spermonde Archipelago between August 2008 and January 2010.Table S1Commercially relevant trepang varieties with their local and scientific names.(0.13 MB DOC)Click here for additional data file.Table S2Makassarese trepang export and production from 1975–2009.(0.07 MB DOC)Click here for additional data file.Text S1References for (0.03 MB DOC)Click here for additional data file.


Given the shortage of human resources and the launching of a new Mental Health Plan, recruitment of psychiatrists is currently a major concern in Portugal, as well as in several other countries. Medical students' attitude toward psychiatry has been pointed as a predictor of recruitment. This study aims to evaluate the medical students' perception of psychiatry before and after a clerkship, and the impact on their intention to pursue psychiatry as a future specialty option.th year students in a medical school in Lisbon, before and after a 4-weeks full-time psychiatric clerkship, in order to evaluate attitudes toward psychiatry and intention to follow psychiatry in the future. Statistical analysis included Wilcoxon and Chi-square tests.Two self-report questionnaires were administered to all 6153 students  filled in both questionnaires (no dropouts). After the clerkship, there was a significant improvement regarding the overall merits of psychiatry, efficacy, role definition and functioning of psychiatrists, use of legal powers to hospitalize patients and specific medical school factors. There was also a significant increase of students decided or considering the possibility to take a residency in psychiatry.However, perceptions of low prestige and negative pressure from family and peers regarding a future choice of psychiatry remained unchanged in about one-third of the students.The results indicate clearly that the clerkship had a favorable overall impact on the student attitude towards psychiatry, as well as in the number of students considering a future career in psychiatry. Attitudes toward psychiatry seems a promising outcome indicator of the clerkship's quality, but further research is needed in order to assess its reliability as a sound predictor of recruitment. Portugal, like many other countries -5, is cuAccording to the available data , Portuganumerus clausus), which has been the norm over the past 30 years. The number of graduating physicians has dwindled so acutely that the yearly Internship allocations have seen an excess of vacancies. Secondly, due to the scarcity of physicians in a given field, particularly in primary care, the Government has allocated substantial amounts of vacancies to fields like family medicine (accounted for 30% of vacancies in the 2009), thus reducing the amount available for other fields.This issue, resulting from a combination of several factors, has recently worsened. Firstly, the small number of physicians graduating from Portuguese medical schools, a direct result of the Governmental policy of restricted admission .The Mental Health clerkship has duration of 4 weeks, on a full-time basis, and includes a module of theoretical and practical seminars (25 h) and a module for clinical practice (75-100 h), in which students can rotate through hospitalization valences, outpatient clinics, day hospital, child psychiatry, liaison psychiatry, rehabilitation and psychiatric emergency. As a general principle, the clerkship was renewed in order to avoid an overemphasis on acute medicine and inpatient settings. This approach contrasts with the traditional inpatient setting where the teaching of psychiatry takes place during the fifth year of the course, with a particular emphasis on psychopathology and clinical diagnosis of major psychiatric disorders.At the beginning of the psychiatry clerkship, the study was presented by one of the authors (MX) to all 6th year students, who were invited to participate voluntarily, with a guarantee of total anonymity.Every student agreeing to participate in this study after informed consent was requested to answer a questionnaire on attitudes toward psychiatry, to be filled in on the first and last days of the clerkship. In order to avoid a potential positive bias caused by the students' fear that negative responses in the questionnaire could lead to less favourable treatment during the clerkship or the final grade, the completed pre-clerkship questionnaires remained in a closed envelope and in possession of a student representative for each class during the entire probation period, while the post-clerkship questionnaires were only opened after the final exam. Ethical approval was obtained from the Institutional Executive Board of the Faculty of Medical Sciences.A self-report questionnaire designed by Balon was the principal tool utilized, which had already been used in several studies in countries with a different cultural context ,20,21; fThe questionnaire contains 29 multiple choice questions (taking 10-15 minutes to complete), which assess medical students' attitude toward psychiatry in the following six domains: i. overall merits of psychiatry, ii. efficacy, iii. role definition and functioning of psychiatrists, iv. possible abuse and social criticism, v. career and personal reward and vi. specific medical school factors. Questions 25 and 26 were not assessed in this study, as there was no previous close contact with residents and tutors that could allow for a pre-clerkship assessment. In each question the student had to choose one of four choices according to their degree of agreement with the contents of the item: 'strongly agree', 'moderately agree', 'moderately disagree' and 'strongly disagree'.Along with this questionnaire, medical students were also asked about how seriously they were considering psychiatry as a future career choice, in a short questionnaire with five items. Data has been described by means of percentages for each item in the questionnaire. In the analysis, the Balon's questionnaire was treated as an ordinal scale of measurement. A comparison between the results obtained before and after the clerkship was carried out with the Wilcoxon test (attitudes towards psychiatry) and the Chi-square test (intention to pursue psychiatry as a future option). The software package PASWStatistics 18 for MAC/OX was used for analysis.All students invited agreed to participate in the study. 153 students  filled in the questionnaires, both at starting and at the end of the clerkship. There were no dropouts between the assessments. The results of the items assessing students' attitudes toward psychiatry are presented in Table scientific (72.5%) and rapidly expanding frontier of medicine (76.5%). After the training, students were even more likely to disagree that psychiatry is unscientific and imprecise , recognizing psychiatry as a after the clerkship, students were more prone to agree that psychiatric consultation is often helpful either to medical or surgical patients , as well as to most people who receive psychiatric treatment , are more qualified than psychologists and social workers , and are not strongly committed with a too theoretical and psychodynamic approach .are too frequently apologetic when teaching ; there was not a significant change about the opinion that psychiatrists earn less money comparing to doctors from other areas , and reported that they felt much more comfortable with patients after the clerkship  and with the encouragement to follow a career in psychiatry . They also felt that psychiatrists are logical thinkers , and respected by the faculty of the medical school  is a constant across all grades in our medical school, and reflects the significant predominance of female students currently attending most university degrees in Portugal, namely in medicine.The results obtained in this study indicate clearly that the clerkship had a favorable overall impact on the student attitude towards psychiatry. Overall, students were more likely to consider psychiatry as a scientific and expanding area of medicine, with a robust level of effectiveness regarding psychiatric treatments. This is a relevant improvement, since the perceived lack of a scientific basis in the psychiatric practice seems to