Chlamydia and genital human papillomavirus (HPV) are the two most common sexually transmitted infections (STIs) among teens and young adults in industrialised countries. The majority of adolescents, however, have limited or no knowledge of these infections. Within the context of a cross-sectional survey on awareness and knowledge of sexually transmitted infections, secondary school students attending the 8th grade and above in Bremen and Bremerhaven, two cities in northern Germany, were asked to rate the risk of peers to get infected with HIV, HPV or chlamydia.Between October and December 2011, students aged 12–20 years completed an anonymous, self-administered questionnaire at their school. In addition to answering questions on awareness and knowledge of sexually transmitted infections, all students were also asked to rate the risk of peers to get infected with HIV, HPV or chlamydia. Furthermore, those reporting ever having sexual intercourse were asked to rate their own risk of getting infected with each of the three infections.1,148 students, 55% female, completed the questionnaire. 27% of the students reported having had sexual intercourse. 68% of all students rated the risk of same-aged students to get infected with HIV/AIDS as high/medium. The corresponding proportions for HPV and chlamydia were 19 and 25% respectively. Those reporting ever having sexual intercourse generally perceived their own risk of getting infected with HIV, chlamydia or HPV as lower than that of their peers.Generally, the risk of getting infected with HIV was perceived as being higher than that of getting infected with HPV or chlamydia, most likely due to the fact that the students were more aware of HIV than of the other two infections. Efforts should be made to improve awareness and knowledge of HPV and chlamydia among school going adolescents, and to make them realize that these are common infections that are preventable. The average age of first sexual intercourse in western European countries is reported to be decreasing Chlamydia and genital human papillomavirus (HPV) are the two most common sexually transmitted infections (STIs) among teens and young adults in industrialised countries, affecting mostly females th grade and above in Bremen and Bremerhaven, two cities in northern Germany, using an anonymous questionnaire. The students were also asked to rate the risk of peers to get infected with HIV, HPV and chlamydia. Those reporting ever having sexual intercourse were asked to rate their own risk of getting infected with each of the three named infections. The results of the analyses on awareness and knowledge have been published elsewhere We assessed the awareness and knowledge of sexually transmitted infections among secondary school students attending the 8th grade and above. Approval to conduct the study was received from the ethics commission of the University of Bremen, the Senator for Education, Science and Health and the Data Protection Officer for the State of Bremen.The study was conducted in 8 secondary schools in two cities in northern Germany, Bremen and Bremerhaven, among 12–20 year old students attending the 8th grade only, and those offering up to the 12th or 13th grade.As described in our manuscript on knowledge and awareness of STIs th grade and above. There was no selection of individual classes or particular grades. Information for parents, including consent forms, was also provided in Turkish and Russian.The teachers, parents and students were provided with written information on the study. The study information was delivered to each school and the class teachers distributed the information to the students, who in turn passed on the study information, including consent forms, to their parents. In all the 8 participating schools, study information was provided for each student attending the 8Only students with signed parental or own consent (for those aged 18 and above) could take part in the survey.On the day of the survey students with signed consent completed an anonymous, self-administered questionnaire at their school during normal school time. In the first section of the questionnaire socio-demographic information such as age, country of birth and parents' school education were collected. The second section covered issues on knowledge and awareness of STIs.Questions on knowledge and awareness of STIs and on risk perception were constructed based on questionnaires used in other studies The students were asked which of the following infections, listed in the questionnaire, they had ever heard of: HIV/AIDS, human papillomavirus (HPV), chlamydia, herpes, syphilis, gonorrhoea and hepatitis B. This was followed by several questions on awareness and knowledge of STIs, covering specific issues on HPV awareness and general knowledge on sexually transmitted infections. The latter included questions on whether the students knew that using a condom protects against getting an STI, that infections such as HIV and HPV are treatable, but not curable, and that there is no vaccine against HIV/AIDS and chlamydia. Thereafter, the students were asked to rate the risk of same-aged adolescents to get infected with HIV/AIDS, HPV or chlamydia. The following response possibilities were offered: high, medium, low or don't know. In the last section students were asked if they had ever had sex, and if yes, their age at sexual debut, and the method of contraception they had used then, and the method they used now. Those reporting ever having sex were asked to rate their own risk of getting infected with HIV/AIDS, HPV or chlamydia. Again the following response possibilities were offered: high, medium, low or don't know.Data analyses were conducted using SAS version 9.2.We used maternal educational status as an indicator of socioeconomic status. The variable father's education was excluded from the analyses as there were many missing values. Responses to the outcome variables peer and own risk perception for HIV, HPV and chlamydia were categorised as ‘high/medium’, ‘low’ and ‘don't know’. Students who did not responded to the questions on rating were excluded from all analyses.We performed descriptive statistics and calculated frequencies for all variables. Chi-squared tests were used to assess bivariate relations between the independent variables age, gender, migrant background, school education of mother, ever had sex, and type of school and the outcome variables peer and own risk perception for HIV, HPV and for chlamydia. For those reporting ever having sex, additional tests for use of condoms at sexual debut and currently and a comparison between indicated peer risk perception and own risk perception were done. As the outcome variables were polytomous, multivariable analyses were conducted using standard ordinal regression analysis (PROC LOGISTIC) with backward selection, including all independent variables. Ordinal logistic regression assumes that the relationship between each pair of outcome groups is the same. In our case this would mean that the coefficients describing the relationship between the category ‘don't know’ versus the category low is the same as that which describes the relationship between the category ‘low’ and the category ‘medium/high’. To assess the appropriateness of the ordinal regression model, the proportional odds assumption was tested and the score test (chi square) was not significant.The study population and the findings on knowledge and awareness of sexually transmitted infections have already been reported 1148 students, (632 girls and 516 boys), aged 12–20 years, participated in the study (response rate 28%). 31% of the students had a migrant background  and 27% reported ever having sexual intercourse. The average age of first sex was 15 years and the average number of lifetime sexual partners was two. Among those who reported ever having sex, 81% (76% of the girls and 86% of the boys) reported using a condom at sexual debut and 65% (79% of the girls and 51% of the boys) reported currently using condoms.Almost all students (99%) had heard of HIV/AIDS, 91% of herpes, 83% of hepatitis, 23% of chlamydia, 17% of gonorrhea and 13% of HPV. Gender differences were observed for HPV, chlamydia, syphilis and gonorrhea, with significantly more girls than boys reporting having heard of HPV and chlamydia, and significantly more boys than girls reporting having heard of syphilis and gonorrhea.Of the three infections for which the students were asked to rate the risk of getting infected for same-aged adolescents, HIV/AIDS had the least proportion of students who responded with “don't know” or with missing responses (4%). The corresponding proportions for HPV and chlamydia were 65% and 60%, respectively. Whereas 68% of the students rated the risk of same-aged students to get infected with HIV/AIDS as high/medium, the corresponding figures where 19% for HPV and 25% for chlamydia. In bivariate analyses, gender was significantly associated with risk perception for all three infections, with a higher proportion of girls rating the risk of getting infected as high/medium . In compOf the 314 students who reported ever having sex, 5% responded ‘don't know’ to the question on own HIV risk perception. The corresponding proportions for HPV and chlamydia were 34% and 29%, respectively. Among those who rated their own risk of getting infected with HIV, 16% perceived their risk as high/medium . Results of bivariate analyses showed an association between age and own risk perception for HIV and chlamydia, with a higher proportion of students older than 14 years reporting their risk of getting infected as low. Students younger than 14 years and those with a migrant background more often responded to the question on HIV risk perception with ‘don't know’ . We did For HIV, 27% of the students reporting ever having sexual intercourse perceived their own risk of getting infected and that of their peers as low, while 51% perceived their own risk as low, but that of their peers as high/medium . For HPVth grade and above were asked to rate the risk of peers to get infected with HIV, HPV and chlamydia. Those reported ever having sexual intercourse were also asked to rate their own risk of getting infected with the three infections. Generally, the students were able to rate the risk of peers to get infected with HIV, with only a small proportion responding with ‘don't’ know’. In contrast, the majority of students responded with ‘don't know’ for chlamydia and HPV. Similarly, the lowest proportion of ‘don't know’ for own risk perception was observed for HIV. All in all, students rated their peers to be at higher risk of getting infected with HIV than with chlamydia or HPV. Those reporting ever having sex generally rated their own risk of getting infected with each of the three infections to be lower than that of their peers.In the context of a cross-sectional survey on awareness and knowledge of sexually transmitted infections, secondary school students attending the 8There is a lack of epidemiological data on risk perception of infection with sexually transmitted infections among school-going adolescents in Germany and our study helps fill this gap. Results of a number of surveys on awareness and knowledge of HIV/AIDS, chlamydia and HPV among this population group have recently been published As we conducted an observational cross-sectional study, our analyses were of an explorative nature. The estimated p-values can therefore only be regarded as indicative of a relationship between the independent variables and risk perception.Although the low participation rate observed in our study can be partly explained by the sensitive nature of the research question and the reluctance of parents to allow their children to take part in such surveys, it still remains a limiting factor.Our observation that only a small proportion of students responded to the question on risk perception for HIV with ‘don't know’, while the corresponding proportions for chlamydia and HPV are very high, is a further indication that adolescents are more aware of HIV than of the latter infections. As has been noted for Germany In bivariate analyses we observed gender differences in risk perception for peers for all three infections, with girls more often than boys perceiving the risk of getting infected to be high/medium. Interestingly, we did not make the same observation for own risk perception. Here the majority of students, irrespective of gender, perceived their own risk of getting infected as low. We also did not observe any statistically significant differences based on use of condoms at sexual debut or currently. The low perception of own risk, particularly for chlamydia and HPV, can be taken as a further indication of the lack of awareness of these infections among the study population. Findings of a chlamydia prevalence study conducted among sexually active school girls aged 14–17 years conducted in 2004 in Berlin, Germany, serve to underline this assumption. In that study, 83% of the participants had never heard of chlamydia. 6% of the participants were found to be infected with chlamydia, with the highest prevalence (10%) being observed among those 17 years old A comparison of the perceived risk for peers and own perceived risk showed that the students, irrespective of gender, generally perceived their own risk to get infected as lower than that of their peers. This discrepancy in risk perception was particularly observed for HIV, the STI almost all students had heard of, with 51% of the students perceiving their own risk of infection to be low, but that of their peers to be high/medium. For HPV and chlamydia, the STIs students were less aware of, the discrepancy was less marked. According to literature, individuals generally perceive themselves to be less at risk than others, particularly where the risk is controllable or behavior related The concept of risk perception is based on the understanding that an individual is more likely to take preventive measures when he or she believes to be personally at risk


