Full recovery after gynecological surgery takes much longer than expected regardless of surgical technique or the level of invasiveness. After discharge, detailed convalescence recommendations are not provided to patients typically, and postoperative care is fragmented, poorly coordinated, and given only on demand. For patients, this contributes to irrational beliefs and avoidance of resumption of activities and can result in a prolonged sick leave.To develop an eHealth intervention that empowers gynecological patients during the perioperative period to obtain timely return to work (RTW) and prevent work disability.The intervention mapping (IM) protocol was used to develop the eHealth intervention. A literature search about behavioral and environmental conditions of prolonged sick leave and delayed RTW in patients was performed. Patients’ needs, attitudes, and beliefs regarding postoperative recovery and resumption of work were identified through focus group discussions. Additionally, a literature search was performed to obtain determinants, methods, and strategies for the development of a suitable interactive eHealth intervention to empower patients to return to normal activities after gynecological surgery, including work. Finally, the eHealth intervention was evaluated by focus group participants, medical doctors, and eHealth specialists through questionnaires.Twenty-one patients participated in the focus group discussions. Sufficient, uniform, and tailored information regarding surgical procedures, complications, and resumption of activities and work were considered most essential. Knowing who to contact in case of mental or physical complaints, and counseling and tools for work reintegration were also considered important. Finally, opportunities to exchange experiences with other patients were a major issue. Considering the determinants of the Attitude–Social influence–self-Efficacy (ASE) model, various strategies based on a combination of theory and evidence were used, resulting in an eHealth intervention with different interactive functionalities including tailored convalescence recommendations and a video to communicate the most common pitfalls during the perioperative period to patients and employers. Fifteen patients in the focus groups, 11 physicians, and 3 eHealth specialists suggested points for improvement to optimize the usability of the eHealth intervention and judged it an approachable, appropriate, and attractive eHealth intervention to empower gynecological patients.The IM protocol was a useful method to develop an eHealth intervention based on both theory and evidence. All patients and stakeholders judged the eHealth intervention to be a promising tool to empower gynecological patients during the perioperative period and to help them to return to normal activities and work. Following gynecological surgery, full recovery (including returning to work) takes much longer than expected regardless of surgical technique or the level of invasiveness -3. In twTo reduce health care costs, there is an increasing trend to limit the duration of in-hospital care and to transfer postoperative care to outpatient and primary care -13. HoweBecause a significant part of the recovery and return to work (RTW) problems of patients seem to be caused by counseling and communication deficiencies, the starting point of this study was to identify these specific problems. Many interventions aiming to improve communication with and counseling of patients have focused only on health care professionals ,20. HoweTherefore, the objective of this study was to develop a feasible and generally accepted eHealth intervention that empowers gynecological patients during the perioperative period about returning to normal activities and work, to obtain timely RTW, and prevent work disability. To develop this intervention, we used the intervention mapping (IM) protocol ,42, whicIntervention mapping was used to tailor the eHealth intervention to patients’ needs and wishes, taking into account the clinical evidence of the main determinants that influence patients’ behavior to reach timely RTW. The project group consisted of 1 research physician, 2 gynecologists, and 2 occupational physicians. Although it is not a theoretical or conceptual framework, IM is a systematic description of a logical planning process involving 6 steps: (1) performing a needs assessment; (2) defining program objectives; (3) selection of theory-based methods and practical strategies; (4) design of the intervention program; (5) development of a plan for adoption and implementation; and (6) design of an evaluation plan . The iteIn needs assessment, the discrepancy between the current and the desired situation in a given group of people is studied. The needs assessment was structured by the Precede-Proceed model , which analyzes and correlates quality of life, health, behavior, and environmental factors in a certain population . The curTo clarify and find possible explanations for prolonged sick leave, a literature search in PubMed regarding behavioral and environmental conditions of prolonged sick leave and delayed RTW in the target group was performed.The focus group technique was considered the most suitable supplement to the literature search for identification of patient’s needs, attitudes, and beliefs regarding postoperative recovery and resumption of work. In addition to supplementing the results of the literature search, it was assumed that focus group discussions would align the results to the Dutch context and give more insight into specific content requirements of the prospective eHealth intervention that could be used during the development process. The participatory technique of focus group discussions is widely used and scientifically accepted to gain insight into public views and needs through group interaction ,54.Participants for the focus group discussions were recruited from the patient files of the VU University Medical Center, an academic hospital in the Netherlands. To mirror the intended target group, inclusion criteria for participation in the focus group discussions were age 18-65, a history of a laparoscopic adnexal surgery and/or hysterectomy on benign indication in 2008, and a job (paid or unpaid) of at least 8 hours per week. To create homogeneity within the focus groups but heterogeneity among the groups, the patients were recruited by means of purpose sampling into 3 groups: fast RTW, intermediate RTW, and delayed RTW. All of the participants had already returned to work after surgery (range 1-36 weeks).The aim of the focus group discussions was to identify patients’ needs regarding perioperative care and counseling in resuming normal and work activities. In addition, patients were specifically asked for the important requirements of a useful eHealth intervention. The identification of patients’ needs and requirements occurred in 3 different steps:1. Identifying and prioritizing patients’ perceived shortcomings in and difficulties with received perioperative care and counseling in resumption of normal and work activities.2. Inventory of possible solutions and improvements to overcome these shortcomings and difficulties, starting with the highest prioritized bottlenecks.3. Brainstorming about favorable content, requirements, and specific tools that should be incorporated into an eHealth intervention that aims to empower patients during the perioperative period and resumption of work activities.The focus group discussions were all recorded and transferred into verbatim transcripts that were analyzed by open coding using the ATLAS.ti software .A detailed process evaluation of the focus group discussions will be published in a separate paper . The study design and procedures of the focus group discussions were approved by the Medical Ethics Committee of the VU University Medical Center . Participants signed a privacy agreement to declare voluntary participation, to give permission for processing the information for the development of an intervention , and to exclude transmittal of information to others.As a starting point for the development of the intervention, the products of this first step were the main behavioral and environmental conditions of the chosen target group contributing to prolonged sick leave.The purpose of this step was to transform the identified behaviors and environmental conditions causing prolonged sick leave into behaviors and conditions that prevent a prolonged sick leave. To achieve this, performance objectives were formulated. Performance objectives describe in detail patients’ behavioral and environmental outcomes that are necessary for patients to reach the formulated behavior objective of “timely RTW.”To select a suitable theoretical framework to reach the performance objectives, a literature search regarding main determinants of recovery and RTW was performed in PubMed. To elucidate, a suitable theoretical framework provides appropriate determinants that could be influenced to reach the behavior objective. Based on this framework, the performance objectives of the target group were elaborated into matrices with change objectives, explaining how patients and their environment will change as a result of the eHealth intervention to reach the behavior objective.In this step, theoretical methods and practical strategies to address the change objectives were searched for and applied. Research has shown that the effectiveness of interventions to change behavior can be increased by the use of theory-based methods . A theorDuring this step, information obtained in previous steps was translated into specific tailored tools and information to empower gynecological patients by the eHealth intervention. Furthermore, to obtain evidence-based information and instruments necessary to fulfill patients’ needs, additional research was performed.To verify if the eHealth intervention matched with the main target group and fitted the expectations of gynecologists, family physicians, and occupational physicians, the first concept version was evaluated by focus group participants (n = 21), physicians (n = 22), eHealth specialists (n = 3), and a representative of a patient organization (n = 1) through questionnaires. The eHealth intervention was scored on 8 main areas used to describe how the intervention functions, empowers, and can be modified to provide the best behavior change to obtain timely RTW and prevent work disability. The 8 areas included: appearance, behavior prescriptions, burdens of using the website, content, delivery, message, participation, and assessment and tailoring. Ritterband et al  describeThe focus of Step 5 is adoption of the intervention by the patients and relevant stakeholders, and the development of an implementation plan. With the input of patients and stakeholders during previous steps, the researchers identified facilitating factors and barriers regarding adoption and implementation of the eHealth intervention. With this information, an implementation plan to enable an extensive evaluation of the intervention was developed and an appropriate linkage system for future implementation was composed.During Step 6, the main objective of this study  was used to compose an evaluation plan. Although the eHealth intervention was based on both theory and evidence and was developed in collaboration with the main target group and relevant stakeholders, its adoption, barriers for usage, and implementation possibilities still had to be evaluated in daily practice. In addition, the effectiveness of this eHealth