Macrotermes, Trinervitermes and Odontotermes. Five collection methods are used to obtain termites and involve either breaking mounds or using containers as traps. Collection methods vary with species and region and the abundance of termite genera varies with season. Farmers identified some species as poisonous to poultry. Termites are important in indigenous poultry production because they are a readily available protein source for local farmers. However, better collection methods need to be developed to aid their optimal use. The aim of the study was to gather information on the use of termites by farmers as feed for indigenous poultry in Ghana and factors affecting its use. We conducted surveys in four regions in Ghana to collect information, by the administration of questionnaires, on the use of termites as poultry feed, termite species collected, species not used and collection methods. Samples of termite species mentioned were collected and identified to the genus level. Twenty-three percent and 19% of farmers mentioned that termites are always or often used to feed poultry whereas 11% never use termites. A binomial regression analysis showed that their utilization was affected by region, sex, education, farm size and income. Termites collected belonged to eight genera, the main ones being  The use of termites by man is a common practice in Africa, Asia, Latin America and Australia. Figueirêdo et al.  recordedNoditermes species caused mortalities in two poultry species while Trinervitermes species were safe. In Burkina Faso, it was reported that some species of Cubitermes are toxic to chicks of domestic fowls but not to guinea fowl and ducks [In West Africa, termites are collected from chippings of termite mounds or by trapping, using inverted pots or baskets filled with organic matters and placed in the vicinity of termite nests ,17,18. Ind ducks . In Ghana, to the best of our knowledge, no such documentation exists and yet verbal communication with farmers practicing indigenous poultry rearing shows the extensive use of termites in their feeding activities. It has, therefore, become imperative to gather knowledge on the practice to allow the assessment of the different techniques in order to disseminate the most efficient ones and improve the availability of protein feed among smallholder farmers. The study was conducted through two large-scale surveys in four regions in Ghana, to access the utilization of termites as poultry feed in the country, determine factors that influence the use of termites, identify the termite species used as feed and the toxic species, assess the availability at different seasons and describe the methods used in obtaining termites. The investigation on the use of termites as feed in traditional poultry production was conducted in four regions of Ghana, i.e., Volta, Northern, Upper East and Upper West. These regions were purposefully selected due to their dominance in indigenous poultry production. The Volta region is in the southern half of the country fringing the eastern border. The vegetation varies from coastal grassland, mangrove swamps, guinea savannah, to mountainous wooded savannah, marked by two annual rainfall seasons. The main socio-economic activity is agriculture, with livestock ranking second to crop production. The three other regions are found in the northern belt of Ghana, occupying almost half of the land area of the country. The vegetation of the three regions is mainly savannah woodland with grassland and scattered drought-resistant trees such as baobab, acacia and shea tree, characterized by six months of a single rainy season with a prolonged dry, cold and hazy harmattan season. The three northern regions are popular with traditional poultry production and account for the majority of the local poultry found in the country .Data from two different surveys were used in the study. The first survey  was a large-scale survey carried out to collect information on poultry farming in Ghana in the framework of the project “Insects as Feed in West Africa—IFWA”. A structured questionnaire was administered to 1960 farmers, randomly selected from 31 districts in the four study regions between October and December 2015. Most farmers were practicing indigenous poultry production but others had a more industrial production. Enumerators were obtained from the Regional Agricultural Departments, trained on the expectations of the study to assist in administering the questionnaires. The questionnaire included, among others, questions on the use of termites as feed to poultry, as well as characteristics of the interviewees. The questions on termites that were retained for this study were: the use of termites as poultry feed . The reasons for using termites or not were also collected. The questions that were used to analyze the factors affecting the use of termites were: region; sex; age ; religion ; educational background ; Annual income from poultry farming (in GHC); years of poultry farming , farm size (ha). A second survey (hereafter named specific survey) was later conducted in selected villages to obtain more precise data on the practices of termite use as feed. Villages were randomly selected from districts that, from the general survey, most frequently used termites as feed for poultry. Since the general survey had shown that large, industrial poultry producers do not use termites, the specific survey focused on traditional poultry farmers. A questionnaire was designed that contained open questions on: termite species used ; description of termites used; collection or trapping methods; toxic termite species ; description of toxic species; reason for being termed toxic/poisonous; effect on the poultry when fed; variations in the termite species collected in the different seasons. The questionnaire of the specific survey is provided in Macrotermes