have a harmful influence on the likelihood of choosing psychiatry as a future career . The stuThe clerkship experience in the medical school was very rewarding. Students were more likely to report general satisfaction with the teaching quality and with the encouragement to pursue psychiatry, also feeling that psychiatry was respected among the other faculty members. This is a valuable result, as research shows that medical schools specifically may influence recruitment, with the strongest academic centers having the best recruitment rates,24. The Background) in which an improvement of attitudes among the students was found after the clerkship. When compared with studies using the same methodology, Portuguese students have an overall attitude similar to that of US students [Generally speaking, these results are in agreement with the above mentioned studies (see students , and morstudents  and Spaistudents . Though On the other hand, the clerkship had no significant impact in some aspects, in which there was no attitude improvement. This can't be seen as unexpected as it had been observed in several studies with similar results ,26-28. AThis is in agreement with other investigators who found similar results in Ghana and in AGiven these findings, what about the intention to choose psychiatry as a future specialty? Taken as a whole, before the clerkship, 51.6% of the Portuguese students did not consider psychiatry as a future career choice, and a further 17% were determined not to enter the residency. This result is coherent with the frequently reported low popularity of psychiatry as a first-choice career in different settings. The numDespite these apparently favorable results, we know that the students' attitudes may not be a reliable factor in predicting the future choice of psychiatry as a career. Although some authors claim that the clerkship is the strongest predictor of specialization in psychiatry,32, thisNevertheless, given that specialty preferences before entering a medical school do not appear to deeply influence a definitive career selection ,36, it cWhat are the implications of our results beyond Portugal? Firstly, we have to be cautious with the interpretation and possible inference of the results, as the likely mechanisms by which the clerkship influences the students' attitudes are not completely understood. The exiMoreover, in our specific case, results may also have been paradoxically improved by the shortage of previous contact with psychiatry during the medical course. Students only get in touch with psychiatry in the fifth year of medical school, during a series of nine seminars in which direct contact with real psychiatric patients is limited in time. Given the direct experience of the clerkship, allowing for a much deeper contact with patients and professionals, we cannot categorically reject the possibility of some degree of halo-effect among the students, thus introducing a positive bias in the results.Taking into account these limitations, this study reiterates the findings of studies published in several countries suggesting that the clerkship has and overall positive effect on attitude towards psychiatry. However, this study also strengthens the notion that there are aspects which do not vary significantly with the clerkship, particularly regarding the perception of the prestige of the specialty, as well as the negative pressure to follow psychiatry as a future career option. This finding is of particular importance, as it identifies areas that require a more profound approach in order to improve attitudes and reduce stigmatization.Lastly, though this is common to other studies in this field yet largely unreported, the clerkship appears not to induce students to a negative perception of psychiatry. Though no precise explanation was found for this, it should nevertheless be highlighted. One possibility is the stark contrast between the negative expectations prior to the clerkship and the rewarding effect of contact with patients and professionals during the clerkship. No studies have been found to address this issue.Further research should address not only this topic, but also i. the inner mechanisms by which the training experience may induce changes in attitudes towards psychiatry, ii. the factors that preclude changes in some negative believes regarding psychiatry and among future medical doctors, regardless of country and socio-cultural background, and iii. the ethical issues regarding the inadequate use of the clerkship as a kind of "recruitment" device, in which the quality of the clerkship seems more orientated to foster recruitment than to promote better teaching and learning.Without a more thorough study of these issues, it will prove difficult to find a solution for the most important factor in the issue of recruitment into psychiatry: Should the improvement of attitudes toward psychiatry after training be considered a mere outcome indicator of the clerkship's quality or can it be a reliable indicator of a future option for psychiatry?The authors declare that they have no competing interests.MX prepared the study, administered the surveys, and wrote the first draft of the manuscript. Both authors have reviewed and approved the text of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/10/56/prepub


Studies have shown that perceived discrimination may be associated with impaired health. The aim of this study was to assess the levels of perceived discrimination on the basis of origin and ethnicity and measure the association with health in three population groups in Israel: non-immigrant Jews, immigrants from the former Soviet Union, and Arabs.A cross sectional random telephone survey was performed in 2006 covering 1,004 Israelis aged 35-65; of these, 404 were non-immigrant Jews, 200 were immigrants from the former Soviet Union and 400 were Arabs, the final number for regression analysis was 952. Respondents were asked about their perceived experiences with discrimination in seven different areas. Quality of life, both physical and mental were measured by the Short Form 12.Perceived discrimination on the basis of origin was highest among immigrants. About 30% of immigrants and 20% of Arabs reported feeling discriminated against in areas such as education and employment. After adjusting for socioeconomic variables, discrimination was associated with poor physical health among non-immigrant Jews  and immigrants , but not among Arabs. Poor mental health was significantly associated with discrimination only among non-immigrant Jews .Perceived discrimination seemed high in both minority populations in Israel (Arabs and immigrants) and needs to be addressed as such. However, discrimination was associated with physical health only among Jews (non-immigrants and immigrants), and not among Arabs. These results may be due to measurement artifacts or may be a true phenomenon, further research is needed to ascertain the results. Discrimination may be based on race/ethnicity, origin, religion, culture, social-class, age and gender: people are distinguished and treated unfavorably by others due to their belonging to a specific group . DiscrimLong-term perceived discrimination can lead to the accumulation of stressors over the life course . Such prStudies consistently report the link between perceived discrimination and mental health, namely more individual experiences of discrimination are associated with poor mental health and mental diseases ,7-9. DisMost information about discrimination and health has come from studies performed in the USA among Black Americans, Hispanic Americans  and AsiaArabs living in Israel comprised 19.8% of the population in 2006. Arabs and Jews differ in ethnicity, religion, culture, and language. Arabs are largely an underprivileged minority with a history of disadvantage in income, education and employment and are a more collective society even though they are regarded as a society in transition ,31. The The mortality and morbidity of the Arab population is higher than in the Jewish population -36. As IIsrael's diverse society, with its national healthcare service, may be an interesting setting to study