intervention regarding a timely RTW to prevent work disability had to be investigated. Therefore, the project group approached 7 gynecology practices  about participation in the evaluation of this intervention through implementation of the eHealth intervention as a supplement to the standard perioperative care given at their hospital. In addition, the project group formulated inclusion and exclusion criteria for patients to participate in the study and developed appropriate outcome measures to evaluate the intervention’s effectiveness, adoption, usage, and implementation. Furthermore, a logistic plan to recruit patients and involve participating health care providers was developed.The literature search revealed that most women extend their sick leave beyond the recommended period on their own initiative . Patient.Out of 105 invited patients, 38 met our inclusion criteria and were willing to participate in the focus group discussions. On the basis of availability on the selected dates for the focus group discussions, 31 patients were assigned to 3 focus groups. Of these patients, 21 were present at the meetings and participated in the focus group discussions (7 patients per meeting). A process evaluation of the focus group discussions will be published in detail elsewhere Starting with the first aim of the focus group discussions, the most important reported shortcomings and difficulties of currently provided perioperative gynecological and reintegration care were (in random order):1. Insufficient or no information about the surgical procedure itself, the logistical process in the hospital from admission to discharge, detailed resumption of work activities after the surgical procedure, and the possible consequences of the surgery .2. Inconsistency of convalescence recommendations given by gynecologists, family physicians, and occupational physicians.3. Lack of written instructions on resumption of work activities, tailored to individual conditions and work, and consequently insufficient information and instructions given to relatives.4. Insecurity with respect to physical or mental postoperative symptoms, complications, or delayed recovery. What to do and whom to contact?5. Poor communication among gynecologists, family physicians, and occupational physicians resulting in inadequate transfer of information about the procedure and one another’s treatments.6. Limited or inadequate guidance by occupational physicians because of a lack of knowledge about different types of surgery and corresponding recovery times. Patients reported experiences of occupational physicians forcing the patient to RTW too early or slowing down the RTW process.7. Difficulties with work reintegration because of insufficient involvement and understanding of the employee/employer during the perioperative and reintegration period.8. Inability of patients to discuss the perioperative period and reintegration process at work (with employer and colleagues).9. Lack of a reintegration plan before the surgery.10. Few opportunities to contact other patients to exchange experiences.In general, patients mentioned that when they were unsatisfied with the information or counseling given by their doctors and nurses, they asked family and friends who had undergone surgery about their experiences. However, this led to unrealistic expectations because of different types of surgical procedures and techniques, and the fact that recovery is affected by individual conditions and circumstances.In the second part of the focus group discussions, the patients brought up many possible solutions and improvements to overcome the mentioned shortcomings and difficulties that were processed into performance objectives during Step 2.Requirements, content, and specific tools that should be incorporated into an eHealth intervention to improve empowerment during the perioperative period may be summarized as follows:1. Reliable detailed and personalized information about mentioned shortcomings and difficulties in the information supply. Pictures and videos were considered an accessible supplement to transfer this information.2. Tools for communication with other patients, employers, gynecologists, occupational physicians, and family physicians.3. Functionalities to develop a personalized reintegration plan.With the results of the literature search and focus group discussions, the project group concluded that the main determinants of patients’ behavior regarding prolonged sick leave are: (1) inadequate knowledge of important information about the surgery, recovery, and RTW; (2) tendency to extend their sick leave beyond the recommended period; (3) insecurity about postoperative symptoms, complications, and delayed recovery without knowing where to receive appropriate help; (4) lack of skills to compose a work-reintegration plan and to identify possible barriers for RTW; and (5) lack of knowledge about the opportunity to develop and discuss a work reintegration plan before surgery with the employer and an occupational physician. In addition, important environmental conditions of patients’ behavior are considered to be: (1) inconsistency and lack of clarity in convalescence recommendations given by gynecologists, family physicians, and occupational physicians; (2) lack of communication among gynecologists, family physicians, and occupational physicians; (3) lack of clarity from health care providers about who to contact in case of postoperative complaints; (4) lack of initiative of the employer and/or occupational physician to develop and discuss a work-reintegration plan before surgery with the employee; and (5) lack of involvement of the employer and occupational physician during the perioperative and reintegration period.In total, 12 performance objectives derived from the main behavior objective were formulated see .In addition to performance objectives for patients, there were also performance objectives formulated for gynecologists, family physicians, occupational physicians, and employers . NeverthThe literature search showed that the main determinants of recovery and return to normal activities and work  are the patients’ attitude, social influence, and self-efficacy -65. In aNumerous practical methods and suitable strategies to affect all formulated determinants were identified and used for the development of tools and materials of the eHealth intervention. With the knowledge obtained in the previous steps of the IM protocol, the project group convened at several meetings to invent various appropriate tools for the eHealth intervention. A website producer specializing in eHealth interventions and a screenwriter were consulted at some of the meetings. In addition, an experienced gynecologist outside the project team was consulted to judge the medical content of one of the tools.http://www.ikherstel.nl/www.ikherstel.nl,” which means, “I am recovering”  Web application framework with a capable built-in content management system (CMS). The Internet address of the eHealth intervention is “overing” -10 73]..http://wWhen a patient logs onto the eHealth intervention, she will be immediately directed to the Action List. This list consists of different tools developed to target specific determinants, aimed at encouraging return to work activities, coaching patients in case of uncertainties, answering possible questions, prevention of common pitfalls, and improving communication among the patient, care providers, and the employer. An algorithm based on the date of surgery determines the priority in which the different actions should be performed to improve the recovery process. Tools of the action list are:By using this tool, the patient is able to select activities that are required to fulfill her work activities and at what level . Consequently, on the basis of the operation date and how the surgery went (input of gynecologist), the eHealth intervention provides the patient with tailored advice about when these activities are thought to be medically safe to resume. The recommendations are based on the results of a modified Delphi study, in which an expert panel of gynecologists, family physicians, and occupational physicians developed detailed multidisciplinary convalescence recommendations for resumption of work activities after hysterectomy and/or laparoscopic adnexal surgery . MoreoveThis functionality guides the patient to compose a detailed tailored plan about the gradual resumption of various daily activities . Recommendations are based on the results of the modified Delphi study . This toWhen a complication has occurred, the eHealth intervention carefully determines through a survey which symptoms require additional consultation with care providers or adaptation of the convalescence recommendations. The project group developed the survey and determined which symptoms are severe complications. If the tool is not able to provide recommendations under these circumstances, an email will be sent to inform the gynecologist of the condition of the patient in order to evaluate her symptoms and possible consequences.Because of the influence of modeling behavior on attitude, a video was chosen as the most appropriate medium to deliver an informative message to patients and relevant stakeholders about common pitfalls during the perioperative and reintegration period. The video aims to prevent these problems by stimulating patients and employers to discuss potential problems and to develop a reintegration plan to facilitate and improve reintegration. The experiences of the patients in the focus group discussions were converted into common pitfalls for patients, employers, and health care providers during this period, and a screenwriter processed them into a script for a video showing two cases of a good and bad interaction between a patient and her environment. The screenwriter worked together closely with 3 gynecological patients to make the video geared to the patients’ perception of the perioperative and reintegration period.Based on the experiences of the patients in the focus groups, the researchers formulated main recommendations for patients and employers regarding a successful reintegration.Answers to questions brought up during the focus group discussions and those found as main topics in patients’ brochures or in discussions of gynecological patients on the Internet were formulated by the researchers  and put into patient leaflets. An experienced gynecologist outside the project team judged all questions and answers on reliability and clarity, and suggested possible adjustments.Based on the literature, an explanation of the most frequently used medical terms was provided by the researchers.The researchers searched the Internet for the most relevant websites for gynecological patients and made a selection based on relevance, reliability, and clearness of the information.Multidisciplinary guidelines with well-defined convalescence recommendations after uncomplicated hysterectomy  and laparoscopic adnexal surgery on benign indication are provided. Recommendations are based on a modified Delphi study.Classic examples of indications for surgery, perioperative course, and recovery after uncomplicated hysterectomy or laparoscopic surgery were developed based on literature and clinical experience of the project group.Elucidation of different types of hysterectomy and laparoscopic adnexal surgery concerning surgical technique, level of invasiveness, and medical consequences were formulated by the researchers.Test PhaseFifteen patients, 11 physicians , 3 eHealth specialists, and 