They achieve an intriguing compromise between depth and width in the sparsely populated domain of internationally comparative research on LTC by characterizing countries' LTC and interpreting the large north/south differences found. Their results also show that 'cash for care' schemes form a substantial alternative to traditional LTC provision. An additional time series analysis showed that many countries seem to be engaged in reorganizing the LTC sector. This study widens knowledge in a neglected area of health services research and should serve as a source of inspiration for further studies.Long-term care (LTC) in the form of care provided in nursing homes, homes for the aged and home care is considered an appropriate answer to the growing needs of the aging populations of the industrialized world. However, the provision of and expenditures on LTC vary considerably between these industrialized countries. Although one would expect LTC to be subject to many internationally comparative studies, including all European countries, this is not the case. A paper presented by Damiani http://www.biomedcentral.com/1472-6963/11/316 [Please see related article:  Patterns of long term care in 29 European countries: evidence from an exploratory study.)[et al. contains all 27 European Union (EU)-member states plus Norway and Iceland (not Switzerland) and covers a recent five-year period (2003 to 2007). The authors use eight indicators derived from international databases, such as the Organisation for Economic Co-operation and Development (OECD) health data [Although the aging of the populations of the developed world, and the huge amounts of care needed to accommodate these aging populations, is considered to be one of the major policy problems for now and the near future , internaet al. ). One ofy study.), showinglth data  and Eurolth data , about tThe use of international databases brings about some additional limitations besides the validity of the data. Firstly, the databases are focused on utilization and expenditure of formal care. Data on family values concerning LTC and data on informal care are either lacking or, if available, often cover one year only and are thus not suitable for trend studies. Secondly, the scope of the database can be limited. For instance, the Eurostat database  only incet al. . et al. consists of two parts: patterns and trends  [Patterns of care', the authors suggest that the eight indicators derived from international databases can be reduced statistically to two 'factors'. Firstly, a factor labeled 'the alignment between elderly needs and old age related expenditures' indicates whether expenditure and demand are in balance. Secondly, a factor labeled 'supply of formal  care' is identified. With the help of the scores on both of these dimensions, four groups of countries can be distinguished, varying from one group scoring high on both factors  to a group scoring low on both factors, with the remaining two groups scoring low on one factor and high on the other. In 'Trends in LTC', the authors show that countries differ in the way LTC develops over time. Some countries are stable; others have a linear development along one of the dimensions (factors) and some countries show a rather 'chaotic' time trend.The study by Damiani  study.) . In 'PatUntil now, international studies were either statistical overviews of 27 to 35 countries with limited interpretation, or studies covering in depth a broad range of topics but for a much lower number of countries. A good example of the latter group is the Survey of Health Aging and Retirement (SHARE) study, covering 13 countries in its most recent version ,13.et al. improved the interpretation of the existing international data. Additionally, by limiting themselves to a statistically defendable two-factor solution, the authors also avoided overstretching the possibilities that the relatively small number of 29 countries permits.By combining the indicators into two dimensions, the study by Damiani The dimensions presented also contain a new element, especially in the dimension they call 'the alignment between LTC expenditures and elderly needs'. The authors interpret this dimension as 'cash benefits' on the one hand , and the need (demand) for LTC in a country on the other, with the percentage of the population over 80 and self-assessed health status used as indicators of demand.The study groups together countries like Luxemburg, Denmark, Italy, France and the UK, which have relatively low levels of supply of institutional LTC. This 'cash for care' dimension as a characteristic for dealing with the needs of the elderly population is a new concept. Also novel is the fact that former East Bloc countries still form a distinctive group, characterized by a weak alignment between LTC expenditures and the needs of the elderly, and a relatively high supply of formal care. If these countries provide LTC, they do it in the form of residential care, in 'beds'.Finally, the trend analysis yields new insights, to a certain extent: trends could be established for each combination of the two dimensions. In some cases these were linear trends, with developments in one direction for one of the dimensions over the five years; in some countries, there existed a stable situation; in other countries, there were chaotic, highly volatile developments. The authors remark that some countries are in, or have apparently been in, a process of transformation - examples include Spain, Norway, Ireland, Italy, Portugal, Cyprus, Romania and Latvia. The trend analysis proves its relevance and should become a standard element of this type of international health care analysis. Changes occur rapidly, as was the case in the Netherlands. In the period between 2003 and 2007, LTC care in the Netherlands did not change much. In the years afterwards, however, the funding and organization of LTC changed considerably; even the 'cash for care' scheme is planned to be abolished in 2012 due to its popularity.et al. to make an international comparison of LTC [We value the attempt of Damiani y study.). HoweverFirstly, we have some remarks concerning the concepts and definitions used in the paper. For instance, with regard to the social benefits indicator (in the paper interpreted as 'cash for care'), it is unclear whether these benefits also include capital based pensions as is customary in the UK, Denmark and the Netherlands and whether benefits in kind are also included. Moreover, it is unclear whether the self-assessed health indicator is a valid measure of 'health status or health need' or, rather, a culturally determined outlook on life. In international studies on 'happiness' , inhabitSecondly, we wondered whether there really is an 'alignment' between LTC expenditure and self-perceived health in a country or whether this is just a statistical association. There may be other issues that influence this relationship, such as supplier-induced demand . Therefoet al. forms a valuable contribution to internationally comparative LTC research and should inspire further research.Finally, an issue that has not been addressed in this study is the question of whether differences within countries could be more relevant than differences between countries; the authors themselves showed in an earlier paper the North/South differences in Italy , other pTo that end, one of the intriguing elements of the Damiani paper is the attempt to interpret the international differences found by pointing to cultural dimensions following Hofstede's division , among oet al., time series are crucial. However, most time series data are only on expenditure and utilization of formal care. Thus valuable information, such as that provided by the Eurobarometer study on views and values concerning LTC [For the method used in the study by Damiani ning LTC ., are miet al. achieved an intriguing compromise between depth and width in the sparsely populated domain of internationally comparative research on LTC. By reducing the set of eight indicators to two interpretable dimensions , the authors increase the insight into LTC developments in Europe. Their use of time series analysis adds further insight into the field.Damiani The interpretations the authors provide of the  differences in the provision and use of LTC between the Protestant North and West and the Roman Catholic and/or Orthodox South (East) of Europe demand further in-depth research of the type that currently takes place on a smaller scale in a survey like the SHARE study . Countriet al.  [To summarize, we think that the article of Damiani  study.)  contribuThe authors declare that they have no competing interests.JvdZ wrote the first draft. Both authors contributed equally to further drafting and revision of the final manuscript, and gave approval for the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/9/124/prepub


Folk names of plants are the root of traditional plant biodiversity knowledge. In pace with social change and economic development, Mongolian knowledge concerning plant diversity is gradually vanishing. Collection and analysis of Mongolian folk names of plants is extremely important. During 2008 to 2012, the authors have been to the Arhorchin National Nature Reserve area 5 times. Fieldwork was done in 13 villages, with 56 local Mongol herdsmen being interviewed. This report documents plant folk names, analyzes the relationship between folk names and scientific names, looks at the structure and special characteristics of folk names, plant use information, and comparative analysis were also improved.Ethnobotanical interviewing methods of free-listing and open-ended questionnaires were used. Ethnobotanical interview and voucher specimen collection were carried out in two ways as local plant specimens were collected beforehand and then used in interviews, and local Mongol herdsmen were invited to the field and interviewed while collecting voucher specimens. Mongolian oral language was used as the working language and findings were originally recorded in Mongolian written language. Scientific names of plants are defined through collection and identification of voucher specimens by the methods of plant taxonomy.A total of 146 folk names of local plants are recorded. Plant folk names corresponded with 111 species, 1 subspecies, 7 varieties, 1 form, which belong to 42 families and 88 genera. The correspondence between plant folk names and scientific names may be classified as one to one correspondence, two or three to one correspondence, and one to multitude correspondence. The structure of folk names were classified as primary names, secondary names and borrowed names. There were 12 folk names that contain animal names and they have correspondence with 15 species. There are nine folk names that contain usage information and they have correspondence with 10 species in which five species and one variety of plant are still used by the local