the effects of discrimination on health and we hypothesis that we will find higher levels of discrimination among Arabs and immigrants compared to non-immigrant Jews and that discrimination will be associated with health in all three groups.The aims of this study were (1) to assess perceived levels of discrimination on the basis of origin and ethnicity, among three population groups in Israel: non-immigrant Jews, immigrants from the fSU, and Arabs; (2) to measure the association of perceived discrimination with mental and physical health in each population group.This cross-sectional study was based on a random sample of the Israeli population aged 35-65 years in 2006. Two random samples of telephone numbers were drawn from a computerized list of subscribers to the national telephone company: one for Arab subscribers including Arab towns and villages, and one for members of the Jewish majority. The Arab sample does not include Arabs living in mixed cities such as Jerusalem and Haifa as it is not possible to sample them separately. The immigrant respondents were sampled from the Jewish list by self-reporting of year of immigration and country of origin. In 2007, telephone lines (not cellular telephones) were present in 90% of Jewish households and in 65% of Arab households, this may under-represent the poorer Arabs in the survey ,39. ExclDue to missing data on some questionnaires the sample analyzed in the final regressions consisted of 952 completed questionnaires.The questionnaire had several parts and covered a wide range of socioeconomic and demographic variables to measure perceived discrimination and health status. The Hebrew questionnaire was translated into Arabic and Russian, then back-translated into Hebrew to ensure accuracy. Arab professionals speaking both Arabic and Hebrew, and familiar with Israeli-Arab culture, validated the Arabic translation from the Hebrew questionnaire, and confirmed that the questions had the same meaning as in Hebrew; the Russian questionnaire underwent the same process. Much thought was put into the exact wording to decrease differential understanding of the questions in the three groups. A pretest with 15 people from each population group  to ensure culture adaptation of the questionnaire encountered no obstacles. The questionnaire was administered over the telephone by trained interviewers from the relevant population group for each language: Hebrew, Arabic, and Russian.No official ethical approval was sought for this study. At the time of the research official ethical approval was not needed in Israel for this kind of study which was a random digit dial survey (no data from lists of patients or clients were used) and no medical information was obtained from other sources. Even so, the highest ethical standards were adhered to and maintained in the study's procedures and methods. The following steps were followed by the interviewers: they introduced themselves; they briefly described the survey topic; they identified the person and organization conducting the research; described the purpose of the research and gave a "good faith" estimate of the time required to complete the interview; they also promised anonymity and confidentiality; the interviewers mentioned to the participant that participation is voluntary and that item-nonresponse is acceptable. Finally, permission to begin was asked. Informed consent was considered to have been obtained when potential participants agreed to answer the questionnaire.All variables were self-reported. Arabs were defined as those describing themselves as Arab Muslims, Druze, or Arab Christians. Immigrants were those who reported arriving in Israel since 1989 from the fSU. Most of the immigrants (75%) arrived in Israel between 1989 and 1996, and 8% of them arrived after 2000. Non-immigrant Jews were those living in Israel before 1989. To measure subjective socioeconomic status (SSS) participants were invited to think of a ladder with ten rungs as representing where people stand in Israeli society. The interviewee gauged his or her SSS on the ladder on a scale from 1 to 10 ,41. EmplThe "Short Form 12" (SF12) questionnaire, validated in Hebrew , served ethnicity in the English version - which can be translated into English as "origin" - has a much broader meaning than ethnicity and as such is more appropriate for the immigrant population. This concept was also used in the Arabic and Russian questionnaires. For each of the seven settings listed above, the respondent was asked to assess the frequency of experiencing discrimination. A choice of four levels was offered, from 1-"not at all" to 4-"frequently". A mean score was calculated including the settings in which discrimination took place. The continuous measure was used in the correlation and regression analysis. In addition, the level of feeling discrimination for each setting was dichotomized into two groups: never  (0) and at least sometimes  (1). An overall dichotomized score was calculated including all settings, where 0 represents respondents who reported no experience of discrimination in any setting, and 1 represents respondents who experienced at least some discrimination in at least one setting. The dichotomized variable was used for the descriptive analysis shown in table The perceived discrimination questionnaire was adapted from the instrument developed and validated by Krieger and colleagues . RespondChi-square analysis was used to identify differences in the socioeconomic variables and in discrimination between the three population groups. Spearman's correlations were applied to assess crude associations between discrimination and health. Multivariable logistic regression analysis was performed for each group separately, with physical and mental health as the dependent variables, to assess the association between health and discrimination, after adjustment for other variables associated with health. The odds ratios (OR), 95% confidence intervals (CI) and p-values are presented in the tables. Variables found to be associated with health in the crude analysis were entered into the models. Age, SSS, and discrimination were entered into the model as continuous variables. Another multivariable regression model for the entire population was run to assess whether Jews and Arabs differed significantly in the association between discrimination and health; this was measured by the interactions of discrimination and population group with health.Statistical significance was set at a p value of less than 0.05. SPSS version 14.0 was used for the analysis.The study population consisted of three groups, non-immigrant Jews (404), immigrants from the fSU (200) and Arabs (400). Of the Arabs, 71% were Muslim, the rest Christian or Druze. Socioeconomic measures are presented in table These characteristics reflect the expected differences between the population groups in Israel, where Arabs and immigrants have a lower socioeconomic status than non-immigrant Jews (excluding education among immigrants). Arabs were significantly younger and less educated, and with relatively fewer of them in the work force; immigrants were older and more educated, and their SSS was lower than that of either non-immigrant Jews or Arabs.The respondents were asked about their perceived experiences with discrimination based on their origin or ethnicity in several life areas, and the findings are presented in table The group with the largest percent of respondents reporting perceived discrimination in at least one of the settings measured were immigrants (71.5%). Of the Arabs, 40.5% reported at least some experience with discrimination, and of non-immigrant Jews 21.0% reported this. Generally, perceived discrimination was high in areas such as employment, the education system, public places, and public institutions. The least reported settings for discrimination were in obtaining housing and using the healthcare system. Among Arabs, the education system was the most frequently cited as a setting for discrimination, whereas among immigrants discrimination in public places was most frequently cited.There was a significant negative correlation between discrimination