1 representative of a patient organization completed the evaluation form regarding the demo version of the eHealth intervention. Appearance and behavior prescriptions were judged by most as pleasant, conveniently arranged, and helpful. With regard to burdens of using the eHealth intervention, almost all respondents judged the application navigation as clear and the intervention length as appropriate. However, a manual providing an overview of the different tools of the eHealth intervention was found desirable by only one of the respondents. Furthermore, two software incompatibility problems were reported. Concerning the content of the information, the way it was delivered, and the message (source and style), most of the respondents were satisfied and expected that it could empower patients, employers, and physicians. Remarks for improvement were related to supplying more detailed information about the surgery, possible psychological complications after the operation, less complicated sentences, and a more prominent place for the source of the information. Finally, participation of the patient in the treatment and the eHealth intervention’s ability to assess and tailor the recommendations to empower patients during the perioperative period and return to work activities were judged as helpful by most of the respondents. There were no suggestions for improvement of these features.The patients indicated that their input provided during the focus group discussions was recognizably integrated into the intervention. Additionally, almost all patients confirmed that they would recommend the eHealth intervention in the current form to a friend.As described previously, the respondents did not request major revisions of the eHealth intervention and only minor adjustments were proposed. Therefore, none of the original developed tools were removed from the eHealth intervention and no new functionalities were added. Following up on the suggested improvements, a manual with directions for use was added to the eHealth intervention, incompatibility problems with different kinds of software were solved, some information on the eHealth intervention was elaborated on and explained in simplified sentences, and the logo of the university hospital was added in a prominent place on the eHealth intervention. This resulted in the final eHealth intervention that was used to perform a randomized controlled trial (RCT) . ScreensIn this study, anticipation of adoption and implementation started with the involvement of patients (target group) in all stages of the intervention development and evaluation. Health care providers, occupational physicians, and eHealth specialists participated in the evaluation of the intervention during IM Step 4. In addition, a committee with representatives of the Dutch medical boards of gynecologists, occupational physicians, and family physicians, and a representative of an umbrella patient organization were involved during the development of all steps of the intervention and agreed to stay involved during the final implementation steps of this intervention. Through this committee, a linkage system was created by involving the future users and implementers of the intervention from the start of the intervention development process. Furthermore, an important target of this study was to develop an eHealth intervention that could be used by patients, doctors, and employers without any support to simplify implementation. Evaluation of self-reliant use by patients and important stakeholders was evaluated positively during the test phase of Step 4.Within the context of a RCT with the eHealth intervention (Step 6), the project group will facilitate its implementation and maintenance. In collaboration with the relevant care providers, the eHealth intervention will be offered as a supplement to standard perioperative care and will involve minimal additional time investment for the care providers. Agreements about usage of the contents of the eHealth intervention will be made with the gynecologists of participating hospitals and the family physicians and occupational physicians of participating patients. Therefore, the main purpose of this step was to create familiarity and support for the eHealth intervention and convalescence recommendations by all prospectively involved users. To reach these purposes for all of the different user groups, information letters will be distributed among patients and care providers. In addition, presentations with background information about the development of the eHealth intervention, its contents, and how to use it will be given to the gynecologists during general teaching meetings at their hospitals. Employers will become familiar with the intervention through invitation for participation by the patients . The eHealth intervention will be primarily used during the period of sick leave after surgery. Therefore, no agreement with the patients’ employers to use the eHealth intervention during work hours will be made.With the information gathered during the process evaluation (Step 6), in collaboration with the committee with representatives of the Dutch medical boards of gynecologists, occupational physicians, and family physicians, and the patient organization, a final implementation plan will be developed. In this plan, medical insurance companies and the Health Care Insurance Board (CVZ) will likely be involved for the final implementation of the eHealth intervention.The evaluation of the eHealth intervention will be performed by a RCT, during which the eHealth intervention will be compared with usual given care at 7 participating medical centers . A powerPatients willing to participate and who meet the inclusion criteria will be randomized to the intervention or usual care group (control group). Main outcome measures of the RCT are the effectiveness of the eHealth intervention compared to usual care with respect to RTW, general recovery, quality of life, pain intensity, and complications. Part of the RCT will be a process evaluation of the patients, their care providers, and employers in the intervention group. Main outcome measures of the process evaluation are the extent to which the eHealth intervention and convalescence recommendations are used and followed up (compliance); appreciation of the different tools of the eHealth intervention and advice; perceived effectiveness, usage, and implementation barriers; and suggestions for improvement.The outcome measures will be obtained using questionnaires administered at baseline and at 2, 6, 12, and 26 weeks after surgery. Gynecologists will complete questionnaires 1 day after surgery for each patient and at the end of the study. Employers will be asked to evaluate the eHealth intervention 8 weeks after their employee’s surgery.The study design and procedures of the RCT study were approved by the Medical Ethics Committee of the VU University Medical Center .In this study, the IM protocol turned out to be a useful method to develop and tailor an eHealth intervention aimed at the empowerment of gynecological patients during the perioperative period including return to normal activities and work. By using available literature and focus group discussions, it became increasingly clear that to obtain timely RTW and prevent work disability, the intervention should target both behaviors of patients as well as environmental determinants. Performance objectives for obtaining timely RTW and prevention of work disability were formulated and matrices with change objectives, explaining how patients and their environment have to change as a result of the eHealth intervention to reach the performance objectives, were developed. Finally, based on the ASE model ,70, theo. In addition to information supply, which is the primary aim of most websites, this eHealth intervention distinguishes itself by monitoring the recovery process, giving tailor-made advice based on patients’ workloads, and informing patients when additional consultation of care providers is needed. By linking patients with their gynecologists, convalescence recommendations can be adapted and insecurities regarding consequences of the complications can be solved. Connecting patients and employers facilitates a dialogue and the joint effort to compose a reintegration plan. Furthermore, this eHealth intervention is developed to be used without support and with minimal effort of care providers. Therefore, use of the intervention costs little and implementation is expected to be relatively easy. Moreover, like most eHealth interventions, an important strength is the possibility to use it at the time, place, and pace that fits the patient, care provider, and employer . Furthermore, these patients already underwent the surgery, whereas the intervention is designed to be used both before and after surgery. It has to be determined whether this intervention is applicable to the entire target population and whether the intervention fits the needs of patients both before and after surgery. Due to practical reasons, not all stakeholders  were involved in the needs assessment and development process of this eHealth intervention. As a consequence, the intervention might be less supported by these groups. However, results of prior focus group discussions with supervisors and care providers in another comparable IM study  were useTo our knowledge, this is the first study that tailors an eHealth intervention through the IM protocol to empower gynecological patients during the perioperative period to obtain timely RTW and prevent work disability. Therefore, comparison with other studies is limited. However, previous research showed several developmental and interventional characteristics. For example, it was demonstrated that IM is a successful method to tailor eHealth ,76 as weAlthough comparable studies are lacking, the approach followed in this study—involving relevant stakeholders in the development of an eHealth intervention—is in line with an observed trend of multi-stakeholder involvement in health care in general ,80. GainThis study shows that the IM protocol can successfully be used for the development and tailoring of an eHealth intervention for gynecological patients. The protocol led to a systematic development of the intervention, it made sure that collaboration with the main target group was realized, and both theory and evidence was used to tailor the intervention.Furthermore, through the detailed convalescence recommendations provided by the eHealth intervention, patients will be better informed about when it is thought to be medically safe to resume daily and work activities after gynecological surgery and it will give them the possibility to arrange workplace adaptations if necessary . ProspecThis eHealth intervention is developed for patients who underwent a hysterectomy or laparoscopic adnexal surgery. However, the strategy used to develop the intervention and the final result may also be used as a blueprint for other kinds of surgical procedures.The development of an eHealth intervention according to the IM protocol to obtain timely RTW and prevent work disability by empowerment and improving communication after gynecological surgery resulted in an intervention based on both theory and evidence and involvement of patients and most stakeholders. This eHealth intervention is well accepted by patients and stakeholders and is considered to be a promising tool to obtain timely RTW and prevent work disability after gynecological surgery. Its effectiveness needs to be proven in a RCT .