species were identified using Ruelle [Termites were identified to the genus using Bouillon and Mathot  and Sandg Ruelle . Only geg Ruelle  and, secData from the general survey were used to analyze the factors affecting the use of termites as poultry feed by farmers. Two groups of poultry farmers were defined according to their use of termites. Those that answered “never” or “seldom” were classified as the non-users. Those that answered “sometimes”, “often” or “always” were classified as users. The effect of the different factors on the use of termites was examined using a binomial regression analysis. All factors were fixed: region; sex; age; religion; educational background; annual income from poultry farming; years of poultry farming; farm size. After the removal of respondents that had not correctly answered at least one of the questions, 1232 cases were included in the analyses. A stepwise selection of variables was first made before adjusting the model to the data, in order to avoid correlations between explanatory variables in the model. A stepwise regression incorporated both backward and forward approaches, and finally considered only significant explanatory variables in the final model. The selection of variables and the adjustment of the binomial regression to the data were carried out using R3.3.4 , with thFrom the specific survey, we used the data of four regions of Ghana to build a termite species relative frequency matrix based on local people citation. Although the total number of the local sample of termite species surveyed in all the districts reached 105, after identification in the laboratory we enumerated only eight genera. Thus, matrix A (four regions and eight genera) was submitted to a principal component analysis (PCA) to describe the relationship between regions and termite genera.Furthermore, we used the data from the four regions of Ghana to build a termite genera collection methods relative frequency matrix based on local people citation. The surveys had identified five collection methods and, thus, in the matrix B four regions and five methods were submitted to a principal component analysis (PCA) to describe the relationship between regions and termite species collection methods.The general survey showed that only 11% of the respondents said that they never give termites to their poultry in Ghana . Twenty-When assessing the factors significantly influencing the use of termites, the stepwise selection allowed us to select five factors: region, sex, education, farm size and income from poultry (Akaike information criterion = 1033.03 for the saturated model and 983.09 after the selection of the five factors). The detailed results of the binomial regression model  showed tMacrotermes, Odontotermes, Trinervitermes, Microtermes, Cubitermes, Allodontermes, Microcerotermes and Amitermes. Samples of Macrotermes spp. were identified to species level and two species, M. bellicosus (Smeathman) and M. subhyalinus (Rambur) were found. The relative proportions of termite species cited by farmers according to the regions are shown in Trinervitermes species in feeding poultry . A basket is placed in the hole created, debris collected into a basket and covered with leaves for 24 h. The basket is collected in the morning and the termites fed to birds. Fixing a basket with the debris of the mound in a hole made in the mound E. A holeMacrotermes species because of their large mounds and the hardiness and difficulty of removing whole mounds. Termites with smaller mounds  are typically collected using method 1 whereas termites with underground nests  are trapped using method 2. However, this latter is also commonly used to trap Macrotermes. The targeted species and the size of the mound determine the collection method. Methods 3, 4 and 5 are used for collecting The results of the principal component analysis performed to describe the diversity of termite collection methods used by local populations in relation to the regions show that the factorial plan formed by axes 1 and 2 explains 98.2 % of the differences in the data matrix. The analysis of the correlations between these two axes and the methods allows us to deduce that methods 3, 4 and 5 have a positive correlation with the first axis A. The sep-value < 2.2 × 10 −16). Trinervitermes spp. are collected mostly in the rainy season  and this method is particularly well adapted to the dry season since, in the rainy season, termite tracks are usually washed off by the rain.Five termite collection methods were reported. While their respective use depends on the targeted termite species and region, the two most common methods were Method 1 (breaking the mounds) and Method 2 (inverted container). These methods are also the most commonly used in Burkina Faso ,30,31. DMacrotermes and Odontotermes are mainly collected using baits and elaborate trapping methods in contrast to Trinervitermes, which are collected by removing the mound, thereby destroying the whole mound in process. Farina et al. [Harvesting and trapping methods depend on the termite species of interest to the farmer. For all species, harvesting and collection are usually done in the early hours of the morning (between 6 am–8 am) as termites move deeper into mounds during the hot afternoons. a et al.  and Chrya et al.  describeContainers of various sizes, shapes and material are used for trapping termites when using the baited container technique. The size of the container is usually dependent on the size and age of flock, larger and younger flock requiring bigger containers as more termites are needed in feeding. Containers are usually made from earthenware, plastic, calabash or metal material; however, farmers advise the use of earthenware as it remains cooler than containers made of other materials. To maintain good microclimate for the termites, baited containers