due to origin or ethnicity and both mental and physical health. Spearman's correlation coefficient for physical health and discrimination was -0.14 (p < 0.0001), and for mental health and discrimination -0.21 (p < 0.0001) (data not presented). The higher the perceived discrimination, the lower were both mental and physical health. These associations were significant among both non-immigrant Jews and immigrants; among Arabs the associations were lower and not significant.Logistic-regression models were used to adjust for age, gender, employment, education, and SSS, as these variables are known to be associated with health. The analysis was run separately for each population group because the interactions between discrimination and population group for the entire population were significant in a logistic regression model (p = 0.004).After adjustment for these variables in a logistic-regression model run for each population group separately table , perceivPoor mental health was associated with perceived discrimination only among non-immigrant Jews , but not among immigrants and Arabs, after adjustment for socioeconomic variables, gender, and age (table Perceived discrimination was reported more frequently in the minority groups (Arabs and immigrants) than in the majority group (non-immigrant Jews) as hypothesized. Many studies on immigrants in other countries found that their perceived discrimination was greater than that of the majority population ,22,24,44This is the first study to analyze quantitatively the association between health and discrimination in Israel where two very different minorities live, an immigrant population living within the Jewish non-immigrant population and an indigenous Arab population that is segregated to some extent from the Jewish majority.The study has some limitations. The data are cross sectional; hence provide no basis for causal directionality. Discrimination may cause poor health; however, poor health may also increase levels of perceived discrimination. Yet no evidence of this has been found . AnotherPerceived discrimination in the three groups arises in different social, historical and political contexts. Discrimination may be perceived by immigrants partly due to a sense of cultural estrangement and the non-realization of the immigrant's high expectations for a better life in Israel. Furthermore, Israeli society may actually discriminate against the immigrants, justifying their perceptions. Within one generation it is expected that this group and their descendents will report similar perceived discrimination as the non-immigrants report. It is expected that their acculturation will eliminate the differences between them and other non-immigrant Jews; the immigrants will be indistinguishable from the non-immigrants. Discrimination among the non-immigrant Jews may be attributed to the heterogeneity of the non-immigrant Jewish society that includes Jews from different origins such as the Sephardic Jews and the Ashkenazi Jews, some of these Jews may still have feeling of discrimination on the basis of their origin.The perceived discrimination of the Arab community may have a more profound basis including institutional discrimination and prejudice against Arabs, where less funding is available for the Arab communities and discrimination in attaining jobs is frequent, in addition to prejudice on behalf of the Jewish population ,31,33.For both immigrants and Arabs the healthcare services seem to be a system with comparatively little perceived discrimination. This may be because some of the employees of the healthcare services are Arabs and immigrants, and they work with their respective communities. Housing discrimination was not reported as a major area of discrimination, as Arabs usually do not try to buy or rent housing in the Jewish community. This does not mean there is no housing discrimination towards Arabs; on the contrary, it is institutionalized discrimination and may contribute to the continuing residential segregation of the Arab population . The disA major difference between Arabs and immigrants is their relationship with the majority Jewish population. The immigrants live among the majority of non-immigrant Jews and expect to be a part of the Jewish society, whereas the Arabs do not; they perceive themselves as Arabs within a Jewish society. These differences may affect both the levels of perceived discrimination and the association between health and discrimination. The finding that among Arabs perceived discrimination was not associated with health can be explained by the Arabs' residential segregation. Lower levels of contact with the majority group may prevent ongoing perceived discrimination, including exposure to everyday hassles and elevated stress, among the Arabs compared to Jews. Therefore, the Arabs' health could be less affected. Another explanation may be that the Arabs do not expect to be part of Israeli Jewish society and their ethnic identity serves as a coping mechanism preventing prolonged stress due to discrimination; this may obviate ill effects on health. A similar condition was found in African Americans, where racial identity was a protective factor in buffering the negative impact of discrimination .Efforts are necessary to lower the level of actual and perceived discrimination in both the Arab population and among immigrants, as Israel prides itself on being a nation founded on democracy and equality. The chances of this happening may increase mainly after the relationship of Israel and its neighbors improves. At present a reduction in institutional discrimination  and more education for tolerance and open-mindedness could bring about a positive change.There is a need to repeat this finding with other measures of health so as to ascertain that the results are not an artifact of measurement. If this phenomenon is not an artifact further research is needed on the impact of segregation in living areas and perceived identity as possible explanations for the differences in the association between discrimination and health in different population groups.Individuals that report perceived discrimination also report poor health, however, this is observed only in the Jewish population but not in the Arab population. Further research on the association between perceived discrimination and health should be performed firstly to ascertain this is a true phenomenon and not an artifact. If this is a true phenomenon further factors serving as coping mechanisms that prevent the ill effect of perceived discrimination in specific communities should be investigated.fSU: former Soviet Union; SSS: Subjective socioeconomic status.The authors declare that they have no competing interests.OBE initiated the study, performed the analysis and wrote the manuscript, GK initiated the study, and helped write the manuscript, MM helped with the collection and the analysis of the data. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/282/prepubThe discrimination questionnaire used in this study.Click here for file