Fish spawning was valued at approximately US$ 363,815 year−1, livestock pastures at US$ 4.24 million, domestic water use at US$ 34 million year−1, and the gross annual value added by wetlands to milk production at US$ 1.22 million. Flood control was valued at approximately US$ 1,702,934,880 hectare−1 year−1 and water regulation and recharge at US$ 7,056,360 hectare−1 year−1. Through provision of grass for mulching, wetlands were estimated to contribute to US$ 8.65 million annually. The annual contribution of non-use values was estimated in the range of US$ 7.1 million for water recharge and regulation and to US$ 1.7 billion for flood control. Thus, resource investment for wetlands conservation is economically justified to create incentives for continued benefits.Wetlands provide food and non-food products that contribute to income and food security in Uganda. This study determined the economic value of wetland resources and their contribution to food security in the three agroecological zones of Uganda. The values of wetland resources were estimated using primary and secondary data. Market price, Productivity, and Contingent valuation methods were used to estimate the value of wetland resources. The per capita value of fish was approximately US$ 0.49 person Wetlands provide important natural resources, upon which the rural economy in Eastern Africa depends . They prIn Uganda, wetlands provide a wide range of tangible and nontangible benefits to various communities , 5. The enabling direct availability of products such as fish, crops grown along the wetland edges, wild fruits and vegetables, and game meat; providing cash income from sale of raw materials and processed products such as crafts, sand, clay, bricks, and ecotourism; which are sold for cash that is used for purchasing/accessing food; andcontributing to increased crop and livestock yields as a result of improved productivity from use of water, silt, and through climate moderation.Over 80% of the people living adjacent to wetland areas in Uganda directly use wetland resources for their household food security needs . BesidesEach of the individual benefits or attributes of wetlands contributes to the household's output, welfare, or utility, thus making wetlands a recognised enabling sector to the economy of Uganda . HoweverThis study was undertaken to determine the economic values of wetland resources, to quantify wetland economic benefits and costs, to and determine the economic value of nonmarketed wetland goods and services in Uganda. The study highlights economic benefits in monetary terms for selected key wetland goods and services and demonstrates to wetland users, managers, and policy makers how valuable wetland resources are, as a basis for guiding decision making on wetland conservation.The study was conducted in eight wetland systems located in areas that represent three of the five agroecological zones of Uganda. The wetlands are Nangabo, Mabamba, and Mende in Wakiso district representing the Lake Victoria crescent agroecological zone; Rucece in Mbarara and Lake Nakivale in Isingiro representing Southwestern farmlands; Limoto and Gogonyo in Pallisa and Kibuku Districts representing the Kyoga plains agroecological zone . These wConsultative meetings were held with environment and wetlands managers of the selected wetland areas to seek their opinions on the most important wetland resources to the communities, challenges, and opportunities for their sound management. Following discussion and advice from wetland managers, important wetland resources for valuation were selected based on (i) whether a resource met the basic needs of the communities from the study area; (ii) number of users harvesting the resource; (iii) whether the resource represented a range of uses to the different users; and (iv) the likelihood of obtaining sufficient quality data on the resource to enable computation of economic values. The other factor considered was whether harvesting, sale or use of the selected resource were particularly important or widespread or where it generated significant local benefits. A summary of the wetland resources selected for valuation is presented in Opportunistic sampling was made for respondents in areas where different wetland resources were harvested, processed, or marketed. Data were collected through interviewing at least 10 respondents for different resources on the value they attached to the wetland goods and services using structured questionnaire interviews. Focus group discussions were also conducted with different wetland resources users to generate information on the uses and associated costs of the resource under valuation. We also reviewed information from district inventory reports on the crop and animal production, population, prices of the associated goods, and wetland area coverage. Value transfers from previous studies , 13 wereData on economic value of wetlands for crop farming in 2012 were collected by estimating the total farming area in each of the agroecological zone and the area of wetlands under crop production from the district inventory reports. We also collected data on the yields and the number of harvests per year for the key crops grown in the wetlands. The key crops considered were maize in the southwestern farmlands agroecological zone, vegetables in the Lake Victoria crescent, and rice in the Kyoga plains agroecological zone. To estimate the value of wetlands for fish breeding, data on the total spawning area were collected from the wetland coverage in the three agroecological zones following spatial data from the National Wetlands Information System. The data were used to derive the estimated value of wetlands for fish breeding per hectare per year. We also collected data on the percentage of the total number of livestock depending on wetlands and the average daily pasture consumption per animal to estimate the economic value of wetlands to food security through livestock production. Data on the total livestock numbers in the three agroecological zones were obtained from the Ministry of Agriculture, Animal Industry and Fisheries (MAAIF) reports. We only took a conservative estimate of the value of wetland pastures only for cattle, leaving out other types of livestock such as pigs, goats, and sheep. The cost of pastures was inferred from the imputed value of the cost of alternative leafy feeds that would be bought, if wetland pastures were not available, estimated at a cost of US$ 0.2 per animal per day following Karanja et al. . Data weThe value of grass mulch was estimated using data on the total land area under banana production. Only two districts of Isingiro and Mbarara in the southwestern farmlands agroecological zone were considered in estimation of the economic value of grass mulch in bananas because this is only where the resource was used. Reports from the focus group discussions indicated that in the two districts, nearly every household was engaged in banana growing. It was estimated that on average each family in the two districts owned at least one hectare of bananas. This was supplemented by data on the total acreage of bananas that were mulched with wetland grass, estimated at 50% of banana plantations, and the number of bundles of mulch applied in the banana plantation per hectare per year.The economic value of papyrus to food security through food accessibility was computed from data collected on the returns to papyrus resource users by either selling raw papyrus materials or after value addition through mat making. Estimates of the total wetland area in the district under papyrus and the productivity per hectare in head loads were made to generate the total productivity per annum. For the craft products from papyrus, data were collected on price of the raw material and of the products, labour costs for harvesting the product, equipment, additives, storage, licenses, transport, hired, and personal time to derive the net returns.The economic value of wetlands for fresh water storage and supply was estimated by use of data collected on the number of household dependents on wetlands for water supply and annual water use for all the households. This was extrapolated to the midyear total human population projections of 2012. About 80% of the populations depend on wetlands for domestic water supply as used by Karanja et al.  and WMD Data on the management costs for conserving wetlands to reflect willingness to conserve (WTC), as reflected in the economic costs for wetland management and conservation, was generated from the existing costs incurred by districts in the wetland management sector. These included costs for staff salaries and allowances, equipment, and their maintenance and monitoring compliance to wetland conservation. Data on estimated income and other benefits foregone from land use, as well as investment and development opportunities precluded or diminished, to maintain wetlands were used to compute opportunity costs. National data from the Ministry of Water and Environment were used to compute the management and operation costs of conservation. In the three agroecological zones, wetland management and conservation were supported by remittances from the central government, Ministry of Water and Environment, and the locally generated revenue from the respective districts.In terms of spawning habitats for fish, wetlands in Uganda contributed an estimated gross value of US$ 1,091,444 per year . WetlandThe economic value of wetlands to crop farming was estimated to be in the range of US$ 417,536 to 25.09 million . In all The gross annual contribution of the wetlands to food security, through provision of grass for mulching, was estimated at US$ 8.65 million per annum . WetlandWetlands provided livestock pastures worth US$ 4.24 million . Focus gThe total economic value of water from wetland areas for livestock consumption was estimated to be worth US$ 34 million per year . During The gross annual value of wetlands to milk production was estimated at US$ 1.22 million . About 1The gross annual value of domestic water supply was estimated to be worth US$ 13.9 million . WetlandThe estimated economic values of wetland nonuse values are presented in The wetland management costs for the financial year 2011/2012 totaled to US$ 48,668 per year . ManagemThe opportunity cost was estimated in the range of US$ 1.40 to 6.61 million . The valWetlands in the three agroecological zones provided an average net contribution of about US$ 10,491 per hectare per year . This toProtopterus, Clarias, Schilbe, Labeo, Alestes spp., and Oreochromis niloticus [Clarias spp., mudfish, Protopterus spp., and various Haplochromis spp. In addition to serving as breeding grounds, the contribution of wetlands through provision of fish is most significant for species that have respiratory systems that are adapted to seasonal flooding and can withstand reduced water levels in wetland areas such as Clarias spp. [Results show that wetlands were valued as major breeding grounds for fish. Wetlands are important for the reproduction of certain fish species like iloticus . They arias spp. . Howeverias spp. .Clarias sp. (catfish) are commonly harvested from wetland areas in the Kyoga plains and Southwestern farmlands agroecological zone, and provide a cheap source of animal protein and are one of the main commercial activities during the dry season when water levels of wetlands reduce, providing easy harvesting. The findings from this study indicate that the contribution of wetlands to food security through provision of fish is significant, and this is supported by other findings that in Uganda fish provides up to 50% of all animal protein [Results from this study further indicate the value of wetlands through fish catch as food and source of proteins and employment to the fishing communities. During the focus group discussions, it was noted that  protein . The res protein , in whic protein . Loss ofThe economic value of wetlands through crop production was enormous. The economic contribution of wetlands through crop farming is locally and globally recognised as indicated by one of the crops valued during this study (paddy rice), regarded as a