can be covered with leaves after placing on termite mounds. Amitermes and Cubitermes species and the soldier caste of Trinervitermes and Macrotermes species. In most cases, it was mentioned that only chicks and keets were vulnerable. Prestwich [Amitermes and Macrotermes bite and inject toxins while Trinervitermes secrete toxins and irritants. Farmers observed that Macrotermes soldiers kill by biting the throat of chicks. They also suggest that the death of poultry fed on soldiers of Trinervitermes are caused by the secretion of sticky substance by soldiers. Indeed, the toxicity of Trinervitermes species, also mentioned by Diawara [Farmers described several termite species or castes as being poisonous or damaging for their poultry. However, the mechanisms of toxicity would need to be investigated and verified through specific studies. Poisonous species described by farmers include restwich  describe Diawara  is most  Diawara ,34,35. Chicks and keets’ throats are probably more sensitive to bites and they may also have an underdeveloped immune system. However, farmers also described various symptoms of illness caused by toxic termites  and the Trinervitermes from mounds, a small hole is first made on the mound causing soldiers to come out to attack. The soldiers are teased out with a branch after which the part containing a majority of workers are removed. Furthermore, farmers avoid collecting Trinervitermes from old mounds and believe that new mounds containing more grass are less poisonous because workers are comparatively more abundant in such mounds. The adverse effect of Trinervitermes may be reversed, when observed, early by soaking bitter leaves of Vernonia amygdalina in water and give to the bird to drink. Farmers have developed techniques to avoid the collection of a high quantity of soldiers. When collecting Macrotermes is usually given to birds older than 1 or 1.5 months. Cubitermes is said to be usually poisonous in the dry season, but when fed to birds 4 weeks after hatching, causes no adverse effect. To avoid injury to chicks and keets, Odontotermes was cited. Farmer communication indicated that among the termite species collected and used, the safest and most nutritious is Odontotermes, supporting growth and wellbeing of poultry. No toxicity of Macrotermes and Odontotermes) are sufficiently abundant to encourage the adoption of trapping methods. The issue of toxicity of some termites needs to be verified, including the cause and mechanisms of toxicity, the toxins responsible for toxicity and methods to avoid the harvesting of toxic species and castes. Some symptoms mentioned relate to common poultry diseases and therefore must be verified. The nutritional profile of the genera should be studied to ascertain the assertion by farmers that the most nutritious is Odontotermes, Farmers consider termites as very important because they are an easily available protein for poultry. However, the collection of termite mounds is difficult because their availability varies with season and, in some cases, farmers must walk long distances to obtain them. In addition, mounds’ collection is destructive and should not be encouraged. Therefore, trapping techniques should be promoted and the existing methods should be improved. In regions where trapping is uncommon, e.g., Volta Region, investigations should be made to find out if the termites suitable for being trapped (


In the original article, we neglected to thank the source of visual materials, Eunice Fernandes, Holly Branigan, and Moreno Coco, as well as Olaf Mikkelsen for his help in running the experiments.A correction has been made to the Acknowledgements:This work was partly funded by the Laboratoire d'Excellence Empirical Foundations of Linguistics (ANR-10-LABX-0083). We thank Yair Haendler for his helpful advice for the bayesian analysis and Olaf Mikkelsen for his contribution in running the experiments. We also thank Eunice Fernandes, Holly Branigan, and Moreno Coco for kindly letting us use their visual materials for the eye-tracking experiment.The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Health Res Policy Syst 15:93, 2017) have suggested that these inconsistencies are primarily due to processes, statistical methodologies and technical capacity varying between regulatory agencies. They go on to name specific individuals involved in the evaluation of this anti-influenza medicine and imply that differences in the judgements of these individuals has affected public policy concerning the market access of this medicine.Decisions regarding the regulation of individual medicines differ from country to country. In the case of Relenza, Mulinari and Davis (This Commentary argues that what may appear as inconsistent decision-making may in fact be due to differences in the applicability of the evidence base to the local population and health system for which each regulator has responsibility. If health technology assessors are providing nuanced judgements on the effectiveness of a medicine for the local population, differences in regulation and reimbursement decisions are to be expected. Health technologies encompass medicines, devices, medical tests, programmes and procedures – basically any form of health intervention. Whenever a new health technology is brought to market it invariably undergoes a process of assessment. Health technology assessment (HTA) occurs over the lifecycle of each new health technology. It is used to inform pre-market horizon scanning, regulatory decision-making, public funding decision-making (reimbursement), clinical practice guideline development, and disinvestment decision-making.Health Research Policy and Systems critiqued the apparent inconsistent decision-making between European and United States regulators regarding the marketing and labelling of an anti-influenza medicine, Relenza [Within the