Evaluation of an implementation process and its fidelity can give insight into the 'black box' of interventions. However, a lack of standardized methods for studying fidelity and implementation process have been reported, which might be one reason for the fact that few prior studies in the field of health service research have systematically evaluated interventions' implementation processes.The aim of this project is to systematically evaluate implementation fidelity and possible factors influencing fidelity of complex interventions in health and social care.A modified version of The Conceptual Framework for Implementation Fidelity will be used as a conceptual model for the evaluation. The modification implies two additional moderating factors: context and recruitment. A systematic evaluation process was developed. Multiple case study method is used to investigate implementation of three complex health service interventions. Each case will be investigated in depth and longitudinally, using both quantitative and qualitative methods.This study is the first attempt to empirically test The Conceptual Framework for Implementation Fidelity. The study can highlight mechanism and factors of importance when implementing complex interventions. Especially the role of the moderating factors on implementation fidelity can be clarified.Supported Employment, SE, among people with severe mental illness -- a randomized controlled trial: NCT00960024. Health service interventions are often highly complex, compared to efforts like drug trials or trials of surgical procedures . Health i.e., a failure to implement a program as planned, could erroneously conclude that lack of program impact was due to attributes of the particular intervention if no process measures were collected [As a result, it has been recognized that aside from outcome evaluations, it is necessary to gain insight into the 'black box' of interventions . It has ollected . Processollected . Howeverollected ,9,10.et al. [i.e., larger social, political, and economic environment that may have influenced implementation). Other studies have focused more precisely on the concept of implementation fidelity and suggested that it can be defined in terms of five elements regarding to what extent the delivered intervention correspond to the designed intervention (adherence), amount of an intervention received by participants (exposure or dose), quality of the program delivery, participants' engagement in the program activities (participant responsiveness), and presence or absence of the critical program elements (program differentiation) [In general, a process evaluation examines what the program is and how it is delivered to the target clients . Implemeet al.  defined tiation) ,12. Sevetiation) ,12,13. Htiation) ,12. Mosttiation) . It has et al. [i.e., whether the active ingredients of the intervention have been received by the participants as often and for as long as was planned. Intervention complexity, facilitation strategies, quality of delivery, and participant responsiveness were included in the framework as moderating factors. Intervention complexity has been found to influence the implementation fidelity, i.e., complex interventions were more difficult to implement with high fidelity than simple interventions [et al. [i.e., when the effect of one factor is dependent on the level of another. In summary, the framework suggested that different moderating factors might affect, positively or negatively, the implementation process and its fidelity. These factors interact with each other and the effect of one factor on fidelity might be influenced by another moderating factor. The framework suggested that all these factors should be evaluated systematically when conducting a process evaluation. In this project, two additional moderating factors were included in the framework, namely context and recruitment. The modified framework is presented in Figure et al. [i.e., not generalization results for subgroups that have chosen not to participate. In this study, the modified framework will be used as a conceptual model to structure the data collection and analyses to identify mechanism and factors that might influence the implementation of complex interventions.Carroll et al.  proposedventions . Complex [et al.  defined e et al.  argued tet al. and contribute to the knowledge base of how implementation fidelity and moderating factors can be evaluated for complex interventions.The aim of this project is to evaluate systematically implementation fidelity and possible factors influencing fidelity of complex interventions in health and social care. The purpose is to test the conceptual framework for implementation fidelity proposed by Carroll The multiple case study method will be used to investigate the implementation processes of three intervention studies. Thus, a case is defined as an intervention study. Each case will be investigated in depth and longitudinally, using both quantitative and qualitative methods. The case study method has been proposed to be a suitable method for conducting longitudinal research of change processes ,19.All three interventions are complex in nature, including several active ingredients. In addition, the interventions are conducted in complex health or social care environments where several professional groups or care provider organizations cooperate. The three interventions are briefly described below.The intervention involves development, implementation, and evaluation of an integrated care chain for frail elderly people. The care chain will cover the older person's contacts with community care providers , primary care, the hospital emergency department and hospital ward. A case manager and a multi-professional team will help the elderly people and their relatives to coordinate care contacts. The theoretical framework for the study is that integrated care with a case manager creates networks of resources and services over time and between different healthcare providers, particularly between health and social care. This is expected to improve health-related quality of life, increase satisfaction with care and rehabilitation, decrease older persons' emergency care consumption, and influence cost efficiency at the community level. The study design is a randomized controlled study with a total of 200 participants divided into intervention and control group. The study is conducted in the city of Mölndal in western Sweden. The possible effects of the intervention on participants' capability to perform activities, health-related quality of life, satisfaction with care, and emergency care consumption will be evaluated at three, six, twelve and twenty-four months after the baseline measurement. The responsible researchers are Synneve Dahlin-Ivanoff, PhD (Medicine), Professor and Katarina Wilhelmson, PhD (Medicine) at the Sahlgrenska Academy at Göteborg University.The intervention involves development, implementation, and evaluation of a support program in palliative care for nursing staff and workplace leaders working in community nursing facilities for older people. The support program is based on a study circle model that combines participants' reflections and discussions based on their expertise and work experiences. The model includes having participants learn to question their work practices and develop new ways of working and solving problems at work. The program consists of regular meetings for each professional group and cross-professional workshops. Reading materials regarding palliative care and other related relevant subjects will be provided prior to a study circle. An external facilitator will lead the circles. Participants are expected to get direct support in terms of improved knowledge as well as indirect support in terms of a collective platform for reflections, discussion, stimulation, and concrete improvement work. The theoretical framework for the study is that support in terms of expertise development and coaching positively affects staff attitudes towards care recipients, their work satisfaction, and general wellbeing. The intervention is conducted in a quasi-experimental design in six nursing homes in the city of Malmö in southern Sweden. The possible effects of the intervention on staff satisfaction, work climate, and general well-being are evaluated at six and eighteen months after the baseline measurement. The responsible researcher is Anna-Karin Edberg, PhD (Medicine), Professor, Lund University.The study involves implementation and evaluation of an evidence-based method, supported employment (SE), for vocational rehabilitation for people with mental illnesses. The purpose of SE, according to the Individual Placement and Support model, is to help people with severe mental illness find and keep employment in a competitive market. SE has been widely recognized as the most effective approach to increasing work opportunities for people with severe mental illness -22, but The author of the paper is the principle investigator of this implementation project. The project is a part of larger research programs at the Vårdal Institute, where the three above-mentioned intervention projects are also being conducted. The responsible researchers mentioned above are responsible for