people. The results of comparative analysis on the Mongol herdsmen in the Arhorchin National Nature Reserve and the Mongolians in the Ejina desert area shows that there are some similarities, as well as many differences whether in language or in the structure.In the corresponding rate between plant folk names and scientific names yielded a computational correspondence of 82.19%, which can be considered as a high level of consistency between scientific knowledge and traditional knowledge in botanical nomenclature. Primary names have most cultural significance in the plant folk names. Special characteristic of plant folk names were focused on the physical characteristics of animals which were closely related to their traditional animal husbandry and environment. Plant folk names are not only a code to distinguish between different plant species, but also a kind of culture rich in a deep knowledge concerning nature. The results of comparative analysis shows that Mongolian culture in terms of plant nomenclature have characteristics of diversity between the different regions and different tribes. Article 8 (j) of the "Convention on Biological Diversity" (CBD) describes that subject to its national legislation, respect, preserve and maintain knowledge, innovations and practices of indigenous and local communities embodying traditional lifestyles relevant for the conservation and sustainable use of biological diversity and promote their wider application with the approval and involvement of the holders of such knowledge, innovations and practices and encourage the equitable sharing of the benefits arising from the utilization of such knowledge, innovations and practices . ArticleFolk names of plants are the root of traditional plant biodiversity knowledge. Indigenous knowledge is the systematic information that remains in diverse social structures. It is usually unwritten and preserved only through oral tradition, and it refers to the knowledge system of indigenous people and minority cultures. Traditional knowledge of biodiversity concerns the names, uses, and management of plants and animals as perceived by the local and or indigenous people of a given area. In the ethnobiological and anthropological area, Berlin has indicated a strong need for linking the scientific and folk systems of classification . ExampleIn pace with social change and development, the Mongols are changing from nomadic people into settlement residents. The knowledge concerning grassland ecosystems is vanishing gradually because the related knowledge is no longer useful to the Mongols who are settled down or engaged in farming or other economic pursuits. The Mongolians in Inner Mongolia have been influenced by other cultures, e.g. in some areas Han Chinese words, including plant names, are more or less mixed up with the Inner Mongolians' spoken language. This may be leading to Mongols forgetting traditional botanical knowledge related to the language of plant folk names and classifications. Both artificial and natural factors lead to the degradation of the grassland and desertification. As a result, plant diversity that Mongolians traditionally named and used has decreased. The reduction of plant diversity may also lead to the extinction of the related knowledge of biodiversity. Thus it will be impossible to hand down to future generations. For this reason, collection and analysis of Mongolian plant folk names is extremely important.Ethnobotanical surveys and analysis on wild plant folk names in the Mongolian language have been carried out since the 1990s -13. Howe2. The altitude ranges from 350 m to 400 m. This area has a temperate zone continental climate, with an average annual temperature of 6°C, and a mean rainfall of about 300 mm. The frost-free period in the area is from 130 to 140 days  or ebes [grass] which indicates the life form, such as hailson mod, honter mod, sobrog ebes, gejige ebes, togon shugur ebes, borchagt ebes, xiher ebes etc. In this type of folk classification, a word mod or ebes serves as a taxon such as family or genus in scientific taxonomy. These types of names belong to productive complex primary names. Other complex primary names don't include a word to express a folk taxon, belonging to the unproductive complex primary name, such as eljigen taurai, dalan turu, malagan zhala, hatu chagan, yamaan eber, temeen huh, xar orongg etc.Chenopodium acuminatum Willd.) and morin nuil  are formed from the simple primary name nuil; bumburen zheges (Scirpus tabernaemontani Gmel.) and gorbaljin zheges (Scirpus yagara Ohwi) are formed from zheges; morin shabag (Artemisia brachyloba Franch.) and honin shabag  are formed from shabag. A word nuil, zheges and shabag serves as a folk generic and equates to the scientific genus Chenopodium, Scirpus and Artemisia.Secondary names are formed from simple primary names by simply adding a modifier which further describes the plant. Among these types of names, simple primary names serve as a folk generic. For example, secondary names honin nuil  are classified by the locals with the folk specifics nena e egër or nena elpjet . The authors considered that churgul and sulker represented Mongolian dialects in different regions. Glyeyrrhiza uralensis was called xiher ebes in Arhorchin, and called xiker buyaa in Ejina. The first word of the name xiher and xiker were a different pronunciation of the same word [sihir] which means sugar in modern Mongolian language. In the name of xiher ebes, the second word [ebes] means grass, so the whole name means ‘sweet grass’. In Ejina, a folk generic buyaa usually is used to name the plants which have fleshy roots [Achnatherum splendens has only one name, deres, in Arhorchin, but has two names, deres and tongge, in Ejina. The name deres was the same in both areas. Iris lactea var. chinensis has only one name, chahirma, in Arhorchin, but has two names, cakildag and cakirma, in Ejina. The name cakirma was the same in both areas. Artemisia frigida has two names agi and altan agi in Arhorchin, and has two other names xiaralji and agi in Ejina. The name agi was the same in both areas. Phragmites australis has only one name hulus in Arhorchin, but has six names, hulus, acamag, shagxig hulus, shaorag hulus, hana hulus, and ajirgan hana in Ejina. Only one name hulus was the same between two area. Thirdly, the Mongol primary name noil of Chenopodium was used in different ways between the two areas. In Arhorchin, the Mongol folk name of Chenopodium acuminatum and Chenopodium album was called honin noil and morin noil, which belong to the secondary name based on the primary name noil. However, the primary name noil is used as a species name in Ejina. Fourthly, Sonchus arvensis has three different names in Arhorchin and only one name in Ejina. They both have the same word, gaxiun, composing the folk name gaxiun nogo and gaxiun ebes. Using the word gaxiun, meaning ‘bitter’, the whole name can be translate into ‘bitter vegetable’ and ‘bitter grass’. Tribulus terrestris was called tumer zhanggu in Arhorchin and called yamaan zhanggu in Ejina. Both have the same word zhanggu. The word zhanggu usually is used to name the plants which have prickly fruits by local Mongols, such as the species of Lappula, Tribulus, Xanthium etc.Among the other 10 species and 1 variety, folk name taan of hy roots . SecondlSome people may pose the question of why do different groups of the same nationality use different names for plants? The authors think that the answers to this question related to the history and status of Mongolian tribes. Mongolian traditional culture formed under certain natural environment, economic and social conditions. Different tribes of the Mongolian people living in different regions, in different natural environment conditions, in different economic and social development stage, which caused them to have certain differences in language and culture. The difference of their traditional botanical knowledge and culture also caused this reason. Arhorchin Mongolians belongs to the Mongolian Horchin tribe, from the area of Ergun (Argun) River and Hulun Buir Lake moved to the present place for more than 400 years. However, the majority of Ejina Mongolians belongs to the Mongolian Oirat tribe, from the area of Volga River Basin moved to the present place for more than 300 years. The distance between Arhorchin Banner and Ejina Banner is about 2000 kilometers. They hardly have contact with each other, they did not have the opportunity and needs to exchange traditional botanical knowledge. This confirms the regional characteristics of the traditional botanical knowledge.The Mongol herdsmen in the Arhorchin National Nature Reserve were capable of naming 120 species including infraspecific taxa in their own language-Mongol language. In the corresponding rate between plant folk names and scientific names, there are 146 folk names that have correspondence with 120 scientific names of plant species and infraspecific taxa, yielding a computational correspondence of 82.19%. The authors think that this corresponding rate was quite high, the local Mongol herdsmen’s plant nomenclature have very high accuracy. It also can be considered as one of the typical case that the level of consistency between scientific knowledge and traditional knowledge in botanical nomenclature.Structurally, folk names of the Mongol herdsmen in the Arhorchin National Nature Reserve were classified as primary names, secondary names and borrowed name. Primary names have the most cultural significance in the plant folk names. However, Secondary names indicated the existence of folk generic, and have important meanings for folk classification. Borrowed names indicated that local Mongols have had cultural exchanges with other ethnic groups for a long time.Special characteristic of the local Mongol herdsmen’s wild plant nomenclature was undoubtedly focused on physical characteristics of animals, particularly familiar domestic animals like cow, sheep, goat, horse, camel, and steppe wild animals like the wolf, marten, rabbit, crow etc. It can be inferred that the local Mongol herdsmen’s traditional botanical nomenclature is closely related to their traditional animal husbandry and Inner Asian steppe land environment.We have seen plant folk names carrying important information about plant use from this case study. In this sense, plant folk names are not only a code to distinguish between different plant species, but also a kind of culture rich in a deep knowledge concerning nature.The results of comparative analysis of the Mongol herdsmen in the Arhorchin National Nature Reserve and the Mongolians in the Ejina desert area shows that there are some similarities, as well as many differences in language and in the structure of plant names. From this we can infer that Mongolian culture, in terms of plant nomenclature, have characteristics of diversity between the different regions and different tribes.Folk botanical nomenclature and classification of the Mongol herdsmen in the Arhorchin National Nature Reserve is an important part of their natural culture. This type of knowledge and culture has a great effect on their adaptation to the environment, utilization of plant resources and traditional biodiversity management on the community level.Why the establishment of a nature reserve in that place? Because the ecosystem and its biodiversity has been preserved so well. Then, Why is the ecosystem there so good? The land of the Arhorchin National Nature Reserve today used to be the grazing areas of the herdsmen in the near past. In this area, local herdsmen were engaged in animal husbandry from generation to generation. However, the environment here is not damaged yet, the ecosystem there is still very healthy. All of these are due to herdsmen, past and the present. It has been preserved because of the herdsmen’s mode of production, model of life, and traditional culture concerning the natural environment. Luckily, the herdsmen were not moved from this area after the establishment of the nature reserve. The local Mongol people still traditionally use local wild plants for various purposes, and actively cooperate with the administration bureau of the nature reserve.The authors declare that they have no competing interest.The fieldwork for data collection were conducted by S, G, Y, Wand K. Identification of voucher specimens were by S, GL and K. Data analysis and manuscript preparation were by S and K. All authors read and approved the final manuscript.