regulatory domain, the 2017 article by Mulinari and Davis in globalises the evidence and localises the decision” [Inconsistent decision-making is expected in HTA. In fact, it is common knowledge that HTA “ecision” . Differeecision”  explain This heterogeneity, or difference in results between studies, is common, and makes the decision to pool the results of studies in a meta-analysis a matter of judgement. In fact, Ioannidis et al.  found thThe FDA was appropriately cautious about allowing Relenza to be marketed given the lack of clinical benefit observed in the American trial population. The situation was reversed for the MPA as a clinical benefit was observed in the European trial population. Because of differences in the applicability of the trial evidence to each regulatory agency’s local circumstances, it would appear that they also held different views as to whether the findings from each of the trials should be meta-analysed. According to Mulinari and Davis , the FDAConversely, the Swedish MPA did accept a meta-analysis of the trial results and, in their context, this is also reasonable. The European trial found a median time reduction of 2.5 days to symptom improvement in influenza-positive patients receiving Relenza; therefore, by allowing the meta-analysis of the trials, the pooled result dropped to 1.5 days, which is a more conservative estimate of the treatment effect for the European population and in accordance with the variability in results observed among all the trials.Each regulatory agency appears to have appropriately interpreted the evidence supplied to them in the context of their own population and health system.Particular individuals from both regulatory agencies were named in the article by Mulinari and Davis . In LettHowever, often the work of HTA assessors is de-identified to protect them from the large, vested interests associated with the technologies they are assessing; otherwise, there would be a large power imbalance. Similar to government public servants, for HTA assessors, the body responsible for the technology assessment and subsequent decisions is the agency, not the individual. The HTA team evaluates the medicine on behalf of the agency. As decisions informed by that evaluation can have multi-million-dollar impacts, the agency handles any associated media and legal ramifications and is ultimately responsible for the quality and credibility of the evaluation.What is clear from the Mulinari and Davis  analysisThe identity of the MPA assessor in the paper by Mulinari and Davis  was obtaThe large FDA assessment team responsible for the assessment of Relenza is a matter of public record but, being a large team, the accountability is shared. Although Mulinari and Davis  lament tHTA assessments are performed by a team, with the HTA agency being ultimately responsible for the technology evaluation and ensuing recommendations. The analysis from Mulinari and Davis  would ha


The quadruple burden of diseases, early discharge from hospital and hospital at home have resulted in home-based care services becoming a requirement in South Africa. These home-based care services generate a significant amount of health care risk waste that is mismanaged. More attention is given to the health care risk waste generated in hospitals and clinics than to health care risk waste generated by home-based caregivers. Therefore, this study investigates the health care risk waste management practices by home-based caregivers. The study adopted a mixed research approach, qualitative and quantitative methods, using a literature review, interviews, and questionnaires as means of data collection. Results show that there are different types of health care risk waste generated as a result of different activities performed by home-based caregivers, but that the waste was found to be managed in an unsafe manner. The majority of households receiving home-based care did not have basic sanitation facilities such as toilets, running water and waste removal services, aggravating the issue of health care risk waste mismanagement. The study recommends a new policy framework that will lead to safe management practices of generated health care risk waste to be adopted by home-based caregivers. South Africa is currently experiencing what is termed by the National Department of Health a quadruple burden of diseases that are chronic in nature . QuadrupThe strain has resulted in appalling conditions in public health care facilities, which are in dire need of upgrading . To easePeople that work in the home-based care programme are referred to as home-based caregivers . They arThe services provided by home-based caregivers yield numerous benefits . HoweverHealth care risk waste is defined as the waste that is generated during the process of providing health care services to patients . The wasHealth care risk waste management in a safe and efficient manner is important and it is the responsibility of all generators, including home-based care givers. This is for the protection of the environment, preservation of human health, and to comply with all waste management laws such as the National Environmental Management: Waste Act. However in South Africa, Kenya, and Botswana health care risk generated by caregivers is managed at the discretion of caregivers and the management practices are usually unsafe ,21,22. MThere have been very few studies on health care risk waste generated by home-based care givers. This paper therefore seeks to investigate health care risk waste management practices by home-based care givers in their daily operations. It seeks to investigate by first evaluating home-based care activities that generate health care risk waste and thereafter quantifying the generated health care risk waste. As this study is focused on the health care risk waste generated by home-based care givers, the