Echinococcosis has a worldwide geographical distribution with endemic foci on every inhabited continent. Due to the frequent outbreaks in different parts of Pakistan in the recent past, echinococcosis is being described as a neglected tropical disease and is considered one of the most neglected parasitic diseases in the country. In endemic regions, predominantly settings with limited resources, there are high numbers of echinococcosis patients, as these communities do not have access to appropriate treatment. In Pakistan, there are limited reports on echinococcosis. The disease is prevalent in human and livestock, but this has not been sufficiently explored yet. Pakistan is an agricultural country and due to the disease’s zoonotic mode of transmission, there is a dire need of future research on it. The present paper is an effort to highlight the importance of echinococcosis in Pakistan.There is a dire need for future research on echinococcosis in Pakistan as very few investigations had been carried out on this topic thus far. The prevalence of the disease in neighbouring countries highlights that Pakistan might be at severe risk of this zoonotic infection and further supports the need for more research. In Pakistan, the majority of the population lives in rural areas with limited acess to proper hygienic/sanitary facilities. These conditions favour the outbreak of diseases such as echinococcosis. The limited available data could result in higher outbreaks in the future, and thus cause the already weak healthcare system to overburden.The country has a meagre annual budget for health, which is being spent on known infections such as polio, dengue fever and hepatic viral infections. A proper surveillance system for echinococcosis is required across the country as treatment is usually expensive, complicated and may require extensive surgery and/or prolonged drug therapy. Development of new/novel drugs and other treatment modalities receives very little, if any, attention. Prognostic awareness programmes against this infection involve deworming of the infected animals, improved food inspection and slaughterhouse hygiene, and public education campaigns.Future research on echinococcosis is anticipated to demonstrate whether the epidemiology, diagnosis and recombinant vaccines/antibodies relating to echinococcosis can meet the quality standards  defined by the World Health Organization. Research work should be carried out on the epidemiology and serodiagnosis of echinocossis in the different areas of Pakistan, which will be useful for the proper eradication of echinococcosis in this region. The health department should implement awareness-raising campaigns for the general public in order to reduce the burden of disease.The online version of this article (doi:10.1186/s40249-017-0309-z) contains supplementary material, which is available to authorized users. Please see Additional file Echinococcus spp. Humans can become infected through the accidental intake of parasitic eggs excreted by the faeces of definitive hosts such as dogs, foxes and other canids [Echinococcosis is a human and animal health problem in many endemic areas worldwide. It is considered a neglected zoonotic disease caused by the larval form of the tapeworm r canids . Cystic r canids .At least 270 million people  are at risk of acquiring CE in Central Asia, including in areas of Mongolia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan, Afghanistan, Iran, Pakistan and Western China . The WorThe WHO recommends that the impact of zoonotic infections be assessed before any control measure is implemented , 7. AccoNeglected tropical diseases are a diverse group of communicable diseases that prevail in tropical and subtropical conditions in 149 countries and affect more than one billion people, costing developing economies billions of dollars every year. These diseases mainly affect populations living in poverty, without adequate sanitation and which are in close contact with infectious vectors and domestic animals and livestock. At least one seventh of the world’s population is affected by NTDs, including roughly 800 million children.In Pakistan, the outbreaks of dengue – declared to be the world’s ‘fastest-spreading NTD’ by the WHO in January 2013 – in 2010 and 2011 were a stark illustration of the challenges which persist in this realm of global health. Traditionally, NTDs exist exclusively in the poorest and most marginalised communities, receiving little attention from the international health community, despite the fact that they are the most common infections among the world’s poorest. The NTDs being targeted by the reports are lymphatic filariasis, soil-transmitted helminthiasis, schistosomiasis, echinococcosis, onchocerciasis, visceral leishmaniasis, trachoma, leprosy, guinea worm, chagas disease and human African trypanosomiasis.In Pakistan, echinococcosis is one of the most important NTDs and the present letter was written to highlight the importance of echinococcosis among humans and livestock in the country.Echinococcus spp. infections.Pakistan is a country with a low socio-economic status. It is highly populated with approximately 200 million inhabitants, with most of these living in rural areas or very crowded urban areas with poor sanitary facilities. A large proportion of Pakistanis is affiliated with agriculture and local dairy farming on a small scale. The workers on these small farms come into close contact with animals and since proper health and hygiene principles are not strictly followed, the inhabitants of these areas are also at high risk of acquiring E. granulosus are circulating among livestock in Punjab and that these strains are highly adaptable to goats, camels and cattle. The molecular characterization of human cysts infected with Echinococcus spp. belong to the common sheep strain (G1) of E. granulosus, reinforcing the fact that this strain has the potential for zoonotic transfer. Both morphological and molecular characterisations of Echinococcus spp. in Pakistan support similar findings from other parts of the world, suggesting that Echinococcus of sheep and buffalo origin is phenotypically and genetically similar worldwide. This adds further evidence to support its recognition as one species, namely E. granulosus sensu stricto [Humans can become infected through ingestion of parasite eggs in contaminated food, water or soil, or via direct contact with animal hosts. It has been shown that common sheep (G1) and buffalo (G3) strains of  stricto .Echinococcosis is a NTD and few investigations have been carried out on its prevalence in Pakistan. However, the limited literature that is available from Sindh, Punjab and Khyber Pakhtunkhw highlights the prevalence of the disease in the Pakistani population –15. EchiIn Pakistan, there is a lack of research and data on echinococcosis and so future research on this infection is indispensable. The prevalence of echinococcosis in neighbouring countries highlights that this zoonotic infection may become endemic in Pakistan and further supports the need for more research. A major proportion of the population lives in rural areas with poor health hygienic/sanitary facilities, which further concretes the aforementioned hypothesis. Even though the WHO has declared the disease as a NTD, few published reports are available on the epidemiology of the disease in humans and animals. Research on the distribution pattern, intensity and molecular characterisation should be carried out in the near future in the different endemic areas of Pakistan.The lack of information on this disease might put the Pakistani population at high risk and might result in a future burden for the country’s health system. Furthermore, there is no health insurance system in Pakistan to support infected individuals. A proper monitoring system for echinococcosis is required across the country as treatment is often expensive, complicated and may require extensive surgery and/or prolonged drug therapy. Some sort of eradication strategies should be implemented on the national level to reduce the burden of the disease. Keeping these in mind, below is a summary of the questions/considerations that should be addressed on a priority basis.Echinococcosis has been declared as a NTD in Pakistan. Why are there not any comprehensive studies on the topic? There are a limited number of parasitologists, especially helminthologists, in Pakistan and most have turned a deaf ear to the importance of echinococcosis because data collection is difficult, whether in the hospital or in the field. Most of the specialists are solely focused on diseases such as dengue and other viral diseases, which might be due to the higher prevalence rates of these diseases and more funding resources allocated to them.Until now, only eight reports on echinococcosis in livestock , 33–38 aThere are limited scientific reports from Pakistan on this topic and the majority of studies focus on epidemic diseases such as dengue. Since very meagre work has been done on this parasitic disease, we hope that this letter would be read by many scientists through your esteemed journal. This letter would hopefully facilitate us in the awarding of funding from national/international organisations for carrying out research on echinococcosis in Pakistan.Echinococcus spp. infection is expanding, and becoming an emerging and re-emerging problem in several regions of the world. Echinococcosis endemicity is geographically heterogeneous and over time may be affected by global environmental change. Therefore, landscape epidemiology offers a unique opportunity to quantify and predict the ecological risk of infection at multiple spatial and temporal scales. The most relevant environmental sources of spatial variation in human echinococcosis risk, and the potential applications of landscape epidemiological studies to characterise the current patterns of parasite transmission across natural and human-altered landscapes has been investigated [According to recent estimates, the geographical distribution of stigated .Pakistan has a rural population and livestock rearing is a common practice. Each family owns one or two livestock animals as well as a pet dog. Vegetables and fruit, which have not been washed with clean water, are sold in markets. People consume vegetables and fruit contaminated with echinococcus eggs, and have no information about this disease and its associated risk factors.Researchers have reported that the major factors contributing to the onset of this disease are an abundance of dogs, engagement in risky behaviour and poor abattoir infrastructure and practices . Others In Pakistan, only two research papers have been published on genotyping and molecular characterization of echinococcosis , 14. ResAs there is not enough data on this disease and it is not explored sufficiently in Pakistan, very little is known about the exact prevalence of the disease in the different regions of the country.Globally, cestode zoonoses cause serious public health problems, particularly in Asia. Among all neglected zoonotic diseases, cestode zoonoses account for over 75% of global disability-adjusted life years (DALYs) lost. An international symposium on cestode zoonoses research and control was organised in China on 28–30 October 2013 to establish joint efforts to research effective approaches to control these zoonoses. It brought together 96 scientists from the Asian region and beyond to exchange ideas, report on progress, make a gap analysis and distil priority settings with a focus on the South Asian region. Key objectives were to agree on solutions to accelerate progress towards decreasing transmission, and human mortality and morbidity caused by the three major cestode zoonoses ; to critically assess the potential to control these diseases; to establish a research and validation agenda on existing and new approaches; and to report on novel tools for the study and control of cestode zoonoses .There is a dire need for cooperation between Central Asia countries in the control of hydatid cyst disease. Meetings on echinococcosis in Asia should be organised on a regular basis to highlight the incidence and burden of echinococcosis. On the basis of these, hot spot area s should be identified and control strategies should be implemented.Future research on echinococcosis is anticipated to demonstrate whether the epidemiology, diagnosis and recombinant vaccines/antibodies relating to echinococcosis can meet the quality standards  defined by the WHO. Research work should be carried out on epidemiology and serodiagnosis of echinocossis in the different areas of Pakistan, which will be useful for the proper eradication of echinococcosis from this region. The health department should implemente awareness-raising compagins for the general public in order to reduce the burden of disease.