Constrained Application Protocol (CoAP), a widely accepted web transfer protocol for the Internet of Things, and propose a service management enhancement that improves the exploitation of the network and node resources. This is specifically thought for constrained nodes in the abovementioned conditions and proves to be able to significantly improve the node energetic performance when in the presence of large resource representations .In the Internet of Things (IoT) research arena, many efforts are devoted to adapt the existing IP standards to emerging IoT nodes. This is the direction followed by three Internet Engineering Task Force (IETF) Working Groups, which paved the way for research on IP-based constrained networks. Through a simplification of the whole TCP/IP stack, resource constrained nodes become direct interlocutors of application level entities in every point of the network. In this paper we analyze some side effects of this solution, when in the presence of large amounts of data to transmit. In particular, we conduct a performance analysis of the  In  defined  server.  defined Network Level.In , the autnon-human-centric specification, can be found in some M2M solutions close to the Semantic Web vision. In this vision, the information is machine processable and automated agents retrieve, extract, and combine it. In [OWL Web Ontology Language [Semantic Web techniques and tools to deal with resource-constrained devices. Document [semantic sensor network vision) which aims at solving difficulties in installing, querying and maintaining complex, heterogeneous sensor networks. In [semantic reasoner for embedded devices.In the literature a reasoning similar to the one proposed in this paper, which is based on e it. In , authorsLanguage  , processing (CPU), and reception (Rx) energy components from the amount of sent bytes. Being, indeed, the proposed model based on a Service ID code (identifying the type of service), this does not make the service representation increases (like for the CoAP case).Following an analysis on the effects of the CoAP packet sizes on the lower layers in terms of fragmentation, a simulative study is conducted in a COOJA environment. It aimed at comparing the performance of the proposed approach with the traditional CoAP approach in terms of energy waste. The obtained results testified to a better performing behavior of the proposed transmission method (when compared to standard CoAP) large and short service representations), the proposed method has the advantage to enable a unique global service identifying scheme. This lets programmers, who want to write back-end applications or middleware IoT solutions, to just refer to any IoT service by referring to its Service ID without the need to first discover the particular resource representation of the underlying object domain. Moreover, the proposed solution is backward-compatible, scalable, and independent from the link layer technology.However, in any case  make it possible for 6LoWPAN nodes to advertise their services along with their IP addresses as soon as they get to know their default router. This would allow more performing nodes to create a distributed network service registry that can prevent most constrained nodes from being massively queried for service discovery procedures. Basically, the most constrained nodes would be queried only if they do offer the sought service. Future research works will be focused on evaluating drawbacks and benefits of the envisioned service advertising and discovery mechanisms.In Section 5.2, we mentioned a procedure for the network startup through which nodes get to know their IP addresses, device level, and service IDs. The procedure we have in mind is an extension of the research problem statement in Section 2, the proposed solution tackles large transmission problems caused by large resource representation. This is in line with the focus of the paper, which focuses on the access to constrained nodes' services. However, future research works may investigate the extension of the use of the SM packet for other large transmission cases . The logic of the link-layer burst suggested in [low layer technologies since it works at the Network Level.As announced in the ested in  may be eService ID encoding in the light of the semantic solutions for constrained nodes highlighted in Section 6. This would let the proposed mechanism evolving towards the perspective depicted in [Finally, further future research works will be finalized to enriching the envisioned icted in , where m


Sir,Bony deformities are common but often neglected and under-achieved anonymity in our country. Even though literature endow with standard protocols, the main hurdle that an orthopedician faces during the management is not the deformities per say, it is shattered moral of patients and their relatives which in turn get reflected by patient’s negligent attitude towards the problem like irregular follow-up or even loss of follow-up.Here we highlight one of the most common encountered bony deformity, Clubfoot or congenital talipes equinovarus (CTEV). Clubfoot is the most common deformity of the bones and joints in newborns. It occurs in about 1 in 1000 babies. Approximately 100,000 infants are born annually with clubfoot, 80% in developing nations.The child with neglected clubfoot is condemned to the downward spiral of deformity, disability, dependency, demoralization, depression, and despair. Digging, plowing, harvesting, and carrying firewood and water are unmanageable tasks for children whose limbs are maimed by heredity, accident, or disease. These children are intellectually capable of integrating into the normal school system but never have the opportunity because their needs are not a high priority. Fewer than 2% of children with disabilities attend school in developing countries. The more difficulty the children experience in locomotion, the less likely they are to attend school. Dr. Ignacio Ponseti, who have done the landmark work for the management of clubfoot, popularly known as Ponseti’s technique, have also highlighted the social stigma and psychological co-morbidity associated with clubfoot.5Developing nations such as ours have limited medical and surgical resources. The human cost of neglected clubfoot is enormous, particularly for women and children. Afflicted females are less likely to marry and more likely to suffer abuse. Worldwide, neglected clubfoot is considered to be the most serious cause of physical disability from musculoskeletal birth defects. In agrarian societies, physical disability is a major cause of poverty and ill health. Afflicted individuals are socially and economically disadvantaged, with reduced educational and employment opportunities. The burden of care of the disabled child falls on the mother, who has less time for other children and for domestic, agricultural, and economic activities. Ill health is the most frequent cause and consequence of poverty. The neglected clubfoot deformity results in disability for the individual, a reduced standard of living for the entire family, and a burden to the community. There is an utmost need of various disciplines of medicine to stand together for the management of this crippling problem.The cause of clubfoot is not exactly known, but it is most likely a genetic disorder and not caused by anything the parents did or did not do.5 TherefoWe emphasize over the need of a regular psychotherapist-delivered counseling sessions as an integral part of regular orthopedic management of clubfoot to improve the current treatment scenario with a better quality of life of clubfoot-affected pediatric population and to educate clubfoot patients about disease, building up their confidence that they can be completely cured and emphasizing on the importance of completing the treatment on time.