intention is to bring attention to this this overlooked situation. The anticipation is the altering of the current procedure and cause formulation of new policies of health care risk waste management by home-based care givers.Research methods of collecting data for this research study had two approaches, that is, using primary data sources and secondary data. Research methods for this research using primary data include two instruments: questionnaires and interviews. Semi-structured interviews was designed for the home-based care manager. The secondary data was obtained from books, journal articles, government publications, published material, and the internet. The research design for this research required the use of the listed tools. In the first qualitative phase of the study, the objective, was to understand the home-based care phenomenon, the knowledge of care givers on health care risk waste, identify the activities carried out by care givers that lead to health care risk waste generation, and the attitude of care givers toward health care risk waste issues. The topics discussed answered these questions.In the second quantitative phase of the research, using questionnaires, data was collected from the sampled home-based care givers employed by the Department of Health and working at Umlazi Township. Questionnaires were administered in July 2016. The first section was on the demographics of the home-based care givers. The second section focused on conditions of employment and workload. The third was on their knowledge of health care risk waste. The fourth was on the different types and quantities of health care risk waste generated. The fifth was on management practices of the generated health care risk waste. The questionnaires were for identifying the type of health risk waste generated by the care givers, and for analysing the management practices of the generated waste. Questionnaires were translated to the local language, IsiZulu. The questionnaires had closed format questions and contained five sections: demographics of caregivers and their patients; home-based care services and workload; protective clothing, different types and quantities of generated waste; management practices of the generated waste; and types of training received. The person interviewed was prepared prior to the interview for the interview process. The questions were open-ended, and the respondent was required to answer in her own words. The open-ended questions allowed the interview process to be flexible and made the interviewee comfortable. The responses were recorded in writing because in general people are not comfortable with being taped while they are talking. There are two managers of home-based care givers at Umlazi, and only one manager was available during the time of collecting data. The interviews were conducted to obtain data on the background of the home-based care givers to have an elaborate understanding of the work of home-based care givers. With the understanding of their work, the researcher was able to grasp how the waste was generated. The interviews were conducted to get an understanding of the support received by the care givers from their employer, the Department of Health. This support is very important because it includes training of care givers on health care risk waste, among other things. The interviews were done to get an understanding on the reporting structures of home-based care and monitoring and evaluation. Monitoring and evaluation would ensure that the care givers carry out their duties efficiently and are accountable for any wrongdoing such as mismanagement of the waste. The questions that were used in the interview sessions were about home-based care givers and the patients that were receiving nursing care from them. These questions were similar to the questionnaires. However, they required more elaborate responses. They were specifically focused on the work of the home-based care givers. They were also on health care risk waste generation and management practices. Since the interviews required elaborate answers, the research also enquired about the working conditions and the challenges faced by the home-based care givers and how the challenges impact on their work. The secondary data was obtained from books, journal articles, government publications, published material and the internet.Face and content validity were established before questionnaire distribution. The questionnaires were submitted to an expert in the field, an Environmental Health Practitioner, whose area of operation is Umlazi Township. She has over twenty years’ experience in the field of environmental health . The purpose of submitting the questionnaires was for an assessment of the content validity of the questionnaire. The questionnaire was also submitted to the Research Ethics Committee of the Mangosuthu University of Technology, and the committee made a few suggestions that were intended to include language translation. With the assistance of an isiZulu expert, at the Mangosuthu University of Technology, the questionnaire was translated to isiZulu, the Umlazi Township local language.The language used was very simple, and the questionnaire had very short questions to avoid confusing respondents. It can, therefore, be concluded that the tool used was reliable. Content validation helped to get the draft questionnaire moderated so that the questionnaire was reliable.For reliability of survey instruments, the questionnaire was tested to avoid ambiguity and anything that might have confused the respondents when answering the questions. The instrument used for testing the internal consistency of responses was Cronbach’s alpha score. The reliability test was implemented within SPSS statistical package , and the outcomes of the reliability analysis are presented in the final chapter.The research