designing, conducting, and evaluating the impact of the intervention studies. Thus, the investigation of implementation process and its fidelity is conducted by other researchers than those involved in the development of the interventions. However, some data collection is conducted in collaboration so that participants and other stakeholders need not experience excessive burdens with interviews, questionnaires, and observations.et al.'s [An overall process evaluation plan was developed for this project. This is presented in Table et al.'s  stepwiseIn the second step, a detailed description of the components of the programs was created. At this stage, each component of the intervention and its intended delivery was described as these were stated in a program plan. Also, the content and delivery of the program for the control group was described. Amount of intervention services and frequency of delivering these services were described in detail. Table In the third stage, general process questions were developed  and the third intervention study (Lund University dossier number 202/2008). For the second study, an ethical application was sent to the research ethics committee at Lund University. The committee reported that they didn't identify any ethical hinders for conducting the study (dossier number 2009-527), but made a decision that in accordance with legislation no formal ethical approval was needed for the study.et al. [The aim of this project is to systematically evaluate implementation fidelity and possible factors influencing fidelity of complex interventions in health and social care. The intention is to empirically test the conceptual framework for implementation fidelity proposed by Carroll et al. . The fraThe study also presents a practical example of how to develop a systematic process evaluation for complex interventions. The results of this study can be used to interpret the results of the outcome evaluation of the interventions. Information will be gained on how, when, and in what context the interventions work. This information can be used for practical future program planning.Some practical issues relevant to the conducting of this study will be briefly discussed. First, these interventions are conducted in local practices, but in a research context. Programs implemented as part of research projects usually receive considerable support to achieve high fidelity . OutsideThe three intervention studies included in the project represent different type of health service interventions. This will offer an opportunity for cross-case comparison of different interventions. Knowledge will be gained regarding each type of intervention specific, and more general knowledge will be obtained when comparing the cases. The strength of using a case study design lies in the opportunity to collect multiple types of data, enabling development of a comprehensive, in-depth picture of the implementation processes.A process evaluation often requires a large amount of data collection, which makes it time-consuming and expensive. This project offers an example of how collaboration between different researchers within a large project can enable collection of process data. The collaboration with data collection enables a rich data material. For instance, stakeholder interviews and worksite observations will be conducted in collaboration with other researchers. In addition, questions regarding participants' experiences of the program implementation will be included in follow-up outcome evaluation questionnaires instead of conducting separate questionnaire surveys or participant interviews. Using results of interviews that have been conducted by other researchers might have some limitations, such as not obtaining primary source information. On the other hand, the positive factors concerning time, resources, and respondent burden were considered to carry more weight.In any type of process analysis, a choice has to be made regarding what data should be collected. On one hand, several implementation process components need to be measured to be able to understand the process . On the The author declares that they have no competing interests.A process-evaluation plan for the Continuum of care for frail elderly persons, from the emergency ward to living at home.Click here for fileA process-evaluation plan for Palliative care in community older people nursing homes - support for nursing staff.Click here for fileA process-evaluation plan for the Supported Employment (SE) among people with severe mental illness - a randomized controlled trial. the files include detailed evaluation plans for each intervention study.Click here for file


Rotavirus gastroenteritis is the leading cause of diarrheal disease mortality among children under five, resulting in 450,000 to 700,000 deaths each year, and another 2 million hospitalizations, mostly in the developing world. Nearly every child in the world is infected with rotavirus at least once before they are five years old.Vaccines to prevent rotavirus or minimize its severity are now becoming available, and have already been introduced into the public vaccine programs of several Latin American countries. The World Health Organization (WHO) has made rotavirus vaccine introduction in developing countries a high priority.The WHOs Guidelines for Vaccine Introduction indicates that a key determinant to achieving vaccine introduction is the public health priority of the disease, suggesting that where the disease is not a priority uptake of the vaccine is unlikely. WHO recommends conducting a qualitative analysis of opinions held by the public health community to determine the perceptions of the disease and the priority given to the vaccine.This paper presents the formative research results of a qualitative survey of public health providers in five low- and middle-income countries to determine if and to what degree rotavirus is perceived to be a problem and the priority of a vaccine. Open-ended surveys were carried out through focus group discussions and one-on-one interviews.Researchers discovered that in all five countries knowledge of rotavirus was extremely low, and as a result was not considered a high priority. However, diarrhea among young children was considered a high priority among public health providers in the three poorest countries with relatively high levels of child mortality: India, Indonesia, and Nicaragua.In the poorest countries, advocacy and communication efforts to raise awareness about rotavirus sufficient for prioritization and accelerated vaccine introduction might benefit from a knowledge translation approach that delivers information and evidence about rotavirus through the broader context of diarrheal disease control, an existing priority, and including information about other new interventions, specifically low-osmolarity oral rehydration solution and zinc treatment. Despite impressive public health gains made in the 1980s and 1990s, severe dehydration caused by diarrheal disease still contributes significantly to childhood morbidity and mortality in the developing world. Today, diarrheal disease is responsible for an estimated 1.6 to 2.4 million deaths annually . Clearly, including rotavirus vaccine in a broader context of diarrheal disease interventions is supportive of this strategy.Shigella, or clean water technologies.Based on the results of this survey, the authors have proposed a knowledge translation strategy that raises awareness about new and existing diarrheal disease control measures using an integrated framework. This approach–the Enhanced Diarrheal Disease Control Initiative (EDD)–integrates information and evidence about rotavirus and rotavirus vaccines, zinc treatment, and the new formulation of low-osmolarity ORS, as well as information to reinforce the use of existing interventions such as ORT, exclusive breastfeeding, and improvements in sanitation and hygiene Figure . This frThe goal of EDD is to stimulate decision makers in developing countries to consider evidence about new and existing interventions for diarrheal disease control. It relies on the establishment of a public health coalition representing