Lack of insight, very frequent in schizophrenia, can be considered a deficit in Theory of Mind (ToM) performances, and is also found in other psychiatric disorders. In this study, we used the first- to third-person shift to examine subjects with psychotic and psychotic mood disorders. 92 patients were evaluated with SANS and SAPS scales and asked to talk about their delusions. They were asked to state whether they thought what they said was believable for them and for the interviewer. Two weeks later, 79 patients listened to a tape where their delusion was reenacted by two actors and were asked the same two questions. Some patients gained insight when using third-person perspective. These patients had lower SAPS scores, a lower score on SAPS item on delusions, and significant improvement in their SAPS delusion score at the second interview. Better insight was not related to a specific diagnostic group. Patients suffering from schizophrenia are incapable of recognizing and monitoring the self or nonself induced character of their own thoughts. This monitoring capacity, which separates self-generated and world-generated perception, is very important to distinguish between imagination and normal perceptions. If this monitoring capacity is disturbed, self-induced perception is experienced as world-induced .There is increased evidence that patients with schizophrenia have difficulties in social cognition which requires sophisticated judgements about other people's mental states. People with schizophrenia have worse performance profiles in tasks that require the interpretation of social inferences underlying indirect speech. Frith and collaborators, first applied the Theory of Mind deficit hypothesis to schizophrenic patients, and since then many studies have attempted to define the concept in a way that could be tested experimentally –4.It has been suggested that some paranoid symptoms and behavioural signs could be a consequence of difficulties in making inferences about the intentions and beliefs of others . Many clLack of insight is a common symptom in schizophrenia and can be considered a critical manifestation of impaired ToM abilities. Insight in schizophrenia is operationally defined according to five dimensions which include the patient's awareness of mental disorder, awareness of the social consequences of disorder, awareness of the need of treatment, awareness of symptoms, and attribution of symptoms to disorder , 8. FollLack of insight is not only found in schizophrenia, but can also be found in other psychotic disorders and in psychotic mood disorders –12. NeurThe lack of awareness of illness is not specific for psychiatric patients and can be found also in neurological patients. An example is emi-neglect syndrome, in which anosognosia for hemiplegia and lack of awareness of illness are fundamental symptoms. In their studies , 15, TegHowever, if the authors asked the same patients, “If my arm was paralyzed, could I shuffle a pack of cards?” some of the patients responded “Of course not.” These results indicate that in some cases, the passage from a first-person to a third-person perspective can change the patient's awareness about his/her illness. We have previously hypothesized  that thiIn the current study, we have evaluated 92 patients with psychotic and psychotic mood disorders using first- to third-person shift. This task resembles the ToM second-order stories. Our hypothesis was that patients should gain insight and self-monitoring capacity when listening to their own delusions presented in a neutral context.92  patients participated in the study. Patients were recruited from the inpatient service of the Psychiatric Branch of the Department of Medicine, Surgery, and Dentistry of the University of Milan Medical School. All patients in the study had been admitted because of their acute psychotic state. Only those who volunteered and gave informed consent were included in the study. Informed consent with respect to the purposes and the procedure of the study was obtained from all subjects prior to starting the testing procedure. Diagnoses were made according to the DSM-IV-TR criteria by the authors (S. Scarone and O. Gambini). 69 subjects had a diagnosis of schizophrenia , 7 had a diagnosis of psychotic mood disorder , and 16 subjects had a diagnosis of other psychotic disorders . Inclusion criteria were one of the previously cited diagnoses and the presence of delusions. Exclusion criteria were organic illnesses involving the central nervous system, current substance abuse and/or past and current alcohol dependence, and clinical evidence of mental retardation. Subjects were asked to participate during the first part of their inpatient stay. All patients were on antipsychotic medication at the time of our study. 25% of them were receiving 1st generation antipsychotics  and 75% were receiving 2nd generation antipsychotics (19% of these were receiving clozapine). As for patients with mood disorders with psychotic features a mood-stabilizing medication was administered on top of the antipsychotic medication to all 6 bipolar patients—all of these patients were evaluated during a manic episode . One patient suffering from major depressive disorder with psychotic features was receiving antidepressant medication, specifically mirtazapine. The patients had different delusional contents; 80% of the patients had delusions with grandiose, persecutory, and reference contents. Remaining subjects had guilt, religious, or bizarre delusions.First part of the study: 92 subjects were assessed by means of Scale for Assessing Positive Symptoms  and theThe patient's opinion about his/her ideas, that is, if he/she considered his/her own delusional ideas believable.The patient's idea about the interviewer's point of view, that is, if the interviewer could consider the patient's delusions believable.Each interview lasted about 1 hour.Second part of the study: the interviews were tape recorded and transcribed during the first part of the study. Subsequently, (with a delay of 2-3 weeks) 79 out of the 92 subjects, participated in the second part of the study. At this time, 29 of these 79 patients had been discharged. Each patient listened to his/her interview reenacted by actors . At the end of the tape session, the interviewer asked the same questions. The questions were:“Do you think that the interviewed subject presents believable contents?” and “If you were the interviewer would you consider what the other person told him/her believable?” Answers were scored according to the following.The patient's opinion about his/her ideas, that is, he/she considered his/her delusional ideas believable even when presented by another person.The patient's idea about the interviewer's point of view, that is, if the interviewer could consider the patient's delusions believable.Statistical analysis used Chi-square and ANOVA. ANOVA was performed on age, age at onset, duration of illness, years in school, sex, diagnosis , SANS and SAPS score, item “delusions” score, and improvement of item delusion between first and second clinical interview for the two groups of patients, that is, those who considered believable (do not achieve insight) and not believable (achieve insight) both for the first interview (Questions P < .027), and improvement of item delusion score between first and second clinical interview (P < .001). Patients with lower item delusion score and a higher improvement of their item delusion score from first to second interview were more likely to provide a negative answer to our questions at the second interview (P < .048), item delusion score at second interview (P < .013), and improvement of item delusions score between first and second clinical interview (P < .001). Specifically, patients who gained insight  was believable for them. However, 12 patients thought it was not believable from another person's point of view. After the second interview, 21 of the 79 patients who underwent the second part of our study, stated that the content of the tape was not believable. 17 of these 21 thought it was not believable from the interviewer's point of view whereas 4 of them thought it was not believable both for them and for the interviewer. None of the demographic and clinical variables was correlated with the answers the patients gave at the first interview. However, the answers that the patients provided after the second interview  showed anterview , we founight see  had a loight see . 53 patiAs for the first part of the study, 91 patients out of 92 state what they said is believable for them. 12 patients out of these 91, however, considered what they said was not believable for the interviewer. This indicates that, similarly to Tegner and Marcels's study, shifting from first- to third-person perspective allows some patients to gain insight . This may indicate that these patients have a functioning ToM and are therefore able to gain insight when asked to modify their cognitive perspective. As mentioned, none of the variables we considered was statistically correlated with the answers the patients gave after the first part of the study. In the second part of the study data are available for 79 patients. After the second interview, 21 patients state what they heard from the tape is not believable; 17 of these patients think it is not believable from the interviewer's point of view, 4 think it is unbelievable both for them and for the interviewer.Statistical analysis showed a correlation between a negative answer at Questions The observation that patients who are less delusional have better insight is consistent with literature data and may depend on the fact that psychotic patients have a rigid cognitive style and a certain overconfidence in their opinions. Also, literature data indicate that the occurrence of delusions is associated with low self-reflectiveness and high self-certainty, possibly reflecting low cognitive insight . StudiesWe also analyzed which patients expressed different opinions about their delusion at the first and at the second clinical interview, and how their opinion changed. Most patients (61), give the same answers at both interviews . These patients show no significant variation at their item delusions scores between the first and the second clinical interview. 18 patients expressed different opinions about their delusion at the first and the second interview. In particular, 10 switch from thinking that the delusion is believable both for them and the interviewer to thinking it is unbelievable for the interviewer ; 3 go from thinking the delusion is believable for both to thinking it is unbelievable for both (gain complete insight); 5 patients lose insight stating the delusion is unbelievable for the interviewer after the first interview and stating it is believable both for them and the interviewer after second interview. Patients who gained partial insight improved by a mean of 7.9 points at their item delusion at the second interview. Patients who gained complete insight improved by a mean 12.3 points; patients who lost insight worsened in their item delusion score (on average 1.8 points) but had a mean overall item delusion score at the second interview which was significantly higher than the score of patients who gain partial or complete insight .Our data indicate the improvement of delusions positively correlates with the capacity to gain insight, and the greater the improvement in delusion, the better the insight (a higher improvement was displayed by patients who gained complete insight). Overall, our data indicate that the shift from first to third person allows certain patients to gain insight, by using their ToM (making inferences about the interviewer's point of view). There is also evidence that the patients ability to achieve insight into delusions is strongly related to the intensity of the delusion itself. The less delusional the patients are, the more likely it is that they will have insight into their delusions, regardless of their diagnosis.