staple diet of more than half the world's population, Uganda inclusive . SuccessDuring focus group discussions, the farmers noted that over time the fertility their soils has declined, which has necessitated the use of inorganic fertilizers and pesticides, which represent a potential threat to the wetland ecosystems. These agrochemicals alter the ecological balance of wetlands and can indirectly eliminate important faunas that play a role in wetland functions and services. As noted by Dixon and Wood  and FAO Typha spp. and Cyperus spp. [Results further show that wetlands contribute significantly to crop farming through grass mulch. Mulching helps retain the moisture, controls soil erosion, and acts as a source of organic manure in the banana plantations. Wetlands are the major remaining sources of mulch, comprising mainly of sedges including rus spp. . During Wetlands were also valued for provision of fodder, especially during the drought periods, when alternative pastures were not readily available. Pastures from wetlands not only provided fodder but also enhanced milk production, thus contributing to food security. The importance of wetlands is also more significant due to the fact that alternative livestock feed is expensive and may not be easily affordable by most farmers in Uganda. This is more significant with the current challenges of climate change and unpredicted weather conditions . HoweverWetlands were valued as the most reliable water sources for livestock grazers. The importance of wetlands for livestock watering is more pronounced during dry seasons when most water sources dry up and large herds of cattle concentrate in few wetlands. However, information from focus group discussions indicated that watering livestock usually leads to grazing the livestock nearby, and when kept near streams and wetlands, they trampled river banks and lake shores, damaging vegetation resulting in increased erosion and sedimentation. This in most cases leads to soil compaction, removal of vegetation, and river bank or lake shore destabilization. It also directly adds animal waste, which most often leads to pollution. Similar impacts of livestock watering on wetlands have been noted by Belsky et al. , RobertsHarvesting of papyrus is one of the sustainable wetland uses of wetlands that would provide multiplier effects, in addition to direct income to papyrus harvesters and processors. This has been confirmed by studies elsewhere, such as Karanja et al. , EmertonAnother important resource provided by the wetlands in all the agroecological zones was water for domestic use. Wetlands are the main sources for the spring wells, boreholes, shallow wells, valley dams, and natural wells where local communities draw water for domestic use. As noted by Akwetaireho , wetlandWetlands were valued for the nonuse values such as micro-climatic regulation, flood control, water regulation/discharge, habitat/refugia, and recreation/tourism. Though rarely appreciated, the nonuse values contribute to the benefits that directly or indirectly play a role in food security. Thus, providing monetary figures for wetland nonuse values gives a basis for planning and decision making on the importance of leaving some wetlands intact. This is critical because the loss of most nonuse values is not easily recognised, compared to the direct resources, whose loss can be realized by lost incomes. It is worth to note that wetland resource utilisation activities are carried out almost exclusively by the people who live in settlements which directly border relevant wetlands. However, the benefits associated with nonuse values accrue over a much larger area, to rural and urban residents, and most of them are of public goods nature and deserve special consideration. This is recognised by different studies as one of the strong justification of leaving some wetland areas intact, with minimal disturbance as justified by Emerton et al. , BalmforThe findings from this study indicates that if wetland resources were used unsustainably, or in a manner which reduces societal net benefits, local people's income would decline. This is likely to affect their perceived value of wetlands and would further encourage even more unsustainable levels of resource use, ultimately leading to the destruction of wetland ecosystems as observed by Korsgaard and Schou  and Bai Results from this study provide evidence of the economic benefits derived from wetland goods and services. The study points out that many rural people's livelihoods depend directly on wetlands in addition to wetlands provision of ecosystem services. Often, these people are resource poor and they have few alternatives once the ecosystems deteriorate. It is also appreciated that the increasing human and animal populations and uncertain climatic conditions are exerting immense pressure on the different wetland resources, leading to varying levels of wetland degradation, which may lead to loss of the benefits.One of the causes of wetland degradation is information failure, which most often is caused by lack of understanding of the values of wetlands, including the economic values. For such reasons, the protection of wetlands does not appear to be a serious alternative for resource users and cannot be advocated for by planners and policy makers. Findings from the study therefore hold great potential for raising awareness about the roles and economic values of wetland benefits and ecosystem services. There is need to disseminate results from this study to resource users, policy makers and implementers, and to make them recognize the economic value of wetlands and put their efforts in sustainable management of the important resources by drawing strategies to sustain the wetland benefits to society.


Motivation has long been emphasized as the most important determinant of action. However, there is a substantial gap between people's goals and their attainment. Patients may be motivated and yet unable to take action if their volitional competencies are insufficient. One of the important tasks of volition is goal-maintenance. Research has stressed the importance of a volitional tool, the implementation intentions. Implementation intentions indicate where, when, and how the action leading to the goal will be performed. Forming implementation intentions favours the execution of goal-directed efforts, and reinforces the relationship between intentions and behaviours. Results from various studies clearly suggest that volitional competencies and implementation intentions could play a role in low back pain (LBP) patients. However, there is at present no questionnaire allowing assessing the capacity of implementation intentions of physical activities in LBP patients.This study will develop such a questionnaire, using a 3-step approach. A first qualitative step to build categories and generate items; 30 patients suffering chronic LBP will be invited to participate in semi-structured interviews; verbatim and derived items will then be submitted to a panel of experts, using a Delphi method; a second quantitative step to examine the properties of items, and determine the factorial structure of the questionnaire; 100 patients suffering chronic LBP will be recruited to respond to this phase; and third, preliminary psychometric analyses ; 180 chronic LBP patients will be recruited for this phase of the study. The relationships between implementation intentions and variables affecting physical activity on chronic LBP patients, i.e. pain, physical capacities, fear-avoidance beliefs, kinesiophobia, work status, and level of physical activity will be considered.Developing a questionnaire to assess implementation intentions would allow investigating the role of these intentions in the transition from acute to chronic LBP. The results of this study should contribute to the understanding of the psychological processes at stake in the development of chronic LBP, and in particular to the identification of factors eventually favouring patients' participation in and adherence to active physical treatments. Advice to stay active and continue daily activities, if possible including work, is strongly recommended in patients suffering low back pain (LBP) to avoid chronicity and to improve both the functional and socio-professional status of chronic LBP . In thisMotivation has long been emphasized as the only or most important determinant of action initiation . Goal thMeta-analyses indicate that attitude, subjective norm, and PBC account for substantial variance in intentions [e.g. ]). But tOne of important tasks of volition is goal-maintenance . In someIn the last decade, research has given prominence to another volitional tool, namely the implementation intentions. Formation of implementation intentions directed towards a specific objective has been shown to lead to better goal attainment than the mere definition of objectives. Implementation intentions are cognitive schemes that indicate where, when, and how the action leading to the goal will be performed ,14.Goal intention has to be distinguished from implementation intention: while goal intention is the focal point of the pre-decisional phase, implementation intention refers to action and the post-decisional phase . Goal inImplementation intentions have the format of if-then plans: 'If situation X arises, then I will do Y'. Thus, in the case of the goal intention 'I want to do physical exercise' a supporting if-then plan could be 'If one of my friends suggests playing tennis tomorrow, then I will accept' . ImplemeFurthermore, forming implementation intentions reinforces the relationship between intentions and behaviours; it may thus lead to increase participation in physical activities in the general population -19. A reThese results suggest that implementation intentions could play a role in LBP patients in order to break the vicious cycle leading to chronic LBP by promoting a return to sustained physical activity. The development of implementation intentions may be effective in combating kinesiophobia. To the best of our knowledge, this question has not yet been examined. Indeed, some authors examined intention to exercise in back pain sufferers ,24 but iThere is at present no tool allowing for the assessment of implementation intentions of physical activities in chronic LBP patients. However, such a tool is necessary to appraise possible volitional competencies and to follow-up the results of therapeutic programs aimed to develop such competencies.Our main objective is to assess the impact of implementation intention interventions on adherence to exercise programs among patients with chronic low back pain. To do so, this study aims to develop and to validate a questionnaire for measuring the various dimensions of volition. This new instrument will allow the investigation of the capacity of implementation intentions of physical activities of patients with LBP. The relationships between implementation intentions and variables affecting physical activity on chronic LBP patients, i.e. pain, physical capacities, fear-avoidance beliefs, kinesiophobia, work status, and level of physical activity will be considered.Furthermore, fear of pain and erroneous beliefs about physical activity have been described as negative internal states which may lead the patient to avoid physical activity and thus to reduce adherence to treatment. Developing a questionnaire to assess implementation intentions would allow investigating the role of these intentions in the transition from acute to chronic LBP Figure .Several hypotheses justify this work. We expect that (a) patients having developed volitional competencies would report more physical activities and that (b) patients having formed implementation intentions would report more physical activities than those who have not formed such intentions Figures  and 2.We also suppose that (c) resumption of physical activity linked to the actual control of exercises by volitional competencies, especially by implementation intentions, would have a positive effect on negative internal states so that fear of pain and erroneous beliefs about physical activity decrease or even disappear Figure .We finally