In the US, growing up with parents with a low socio-economic status (SES) has been shown to increase the chance of having a birth outside marriage. However, less is known about the influence of parental SES in other Western countries. The current paper examines the association between parental educational attainment with the partnership context at first birth in 16 European and North American countries, by differentiating births within marriage, within cohabitation, or while being single. Moreover, we test whether the association between parental education and partnership context at childbirth changes over cohorts and whether its influence changes when controlling for own educational attainment. Data from the Generations and Gender Programme were used, as well as data from the American National Survey of Family Growth, the Canadian General Social Survey, and the Dutch Survey on Family Formation. The results show that in North American and East European countries, but not in West European countries, lower parental education increases the risk of having a birth within cohabitation. Moreover, in North American countries and half of the West and East European countries, lower parental education increases the risk of having a birth while being single. The association of parental education with the partnership context at birth tends to change furthermore over cohorts, although no clear pattern could be observed between countries. The study suggests that the intergenerational transmission of education is an important mechanism in explaining the influence of parental education, although other mechanisms also appear to be at work. Over the past decades, the percentage of children born outside marriage  in Western societies has increased strongly. Within the European Union, the percentage of all births to unmarried women increased from 9 per cent in 1980 to 40 per cent in 2011 Eurostat , 2015, aIn the US, growing up with parents with a low socio-economic status (SES) has been shown to increase the chance of having a birth outside marriage Aassve ; Wu 1996Some cross-national studies have looked at the influence of own education on the partnership context at birth . We study union status at first birth, because starting a family is an important event in people’s lives which often triggers changes in partnership relations , improving living standards, weakening normative regulations, and increasing female autonomy resulted in an increasing need for self-development and individualism  retrospective information on the occurrence and timing of cohabiting and marital partnerships, as well as fertility. For this paper, we were able to use data of four West and nine East European countries. Insufficient information on fertility history, partnership history, or parental educational attainment was available for Australia, Italy, Japan, and the Netherlands. Investigation of retrospective data of various countries of the GGS has suggested that there are issues with the quality of the fertility history of the German dataset  coding system, with scores ranging between 0 and 100. The ISLED-coding system was recently developed by Schröder and Ganzeboom  and has Respondent’s own educational attainment is included as a time-varying covariate by using information on the highest educational level (in ISLED) attained by the respondent in combination with information on the year and month in which this highest level was reached, thereby assuming that respondents remained enrolled in school continuously after finishing primary education.Cohort is a continuous variable reflecting the year of birth of the respondent. Only for the descriptive results showing the changes in partnership context at birth over different cohorts, a categorical variable was constructed. This variable differentiates people born before 1955, between 1955 and 1975, and after 1975. Because of the younger age range for the data of Austria and the US, and because for the US only data collected in 2006–2008 was used, these countries lack a cohort with people born before 1955. For the interaction model testing the difference in the association of parental education over cohorts, cohort was centred around the year 1960, because the SDT assumes that in many countries changes in family behaviour started from the 1960s onwards .As control variables, A discrete-time competing risk model is estimated to test the association of the independent variables with the risk of having a first birth within cohabitation or while being single as compared to having a birth within marriage. This model examines the monthly risk of a respondent to experience one of the events, starting from the age of 15. The model is competing because as soon as a person has experienced an event, he or she is no longer at risk of experiencing any of the other events. The results of the multinomial logistic regressions are reported in relative risk ratios. A relative risk ratio greater than one indicates that an increase in the independent variable increases the risk of becoming a cohabiting or single parent compared to becoming a married parent. A relative risk ratio smaller than one indicates that an increase in the independent variable decreases the risk of having a first child within cohabitation or while being single compared to having a first child within marriage. Since we are interested in how trends differ between countries and between gender, all analyses are run separately by country and gender.In this section, we start with discussing the results of women. In subsections Table 2, and age3. The results of these models are presented in Table To answer the first research question on the association of parental education and partnership context at birth, we estimated a model including parental educational attainment, cohort, and the control variables age, agePanel 1 shows that in the North American countries, most of the East European countries (except Poland), and in Norway, women with parents with a lower educational level have a higher risk to have a first birth within cohabitation compared to a birth within marriage, than women with higher educated parents. In the Netherlands, women with lower educated parents instead have a lower risk of having a birth within cohabitation, compared to women with higher educated parents. In Austria, Belgium, and Poland, parental education is positively associated and in France negatively associated with the outcome variable, but in these countries the associations do not reach statistical significance. In all countries, the risk to have a first birth within cohabitation rather than within marriage increases across cohorts.Panel 2 of Model 1 shows that in all countries, except Georgia, parental education is negatively associated with the risk of having a birth while being single compared to a birth within marriage, indicating that overall women with lower educated parents have a higher risk of having a birth while being single. The coefficients reach statistical significance in the North American, half of the West European , and half of the East European countries .In order to examine whether the association of parental educational attainment and union status at childbirth differs across cohorts (research question 2), we re-estimated the previous model and included an interaction term between parental education and cohort. The main effect of cohort represents the association of cohort for women with an average level of parental education. The main effect of parental education can be interpreted as the estimated association of parental education for women born in 1960. The results are presented in Table The results of the main effect of parental education on the risk to have a birth in cohabitation (Panel 1) and the interaction effect with cohort show that in Canada and Norway the negative association of parental education is more negative for younger cohorts. In Austria, Estonia, Georgia, and Russia, the negative association instead becomes less negative with consecutive cohorts . The opposite is found in the Netherlands, in this country the positive association becomes less positive with consecutive cohorts (in Belgium this association does not reach significance). In France, the positive association for older cohorts changes into a negative association for more recent cohorts.For the model comparing the risk of having a birth while being single versus within marriage (Panel 2), only for a few countries significant interaction effects are found. In Canada, the negative association of parental education is more negative for consecutive cohorts, while in Austria and Russia the negative association become less negative. In Poland, the negative association for older cohorts changes into a positive association for younger cohorts.To examine to what extent the association of parental education with the partnership context at birth changes by including own educational attainment, a model was estimated including both variables.When comparing Panel 1 of Tables For the models comparing the association of the independent variables with the risk to have a first birth while being single versus within marriage for women .The association of parental education with the risk of having a birth within cohabitation versus within marriage is fairly similar for men and women in most countries. Only in the Czech Republic, Lithuania, and Russia, a negative association is found for women, while for men no significant difference between the higher and lower educated is found, however, note that in the Czech Republic the association almost reaches significance for men .p-value is .045 for French men). In Estonia, we find a similar negative coefficient of parental education for men and women, however, for men this coefficient does not reach significance, although both p-values balance around the .05 level .For the model including a respondent’s own educational attainment, we only find different results for men as compared to women in three countries. In France and the Netherlands, a positive and significant association is found for men and no significant differences are found for women  are more likely to have non-marital births , this negative association coincides with a negative association between parental education and the risk of having a birth within cohabitation. Births to cohabiting couples in these East European countries thus appear to be part of a pattern of disadvantage together with births to single mothers, something previous research also observed in the US . There also did not appear to be clear patterns between the different groups of countries. This low level of consistency in the pattern between and within countries complicates the identification of societal changes that can explain the results. We therefore have to leave it to future research to further explore changes over time.Lastly, we wanted to know to what extent the association of parental education changes when a person’s own educational attainment is included in the model. In most countries, the initial negative coefficient of parental education on the risk of having a first birth within cohabitation or while being single became smaller after including information on respondents’ own educational attainment. For births within cohabitation, the negative associations of parental education, however, remained statistically significant in the North American countries, Norway, and half of the Eastern European countries. For women who had a birth while being single, this was less often the case, as after including own educational attainment, the initial negative association only remained statistically significant in the US, Austria, and Norway. Our expectation was that including own educational attainment in the model could reduce the association of parental education because US research has shown that part of the association between parental SES and family structure can be explained by the intergenerational transmission of SES  education and cohort. In view of other possible mechanism linking parental SES and partnership at first birth, additional insight into the topic could be gained by including additional childhood indicators .Most fertility research has focused on women. One additional objective of this paper was to examine whether the patterns for men and women are comparable across and within countries. In fact, the association of parental education was remarkably similar for men and women. The model including own educational attainment also did not differ much between men and women. This supports the idea that in most instances the mechanisms explaining partnership context at birth are fairly similar for men and women. We therefore recommend to study data of men in addition to that of women more often in fertility research, as it can serve as a test of the robustness of one’s findings in a certain context. In the few cases where statistical gender differences were found, the overall association of parental education was more negative for women than for men. This is in line with previous research suggesting that the mechanism of socialization and role modelling could potentially be stronger for daughters than for sons. Moreover, in quite some countries differences between men and women were found for the interaction model, indicating that the association of parental education changes differently across cohorts for men and women. This could be an interesting topic for further study. It could also be fruitful to expand analyses to higher-order births. In some countries, cohabiting parents are likely to get married after their first birth (Perelli-Harris et al.