a range of disciplines concerned with diarrheal disease  to begin the knowledge translation process aimed at the following objectives:1. Emphasize to decision-makers the importance of diarrheal disease as a public health priority and the need for new interventions.2. Present the evidence about new interventions for diarrheal disease control to appropriate stakeholders in a manner reflective of local knowledge, experience, and practice.3. Reinforce the importance of existing diarrheal disease interventions, such as ORT, breast feeding, and improved sanitation and hygieneWith support from the GAVI Alliance, EDD is being piloted in several countries in Latin America and Asia. Early indications suggest that local diarrheal disease coalitions have used the concept successfully to raise awareness for the new interventions throughout the public health system, stimulate policy changes such as the listing of zinc as an essential drug, and in one country, may have spurred the decision to undertake a demonstration project of rotavirus vaccine. Perhaps most importantly, diarrheal disease is once again near the top of the public health agenda in these countries, EDD having catalyzed consideration of both the problem and the solutions. Formal impact evaluations of EDD pilot projects are planned. We believe that in some countries the EDD strategy will help RVP achieve its mission of accelerating introduction of rotavirus vaccine by raising the awareness of the vaccines in the context of a renewed diarrheal disease control strategy.This qualitative study was conducted to develop a generalized public health view of rotavirus and diarrheal disease in developing countries, particularly with regard to the priority and concern for diarrheal disease and its causes. As a result, we did not stratify nor quantify the data, choosing instead to find common themes and perspectives.As with many qualitative studies, the responses are open to bias from those collecting the information. In addition, FGD are often limited by the potential of participants to be unwilling to say certain things in public.Greater attention should be paid in future studies to quantifying levels of knowledge and attitudes by particular sectors of the public health community in order to further refine communication, education and information programs.Finally, the paper recommends a knowledge translation strategy, fully accepting the fact that there are few if any studies indicating that knowledge translation is effective in accelerating adoption of policies or interventions. However, the authors believe that as a theory knowledge translation has merit. The Enhanced Diarrheal Disease Control Initiative adopts the knowledge translation theory to achieve the desired objectives of rebuilding momentum for diarrheal disease control, accelerating introduction of new interventions, and reinforcing use of established interventions.RVP was established to accelerate the introduction of rotavirus vaccines but found that the lack of knowledge of rotavirus by the public health community in some developing countries was insufficient to prioritize the vaccine as needed for uptake. In addition, it was found that the broader diarrheal disease control effort has lost considerable momentum, and is currently a weak platform for advancing new interventions.global prioritization, even if the disease are relatively obscure or unknown. But in developing countries where lack of familiarity with rotavirus and pre-existing priorities compete for scarce resources, global evidence alone may not be enough to guarantee prioritization of the disease and uptake of the vaccine.The availability of research evidence that includes rotavirus disease burden estimates and clinical trial results may be enough for Knowledge translation offers one potential approach to link global evidence with a local context of diarrheal disease control knowledge, experience and practice in order to build an association between rotavirus and the expressed priority of diarrheal disease.The EDD approach is designed to rekindle interest in diarrheal disease control at the country level, and to put knowledge translation into practice by stimulating the prioritization and uptake of rotavirus vaccines, as well as zinc treatment, and to reinforce use of existing diarrheal disease control measures and prevent child deaths.The author(s) declare that they have no competing interests.ES developed the survey instrument, assessed the final data from each country, and was lead author. SW assisted with developing the survey instrument, site selection, and managed data collection from Thailand and India. JB managed data collection, analysis, and reporting for research in Nicaragua. KG managed data collection, analysis, reporting, and translation from research in Ukraine. LC managed research activities in Indonesia and editing of Indonesia reports. JW assisted with data analysis from Nicaragua and translation. All authors have read and approved this manuscript.The pre-publication history for this paper can be accessed here:


Quantitative models of gene expression generate parameter values that can shed light on biological features such as transcription factor activity, cooperativity, and local effects of repressors. An important element in such investigations is sensitivity analysis, which determines how strongly a model's output reacts to variations in parameter values. Parameters of low sensitivity may not be accurately estimated, leading to unwarranted conclusions. Low sensitivity may reflect the nature of the biological data, or it may be a result of the model structure. Here, we focus on the analysis of thermodynamic models, which have been used extensively to analyze gene transcription. Extracted parameter values have been interpreted biologically, but until now little attention has been given to parameter sensitivity in this context.We apply local and global sensitivity analyses to two recent transcriptional models to determine the sensitivity of individual parameters. We show that in one case, values for repressor efficiencies are very sensitive, while values for protein cooperativities are not, and provide insights on why these differential sensitivities stem from both biological effects and the structure of the applied models. In a second case, we demonstrate that parameters that were thought to prove the system's dependence on activator-activator cooperativity are relatively insensitive. We show that there are numerous parameter sets that do not satisfy the relationships proferred as the optimal solutions, indicating that structural differences between the two types of transcriptional enhancers analyzed may not be as simple as altered activator cooperativity.Our results emphasize the need for sensitivity analysis to examine model construction and forms of biological data used for modeling transcriptional processes, in order to determine the significance of estimated parameter values for thermodynamic models. Knowledge of parameter sensitivities can provide the necessary context to determine how modeling results should be interpreted in biological systems. Mathematical modeling of gene transcription is becoming a common approach to gain insight into the physical and chemical properties that drive transcription and to characterize the nature of gene networks that form the basis of biological systems -9. By foTo address these questions, one must examine the mathematical model itself to determine the uncertainty in parameter values and ascertain the impact that perturbations in parameter values will have on the model output. This question of parameter uncertainty and sensitivity analysis has been addressed in many different applications, including biological, chemical and risk assessment -16. ParaThermodynamic models, also termed fractional occupancy models, are based on formulations originating from statistical physics. For transcriptional analysis, these models consider all possible states of a DNA regulatory element, where a state refers to a specific configuration of regulatory proteins (transcription factors) bound to DNA -4,6. EacSensitivity analysis can be applied