hypothesize that (d) erroneous beliefs about physical activity have an inhibitory effect on the formation of volitional competencies, particularly on implementation intentions Figure ; and thaThe questionnaire will be developed using a 3-step approach ,26. A fiPsychologists, rheumatologists, specialists of functional rehabilitation, and patients suffering chronic LBP contribute to reframe the constructs of volitional competencies and implementation intention within the context of chronic LBP and physical activities. The constructs of volitional competencies and implementation intention used to develop the questionnaire will be supported by a systematic review of the literature on this topic. The aspects to be explored will be drawn from the data available in the main electronic databases  between 1999 and 2010. Semi-structured interviews will be constructed at the end of this stage in order to proceed to the next step.Participant samples: thirty patients suffering LBP for more than 12 weeks and consulting rheumatologists, specialists of functional rehabilitation, or orthopaedic surgeons, chosen for their ability to elicit comprehensive and relevant items, will be invited to participate in semi-structured interviews. A multidisciplinary group of eight health professionals including psychologists, rheumatologists and specialists of functional rehabilitation, regularly involved in the treatment of chronic LBP patients, will also respond to semi-structured interviews.Data collection: the semi-structured interviews will be conducted by a psychologist trained in interview procedures. The interviews will be audio-taped and then fully transcribed.Content analysis and item generation: a content analysis will be performed on the verbatim transcripts of the interviews, using a manual data indexing technique to identify key categories. Content analysis will be performed by two psychologists, trained in qualitative procedures and then completed by data from software such as Alceste and Tropes. This will be followed by a discussion and comparison of the readings of the data, which will be subsequently used to establish analytical categories, as it is the rule in qualitative analyses [analyses -30. ThesItem selection: verbatim and derived items will then be submitted to a panel of experts for selection, using a Delphi method [i method . A groupA first version of the questionnaire investigating volition and exercise in back pain patients (VEBPQ1: Volition Exercise Back Pain Questionnaire) will be edited at the end of this qualitative step.100 patients suffering LBP for more than 12 weeks, with no previous back surgery, free of any other disabling disorder, and French-speaking will be included and recruited according to the type of treatment, i.e. medical consultation alone, active physical therapy, or surgical candidate.Patients will be asked to fulfil a demographic questionnaire along with the first version of the VEBPQ at inclusion and two weeks later to allow for reliability analyses.The selection and reduction of items will be performed essentially by means of a principal component analysis (PCA). Distribution of responses to the various items will be investigated in order to verify whether all modalities of response have been used and to assess the possible presence of floor and ceiling effects. Dimensionality and factorial structure will also be investigated using an exploratory PCA. The number of factors to be retained will be determined by means of Kaiser criterion  and the screenplot of eigenvalues. Orthogonal rotations (varimax) and then oblique rotations (promax) will then be carried out.A second version of the questionnaire (VEBPQ2) will be edited at the end of this quantitative step.180 chronic LBP patients will be recruited for this phase of the study. Inclusion and exclusion criteria as well as recruitment will be similar as in the first two steps.Scales' convergent and discriminant validity will be assessed using confirmatory factorial analysis ,33. TherPatients will be asked to fulfil the second version of the VEBQ along with the validated questionnaires allowing to probe into the construct validity of the VEBQ. They will be mailed the VEBQ again two weeks later to allow for reliability analyses. Patients experimenting changes in their clinical status in-between will be excluded from this analysis.Reliability of the scales will be assessed by composite reliability coefficients  and by tThis study will be carried out by a multidisciplinary team also involving members of the Belgian Back Society (BBS) and of the "Section Rachis", a working group acknowledged by the French Society of Rheumatology (SFR). This will allow for teamwork within the context of the Back Pain Group of the SFR and for reaching to a large multidisciplinary expert panel.The study will be conducted in France, Belgium and Switzerland in compliance with the principles of the Helsinki Declaration and the protocol of Good Clinical Practices as well as in accordance with the ethic and regulatory national laws. At each step of the study, patients and physicians will have to give their written consent to participate after being informed about the study protocol. Data collected will be confidential.This study was approved by the Ethics Committee from the University of Liege and had the Belgian number B707201110271.In this paper we presented the rationale and the methods for the development of a questionnaire allowing for the appraisal of volitional competencies and of implementations intentions to perform physical activities in chronic LBP patients. This appraisal raises various issues pertaining to different fields, i.e. psychology, rheumatology, and functional rehabilitation. Furthermore, chronic LBP may trigger disabling physical and psychological consequences for the patient; it also generates important economical challenges, both at the personal and the social level. The results of this study should contribute to the understanding of the psychological processes at stake in the development of chronic LBP, and in particular to the identification of factors favouring patients' participation in and adherence to active physical treatments. The development of a questionnaire allowing for the utilization of the constructs of volitional competencies and of implementation intentions in the field of chronic LBP should thus be useful for researchers and therapists as well.The authors declare that they have no competing interests.JPB, CM, YH, CC, MM, SG, BD, TB and FL participated in study concept and design. CC, JPB, CM, YH, MM and VL drafted the manuscript. JPB, YH, CC, CM and MM were involved in critical revision of the manuscript for important intellectual content. YH and VL obtained funding. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/12/111/prepub


In a polygynous African society, rich men have much more life time offspring than women through the marriage of multiple wives. In line with evolutionary predictions, we found that in rich households more newborn sons were registered, sons had lower mortality and higher body weight. Conscious or unconscious, this maximizes reproductive output. Background and objectives: In polygynous societies, rich men have many offspring through the marriage of multiple wives. Evolutionary, rich households would therefore benefit more from sons, and according to the Trivers–Willard hypothesis, parents invest more in offspring of the sex that has the best reproductive prospects. We determined the sex differences in number of offspring, sex ratio of offspring, offspring survival and offspring weight in rich and poor households in a polygynous population.Methodology: We studied a population of 28 994 individuals in Northern Ghana during an 8-year prospective follow-up. We determined the fertility rate for both men and women, sex ratio of 3511 newborn offspring and offspring survival in 16 632 offspring up to reproductive age (≤18 years). Also, we collected 9842 weight measurements of 1470 offspring up to the age of 3 years from growth charts of local clinics.Results: In rich households, men have a lifetime number of 6.0 offspring, while for women this was 3.1. In line with evolutionary predictions, the male:female sex ratio was higher in rich households , sons had lower mortality in rich households  and sons also had higher weights in rich households (P = 0.008).Conclusions and implications: In rich households, men have higher reproductive prospects in this polygynous society and, in line with Trivers–Willard, we registered more sons in rich households, sons had lower mortality and higher weights, maximizing the reproductive output in this society. In polygynous societies, richer men can afford to marry multiple wives and consequently increase their reproductive success. In terms of Darwinian fitness, rich households would therefore benefit more from sons with their higher reproductive prospects. According to the Trivers–Willard hypothesis, parents invest more in offspring of the sex that has the best reproductive prospects .Although Trivers–Willard effects have been found in many animals, they are highly debated in humans. In a recent review of 422 studies in mammals, which investigated sex ratios at birth, excluding humans, a Trivers–Willard effect was consistently found in several species, while in other species, including non-human primates, more contradictory findings are found . Here, lWe studied reproductive output of men and women in poor and rich households in a large population of 28 994 individuals in a rural African society in the Upper East Region of Ghana with a high degree of polygyny. Second, we investigated the differences in offspring sex ratio, sex differences in offspring survival and offspring weight in poor and rich households.This study was conducted in the Garu-Tempane district in the Upper East region of Ghana. General fertility and mortality patterns have been described elsewhere . The chaIn 2007, we designed a DHS-type questionnaire to assess the socioeconomic status (SES) of the households of the study participants using a free listing technique whereby we asked people from different villages of the research area, both male and female, in focus group discussions to list the household items of most value . These sz-scores. Second, the factor coefficient scores or factor loadings are calculated. The DHS wealth index is the sum of the indicator values multiplied by the loadings. This index is itself a standardized score with a mean of 0 and a SD of 1. We defined poor and rich as the poorest 50% of households and the richest 50% of households divided by the median of the DHS wealth index.From these assets, a DHS wealth index was calculated. This was done as explained in paragraph 2.2 of the DHS wealth index comparative report . Using SFrom the registered newborn offspring and the observed person-years of fertile men and women during our 8-year follow up, we calculated the age-specific fertility rates. Next, we multiplied the age-specific fertility rates with the fraction of surviving men and women of these ages to calculate the number of offspring of each age group per year. The lifetime number of offspring was calculated as the sum of these numbers of offspring per year for all age groups multiplied by 5 since all age groups are 5-year age groups.The survival analysis used a multivariable left-truncated Cox regression analysis adjusted for sex, tribe and drinking source. We found no evidence that the assumption of proportionality of hazards was violated. The left-truncated plots represent age-specific survival probabilities calculated from the 8-year follow-up rather than a prospective lifetime follow-up. For the survival analysis up to reproductive age, we included all offspring up to 18 years. This survival analysis was performed on all person-years observed ≤18 years during our 8-year follow-up. Some individuals were followed 8 years below the age of 18 years; some individuals were followed both below age 18 years and above and in those cases only the person-years observed below age 18 years were included in the analysis. In total, we followed 16 632 individuals for 91 256 person-years which makes an