To conduct a systematic search for grounded and quality evidence of sensory processing in preterm infants during childhood.  The search of the available literature on the theme was held in the following electronic databases: Medical Literature Analysis and Retrieval System Online (Medline)/PubMed, Latin American and Caribbean Literature in Health Sciences (Lilacs)/Virtual Library in Health (BVS), Índice Bibliográfico Español de Ciencias de la Salud (IBECS)/BVS, Scopus, and Web of Science. We included only original indexed studies with a quantitative approach, which were available in full text on digital media, published in Portuguese, English, or Spanish between 2005 and 2015, involving children aged 0-9years.  581 articles were identified and eight were included. Six studies (75%) found high frequency of dysfunction in sensory processing in preterm infants. The association of sensory processing with developmental outcomes was observed in three studies (37.5%). The association of sensory processing with neonatal characteristics was observed in five studies (62.5%), and the sensory processing results are often associated with gestational age, male gender, and white matter lesions. The current literature suggests that preterm birth affects the sensory processing, negatively. Gestational age, male gender, and white matter lesions appear as risk factors for sensoryprocessing disorders in preterm infants. The impairment in the ability to receivesensory inputs, to integrateand to adapt to them seems to have a negative effect on motor, cognitive, and language development of these children. We highlight the feasibility of identifying sensory processing disorders early in life, favoring early clinical interventions. Sensory processing concerns the way the central nervous system manages the information received from sensory organs, that is, the visual, auditory, tactile, gustatory, olfactory, proprioceptive, and vestibular stimuli. The process includes reception, modulation, integration, discrimination, and organization of sensory stimuli as well as adaptive behavioral responses to these stimuli.,,Sensory processing disorder (SPD) is the term used to refer to difficulties in processing and using sensory information for the regulation of physiological, motor, affective, and/or attention responses that interfere in the organization of behavior and in the participation in activities of daily living.,Although the etiology of SPD remains unknown, genetic, family, and environmental factors have been reported in the literature.,,,,,SPD is an alteration of development in the first childhood, that has received increasing attention in the last decade.SPD is a heterogeneous condition that includes several subtypes.,,It is worth mentioning that none of these conditions is in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) or in the International Statistical Classification of Diseases and Related Health Problems (ICD-10), and there is no consensus on howthey should be defined.,The clinical manifestations of SPD are varied and include crying and excessive agitation, difficulty in self-consoling, sleep problems and acceptance of food, exacerbation of parental separation anxiety, persistent and exaggerated shyness with strangers, intolerance to change, lack of interest and indifference in social interaction.The diagnosis of SPD is based on child behavior observation and/or the application of questionnaires to parents.,,,Recent studies show that children who were born prematurely have different responses to sensory stimuli and may exhibit alterations in sensory processing.Environmental stimuli of the fetus and child after birth, including sound, voice, touch, movement, smell, and vision experiences are crucial for the proper development of the sensory systems. Although not all these experiences have a significant role in establishing the initial patterns of the sensory systems connectivity, they contribute to the improvement and maintenance of appropriate connections in the developing brain.According to Lickliter,In this scenario, the objective of this review was to search for grounded and quality evidence concerning the sensory processing in preterm infants. This was conducted by means of a systematic knowledge synthesis,based on the literature available on the subject that was published between 2005 and 2015.A systematic literature review was carried out following the protocol adapted from the principles established by the Cochrane Library.Only studies that were indexed, original, quantitative, and fully available in digital media were included in the review. They were also published in Portuguese, English, or Spanish between August 2005 and August 2015, and included children in the age group of zero to nine years. This time limit was established aiming at reviewing the most recent literature on the subject, and the selection of the age range is due to the particular interest in investigating how preterm birth can affect sensory processing during childhood.Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs)/Biblioteca Virtual em Saúde (BVS), and Índice Bibliográfico Español de Ciencias de la Salud (IBECS)/BVS, based on the strategy of the combination of two sets of keywords using the boolean operators AND and OR. The descriptors chosen were “sensation disorders” and “infant, premature”. Free terms were “prematurity,” “sensory processing disorders,” “sensory functions in infants,” “sensory profile of infants,” and their counterparts in Portuguese and Spanish. We opted for the use of descriptors and free terms in the strategy design to ensure a more comprehensive search, reducing the risk of missing relevant studies.First, an electronic search was conducted in the databases Medical Literature Analysis and Retrieval System Online (Medline)/PubMed, Reading of articles’ abstracts that were located in the search was the main source of selection of the publications, which intended to confirm that they were related to the theme and met the established inclusion criteria. In addition to the electronic search, the citation search was carried out using the reference lists of the selected articles and their citation indexes in Scopus and Web of Science databases. All the search process was conducted by the first and second authors. The two reviewers read and selected the papers independently, and then they did across-check. Finally, the matching articles were selected. The retrieval of the selected papers in digital media in their full version was performed in the Capes Portal.Full reading of the articles enabled the extraction of the relevant aspects of each article and its summarization in tables to ensure that the same information was obtained from all publications. This step was conducted by the first and second authors, and the results were subsequently discussed and analyzed together with the other authors.By the combination of descriptors and free terms mentioned earlier, 581 articles were found in the electronic search. Six articles were selected after the application of the established inclusion criteria. The significant difference between the number of publications found and the number of publications selected is due to the fact that most studies covered different populations from the target defined for this investigation. Studies involving individuals with autism spectrum disorder and attention deficit disorder/hyperactivity, and those with children born at term were excluded. Other studies on sensorineural impairments (blindness and deafness), retinopathy of prematurity, asthma, and drug effects, studies using animals, literature reviews and others publications before the established cutoff date were also excluded. Citation searching enabled the selection of two additional articles.,,,,,,,The eight selected publications were included in the study.,,,,,,,,All the studies included in this review were published in the last five years, and only one was carried out in Brazil(12.5%).,,,,,Of the studies, six (75%),,,,,,,,,,,With regard to the age in which sensory processing was evaluated, six studies (75%),,,,,,The comparison of children who were born prematurely with their peers who were born at term was carried out in four studies(50%),,,,,,,,,,,,,To verify the association of sensory processing with development outcomes,was the objective of six studies(75%).Analysis of the selected literature suggests that preterm infants are different from their peers who were born at term with respect to sensory processing. They present high frequency of alterations in sensory processing during childhood. Therefore, prematurity can be considered a risk factor for SPD. This fact is not surprising, as preterm newborns, in addition to being biologically vulnerable, are deprived of the natural sensations of the intrauterine environment and need prolonged periods of stay in the NICU, where the sensory experience conflicts with their needs. Most studies investigated the sensory processing of preterm children who were born with gestational age below 34 weeks; however, the study of Bart et al.,,,,,,,,From the six studies that were reviewed, the sensory processing was evaluated in the first two years of life,With regard to the evaluation instruments, Infant/Toddler Sensory Profile (ITSP),,,,,,Six studiesAccording to White et al.,Finally, the results of this review suggest that sensory processing issues in preterm infants are caused by a combination of biological and neonatal risks of prematurity. Gestational age, male gender, and presence of white matter lesions were the main factors associated with sensory processing outcome in the studies reviewed.Chorna et al.Rahkonen et al.,The association of poorer results of sensory processing with male gender in the revised articles may be a disadvantage related to the phenomenon known as “male disadvantage.”,,,,The results of this review should be interpreted with caution. It was observed that most of these studies described efficiently the populations analyzed, including context delimitation of the search (places and relevant dates), presentation of eligibility criteria, sources and methods of selection of participants, and description of their clinical, demographic, and social characteristics. However, no study reported how the sample size was determined, and this analysis is crucial to ensure the consistency of the results found. Moreover, the evaluation of sensory processing was carried out only by means of questionnaires applied to parents in 62.5% of the studies reviewed.,,,,,,It is also worth noting that only 50% of studiesA possible limitation of this review was the exclusion of gray literature - term used to refer to any source of information that is not indexed for publication databases, such as conference abstracts or government reports.Although few studies have currently investigated the sensory processing of children born preterm, this review suggests that prematurity has negative impact on sensory processing in children during childhood. Gestational age, male gender, and white matter lesions appear as risk factors for SPD in preterm infants. The impairment in the ability to receive sensory information and to integrate and adapt to them appears to interfere negatively in motor, cognitive, and language development in this population; however, there is no consensus in the literature on this issue.The feasibility of the identification of sensory processing issues in the early years of life should be highlighted, a s it favors early referral for intervention. The lack of national studies or of those published in local journals on the theme is clear. Furthermore, the need for longitudinal studies to investigate the prevalence, persistence, and potential consequences of SPD in preterm infants in the medium and long terms should be highlighted.