to any field that uses mathematical modeling as a tool, and has been used extensively on diverse models in economics, civil engineering, and medicine -19. In dSensitivity analysis, whether local or global, has the primary goal of determining how a given model responds to variations in parameter values. Local sensitivity analysis  focuses on a particular point in parameter space, varying parameters one at a time to obtain a local response of the model to each parameter ,15,20,21Our approach initially used local sensitivity analysis to calculate the model's rate of change with respect to each variable at a given point in parameter space, quantifying at that point how small changes in each variable will affect the model output. Then, we turned to global analysis, employing three different methods. The first simply takes an average of results obtained from local sensitivity analyses on different points in parameter space. The other two global methods each rely on determining which parameters and parameter combinations contribute most to the variation in the model output that resulted from sampling a wide range of parameter values. The eFAST algorithm does this through Fourier analysis, while the HDMR algorithm does this through polynomial approximation. For more details on each individual method, see the following text and the model descriptions and formulas found in the Additional file C, with respect to a parameter, μ, one uses the formula  and cooperativity values were taken in the range . For each enhancer structure, we chose 100,000 sets of parameter values at random and calculated the Pearson correlation coefficients. We sorted the Pearson correlation coefficient values and selected for further analysis all parameter sets that resulted in values greater than 0.981, a threshold chosen based on the lowest value that appeared in Table S2 (log[correlation coefficient] = 1.72) [rho and vnd were exactly as predicted by Zinzen et al., and how often some or all of these relationships could be changed, yet still recover a satisfactory correlation (greater than 0.981). We carried out this test a second time, again testing 100,000 different random parameter sets for each construct and obtained essentially identical results (data not shown). The relationships that were said to be of greatest importance in Zinzen et al. appear in a plurality of parameter sets in almost every scheme, but other relationships between the cooperativity parameters also result in a very high correlation. The relationships predicted in Zinzen et al. hold for less than 40% (between 13 and 59 of between 105 and 174) of the parameter sets that show satisfactory correlation (> 0.981). As modeled in that study, the relationships may not represent biological features that reflect a compelling best fit with the experimental data; rather, the low sensitivities of these particular parameters may allow one to accept a local best fit. The biological conclusions, that rho and vnd expression patterns differ based on Twist-Dorsal cooperativity, should therefore be interpreted with caution.By investigating the parameter values listed in their study, a reasonable range for the parameter values was deduced . The scaTable Thermodynamic models represent the most powerful approach to quantitative understanding of gene transcription because of their use of DNA sequence information that can capture subtle differences in enhancer architecture. As with other models, this approach involves many unknown parameters and interactions, however, a rigorous sensitivity analysis has not been applied to recent studies in this area. We show here, through local and global sensitivity analyses, that there is a wide range in sensitivities for parameters in these models. In some cases, this is due to the biology of the system, or the experimental data used to calculate the error, while in other cases it may simply be an artifact of the mathematical formulation Figure , and theOur analysis also uncovered previously undescribed interactions between parameters that may reflect true biological interactions, and at the same time found very low sensitivities in parameters that were previously thought to be most informative in explaining the overall architecture of distinct enhancers. We used the insights drawn from sensitivity analysis to redesign experiments, and discover new parameter values that are well correlated with experimental data. Clearly, standard parameter estimation techniques used alone, in the absence of sensitivity analysis, cannot fully show the importance of possible biologically-driven or model-driven effects.To improve upon thermodynamic modeling attempts to unlock key aspects of cis-regulatory grammar, we should recognize a need for sensitivity analysis and a thorough exploration of parameter space. With this analysis, new iterative parameter estimation and model selection techniques can be designed and implemented ,32. AnalMathematical models of transcription are becoming increasingly widely applied, but analysis of the sensitivity of fractional occupancy (thermodynamic) models has lagged. We have examined two recent thermodynamic modeling studies of transcriptional regulation and shown how parameter sensitivities vary widely. From this examination, we have identified both biological and mathematical bases to differential sensitivity.In our sensitivity analysis of the Fakhouri et al. model, we first observed that quenching parameters were found to be more sensitive than other model parameters and cooperativity parameters to be least sensitive. Through careful inspection of the model formulation, we concluded that this differential sensitivity was heavily dependent on the mathematical form of the model. We also noted that parameters that were represented in a larger portion of the data set were more sensitive than others. This effect can neither be attributed solely to the mathematical form of the model nor solely to the biology of the system; it is a combination of the two, which emphasizes the importance of designing the model and the experiments in unison. We created synthetic data sets and conducted global sensitivity analyses using these sets as our experimental data, and show that not only an evenly designed data set is important, but the parameter values as represented in the biological data also have a large impact on parameter sensitivities. Thus, sensitivity analysis is not only useful in dissecting the mathematical model formulation, but also in investigating the real parameter space and the impact the data set will have on the model's sensitivity to certain parameters.Our examination of the Zinzen et al. model produced similar results, in which cooperativity parameters were the least sensitive of all parameters in almost every formulation of their model. We investigated these cooperativity parameters and found that this low sensitivity allowed for a wide array of acceptable cooperativity values, all of which showed high correlation with experimental data. Importantly, these alternative cooperativity values lead to very different biological interpretations of the system under investigation. Without thorough sensitivity analysis and parameter space exploration, parameter values extracted using thermodynamic models may be easily misinterpreted.Our study underscores the importance of carrying out sensitivity analysis to identify model- and data-driven influences on parameters, and to improve the construction and interpretation of transcriptional models based on thermodynamic approaches.JMD carried out the global sensitivity analysis, the creation of the synthetic data sets, and the data analysis, participated in the design of the study, and drafted the manuscript. XL carried out the local sensitivity analysis, helped to draft the manuscript and created the figures. DNA participated in the design of the study and writing the manuscript. AA conceived of the study, participated in the data analysis, and helped in writing the manuscript. All authors have read and approved the final manuscript.Dresch et al. 2010. This file includes all supporting text, figures, and tables in pdf format.Click here for file