average of 5.5 years follow-up below the age of 18 years per individual observed. During our follow-up, we observed 471 deaths below the age of 18 years.z-scores by subtracting the mean from the observed weight and dividing by the standard deviation.The weights of the offspring were obtained from growth charts of local health clinics in 2008. The clinics use hanging scales to measure the weight and use growth charts from the Ghana Health Service, adapted from the World Health Organization. For the separate sexes of each age, we standardized the weights on age and sex by calculating SDS or Supplementary Fig. S1). The point estimates presented in this article are estimates derived from this model and therefore do not always add up to zero for each age.On average, we had seven measurements per child during their first 3 years of life. To take these repeated measures into account and not treat them as independent measures, we used a linear mixed model. In the model, we adjusted/corrected for tribe of the offspring. The offspring from different tribes in the area have very different biometrics. Some tribes have cows, and the offspring of these tribes drink milk. Therefore, these offspring have less stunted growth and also do not suffer from (protein) malnutrition. We also adjusted the model for drinking source and the month and year of measurement, as weights fluctuated dependent on the season and year .We visited the research area annually from 2002 to 2010. Each year we registered the deaths, migration and newborn offspring. Studies have shown a strong heritability of SES in pre-transitional societies . This seP = 0.01). In rich households, however, mortality risk of sons was similar to that of daughters .Second, we studied survival of 16 632 offspring up to reproductive age (≤18 years) c. In pooTo further investigate the observed sex differences, we also looked at the survival differences in different strata of SES. P for interaction = 0.008).Third, we analyzed the weights of offspring using repeated measurements from growth charts of the local health clinics. In an analysis of 9842 age and sex standardized measurements among 1470 offspring up to the age of 3 years, daughters had higher weights in poor households, whereas sons had higher weights in rich households d. These We observed sex-specific effects of SES on the sex ratio of offspring, offspring survival and offspring weight. Several points should be discussed when interpreting these results.First, concerning the high ages of continued reproduction in this area. Since there is no official registration of births in this area, the ages are estimated ages by three independent observers, both local and Dutch fieldworkers. We used all information available to come to a best estimate, most notably the relation to other family members with known ages, but some ages could be estimated too low and some too high. Although we did our best to come to an objective estimate, old age carries a certain status in this area, and it is possible that more ages are overestimations than underestimations. This could explain the unusual high age of retained fertility for some women and it is also possible that the high reproductive output of some old men could be a little less extreme. Although misclassification of ages does not change the interaction of wealth and sex as we describe in this article, it is important to recognize this when interpreting the fertility data.Second, the sex ratios are sex ratios during registration at our annual field visit. Therefore, they are secondary sex ratios at an average age of 6 months and they do not necessarily reflect sex ratios at birth. Therefore, they could be the result of early mortality differences instead. We have observed mortality differences up to 18 years and it is expected that these differences also exist in the first 6 months of life.Another important point to discuss in this polygynous society is that men that fail to marry migrate to the south of Ghana to work in poor conditions in large cities or large-scale agricultural plantations. We have no estimate of their reproductive output but it is possible that this is low. Since the men that migrate are preferential poor males, the fertility figures for poor males in the research area are most probably overestimations of the reproductive output of all men born in poor households in the area. The contrast in reproduction between poor and rich is therefore probably even stronger than presented here. It is even possible that the lifetime number of offspring of poor women is greater than the lifetime number of offspring of poor men if this would be taken into account. However, it is not possible to calculate this without knowing the exact fertility characteristics of the men that migrate. This does not change our conclusions, however, and in fact, it is possible that the Trivers–Willard effect could even be stronger than presented here.Concerning the mechanism behind the observed sex differences dependent on SES, two possible explanations exist. First, they could be a reflection of higher intrinsic vulnerability of sons to poor conditions. Looking at the mortality patterns in poor and rich households, A last thing to consider is a potential effect that birth order could have on the observed patterns. It could be expected that the first-born son would be preferred; because he would inherit the wealth and therefore have high reproductive prospects while later born sons would be less favored. Unfortunately, we do not have reliable data on this, but we are planning to collect this in the future. On the other side, although the oldest son inherits the house, his brothers together with their wive(s) will often live with him in his household. Also, it is important to realize that in this society, possessions are not owned individually but are shared to a high degree among the  kin of the household.Whether the sex differences that we have observed in our study reflect the higher vulnerability of sons to poor conditions, or reflect a sex-specific parental investment as proposed by Trivers and Willard, the net result is the same; sons are better off in richer households which maximizes the reproductive prospects of households in this polygynous society. In fact, the two explanations are not mutually exclusive. The Trivers–Willard hypothesis refers to an ultimate explanation in terms of evolutionary optimization. Differential vulnerability to poor conditions is a proximate explanation referring to a potential mechanism, even if unspecified.Supplementary data are available at EMPH online.Netherlands Foundation for the advancements of Tropical Research (WOTRO); the Netherlands Organization for Scientific Research (NWO); the EU-funded Network of Excellence LifeSpan, an unrestricted grant of the Board of the Leiden University Medical Center and the Association Dioraphte. None of these organizations had any role in the design, analysis, interpretation or report of the study.This research was supported by the Conflict of interest: none declared.Funding to pay the Open Access publication charges for this article was provided by the Leyden Academy on Vitality & Ageing.


The algorithmic approach to guidelines has been introduced and promoted on a large scale since the 1970s. This study aims at comparing the performance of three algorithms for the management of chronic cough in patients with HIV infection, and at reassessing the current position of algorithmic guidelines in clinical decision making through an analysis of accuracy, harm and complexity.Data were collected at the University Hospital of Kigali (CHUK) in a total of 201 HIV-positive hospitalised patients with chronic cough. We simulated management of each patient following the three algorithms. The first was locally tailored by clinicians from CHUK, the second and third were drawn from publications by Médecins sans Frontières (MSF) and the World Health Organisation (WHO). Semantic analysis techniques known as Clinical Algorithm Nosology were used to compare them in terms of complexity and similarity. For each of them, we assessed the sensitivity, delay to diagnosis and hypothetical harm of false positives and false negatives.The principal diagnoses were tuberculosis (21%) and pneumocystosis (19%). Sensitivity, representing the proportion of correct diagnoses made by each algorithm, was 95.7%, 88% and 70% for CHUK, MSF and WHO, respectively. Mean time to appropriate management was 1.86 days for CHUK and 3.46 for the MSF algorithm. The CHUK algorithm was the most complex, followed by MSF and WHO. Total harm was by far the highest for the WHO algorithm, followed by MSF and CHUK.This study confirms our hypothesis that sensitivity and patient safety (i.e. less expected harm) are proportional to the complexity of algorithms, though increased complexity may make them difficult to use in practice. The algorithmic approach to guidelines has been introduced and promoted on a large scale since the 1970s. This flowchart representation of step-by-step clinical logic guides the management of a patient with symptoms, clinical signs, or results of technical examinations. The transition from one step to the next is mostly dichotomous, which means that only one out of two choices can be made at each step. Moreover, the logic is serial: only one pathway can be followed by a single patient.The original purpose of algorithmic guideline implementation was twofold. First, with continuing concern over the rising costs of health care, health policy makers have been impressed by the high levels of variation and inappropriateness in medical care. Second, in resource-poor settings, nurses provide frequently the first-line medical care. To deal with the relative lack of knowledge in this medical professional group, algorithms have been used to help rationalise and standardise clinical decision making, an approach considered so far to be effective and efficient . AlgoritClinical algorithms are often controversial: on the one hand, they have often been considered with suspicion because of their restrictive, "cookbook"-medicine approach. On the other hand, they have been viewed as a valuable educational tool, providing neophytes with a method for making diagnostic and therapeutic decisions in clinical practice apprenticeship . AlthougAlgorithms usually lead to a single diagnosis, potentially neglecting another serious one, leading to delayed investigations and treatment. In some situations, the burden of harm might grow considerably: when we follow an algorithmic guideline step-by-step, it is obvious to stop at the first diagnosis corresponding with the patient's findings. It induces a tunnel-vision and limits the search of certainty in diagnosis.Epidemiology shows the relevance of the dynamics of the disease spectrum in time as well as in space. The utility of a given clinical algorithm can vary substantially across different epidemiologic and socioeconomic contexts. As a result, every algorithmic guideline must be adapted to every local context and regularly revised . MoreoveSeveral studies have evaluated or compared guidelines but none of them has compared them in terms of complexity or harm -7. WabitAt the end of 2007 the global estimate of the number of people living with HIV was about 33,2 million, with more than 96% in low- and middle-income countries .Except fThe purpose of this research was to compare virtually three algorithmic guidelines intended for use at a tertiary level in terms of sensitivity, delay to diagnosis, harm, complexity and similarity. We intended to evaluate how complexity relates to accuracy and expected harm. We hypothesized that increasing complexity, thereby approaching the clinician's intuitive logic, improves accuracy and diminishes expected harm, but that, on the other hand, the degree of complexity can become too high and make the algorithm less useful in practice.Data were collected at the University Hospital of Kigali (CHUK), a national reference centre for Rwanda, during a 4 months period in 2002. The study included all adults (> 15 years of age) hospitalised in the internal medicine department with cough of more than three weeks' duration as their chief