Ascaris spp. free-living stage development and host reinfection, but the impact of these differences on human infections, and interventions to control them, is variable. A new model framework reflecting four key stages of the A. lumbricoides life cycle, incorporating the effects of rainfall and temperature, is used to describe the level of infection in the human population alongside the environmental egg dynamics. Using data from South Korea and Nigeria, we conclude that settings with extreme fluctuations in rainfall or temperature could exhibit strong seasonal transmission patterns that may be partially masked by the longevity of A. lumbricoides infections in hosts; we go on to demonstrate how seasonally timed mass drug administration (MDA) could impact the outcomes of control strategies. For the South Korean setting the results predict a comparative decrease of 74.5% in mean worm days  between the best and worst MDA timings after four years of annual treatment. The model found no significant seasonal effect on MDA in the Nigerian setting due to a narrower annual temperature range and no rainfall dependence. Our results suggest that seasonal variation in egg survival and maturation could be exploited to maximise the impact of MDA in certain settings.There is clear empirical evidence that environmental conditions can influence  Ascaris spp. eggs, which are exposed to the environment during maturation. Field studies in a number of countries, including Sri Lanka, Saudi Arabia and South Korea have demonstrated seasonal variation in reinfection rates; in Sri Lanka significant correlations were found between reinfection and both temperature and the number of wet days recorded. The impact of these variations on transmission, and therefore control, are unknown. Using a deterministic macroparasite model we demonstrate that seasonal changes in maturation and death rates of free-living stages, as well as transmission, could result in large seasonal swings in the infective larval population and mean worm burden in the human population. Although the seasonal effects are likely to vary between species of STH due to disparate life-cycles, this could have large knock-on consequences for timings of MDA programs and expected public health outcomes for A. lumbricoides infections in certain settings, indicating the need for further investigation in this area.Soil-transmitted helminth infections affect 1.5 billion people worldwide and mass drug adminstration (MDA) is one of the key public health measures for reducing the burden of infection. A number of experimental studies have demonstrated links between temperature and the dynamics of  Ascaris lumbricoides, is one of the most common of these infections , where xi were the positive cases from the data, N was the total population size and pi were the model prevalences.A binomial log-likelihood is used for fitting: ∑In South Korea the model considers larval mortality to be very low across the entire year, due to low overall temperatures, with a peak during the summer months between May and September. In contrast, larval mortality in Nigeria is taken to fluctuate across the year, but with a higher average death rate. However, in both settings the temperatures don’t get high enough for the model to predict much effect on the proportion of eggs that remain viable following maturation.


In 2011, Fukushima was struck by a triple disaster: an earthquake, tsunamis, and a nuclear accident. In the aftermath, there was much fear among hospital staff members about radiation exposure and many staff members failed to report to work.One objective is to measure this shortage in hospital staff and another is to compare the difference in recovery by hospital types and by categories of hospital staff.The monthly records of the number of staff members from May 2011 to September 2012 were extracted anonymously from the records of 7 local hospitals in the Soso district in Fukushima. Change in the number of staff was analyzed.Staff shortages at hospitals reached a maximum within one month after the disaster (47% reported to work). The shortage of clerks was the most severe (38% reported to work), followed by nurses (48% reported to work). The shortages remained even 18 months after the disaster.After a disaster in which the damage to hospital functions surpasses the structural damage, massive support of human resources in the acute phase and a smaller volume of support in the mid-term phase appear to be required, particularly for non-medical staff. Hospitals are vital assets for local communities to maintain the health of their populations. After a huge disaster, the need for healthcare in affected areas greatly increases due to the injuries associated with damage from the disaster and deterioration of chronic medical conditions in the short term, as well as the aftermath of the disaster in the long term. In this regard, enhancing the capabilities of local hospitals beforehand to manage such unusual situations is one of the highest priorities of disaster mitigation because disasters may endanger the functions of hospitals in many ways. For example, after meteorological or geographical disasters such as floods, earthquakes, and landslides, the structural and infrastructural damage to hospitals has been reported to impair hospital functions . In addiOn March 11, 2011, the second largest nuclear accident in history occurred at the Fukushima Daiichi nuclear power plant (NPP) in Fukushima Prefecture, Japan, following an unprecedented earthquake and subsequent tsunamis. This triple disaster—an earthquake, tsunamis, and an NPP accident—severely affected the area around the plant.One of the affected areas, the Soso district, is located approximately 15–40 km north of the plant and was one of the areas most affected by this triple disaster . Two of On March 11, 2011, an earthquake of magnitude 9.0 and subsequent tsunamis of up to 14 m struck the northeast coast of Japan. The tsunamis disabled the cooling system of the reactors of the NPP. Meltdown started soon after the tsunamis, and the first visible explosion, which was suspected to be caused by leaked hydrogen gas, occurred on March 12. Over the following 3 weeks, several suspected hydrogen detonations occurred.In response to the nuclear accident, the Japanese National Government established the following evacuation zones on March 12, 2011: a compulsory no-entry zone within a 20-km radius of the NPP, in which all of the residents were mandated to evacuate; and a planned evacuation zone within a 20- to 30-km radius from the NPP, in which the residents were recommended to stay at home to avoid excessive external radiation exposure. Although evacuation from the planned evacuation zones was voluntary, mass evacuation occurred in this area due to fear of radiation. As a result, the population of the Soso district was reported to decrease from nearly 100,000 to 40,000 after the evacuation order .Twelve hospitals were in the Soso district before the disaster. Three hospitals were located within no-entry zones, and all of the hospitalized patients were transferred to other hospitals by March 14. Two other hospitals sustained catastrophic damage from the disaster, and stopped functioning on March 11. Therefore, this survey was conducted on the remaining seven hospitals. Informed consent was obtained from each hospital prior to beginning the survey.The monthly records of the number of staff members from May 2011 to September 2012 were extracted anonymously from the records of each hospital. The number of outpatient visits during the same period were also collected. Staff members were categorized as medical doctors, nurses, other clinical staff (OCS), and hospital clerks. OCS included pharmacists, clinical laboratory technicians, clinical engineers, radiology technicians, physiotherapists, occupational therapists, dieticians, and nurse’s aides.Following the rules of the Soso Public Health Institute, the number of part-time staff members was converted into a number of full-time workers by dividing their weekly working hours by those of full-time workers.Monthly data on number of resistered residents in Soso district was also calculated based using municipal data , 8.Written informed consent was obtained from every hospital. The institutional review board of the University of Tokyo approved this study.All seven hospitals agreed to participate in the survey. The fluctuation of the number of staff, patients, and resistered residents in Soso district was shown in Three months after the disaster, the number of staff members started to recover gradually, but had not fully recovered even at 18 months after the disaster. In September 2012, the recovery rate remained at 85% . The recovery was slowest in clerks  followed by nurses (85%) and OCS (87%). Interestingly, the number of medical doctors increased by 6% compared to that before the disaster .In the Soso district, the number of residents also declined sharply after the disaster. Although registered residents in Soso district decreased only by 10% during 18 months after the disaster , actual On the other hand, inpatients per staff decreased except clerks . This deThe extent of staff reduction and speed of recovery varied among the different hospitals . The shoThis is the first study to illustrate how the number of hospital staff members fluctuates after a huge disaster. Staff shortages at hospitals reached a maximum within 1 month after the disaster but recovered to some extent after 3 months. Even so, the shortages remained even 18 months after the disaster. This study also revealed that the speed of recovery varied by the category of hospital staff.Sharp decreases in the healthcare staff during the acute phase of a disaster, as observed in the Soso district, have also been observed at other nuclear accident sites. After the nuclear accident at Three Mile Island, only 7 of more than 70 medical doctors reported for service at a hospital .Several reasons may explain the unwillingness of staff to work after a disaster. First, a psychological fear may exist among the staff. The closer the houses of the staff members are to the NPP, the stronger the fear and anxiety about radiation exposure might be. Therefore, staff living near the plant are more likely to evacuate. Second, disruption of the supply of commodities such as food, fuel, and the means of transportation. Many distributors outside of the Soso district refused to send their staff within a 30-km radius of the NPP based on ground security . As a reThere is no report on effective intervention to prevent staff from leaving their workplace during such social disruption. However, based on the aforementioned background, at least the following conditions might be needed to prevent hospital staff from taking unprepared evacuation.First, approach to provide timely information about the source of fear needs to be established. In Soso district, little information was available on the outcomes of the NPP accidents, which fostered fear among the staff at local medical services . Second,Third, minimizing