The Global Fund is experiencing increased pressure to optimize results and improve its impact per dollar spent. It is also in transition from a provider of emergency funding, to a long-term, sustainable financing mechanism. This paper assesses the efficacy of current Global Fund investment and examines how health technology assessments (HTAs) can be used to provide guidance on the relative priority of health interventions currently subsidized by the Global Fund. In addition, this paper identifies areas where the application of HTAs can exert the greatest impact and proposes ways in which this tool could be incorporated, as a routine component, into application, decision, implementation, and monitoring and evaluation processes. Finally, it addresses the challenges facing the Global Fund in realizing the full potential of HTAs. The Global Fund, created in 2001 as a global financing mechanism, enables low-income countries (LICs) and middle income countries (MICs) to promote access to certain health interventions and technology for the prevention and treatment of HIV/AIDS, tuberculosis, and malaria. Given the commitment from its donors—amounting to almost $30.5 billion in pledges and $24 billion in contributions to date—as well as its scale of work in approximately 100 countries [As a global health financier rather than a technical or implementing institution, the Global Fund does not operate directly within countries or implement its own programs . HistoriIf a proposal is approved, funds can be disbursed under the supervision of the CCM to the Principal Recipients (PRs) and/or Sub-Recipient(s) (SRs) who are responsible for the program’s implementation. In addition, a Local Fund Agent (LFA), an independent body contracted by the Global Fund Secretariat, is responsible for monitoring the PR’s performance, grant implementation, and financial reports. Global Fund grants can be made for a period of up to five years, although funds are typically reviewed after two years, with continued funding conditional upon performance  and otheAs donor funding for global health declines due to the global recession, the Global Fund is experiencing increased pressure to optimize results and improve impact per dollar spent . In its As of 2013, the Global Fund has disbursed a total of over $20 billion in 151 countries . Its invThe Global Fund is governed in a unique way, both at a board and implementation level. Leadership is sourced from within developing counties, the private-for-profit sector, and civil society. There is a strong commitment to increasing transparency and accountability, and as a result, the fund has improved the availability and accuracy of information related to the disbursement of funding and coverage of specific services, including the establishment of specific surveillance of the focal diseases, despite difficulties involving duplication of information systems in some recipient countries . In addiAlthough there is an argument that performance-based funding systems might place LICs at a disadvantage due to their comparatively poor access to resources and capacity, at least three studies have rejected this hypothesis ,10,11. TAlthough the Global Fund has dedicated itself to increasing prevention and control of AIDS, tuberculosis, and malaria, it has also made significant investments in improving the health systems of LICs . FlexibiAs with a number of global health initiatives, including the GAVI Alliance, the policies and priorities of the Global Fund are defined at a global level. Although the Global Fund works to maintain relatively high levels of national ownership in its programming, evidence suggests that there remains misalignment between its policies and programs and those of national governments. As a result, services that are managed both by the government and the Global Fund are often badly coordinated and inefficiently managed, with duplication of tasks—including reporting, monitoring and evaluation, and funding/disbursement mechanisms—representing significant obstacles to efficiency ,14. DelaSeveral studies have identified efficiency shortfalls within the Global Fund. At a macro-level, Zhao et al.  reviewedThis situation is repeated across HIV and tuberculosis programs. Effective and efficient prevention and control depend on implementing the right mix of interventions for each setting and assuring the necessary coverage of those interventions. Bridge et al.  found thAside from the issue of effectiveness, an increasing amount of information on resource use and health consequences, i.e. cost-effectiveness, has been amassed in recent years. Global health professionals no longer focus only on effective prevention and treatment; instead, more sophisticated models that examine cost-effectiveness and comparative effectiveness as a way of improving public health without requiring significantly more funding are at the centre of most public health initiatives. The differences in cost-effectiveness between interventions can be staggering, particularly when considering initiatives that require implementation at scale. For instance, despite massive increases in access to HIV treatment, WHO and UNAIDS estimate that, as of 2011,there are still as many as 15 million people around the world in need of antiretroviral therapy. To treat populations of this scale, the difference in cost-effectiveness between the most cost-effective treatment option and the least can be as much as 1,400 fold (Disease Control Priorities in Developing Countries Project) . Even diDespite the Global Fund’s explicit commitment to implementing cost-effective and proven initiatives, it is clearly failing to fund programs that fulfill these criteria to the extent that it should. This may be because the Global Fund provides support to countries based on requests received from CCMs, who themselves may not have a clear idea about a country’s needs or the most cost-effective strategies that can be implemented to meet those needs. As a funding organization, the Global Fund has little in-house technical capacity and little direct engagement with countries to which they provide funding. There is no systematic support to PRs on whether proposed interventions are among the most effective and cost-efficient for achieving the desired outcome in a given context. Although the TRP has been set up to provide funding recommendations to the Board of the Global Fund for making final decisions, it is difficult for the TRP to assess technical soundness and value for money or to make rational recommendations on strategic investments based only on the data presented in the applications, especially when the information is weak, patchy, or inconsistent, and where funding is limited to specific time periods. Moreover, an absence of guideline on what information should be used in order to assess value for money and a lack of HTA capacity of the TRP secretariat prohibit the use of value for money information in TRP review process.Furthermore, it is widely accepted that the impact and cost-effectiveness of interventions depends to a large extent on the strength of the health system within which they are delivered. A lack of absorptive capacity at all levels of grant implementation has been identified in many settings and may explain the slow progress in grant implementation outside of a robust health system ,27. PrevThe situation can also be applied to the substantial investments in health information systems for improving healthcare services and enhancing management, monitoring and evaluation of the fund itself. Until now, very few studies have addressed this issue ,35. As aAs is made clear in The Global Fund strategy 2012–2016, the organization must make the transition from an emergency funder to a long-term, sustainable financing mechanism. To this end, it needs to develop new risk-management approaches, strengthen internal governance, institute a new grant-approval process, strengthen decision making by middle management, and improve its focus on results . AlthougAn experienced independent expert body such as the National Institute for Health and Clinical Excellence (NICE) could be commissioned to conduct robust comparative cost-effectiveness analyses of two or more WHO-recommended products and provide that information to the Global Fund and its recipients.” This is not the first time that academics have urged the Global Fund to consider the use of HTA to improve its cost-effectiveness [A 2011 report  by the Rtiveness . The apptiveness .HTAs not only generate a wide range of policy-relevant information that can aid decision making, but also empower stakeholders that are involved in the decision making process. This is because HTAs, as tools in a priority setting approach, are often designed according to a set of questions that themselves encourage a critical evaluation of the relevant social and financial factors . This kiFigure the value for money guidance, but also that HTA be applied to at least some aspects of a proposal before implementation. These ex-ante HTAs would use existing evidence and assumptions to estimate the likely costs and impacts of the proposed program  will be a valuable resource for the Global Fund and other development agencies in making future resource allocation decisions. An equally important implication is that ex-post HTA can provide information to various responsible authorities in recipient countries to encourage them to continue financing programs that are proven to be good value for money. As sustainability is a serious concern for all parties involved in the delivery of external aid, and local governments are often in a difficult situation on whether to continue the support for initiatives previously funded by external donors, ex-post assessments can provide good opportunities to inform decision makers in recipient countries about the usefulness, value for money, and other implications the program might have if it is maintained.Lastly, it is advised that HTA be included as part of the final report that all CCMs submit to the Global Fund when a particular program comes to an end. This should help the Global Fund incorporate feedback mechanisms regarding the requirements, constraints, and potential of the PR and SRs, who will ultimately determine if the Global Fund will achieve its goals. Collective information on the value for money of various programs implemented in different settings  and PRs  to negotiate prices with those in the industry, by using its evidence as their guidance.The Global Fund has enjoyed reputational benefits due to its promotion of performance-based financing. It is possible that the use of HTAs may help this reputation to grow. Firstly, the Global Fund would be able to make better-informed interventions, due to the evidence garnered by HTAs and by complying with the HTA-informed ing ITNs . Health ing ITNs . Under ting ITNs . ClearlyAlternatively, efforts can also be made for improving the efficiency of performance-based payments, which currently rely on many input indicators rather than outcomes or impacts. The use of HTA data would allow the fund to set standard payments per unit of output (e.g. number of condoms distributed) or outcome (e.g. % reduction of unsafe sex) which are closely linked to the final goals of the program (e.g. rate of HIV infection averted). This ceiling on standard payments would serve to drive substantial efficiency gains across the Global Fund’s investment portfolio and exert pressure on other funders to decrease their own unit costs and improve efficiency. Countries that cannot meet the low-end unit costs set by the Global Fund would make up the difference from other sources, leading to enhanced cost sharing. With this option, the Global Fund can focus on providing effective coverage of proven interventions, an area where current monitoring and evaluation had identified significant shortfalls.There is currently a new emphasis at the Global Fund and other global health initiatives to focus on ensuring the effective use of resources and on generating improved value for money. This timely report proposes that additional mechanisms, such as conducting HTAs before, during, and after grant implementation, can help improve the efficiency of Global Fund investment. Although some technical and management challenges merit further investigation, the costs of delaying the use of HTA evidence-informed investment in the Global Fund are high given the severe disproportion between the current resources available and the need for prevention and control of three major disease burdens worldwide.With regard to ethical approval, this was not required because of the nature of our paper. Also, the authors have no conflict of interest to declare.We confirm that all named authors meet the criteria of authorship. All authors equally contributed to the course of the review and provided critical comments to the manuscript.


The misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect. Shared decision-making could be a promising strategy to improve appropriate antibiotic use for ARIs, but very little is known about its implementation processes and outcomes in clinical settings. In this matter, pilot studies have played a key role in health science research over the past years in providing information for the planning, justification, and/or refinement of larger studies. The objective of our study was to assess the feasibility and acceptability of the study design, procedures, and intervention of the DECISION+ program, a continuing medical education program in shared decision-making among family physicians and their patients on the optimal use of antibiotics for treating ARIs in primary care.A pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program.Among 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians  and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% , and the overall mean level of satisfaction regarding the workshops was 94%.This trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making.NCT00354315Clinicaltrials.Gov  The misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect -4. Only i.e., patient decision aids) have been found to improve knowledge of the options and accuracy of the perception of their benefits and harms, to reduce difficulty with decision-making, and to increase participation in the process [SDM is a process by which a healthcare choice is made by physician together with the patient and is characterised by a two-way exchange of information, values, and preferences, both parties taking steps to build a consensus and reach an agreement on the decision to be made ,7. From  process . Althoug process ,10.Decision-making occurring during a clinical encounter between a patient and a physician is a complex and highly interactive process. Although many studies have attempted to capture the relational nature of this encounter, members of this dyad have been mostly studied independently, as if living in different worlds ,10,11. RPilot studies, in providing critical information on both the processes and outcomes, offer a unique opportunity to identify the difficulties of evaluating an intervention, and thus enhance the rigour of larger full-scale studies. There is growing interest in the use of pilot studies for randomised trials -20, partpilot study is defined as a small-scale version of anticipated research [pilot work has been referred to as any background exploratory research that may form the basis of a future study [pilot studies or trials have been recommended for studies with a specific hypothesis, objective, and methodology, the latter including a randomisation procedure [In general, a research ,19. Morere study ,29, wherrocedure . Feeley rocedure . Accordirocedure . Whetherrocedure .The current paper describes the recruitment process and reports on the feasibility and acceptability of conducting a larger clustered randomised trial of the DECISION+ program, an innovative, theory-driven continuing medical education (CME) program in SDM on the optimal use of antibiotics for ARIs in primary care settings among family physicians and their patients . SpecifiThis study was a two-arm pilot clustered randomised trial. FMGs, the unit of randomisation, were simultaneously and randomly assigned using an Internet-based software to either an experimental group in which participating family physicians were provided the DECISION+ program immediately or a control group in which exposure to the DECISION+ program was delayed Figure . The DECThe study was conducted in FMGs of Quebec City and surrounding areas  between January 2007 and March 2008. FMGs are groups of family physicians  who work in close cooperation with nurses to offer family medicine services to registered individuals. During the last decade, in the province of Québec, the Ministry of Health and Social Services has provided incentives and support to private practitioners to construct such primary care groups in order to improve accessibility and continuity of care and facilitate interdisciplinary collaborations .e.g., pregnancy, retirement, practice restricted exclusively to administrative duties). Patients, adults or children, were included in the study if consulting a participating family physician for an ARI and if an antibiotic treatment was being considered by either the patient (or guardian) or the family physician. Patients with a condition requiring emergency care were excluded. Patients could take part only once in the study. All participants, family physicians and patients, signed an informed consent form approved by the ethics committee from the university hospital institutional review board.FMGs were eligible if located in two pre identified health regions  and if their family physicians were being paid fee-for-services . Family physicians from participating FMGs were excluded if they were currently involved or had previously participated in an implementation study of SDM in clinical practice, or if they did not plan to practice for the duration of the study  after an initial introduction phone call by a research assistant. When contacted, the director was provided with information regarding the DECISION+ program, and a one-page summary of the project was faxed. The director was requested to discuss potential participation in the project with his/her colleagues. An FMG could either accept or decline to participate at this point. However, a short meeting between the research team and FMG members was offered up-front to all directors in order to facilitate decisions about participation in the study. All members of the FMG, including nurses and practice managers, were invited to participate in this meeting. One of the principal investigators and one or two research team members subsequently attended the meeting to present the study to family physicians and to clarify concerns or ambiguities regarding the program or the project. If at this point an FMG confirmed its participation, attending family physicians immediately completed the consent form. Additional information and consent forms were provided for family physicians not attending the meeting, and they were personally contacted by a research assistant one and two weeks later if they had not returned the consent form. Those who had still not responded after two weeks were contacted personally by one of the two principal investigators. If a given FMG decided to delay its acceptance or refusal to participate in the study, the research assistant or one of the principal investigators would contact the medical director once a week until receiving a final answer. Participating family physicians were offered CME credits upon the completion of the program and the opportunity to keep all the materials and tools offered during the project. No financial incentive was offered during the study beyond the usual Provincial Government subsidy provided to all family physicians participating in a three-hour-a-day-accredited CME activity.Fifteen patients per family physician were recruited, five per data collection period Figure . Family i.e., phone calls, emails, personal visits) with the practice manager, the medical director of the FMG, and reception staff to sustain and reinforce commitment to the project. The research team provided a biweekly bulletin to keep FMGs and their family physicians informed about the progression of the study and about any recent findings regarding antibiotic use for ARIs, when available. The research team ensured that the questionnaires, when possible, were completed during a planned activity .The disruption of office routine was kept to a minimum. Research assistants were responsible for all stages of the recruitment process and served as the primary means of communication between the research team and the FMG manager and participating family physicians. They maintained regular contact .The development of the program was under the supervision of the principal investigators, two family physicians (an epidemiologist expert in evidence-based medicine and an expert in SDM and its implementation in primary care), in collaboration with two CME university offices. All three workshops and material were pretested with a panel of family physicians and experts from various related fields  a diagnostic aid for physicians to better appraise the probabilistic nature of the diagnosis of a bacterial versus viral ARI, (2) a graphic display of the benefits and risks of antibiotic use for ARIs to be shared with their patients, (3) a section helping patients to elucidate their values and preferences regarding the benefits and risks of using or not using antibiotics, and (4) a section regarding the decision to be made with the patient. The first two sections were based on the best scientific evidence regarding the probabilistic nature of the diagnosis of an ARI and the effectiveness of antibiotics for treating ARIs. The remaining sections were adapted from the O'Connor generic decision aid  and inclAside from the biweekly progression bulletin, one-sheet letter-size paper reminders reemphasizing the use of the decision support tools discussed in a previous workshop were sent to participating family physicians every one to two weeks after the first and second workshops. During the third workshop, family physicians were provided with individual feedback on the agreement with their patients' evaluations on comfort with the decision to use or not to use antibiotics in ARI. In addition, they were informed of the pooled results from their colleagues. Time was made available during the workshop to explain how to interpret the results. This information was collected at the time of the first data collection period (the first five patients per physician) prior to exposure to the workshop Figure .To facilitate attendance, workshops were offered at the site of each participating FMG. Family physicians not available at that time were given the opportunity to attend the workshop of another FMG within their study group (immediate or delayed). All family physicians received copies of the program material. Family physicians were considered to be collaborators and were invited to give their insights. This resulted in open discussions regarding logistical aspects of the project following each workshop. Family physicians also completed a questionnaire regarding their level of satisfaction with the CME program, and they had the opportunity to express anonymous comments on the project.Data about the organisation were collected from participating FMGs at the beginning of the study. Modifications to the FMG status or staff or significant events occurring in the participating FMG throughout the study period were also recorded. Sociodemographic variables along with entry/exit measures were collected from family physicians through self-reporting questionnaires before the first and after the last patient recruitment period Figure . Postclia priori threshold for specific feasibility and acceptability criteria. These were the following: (a) the proportion of contacted FMGs participating in the pilot study would be 50% or greater, (b) the proportion of recruited family physicians participating in all three workshops would be 70% or greater, (c) the mean level of satisfaction from family physicians regarding the workshops would be 65% or greater, and (d) the proportion of missing data in each completed questionnaire would be less than 10%.Feasibility (delivery) and acceptability (uptake) of the DECISION+ program were the main outcome measures of this pilot trial. Investigators had established Satisfaction with the program was measured using a standardised CME satisfaction questionnaire from the CME university office. This questionnaire contains 13 items, each assessed on a four-point (1 = completely disagree to 4 = completely agree) Likert-scale, related to the relevance and scientific quality of the content, the