complaint, known or newly confirmed HIV-positive and suspected of World Health Organisation (WHO) stage 3 or 4 . PatientClinical care depended only on the clinician's judgment. Moreover, clinicians were blinded to hypothetical results of the application of the algorithms.For each patient, we collected data through a questionnaire in Epi-Info software 2000: age, sex, history, physical examination, tests done, treatment, outcome and final diagnosis. Data were made anonymous for analysis. Sensitivity was computed with and without considering patients for whom no final diagnosis was made and those with a rare diagnosis not included in the algorithms. For the remainder of the analysis they were excluded.Using the graphic format described by Margolis, a serial and dichotomous flowchart representation adopted by the Harvard Community Health Plan, a locally tailored algorithm was developed based on clinicians' logic and availability of complementary exams Figure . Two resThe Médecins sans Frontières (MSF) algorithm was published in 2001 by L. Lynen for management of opportunistic infections in HIV-positive patients, and based on an extensive literature review Figure  14]. Bo. Bo14]. We virtually applied the three algorithms to each patient, using data from the database, simulating a step-by-step management as would have been done following the algorithm. We calculated the number of patients who found a way through the algorithm ("fit") and we compared their management in the ward with the pathway they would have followed with the algorithm. Sensitivity represents the proportion of correct diagnosis made by an algorithm. We estimated the sensitivity first for each diagnosis, and further for the algorithm as a whole, with the final clinical diagnosis as the "true condition". If the algorithm missed a diagnosis, we considered this as a false negative for the true condition. If another diagnosis was reached instead of the true condition, it was considered as a false negative for the true condition and as a false positive for the wrong condition. In other words, the false positive is a wrong diagnosis whereas the false negative is a missed diagnosis.Starting from the clinical state box to the action box, we defined for each diagnosis a minimal hypothetical  delay, depending on the execution of the different investigations. For every patient we compared the time clinicians needed in the ward to reach a therapy, with the delay predicted by the different algorithms. Delays were considered on theoretical grounds, supposing that all steps had to be taken in a sequential way .We compared the algorithms following the Clinical Algorithm Nosology. It is made up of two components . The Cli1Dx = number of diagnostic boxes, n2D0 = number of all other boxes, and ∑ (Lp) i = the summation of "loop parameters" (i.e. nodes that send the clinician back to an earlier point). The Clinical Algorithm Patient Abstraction (CAPA) then accomplishes a clinical comparison of two algorithms and explains the differences between them. The CAPA has three steps: clinical rule analysis, patient abstraction and patient comparison. "Identical" (score = 10) means same order of clinical exams and decision, "similar" (score = 8) means the same steps and treatment but in different order and "different" (score = 0) means a management without the same diagnosis or therapeutic decision.where nWith a questionnaire featuring scoring scales from 0 to 10, nine internal medicine clinicians of CHUK estimated intuitively the weight of harm by commission  and harm by omission  in therapeutic decisions compared to natural death . We reliData were recorded for 201 patients. Nine patients had no diagnosis, 9 had a rare diagnosis not included in the algorithms, leaving 183 for analysis. One patient had two probable diagnoses. Sex ratio was 82/119 M/F , mean age was 35,9 years (range 15-70 years). Baseline characteristics and main diagnostic frequencies are summarized in table Of the 184 cases (one patient with 2 diagnoses) we made follow the CHUK algorithm, 183 fit a pathway . Comparing the algorithm pathways with the one followed by the clinicians, for 61% the management was "identical", for 38% it was "different" and for 1% it was "similar".The same procedure was also applied for each of the 184 cases to the other two algorithms under study. A fit was found in 183 (99.5%), 183 (99.5%), and 171 92.9%) cases for the CHUK, MSF and WHO algorithms, respectively. Sensitivity was 95.7%, 88% and 70.1% for the CHUK, MSF and WHO algorithms, respectively .  no similarity between the three algorithms.Table The purpose of this study was to assess the hypothetical utility of three algorithms in terms of sensitivity, delay to action and harm at a tertiary care level. The CHUK guidelines proved to be the most complex, but the most sensitive and the least harmful. The results confirm that increasing complexity improves sensitivity and diminishes expected harm. But the degree of complexity becomes so high that it might be one of the reasons why clinicians are reluctant to use them. As a matter of fact, none of these algorithms has ever been used in daily practice in CHUK.Pneumocystis jirovecii (formerly carinii) is seen. Our study reveals a prevalence of 19% of pneumocystosis. This is fourfold the prevalence found by Batungwanayo in the same hospital ten years earlier, but this result was based on microbiological evidence after bronchoscopy and was restricted to unsolved cases [Due to limited diagnostic means, the gold standard in this study is the clinical diagnosis made by the clinicians at CHUK. This might be considered as a weakness. However, the prevalence of final diagnoses is close to the spectrum of diseases that cause chronic cough in people living with HIV in Africa : tubercued cases . In Uganed cases . Since ied cases .In our study, mortality rate was high (39%). At that moment in time, ART was not subsidized; patients feared hospitalisation in our wards because they knew beforehand the high mortality, leading to late referral or consultation. Beyond this, some deaths could be attributed to missed diagnosis of uncommon diseases.The average delay to appropriate management would be shorter for the CHUK algorithm (1.8 days) than for the MSF 3.4 days). The CHUK delay is therefore closer to that seen in clinical practice at CHUK, as well as to the ideal one  would not reach a correct final diagnosis.Firstly we noticed that in the set of patients and also in the different diagnoses available in the CHUK algorithm, uncommon but treatable diseases such as aspergillosis, nocardiosis, cryptococcosis, and some others are not taken into account. These diseases, however, are well described as opportunistic infections in HIV-positive patients and deserve priority before considering frequent diseases because of their seriousness and treatability. We omitted them from the analysis since algorithms cannot cover all rare diseases.Secondly, in current practice in low resource settings, diagnosis of pulmonary infection is often a presumption, based on clinical signs and radiological results because of the limited availability of serology, culture or PCR. These presumptive diagnoses were considered as gold standard-not always with formal proof. It casts doubt on the reliability of the comparison of the diagnosis obtained by following the algorithm with the gold standard diagnosis, as the latter may have been false. The ideal situation should offer availability of complementary exams to confirm these presumptive diagnoses, but it would imply submitting patients to invasive procedures and spending much more money. Moreover, in advanced AIDS, more than one pathogen is frequently identified ,19.Finally, a large part of the difference in sensitivity of the CHUK and MSF algorithms is due to one single step differentiating between lobar and atypical pneumonia.The three algorithms might not be comparable: the WHO algorithm leaves much to the discretion of the clinician, without specifications.The CAN methodology can be applied easily. By itself, however, it does not judge which of the algorithms is likely to provide better patient care. This sole method of comparison is not really used in practice and remains an elusive concept. It is only a comparative tool to quantify the degree of similarity and complexity with no attention for sensitivity and harm which is the most important quality of a diagnostic aid. The authors mention that the ideal objective in the comparison of algorithms would involve decision analyses of the management pathways and prospective clinical trials comparing patient outcome in guided care . DecisioSo far, a practical way of comparing clinical guidelines proving their reliability before their implementation is still needed to validate any guideline program . In our Intuitive weighting of harm is a gross intuitive estimation given by clinicians on a simple scale scoring from 0 to 10 about commission error  and omission error  in therapeutic decisions. Calculated weighed harm is more accurate than intuitive weighed harm, because it is based on observed probabilities related with the outcome of treated and non treated diseased and non diseased patients. In a recent study, we proved that the ratio of the intuitively estimated harm was almost 32 times lower than the calculated based on (by the same clinicians) intuitively estimated influencing factors, and two times lower than the calculated weighed harm based on literature data . For ourOur study has shown that some published algorithms have limited accuracy. This can be overcome by increasing the complexity, at the possible expense of user-friendliness. We hope that this study encourages policymakers to "dry-run" new draft-algorithms with an existing database of a cohort of patients, before organizing a formal validation in a real situation. The latter is not always possible, given the lack of a gold standard in most situations where the algorithm is to be applied.A second impact of this study might be that writing algorithms for problems with a large differential diagnosis at the tertiary care level should be abandoned for many reasons, for instance: the burden of work necessary to adapt the algorithm to time and place, the neglect of rare but serious and treatable diseases, the possible coexistence of several pathologies, the reduction of a clinical presentation to only a few signs, and the difficulty in reaching a reasonable accuracy. We might state that at this level of care, medical decision tools based on a serial dichotomous approach may be replaced by the more human parallel and weighed logical approach recently proposed -23.Little research has been done to evaluate the real-world use of algorithms by health professionals ,3. AnecdThe concept of threshold approach in clinical decision-making has existed since the 1970s, and this concept has been substantiated to the point that ignoring it would be unethical -26. All Considering that application of an algorithmic approach involves a short course training, especially for nurses and inexperienced personnel, future studies should assess which logical approach is the most effective for a given amount of training .Inexperienced medical staff could go on using the algorithmic approach in order to solve simple problems at the first level of care. The condition is that they should have a short basic training and that the flowchart should be validated, adapted to the local context and regularly revised. But at the tertiary care level, approaching the competence of specialised clinicians by improving sensitivity and diminishing expected harm will increase complexity at that point that it turns out almost impossible to apply.The authors declare that they have no competing interests.CM contributed to the concept, data collection and analysis, JN contributed to analysis and writing, BB contributed to concept and analysis, LL contributed to analysis and supervision of writing, YC contributed to data collection and analysis, AA contributed to concept, data collection and analysis, JVDE contributed to concept, analysis, writing and overall supervision. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6947/12/2/prepub