the disruption of the supply chain of essential life resources such as food, water, and fuel is indispensable to retain hospital staffs to continue work at the affected areas after a huge disaster because hospital staffs were unable to stay at their workplace without external resources. On top of these, it is essential to build up atmosphere where no other staff member is blamed for the leavers in their evacuating, so that the evacuated staffs will feel it easy to return to their workplace without hesitation.Whether financial support has some effect on retaining staff is still an open question, but it is essential to retain function of local hospitals. In Soso district, Tokyo Electric Power Co., Inc., the owner of the Fukushima Daiichi Nuclear Power Plant, compensated the damage of the hospital based on yearly income of each hospital. Prefectural government of Fukushima also subsidize the hospitals to reconstruction of their buildings. Most of the hospitals, especially private hospitals, might not be able to continue care without these supports.Interestingly, the number of medical doctors rather increased after the disaster, owing simply not to return of the evacuated medical doctors. Rather, the disaster area was attractive in newly recruiting many young medical doctors, who were willing to conduct their clinical and academic practices related with disaster medicine or public health research. For example, before disaster junior residents out of Fukushima prefecture did not join Minamisoma Municipal General Hospital. However, during 5 years after the disaster, 11 junior residents as well as many more senior residents from the nation-wide areas have already joined in Minamisoma Municipal General for medical cares, and many of young doctors have been also scientifically very active by writing academic papers and case reports related to the disaster. , 13.On the contrary, only few nurses and OCS have come from the outside to date. To retain nurses and OCS, further research is needed to identify factors that made the staff remain at the hospitals.The speed in recovery varied also among the hospitals. Psychiatric hospitals are often more severely affected by any damage by disasters , presumaThe fact that the number of hospital staff members decreased by up to 50% strongly suggests that the number of rescue teams dispatched to the disaster area was not sufficient to support the functions of local healthcare systems. After the Great East Japan Earthquake, approximately 380 disaster medicine assistance teams (DMATs) with 1,800 members entered the disaster area, including Fukushima . HoweverThe results of this study also suggest that sufficient human resource support is important not only for maintaining hospital functions but also for achieving early recovery. Two hospitals that closed their outpatient wards  still suffered from low recovery rates even at 18 months, whereas a hospital that retained its functions during the acute phase  experienced a faster recovery than other hospitals.Intensive short-term human resources support from external sources might be important for avoiding delay in recovery of hospital functions, and such support is presumed to include not only DMATs with enhanced volume, but also supports by other hospital staffs such as medical clerks and other paramedics. In addition, such supports need to be equally distributed to both public and private hospitals.Although the number of hospital staff members recovered to some extent within 3 months, the shortage lasted for over 1 year . TherefoAnother issue to be addressed is the discrepancy in the speed of recovery between different categories of staff members. In particular, the recovery of the number of medical clerks was the slowest among all occupations surveyed. This result is compatible with those of a previous report suggesting that non-professional workers have a lower willingness-to-report in disaster settings . BecauseIn addition to nuclear disasters, other CBRN disasters can also cause social disturbance due to fear . For exaThis research was unable to provide a reason some hospitals recovered more rapidly than others. For example, it is not clear whether Hospital F recovered more quickly because it is a public hospital or because it did not close outpatient wards in the acute phase. In addition, the present assessment did not verify changes in the size of the population surrounding the hospitals, so the numbers may not fully represent the workload of each hospital. Further research may reveal more factors that influence the number of staff members at hospitals during disasters.This study describes the changes in the number of hospital staff members after a triple disaster that consisted of an earthquake, tsunamis, and a nuclear accident. Based on the present findings, massive support of human resources in the acute phase and a smaller volume of support in the mid-term phase appear to be required, particularly for non-medical staff. According to the Sendai Framework for Disaster Risk Reduction, understanding the disaster risk and the need “to systematically evaluate, record, and publicly account for disaster losses” is one of the highest priorities of action . By shedS1 Table(DOCX)Click here for additional data file.


Much of the literature on recovery focuses on the economy, the physical environment and infrastructure at a macro level, which may ignore the personal experiences of affected individuals during recovery. This paper combines internal factors at a micro level and external factors at a macro level to model for understanding perception of recovery (PoR). This study focuses on areas devastated by the 2008 Wenchuan earthquake in China. With respect to three recovery-related aspects (house recovery condition (HRC), family recovery power (FRP) and reconstruction investment (RI)), structural equation modeling (SEM) was applied. It was found that the three aspects  effectively explain how earthquake affected households perceive recovery. Internal factors associated with FRP contributed the most to favourable PoR, followed by external factors associated with HRC. Findings identified that for PoR the importance of active recovery within households outweighed an advantageous house recovery condition. At the same time, households trapped in unfavourable external conditions would invest more in housing recovery, which result in wealth accumulation and improved quality of life leading to a high level of PoR. In addition, schooling in households showed a negative effect on improving PoR. This research contributes to current debates around post-disaster permanent housing policy. It is implied that a one-size-fits-all policy in disaster recovery may not be effective and more specific assistance should be provided to those people in need. As a severe regional environment event, an earthquake causes dramatic changes in the natural environment and human society. Facilitating recovery, in order to regain sustainability in daily life and in economic activity, after a disaster is an important priority for affected families, the local community and the wider society. The Sendai Framework for Disaster Risk Reduction issued by the United Nations called for a broader and more people-centered approach to reduce disaster risk . This frPrevious research suggests that governments and citizens have different perceptions of recovery –7. Long-Recent research has gradually begun to examine the perception of recovery and adaption following natural disasters , 5, 9. RIn extant studies about recovery, many were conducted at a macro level to determine persuasive statistical indicators that could be used to calculate the degree of recovery, such as urban disaster recovery from earthquake , housingFrom these previous studies, conditioning factors on perception of recovery can be grouped into internal factors at the micro level (i.e. those subject to the will of households) and external factors at the macro level (i.e. those not subject to the will of households). Starting from this basis, this paper tried to combine internal factors at the micro level and external factors at the macro level to construct and test a model for the perception of recovery. This research also aimed at discovering conditioning factors of PoR and interactions of these conditioning factors in the PoR model.On May 12, 2008, a large earthquake of magnitude 8 on the Richter scale occurred in the Wenchuan area of Sichuan Province, China. It was the worst earthquake to occur in China since the M7.8 Tangshan Earthquake in 1976. The earthquake also caused severe secondary disasters, such as landslides, rock falls and debris flows –19. By AIn the post-earthquake loss assessment, Wenchuan County and Beichuan County  was defined as the subjective assessment of the degree of recovery by the disaster affected family. In the existing literature, subjective assessment by interviewees of household recovery has been commonly used because it reflects the core of PoR in self-evaluation and subjectivity ;23–25. IAs one independent latent variable in the model, house recovery conditions (HRC) was defined as the measurement of external conditions and difficulties each affected family faced to achieve housing recovery. The retaining of dwellings plays a significant role in the process of disaster recovery. From the Northridge and Kobe earthquakes, it was learned that housing losses could have devastating effects on the recovery effort . On the As one independent latent variable in the model, family recovery power (FRP) was defined as the measurement of internal conditions and drivers each affected family had to achieve a good recovery. Family recovery power (FRP) can be a socio-economic attribute that is closely related to household recovery and plays an important role in the recovery process , 34. FRPIn addition, it was discovered that there were some special factors that could be influenced by both external and internal factors during recovery. In this research, reconstruction investment (RI) was defined to play such a role, and it represented the actual monetary input affected families spent to finish recovery. Apparently, RI may be closely related to HRC. A better HRC reduces rebuilding difficulties and reconstruction input. However, RI can also be closely related to FRP. The monetary value of investment made in a housing unit over the recovery period can be significantly influenced by factors such as permanent economic income, current economic resources and dwelling condition . TherefoGenerally, PoR was set to represent the main target of this research, the perceived recovery of households after a disaster. HRC, FRP and RI served as explanatory variables to PoR, while HRC and FRP addressed the external and internal factors of households, which may influence how PoR was formed. RI can be special but necessary for its influence on PoR and its connecting role between HRC and FRP.Prior to conducting our study, we received approval from the Human Subjects Committee of the School of Social Development and Public Policy (SSDPP-HSC), Beijing