instrument was tested using a pilot study before the questionnaires were distributed to the research participants. The questionnaires were submitted to eight home-based care givers who were not participating in the research. The home-based care givers were randomly selected, and all worked in Umlazi Township. The pretest results reflected questions that were not clear or not understood. Minor changes were found to be necessary (2016/CAES/015).The rights and identities of the study participants were protected. They did not include their identities on the questionnaires. The participants participated in the study voluntarily, and their information was kept anonymous and confidential. The study adhered to the ethical guidelines of the University of South Africa and the Department of Health. A research ethical clearance application was submitted to the University of South Africa, and the Department of Health. Ethical clearance was granted by the College of Agriculture and Environmental Science Research Ethics Review Committee of the University of South Africa for the research to be done (2016/CAES/015).Before applying for ethical clearance from the University of South Africa, the researcher had to obtain permission from the KwaZulu-Natal Department of Health to conduct the study. This is because the research subjects, home-based care givers, were employees of the KwaZulu-Natal Department of Health. Application for permission was requested in writing. The letter explained the research, the purpose and the objectives of the study. The KwaZulu-Natal Department of Health granted permission for the study.Consent for this research was obtained. A consent letter was attached to the questionnaires. It was written in English and translated to IsiZulu because the respondents are isiZulu speakers. The purpose of the consent letters was for thoroughly debriefing the participants of the study. The consent letter introduced the research and research topic. It further explained the purpose and benefits of the research. The participants were asked to participate in the research, and it was explained how they were chosen to be in the study. The letter further explained that their participation was strictly voluntary and they could withdraw if they wanted to. The consent letters were for the questionnaires and the interview respondents.The study area was Umlazi, a South African township established in 1845 to accommodate black labourers . Umlazi Umlazi is not sufficiently provided with basic infrastructure and services such as health care facilities, sanitation facilities, safe drinking water, waste collection services and electricity ,28. The Another great challenge in Umlazi is the prevalence of HIV/AIDS, tuberculosis (TB), a high rate of unemployment, poverty, violence and crime . HoweverThe study only targeted home-based care givers employed by the Department of Health and not the entire population of Umlazi. The reasons for selecting home-based care givers employed by the department of health were the following: Department of Health care givers are formally registered caregivers, and the non-government care givers are formed and dissolved constantly making it difficult to collect data from them. There were 219 home-based care givers and two managers at the time of data collection. Therefore, for questionnaires the study population was 219 home-based caregivers employed by the Department of Health in Umlazi Township. The questionnaire survey instrument targeted home-based care givers employed by the Department of Health because the study was targeting employees employed in a formal manner and respondents that would be available for the entire duration of the research.The study population for interviews was managers of home-based care givers who are also professional nurses. There were two managers of home-based care givers in Umlazi Township employed by the Department of Health. One manager was selected to participate in the study. Purposive sampling, explained by Kumar (p. 207) as deliberately selecting the cases that will be studied, was applied . The intOral interviews were used to obtain data from the available home-based care manager. The selected interviewee was interviewed four times over a period of six months, from January to July 2016 at Maweleni office in Umlazi. The duration of each session was approximately 30 min for each section. The questions were open-ended and required lengthy narratives from the interviewee. The questions allowed for flexibility in response and were also probing in nature as is encouraged for qualitative research. This is because probing deepens the response to questions and increases the quality of responses. The questionnaires were used to obtain survey data from the caregivers. A database of total population of registered caregivers was extracted from the home-based care giver population, registered in the department of Health, into MS Excel spreadsheet. Thereafter, a representative sample of caregivers was selected by random probability sampling using the random sampling functionality in MS. Excel. Caregivers in the sample were administered survey questionnaires with the assistance of the manager of home-based caregivers at Umlazi.The respondents were given questionnaires. The questions in the questionnaire were numerically coded. Using the numerical codes, the responses from the respondents were entered into a spreadsheet. The data entered on the spreadsheet was then checked for accuracy and transferred into SPSS. The data was then analysed to provide outputs such as frequency tables, histograms, and charts.Face and content validity were established before questionnaire distribution by submitting them to an Environmental Health Practitioner (EHP) who works with caregivers, whose area of operation is Umlazi and Isipingo Townships. She has over twenty years of