educational structure of the workshops, the trainers, and the workshops in general.After the onset of the trial, investigators and the research team met regularly (biweekly or monthly steering group meetings) to evaluate the progress of the study and to overcome or discuss issues and barriers that had arisen. These evaluations were based on reports from on-site research assistants and comments and evaluation from trainers and participants in the workshops. Thus, retention and burden outcomes were added to the preestablished outcomes. The appropriateness of selection, timing, and sequencing of similar study measures for patients and their family physicians were also documented.Secondary outcome measures are detailed and reported elsewhere ,31. BrieAccording to the list extracted from the Ministry of Health and Welfare web-based registry, there were 24 accredited FMGs in the two selected health regions at the time of recruitment. In total, 21 FMGs were eligible Figure .A research assistant made 41 introductory phone calls to contact the medical directors of the 21 eligible FMGs over a four-week period. One director could not be contacted. Information leaflets were faxed to the 20 contacted FMGs. Second attempts by the research assistant to assess willingness to participate in the study or to attend an information meeting resulted in 39 calls over an 11-week period. Twelve FMGs declined participation in the study and eight FMGs agreed to meet with the research team. After the meeting, a total of 36 additional calls over a period of nine weeks were necessary to get a final answer. Four FMGs agreed to participate. Two were randomly assigned to the experimental group (immediate DECISION+ program) and two to the control group (delayed DECISION+ program). A fifth FMG accepted too late to be randomised and was assigned to the control group, for a total of five (24%) contacted FMGs participating in the study  agreed to participate in the study. Proportions of participating family physicians in the two experimental and three control FMGs were 90% and 66%, respectively. The characteristics of family physicians by study groups are detailed in Table A total of 544 patients were recruited, and 510 (94%) were contacted one week after the medical visit. On average, there were 5.3 patients recruited per family physician per period per group. Patients' characteristics are reported in Table All five FMGs completed the study. A total of 36 (92%) family physicians completed the study  were offered by both principal investigators, whereas the remainder was offered by one of the principal investigator and a collaborator in the study. None of the workshops was reassigned. In the control group (delayed), only one of the nine workshops was offered by both principal investigators. Six workshops were offered by one principal investigator and a collaborator, one was offered by one principal investigator only, and one was conducted by two collaborators. Two workshops had to be reassigned because of anticipated poor attendance or the unavailability of principal investigators or collaborators.Overall, 29 (74%) family physicians participated in the first workshop, 27 (69%) in the second workshop, and 22 (56%) in the third workshop Table . AlthougGlobal mean levels of satisfaction for the workshops in the immediate and delayed groups were, respectively, 97% and 98% for the first workshop, 96% and 90% for the second workshop, and 95% and 89% for the third workshop. The overall level of satisfaction of family physicians for the workshops of the DECISION+ program was 94%. The results according to the various items evaluated were similar to global mean levels and, thus, are not reported in detail.To the best of our knowledge, this paper is among the first to describe in detail the recruitment process of FMGs, family physicians, and patients to a pilot trial of the DECISION+ program, a CME program in shared decision-making on the optimal use of antibiotics for treating ARIs in primary care practice. Moreover, the results of this trial support the feasibility and acceptability of conducting a large clustered randomised trial involving dyads of family physicians and their patients in SDM regarding the optimal use of antibiotics for ARI. This conclusion is reached even if not all predetermined standards for our criteria were always fully met. Indeed, it has been established that not reaching the preestablished criteria does not necessarily indicate unfeasibility of the trial but rather underlines changes to be made to the protocol .Identification of FMGs and associated family physicians was a relatively simple process. The necessity for FMGs to be accredited, the relative stability of these FMGs, and the availability of a free web-based registry facilitated this process. Identification of individual family physicians would have been more difficult because available registries are rapidly outdated .The main difficulty in recruitment appeared during the initial contact by the principal investigator with the medical director of the FMG. Twelve FMGs (57%) declined the invitation even before the face-to-face meeting. Thus, 24% of the eligible FMGs agreed to take part in the study, less than the 50% expected. We were probably too confident when targeting a 50% positive response rate from all identified FMGs. Recent studies regarding appropriate use of antibiotics reported recruitment rates for groups of providers of 56% and 37% ,39. RecrNonetheless, it is interesting to note that out of the eight FMGs that agreed to an on-site meeting, four immediately accepted the invitation to participate in the study. This suggests that having the opportunity to clarify face-to-face the nature of the study and the time and efforts required from participants may facilitate the recruitment process when participants are interested in learning about the study. According to Dormandy and colleagues (2008), factors that appeared important in retaining practices in a study are good communication, easy collection methods, and payment of incentives as scheduled . At the Conducting studies with family physicians and their patients is challenging, mostly as a result of the competing time demands of family physicians for other clinical and administrative tasks ,17. FurtAs for patients, the challenge was to proceed to recruitment in the FMG waiting room, without disrupting or delaying the patients' consultation flow. Having research assistants recruiting patients minimised a potential selection bias if recruitment had been driven by family physicians and maximised the recruitment rate, as recruitment driven by physicians is usually only moderately successful .Considering their busy schedules, we anticipated that collecting information from physicians after each clinical encounter would be challenging, and therefore, we were particularly interested in the proportion of missing postencounter questionnaires. Surprisingly, all completed the questionnaires (100% completion rate), and there were very few missing data, suggesting that it is possible to collect similar and simultaneous measures from both family physicians and their patients. Factors that might have contributed to this high rate could include the fact that postencounter questionnaires were very short (approximately two to three minutes to complete) and were included with the patient's medical file so that they could be completed at the same time as the medical note. Furthermore, completion is likely to have been enhanced by the presence of a research assistant who reminded physicians of their task.Based on this pilot trial, the planning of the recruitment of participants for a larger trial needs to be carefully thought out. Although demanding for principal investigators, having a meeting with members of the FMGs seems to be useful, as it could have reinforced the decision to participate in this type of study. Moreover, it could have led to a more informed consent, conducive to sustained participation. Second, recruiting patients particularly in the context of ARI also needs to be carefully planned. One of the data collection periods occurred during summertime, when patients consulting for ARIs are less frequent, and thus, the time for collection period was longer than anticipated. Third, the pilot study was limited to FMGs, as they had a fee-for-service organisation, but other primary care groups might be considered for a larger trial. Family practice teaching units could be an interesting group to target, as they are usually larger in size than FMGs and have more physicians, including residents. Regardless of study type or method, successful identification, selection, and recruitment of participants, whether they are groups of physicians, individual physicians, or patients, are important issues to be considered by all intending researchers , and pila priori acceptability criteria that a 70% participation rate would be ideal for the success of a larger-scale study. Considerations need to be taken and lessons learned. Findings from a recent systematic review on the adoption of SDM by providers revealed that participation of providers in the intervention varied between 47% and 100%, with a median of 52%, independent of the length of the intervention [Regarding participation in the DECISION+ program, a total of 46% of all participating family physicians completed the three 3-hour workshops, for a total of nine hours over four to six months. We had made rvention . In retrrvention .Considering all these elements, the length and duration of the workshop should be considered when planning and conducting a larger trial to increase generalisability of the intervention. Introduction of a web-based or self-learning element, reduction of the length and/or numbers of workshops for both participants and trainers, and improvement of train-the-trainers strategies for collaborators needs to be considered.Limitations need to be acknowledged. First, the pilot study was limited to FMGs, as they had a fee-for-service organisation, but other primary care groups might be considered for a larger trial. Second, the low response rate of FMGs may limit the generalisability of the findings, although the sociodemographic characteristics of participating family physicians were similar to the characteristics provided by the provincial registry (data not shown). Third, we lacked information regarding the number of patients that presented themselves at the outpatient clinics for an ARI and the total number of patients seen by physicians during the study period. Finally, it is possible that FMGs, family physicians, and patients who participated in the study might have had higher interest or motivation in the DECISION+ program than those who did not participate in the study.Notwithstanding these limitations, rigorous pilot trials are meritorious projects, and their results should be subjected to the same level of scrutiny and requirements as those provided to the results of full-scale trials . HoweverThe present study has highlighted the significant practical and methodological issues in undertaking a clustered randomised trial involving family physicians and their patients while minimising burden on the normal state of the clinical encounters. This pilot trial will help to better define a larger cluster trial concerning the evaluation of an intervention targeting the improvement of the SDM process among family physicians and their patients regarding the use of antibiotics for treating ARIs in primary care.The authors declare that they have no competing interests.AL, who was a doctoral student at the time, participated in all stages of the study, was responsible for the analysis, and wrote the manuscript. FL and ML developed the research protocol, were responsible for the overall conduct of the study, and participated in the drafting of the manuscript. All authors contributed to the final version. AL is its guarantor. All authors read and approved the final draft.