Normal University (BNU). Written informed consent was obtained from each of the participants prior to being interviewed. Each of the participants was free to withdraw from this survey at any time without any consequence.This study sought to address the research gap in the PoR field by examining how HRC, FRP and RI influence a household’s perception of recovery using the questionnaire survey method. In the designed questionnaire, most items were ranked on a Likert scale , and theThere were two investigations in this research. The first one, pre-survey, was conducted in August 2012, approximately 4 years after the earthquake. The second one, the main investigation lasted approximately two weeks and was conducted in January 2014, approximately 5 years after the occurrence of the earthquake. Samples in this research came from the second survey, with a total of 878 households. Eleven experienced investigators who had participated in other disaster surveys and were well trained before departure participated. The geographic extent of this investigation covered the densely populated towns of two rural areas stricken severely by the earthquake  , the proa priori on the basis of theoretical rather than empirical considerations.Structural equation modeling (SEM) is a widely used multi-variable statistical method in the field of behavior research and social science. It enables the researcher to explicitly model measurement errors and may therefore result in less biased parameter estimations, which is an advantage over multiple regression and path analysis. Although techniques such as principal component analysis (PCA) can decrease the dimensionality of a set of correlated variables using a smaller number of axes , PCA cannot be performed The basic assumption when using SEM is the same as when using other multi-variable methods: the population is required to follow the hypothesis of multivariate normality . On thisa priori model (displayed in the following section on model specification). During the construction of the structural equation model, a series of technical tasks were performed. First, a descriptive statistics analysis of each variable was done and a table of correlation coefficients was generated  and observed variables (which can be measured in a survey) are required to construct a hypothesis model . When coFor HDD, it was assumed that the worse HDD that a family experienced, the lower the HRC it may have (H4). From the items in HDD, it was discovered that these items were about how bad the damage was in the house and thus could be negative to PoR but to a different extent. For instance, houses without any need for repaire could easily help the affected families recover to pre-disaster life, while completely damaged house could be heavy burdens on the affected families, for they had to earn more to rebuild. Because of the negative effect of house damage on PoR, HDD was coded from -4 to -1, illustrating the damage degree from severe to slight. For RM, a complex and costly reconstruction method could be negative for recovery perception. It was assumed that the fewer burdens that a family carried during rebuilding, the higher HRC they may have (H5). For instance, simply repairing may cost the affected house in monetary input, while the policy of planning by the government and building alone could make the affected households complete the series of administrative procedures and thus cause mental and physical fatigue. Because of the negative effect of the rebuilding method on PoR, RM was coded from -5 to -1, illustrating the reconstruction method from complicated and costly to simple and inexpensive.For PeLWP, it was assumed that the more members of the affected families there were who could work and earn money, the higher FRP they might have (H6). For HIC, it was assumed that if the total income of a family could be more than before the disaster, the higher the level of FRP it could have (H7). EC was an important component of social capital –39. It wIn addition, several hypotheses were proposed regarding the contributions of HRC, FRP and RI to PoR and the interactions between HRC, FRP and RI. From the correlation analysis of the observed variables, it was discovered that HDD and RM (components of HRC) had a positive correlation with SEQoL, SERS and FA (components of PoR) as well as HIC, PeLWP and EC (components of FRP). It may mean that good HRC and strong FRP could improve the level of PoR. Additionally, a high level of RI demonstrated that the affected family had been equipping a new house and certainly would result in better living conditions, which could improve PoR. Therefore, it was assumed that HRC, FRP and RI could have a positive direct connection with PoR , whereas a positive correlation was assumed to exist between HRC and FRP, between HRC and RI and between FRP and RI .First, a descriptive statistical analysis on observed variables was performed to obtain a general view of the sample families . The anaThe process of model-building and estimating was completed using the statistical software SPSS AMOS 22 , and the model result can be found in The path weights of the observed variables for the latent variables are as shown in Regarding the contributions and interactions of the three conditioning aspects, it was found that hypotheses H9, H10 and H11 were supported. FRP, HRC and RI contribute significantly to PoR, with regression weights of .63, .29 and .17, respectively. Generally, the model constructed using SEM, which was intended to explain PoR with respect to the three aspects RI, HRC and FRP, was reasonable. The model could explain 46% of the total variance in the dependent variable. Unexpectedly, the relationships between HRC and FRP and between FRP and RI were not significant, which implied that hypotheses H12 and H14 were not supported. In addition, HRC had a significant negative influence on RI (-0.37), which implied that hypothesis H13 was not supported.Based on the model result, HRC as the direct sequential factor from the earthquake had substantial influence on PoR but was outweighed by FRP when considering its effect on PoR. However, the education condition failed to play a positive role in strengthening FRP for better PoR. There were significant interactions between HRC, RI and PoR. HRC had a negative direct influence on RI. RI had a positive direct influence on PoR. However, HRC had a positive connection with PoR. The role of HRC may appear confusing. Based on the model result, there was no significant relationship between FRP and HRC or between FRP and RI.The results of SEM modeling imply that a positive response by the affected families to challenges in recovery truly matters. Actions such as having a large workforce and seeking to generate more economic income can be effective methods to improve FRP. For limited public resources, more investments in boosting the household’s capacity could lead to relatively higher PoR. As recommended by the World Bank, the housing owner-driven reconstruction (ODR) approach, which could be summarised as giving conditional financial assistance, accompanied by regulations and technical support aimed at ensuring that houses are built back better, is regarded as the best strategy for post-disaster housing provision , 53. SucEconomically, the return period on education investment is so long that no significant gain is available short term . This phenomenon is so wide spread that most households that survived the earthquake have many consuming members but few productive members. If a family member was of the proper age for employment but still studying at a university, the family would have to feed one more member with one fewer member earning. In such circumstances, a higher schooling population means a heavier economic burden, which could be why the education condition played a negative role in PoR.The dual effect of HRC was also reflected in this model. On the one hand, a household trapped in worse HRC could invest more money in recovery. The dwellings they had and the facilities at home consequently improved and these conditions could raise their mental wellbeing after such arduous work. Then the affected families could perceive the effort they exerted to improve their lives. On the other hand, if one household had to face worse conditions of post-earthquake housing, they might have to face more challenges than do their neighbors. These difficulties could result in a low level of PoR. From the model results, of the two effects, the latter is predominant.As mentioned above, the SEM model in this study could explain 46% of the total variance in the dependent variable. To explain the additional 54% of the variance could be the next focus of this research. Improvements could be conducted by enriching the observed variables of the related latent variables. First, PoR is a widely relevant topic with multiple aspects. How to select comprehensive and proper indices should be further discussed. This paper uses FA, SERS and SEQoL as three compound elements of PoR. Other factors, such as living convenience , sense oUsing field survey data from two rural areas  in regions disastrously afflicted by the 2008 Wenchuan earthquake in China, this paper focused on assessing the perception of recovery (PoR) in the affected families. Because of the substantial importance of housing recovery in the entire recovery process, this paper departed from the perspective of rehousing and chose three aspects, house recovery condition, family recovery power and reconstruction investment, to build a household PoR model by applying structural equation modeling. It was discovered that all these three aspects could effectively explain the formation of the affected family PoR. Among the three aspects, family recovery power made the largest contribution, followed by house recovery condition. A significant correlation between house recovery condition and reconstruction investment was found, which reflects the dual effect of house recovery condition. In addition, family recovery power did not significantly influence reconstruction investment.Findings from this study basically agree with some conclusions in the extant research about the relationship among perception, household attributes and damage severity. In the research on Hurricane Katrina from Khunwishit and McEntire , it was As for the method of housing reconstruction, this study proved that different reconstruction methods can have different effects on a household’s perception of recovery. The variable of rebuilding method was divided into five categories and was proven to be significantly influential. Such a finding reflects the research conclusion by Andrew , which cAs an important aspect of a comprehensive assessment of disaster recovery quality , a betteS1 File(XLSX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