experience in the field of Environmental Health . She took the questionnaires to her colleagues. The purpose of submitting the questionnaires to an EHP was to conduct a pilot survey so as to assess the content validity of the questionnaire. EHPs read the questionnaire and made suggestions about it. The questionnaire was also submitted to the Research Ethics Committee of the Mangosuthu University of Technology, which made a few suggestions that were intended to include language translation. With the assistance of an isiZulu expert, the questionnaire was translated to isiZulu, the Umlazi Township local language.The language used was very simple, and the questionnaire had very short questions so as to avoid confusing respondents. It can be concluded from the pilot study that the tool used was reliable as the content validation helped to make the draft questionnaire so.The instrument used for testing the internal consistency of responses was Cronbach’s alpha score. The reliability test was implemented within the SPSS statistical package. The research instrument was tested using a pilot study before the questionnaire was distributed to the research participants by submitting it to eight home-based caregivers who were not participating in the research. These home-based caregivers were randomly selected, and all worked in Umlazi Township. The pretest results reflected questions that were not clear or not understood. This meant minor changes were necessary to those questions in the pilot study.The sample size was 80, and all 80 questionnaires were returned answered. Interviews were conducted with one home-based care manager.The majority of caregivers were middle-aged females. From the study sample only two caregivers were males while 78 were females. Majority (37) of caregivers are between the ages of 41 and 50 years old, followed by 24 caregivers between 31 and 40 years old. The last group of 16 are between 51 and 60 years old. There are no caregivers below the age of 31. Mean age is 43. Only 32 caregivers had completed Grade 12. All other caregivers dropped out of high school. None of the caregivers had tertiary qualifications. The majority of the caregivers had vast experience as caregivers. Only six had less than five years of experience.Out of the eighty (80) participants that were selected for the study, seventy-seven (78) were women and two (2) were men.Results from the study show that the age of the care givers ranged between twenty (20) and sixty (60). The majority of the home-base care givers between the age group of thirty-one (31) and fifty (50). Mean age of care givers is 43, derived from the calculation below:The majority of care givers who participated in the study did not complete grade 12 (12), only thirty-two (32) had completed grade twelve (12). None of the care givers who participated in the study had university qualifications.Responses to the question on the recruitment of care givers indicates that the Department of Health recruits community members to work as care givers, because community members are familiar with the area, have the same cultural affiliation and speak the same language as the patients and their relatives. It was also preferred that the care givers stay within a walking distance from the homes of the patients.The majority of the care givers had between six (6) and ten (10) years’ work experience of home-based care. Some had worked as care givers for over twenty (20) years. Only six had worked as care giver for less than six (6) years, thirty-six (36) had worked for between six (6) and ten (10) years, twenty-four (24) for between eleven (11) and fifteen (15) years, ten (10) for between sixteen (16) and twenty (20) years, and two (2) for between twenty-one (21) and twenty-five (25) years.Care givers have eighty (80) patients each a month, however in the month of July one care giver had 86 patients. These demographics are based on the eighty patients receiving services from the eighty (80) participants. The home-based care givers indicated that the majority of their patients were female. The female population of the care givers was 4772 compared to the male population which was 1634 and the majority of their patients were between the age of 40 and 60 years. Some of their patients had never been to school. Of the patients who attended school, only 2500 patients completed grade 12, and only 600 had a tertiary education qualification. The majority of their patients were unemployed (5200). Patients lived on government grants (2700) and pensions (3100), others had no means of income.According to the manager, home-based caregivers provide different types of services depending on the needs of the patient. The services are nursing care, physical care, patient support, psychological care, and domestic chores for their patients. The services that generate health care risk waste are nursing care and physical care. On average the study participants generated 2.2 kg of health care risk waste individually and 183.75 kg of health care risk waste combined on the day of data collection.An interview response on the number of houses a day that home-based care givers is not fixed. It is based on the duties they need to perform and the needs of the patients that they are servicing. The home-based care givers were therefore asked to answer questions related to their work based on the day they were completing the questionnaire. The response on the question on workload of care givers showed that care givers visit on average visited three (3) to four (4) houses on the day of data collection with each house having two to three chronically ill patients.An interview question was also asked on how care givers get to know about patients that require their services. The response was that the care givers work on a referral system. The health care facilities has a list of people that require