The use of economic evaluation in healthcare policies and decision-making, which is limited in low- and middle-income countries (LMICs), might be promoted through the improvement of the conduct and reporting of studies. Although the literature indicates that there are many issues affecting the conduct, reporting and use of this evidence, it is unclear which factors should be prioritised in finding solutions. This study aims to identify the top priority issues that impede the conduct, reporting and use of economic evaluation as well as potential solutions as an input for future research topics by the international Decision Support Initiative and other movements.A survey on issues regarding the conduct, reporting and use of economic evaluation as well as on potential solutions was conducted using an online questionnaire among researchers who have experience in conducting economic evaluations in LMICs. The respondents were requested to consider the list of issues provided, rank the most important ones and propose solutions. A scoring system was applied to derive the ranking of difficulties according to researchers’ responses. Issues were grouped into technical and context-specific difficulties and analysed separately as a whole and by region.Researchers considered the lack of quality local clinical data, poor reporting and insufficient data to conduct the analysis from the chosen perspective as the most important technical difficulties. On the other hand, the non-integration of economic evaluations into decision-making was considered the most important context-specific issue. Finally, context-specific issues were considered the larger barrier to the use of economic evaluation.The technical issues that were considered most important were closely linked with the lack of an appropriately functioning information system as well as the capacity to generate essential contextual information , especially when the methodology is complex. To overcome this, simpler approaches to collect data that yields information of comparable quality to more rigorous methods should be developed. The international community can play a major role through research on methodologies feasible for LMIC settings as well as in building research capacity in countries. Context-specific issues, which were recognised as larger barriers, should be improved in parallel.The online version of this article (10.1186/s12961-018-0280-6) contains supplementary material, which is available to authorized users. Economic evaluation is a process that identifies, measures, valuates and compares the costs and consequences of at least two alternative courses of action. It aims to determine the efficiency or cost-effectiveness of the implementation of studied alternatives . The useEvaluation practitioners in LMICs often face capacity and technical challenges in the conduct of economic evaluation compared to those in HICs. This is evident in a review comparing the methodology of economic evaluation in HICs and LMICs, which reveals major differences in the methodology and indicates that there could be many limitations that hinder researchers conducting studies in LMICs using practices used in HICs . Since eFindings in many studies have further indicated that the issues on availability and quality of data used in the economic evaluation as well as relevant research standards are significant in LMICs , 6, 8. ASolving these technical shortfalls will promote the use of economic evaluation in policy decision-making, but careful consideration should also be paid to non-technical issues. It should be noted that, although the likelihood of high quality and context-relevant economic evaluations being used is higher, these improvements cannot guarantee more and better use of the evidence. This can be viewed as the result of an outstanding example of a non-technical barrier, namely the lack of formal mechanisms to consider the evidence for decision-making. The availability of quality evidence will not be meaningful unless policy-makers acknowledge its existence and usefulness, and unless there is a capacity and supportive mechanism to translate it into policy. On the other hand, strong political buy-in will lead to a demand and financial support for quality economic evaluations and political support to develop the systems and infrastructure needed for the conduct, and eventually the use, of quality economic evaluation. These issues are overarching concerns that need to be tackled simultaneously with technical issues to achieve success in integrating economic evaluations into policy-making.With a broad range of issues to be solved, prioritisation is needed to identify the most important challenges. Although there have been attempts to identify these challenges, the majority of the research is disease-specific, country-specific or without a focus on LMICs –27. MoreFor the purpose of this study, issues were categorised into technical issues and context-specific issues. Technical issues are those that are directly linked to the feature, methodology and reporting of economic evaluation and can be solved through changes in the methods or methodological reporting specifications. It is worth noting that some technical issues are limitations that researchers face in the conduct of economic evaluation, while others are weaknesses in the studies produced due to inadequate research capacity. Therefore, technical issues can be sub-grouped into lack of data, an inappropriate use of data, lack of commonly accepted methods, and an inappropriate use of methods. On the other hand, context-specific issues are defined as non-methodological issues that are bound to the situation in the researchers’ context and cannot be solved with the adjustment or standardisation of methodology. At their foundation, context-specific issues centre around a lack of capacity and resources in evidence users, evidence generators and relevant supportive mechanisms in the context. While technical issues are focused on evidence generation and use, context-specific issues focus on the effective application and use of the studies produced. It is important to highlight that these issues are closely intertwined – one context-specific issue may affect another as well as context-specific issues affecting technical issues and vice versa.In an attempt to build upon real-world experience of those who have conducted the studies and have been hard-pressed with those challenges, economic evaluation practitioners in LMICs are the sources of information since they are in the best position to provide a perspective on the technical details that evidence-users may not be familiar with. A survey approach was adopted since this study aims to explore opinions that cannot be gathered through literature reviews. This study asks the economic evaluation practitioners to assess the technical and context-specific issues they have encountered in their career with the objective of selecting priority technical issues and context-specific issues as well as comparing which barrier has more impact on the conduct and use of economic evaluation evidence.The findings of this study will be an input to the International Decision Support Initiative (iDSI), through which this study is initiated, and potentially for the future research of other global donors seeking to provide solutions for these issues.This study was conducted as a survey using a web-based online questionnaire. The questionnaire requests the respondent to consider the list of technical and context-specific issues provided and then to rank the those that they considered most important in their contexts . The respondents could choose to propose important issues not yet in the list provided (a maximum of one issue for each category). Moreover, respondents could propose solutions that they consider relevant to the issues chosen. The questionnaire went through consultation with experts to ensure face validity and was piloted before the conduct of the online survey. This survey was conducted anonymously and did not collect sensitive information of the respondents nor did it affect the respondents physically or psychologically, and the data was not publicised at individual level. Therefore, ethical approval was not applicable nor sought.Potential issues which might affect the methodological quality of economic evaluations were identified from existing key studies that discuss challenges, barriers or flaws in the conduct and quality of economic evaluations –4, 11–31The issues identified from the review were summarised and categorised into either technical or context-specific issues. Triangulated with inputs from experts, lists of technical issues and context-specific issues were constructed. Details of issues included in the questionnaire can be found in Additional file The study population comprised researchers who had completed at least one economic evaluation project as the primary investigator or as a part of a team in LMICs, defined per World Data Bank classifications as of 2015. In addition to the main survey component, qualifier questions, whether the respondent has experience in conducting an economic evaluation in LMICs and whether the respondent gives consent for the use of their response for analysis and publication, were also included. If respondents chose ‘no’ for any of the qualifier questions, the survey ended without proceeding further.Potential respondents were contacted through research networks and individually. For the health technology assessment (HTA) networks, invitation to participate in the survey was sent to the secretariat of health economic and outcome research networks as well as various health technology assessment networks in different regions, who distributed the survey to their network members in the mailing list. The participating networks included the African Health Economics and Policy Association, HTA Network of the Americas and HTAsiaLink. Individuals who were contacted were the corresponding authors of economic evaluations conducted in LMICs in NHS EED. A search using the names of all LMICs returned 568 hits, of which 180 studies were conducted in LMICs; for these, the corresponding authors were contacted through the e-mail address provided.Since the number of technical issues identified was significantly larger than context-specific issues, respondents were asked to rank the three most important technical issues along with the most important context-specific issue. The solutions proposed that fell within the same concerns or areas were grouped together. The results of the ranked issues were then analysed as a whole and by WHO regions , consideThe top priority issues for technical and context-specific issues were analysed separately using a scoring system. For each response, the technical issue that was ranked first, second and third were assigned the score of 3, 2, and 1, respectively, while the context-specific issue that was picked got the score of 3. Thus, higher scores indicate a higher priority. The scores for each issue were summarised across responses and ordered by scores to derive the list of top priority issues. Where there were two or more issues that received the same score, the frequencies of the issues being ranked in the first, second, and third levels were considered.In total, there were 927 recruited respondents. Of these, 178 people responded to the invitation (19% response rate). However, only 110 passed the qualifier questions. The respondent characteristics can be found in Table For technical issues, the top five priority issues were the lack of essential local clinical data, poor reporting, insufficient data to conduct the analysis from the chosen perspective, lack of a standard practice that is relevant to LMICs, and the lack of a tool to derive quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). The score and frequencies for each issue are presented in Table Considering each WHO region separately, the lack of high-quality local clinical data was noted as the most important issue for South East Asia (SEA), Pan America (PAH), and Eastern Mediterranean (EMR) regions, and the second most important issue for the African region (AFR). In addition to this, insufficient data to conduct the study from the chosen perspective was also noted for almost all regions except for the Western Pacific region (WPR). Poor reporting was noted for SEA, EMR and WPR as the second, third, and most important issue, respectively. Lack of commonly accepted standards was noted as being very important for AFR and the European region (EUR), while the absence of relevant health-state preference data was ranked highly only for PAH and inappropriate choice of comparator was ranked highly only for EUR Fig. .Fig. 1PrThe context-specific issues that were considered important were economic evaluations not included in the decision-making process; limited local capacity to conduct the research; and lack of funding. For scores and frequencies, please see Table Considering each WHO region separately, exclusion of economic evaluation from the decision-making process was a priority issue for all settings, particularly in SEA, AFR, EUR and EMR. It was the second most important issue in WPR and the third in PAH. The lack of funding for research was considered high priority in most regions except EMR. It was considered the third most important issue in SEA, AFR, EUR and WPR, and the most important issue in PAH. The third most common issue was the limited capacity, which was an issue in AFR, PAH, EMR and WPR. Finally, misunderstandings and weaknesses in communication between researchers and relevant stakeholders was cited as another important challenge.Sixty-six percent of respondents reported context-specific issues as more of an impediment to economic evaluation compared to technical issues (34%) Fig. .Fig. 2Prn = 19); construction of a database for information essential for the conduct of economic evaluation (n = 7); and capacity-building (n = 7). The majority of respondents did not propose solutions.Respondents’ proposed solutions for technical issues are shown in Table Across all settings, the top priority technical issues were the lack of quality local clinical data, poor reporting, insufficient data to conduct the analysis from the chosen perspective, i.e. the lack of cost data, lack of commonly accepted standards for economic evaluation, and lack of local health state preference data for estimating QALYs and DALYs, respectively.The fact that the lack of quality local clinical data ranked as high priority in the survey is not surprising. Clinical data comprises two main components, namely treatment effect, i.e. efficacy and effectiveness, and baseline risk. It is likely that data on both components are missing in LMICs. The gold standard for deriving treatment effect is randomised controlled trials (RCTs), of which the conduct is capacity, time and resource intensive such that many LMICs cannot afford to conduct them. Although data might be available through other types of research, e.g. observational study, researchers may find the quality of data derived as inadequate. Since treatment effect is transferable  across dTo overcome the lack of quality local clinical data, economic evaluation practitioners demand easy-to-apply research standards that are not resource-intensive and the construction of a database, preferably at national level, for baseline risk data. With resource constraints in LMICs, the gold standard study design in HICs might not be applicable. Research methods for clinical trials and data collection that are applicable globally (or specific to LMICs) are therefore warranted to overcome the issue in deriving treatment effects. For example, instead of traditional RCTs, a pragmatic trial design that observes treatment effect of the intervention of interest in its routine clinical settings has a good potential as a solution to the measurement of treatment effect in LMICs. In addition, other types of implementation research  of whichThe lack of sufficient cost data for the chosen perspective, which is the third priority issue, is also prominent since this information is highly context specific. With the lack of cost data, researchers have to either retrieve cost data through a review of other existing related studies, if available, or collect primary data . The useInformation on health state preference data is, on the other hand, more difficult to derive, especially without existing local tools such as a tariff for converting the EQ-5D questionnaire result into utility scores. The second-best approach is to employ the information available in other jurisdictions of which the determinants of quality of life are comparable to the jurisdiction of interest. However, a LMIC is likely to be comparable to another LMIC, and most of LMICs do not have this information even for the use in their respective country. To overcome this, the survey respondent pointed out that there is a need to consider the possibility and the approach on deriving a dataset at a regional or sub-regional level. Another solution could be to develop an approach to effectively translate health state preference data from one context to another by taking into account the social, economic and health system context.The second priority issue, poor reporting, is a weakness found in many economic evaluation studies in LMICs, and is closely linked to the fourth priority issue, which is the lack of commonly accepted standards for economic evaluation. Not only does poor reporting hamper the usability of the study since evidence-users cannot determine whether the studies are context relevant or comparable with other studies, it also prevents replication and reproduction, which are the basis for further capacity-building in related settings. Commonly accepted standards in reporting should be made available in the local context to improve this issue.The fact that the lack of locally accepted standards was ranked fourth despite the availability of several standard guidelines and reference cases for LMICs may imply that the standards available are not perceived as relevant to the context, researchers are not well-informed of the standards’ existence, or there simply has never been a discussion to reach a consensus among researchers and policy-makers in the given contexts. As a result, researchers individually choose from a broad range of guidelines available in international for a, decide which guidelines to apply to their studies or probably do not refer to any at all. This leads to variation in the methodology and quality of studies. Therefore, reconsideration of the relevance and applicability of existing international methodological and reporting standards in LMIC contexts is necessary. If they are deemed applicable, the reason why researchers do not recognise their usability or cannot reach a consensus on a common standard should be explored and addressed. For example, the dissemination of the standards and guidelines existence and having a consensus on the standard for both reporting and methodology should be promoted. For example, there is a methodological reference case for economic evaluation in LMICs recently developed by the iDSI , the appOn the other hand, these technical concerns are closely linked to the lack of research capacity, budget and supportive infrastructure, which are prioritised among the context-specific issues. With a limited number of trained personnel and insufficient budget, it is difficult to yield quality treatment effects from locally conducted clinical trials or to generate reliable baseline, cost and health-related preference datasets from local data collection. Therefore, local researchers should be incentivised and encouraged to conduct local studies at a high level of quality through, for example, capacity-building activities with assistance from international partners and forums.n = 7). Instead, the focus of respondents was on the development of commonly accepted standards for economic evaluation (n = 19). This may partly be because most of the respondents did not specify the type of the standard proposed or whether a methodological or reporting standard is needed, and therefore it is difficult to distinguish between whether the proposal aims to solve the second priority issue (poor reporting) or the fourth priority issue (lack of commonly accepted standard). Moreover, respondents may anticipate that the guidelines will specify how to tackle their other technical issues of concern. However, if there is no methodological research performed, the specifications available in the guidelines alone may not be able to solve the issues in the long term. Another most frequent proposed solution was capacity-building to increase the number of researchers and the quality of their work (n = 4). It is noteworthy that the proposed solutions include various non-technical measures. This highlights the close link between technical and context-specific issues.Interestingly, although the lack of quality local clinical data was the first priority issue, only a minor group of respondents proposed solutions related to clinical information , lack of context-relevant standards for economic evaluation, and lack of local health-related preference data, respectively. The most important context-specific challenge was that economic evaluation is not included in the decision-making process. Context-specific issues are also considered to be a bigger challenge to the conduct of quality economic evaluations as compared to purely technical or methodological issues.www.gear4health.com. It will showcase the results of this research as well as providing quick consultation to economic practitioners who encounter methodological difficulties in the conduct of studies.The results will be inputted into the iDSI programme for future work on methodological development in 2016–2019, with the aim to promote a generation of robust evidence for health resource allocation to policy-makers. Based on findings from this study, an online database is being created as a comprehensive web-based knowledge-sharing platform that addresses methodological issues regarding policy-relevant research. An online resource, entitled ‘Guide to health Economic Analysis and Research’ can be accessed at the Additional file 1:Issues included in the questionnaire. (DOCX 14 kb)Additional file 2:Further information of respondents. (DOCX 16 kb)