the assistance of care givers and they then contact the managers of care givers and forward contact details and the address of the patient that needs the services. The managers then contact care givers that work in the area to make a follow up and the patients will be included on the patients’ database. Sometimes it is community members who will identify people that need the services of care givers. The community members then inform the care givers in the area about the patient or household.The majority of the care givers on average visited a few houses on the day of data collection. Thirty-nine (39) and thirty-one (31) care givers visited three and four houses respectively. Four (4) visited up to five houses a day.Fifty-one (51) care givers attended to one patient per household. However, some care givers attended to more than one patient per household. Four (4) care givers attended up to three patients per household nursing care.Most of the caregivers do not use any protective gear when working. Data obtained showed that 47 of the caregivers do not wear gloves, 53 do not wear mouth masks, and 52 do not wear aprons. However, 79 of them use hand sanitisers after nursing patients. The hand sanitiser is used as a form of protection to prevent contamination .The interview responses showed that care givers generated health care risk waste every time they provided nursing and physical care to patients and that different types and quantities of health care risk waste were generated.The different types of health care risk waste generated in a day include used aprons, gloves, cotton, gauze, plasters, nappies, needles, syringes, toilet paper, medical containers, expired medication, human waste, vomit, sputum, pus, soiled linen, and plastic bags. Home-based care givers do not inject patients, however they assist the patients to self-inject. Therefore needles wastes are not generated by home-based care givers but they are responsible for the management after they have assisted patients to self-inject.Caregivers were asked to fill generated health care risk on the day of data collection in a plastic bag. The plastic bags were approximately 32 × 50 cm in size. Each plastic bag given by care givers was weighed on a scale to quantify the health care risk waste generated by each home-based care giver on the day of data collection. The weight was rounded off to the nearest number to avoid decimals.Thirteen (13) caregivers collected 0.5 kg, thirty one (31) collected 1 kg, twenty five 25 collected 2 kg, nine (9) collected 3 kg, and two (2) collected 4 kg . Total aThe interview response on health care risk waste management was that the generated waste that was left in the homestead was included with domestic waste. It was stored in domestic waste containers or plastic bags for a week. The houses are not equipped with waste storage facilities or areas therefore waste is stored outside the homes. The waste is then collected by Durban Solid Waste to be disposed of in domestic waste landfill site. The interview response on the health care risk waste management practices, the handling, storage, and disposal practices by care givers was that the care givers use different methods to dispose of the generated health care risk waste. The care givers chose the most suitable methods for disposing of the health care risk waste.Questionnaire data collected indicates, as shown in According to the caregivers, training has not been provided for everyone. Only 70 caregivers had received training on home-based care before they assumed their duties; and four caregivers indicated that they did not receive any form of training . FurtherThe findings revealed that home-based care is mostly offered by middle-aged women. This is because the services offered are physically demanding and not suitable for the elderly to administer. About 60% of the home-based caregivers had completed their basic education level. They are therefore literate and can be educated on home-based care and health risk waste matters.Services provided by caregivers, as stated above, are nursing care, physical care, patient support, domestic chores, and psychological care. Nursing care includes dressing wounds, administering medication, and supervised treatment support (directly observed treatment support). Physical care includes assisting patients to use toilets, feeding and bathing patients, changing patients, and helping patients exercise. Domestic chores include collecting water for patients, and cleaning and washing for patients. The psychological care includes health education, counseling, rehabilitation, and praying. Support includes referring patients to health care facilities, identifying people who do not have any source of income, and bereavement counseling. The services that mostly generate health care risk waste are nursing care and physical care. As physical care includes bathing patients, and assisting them to go to the toilet, the water used may be contaminated. The contamination may be either body secretions or blood resulting in the used water being health care risk waste. The materials used during nursing care such as bandages, cotton wool and gauze are often contaminated with human secretions such as pus and blood. Nappies used by bedridden patients, and cotton wool and bandages used for treating wounds contain human secretions and are health care risk waste. Discarded medication containers are also health care risk waste. Results from the study further revealed that home-based caregivers provide counseling to patients and members of the family with sick people. However, counseling does not generate health care risk. People with terminal illnesses needed to be counseled so that they can cope with the disease. It is also done to assist family members to cope with living with a terminally ill person and with a death in the family. Furthermore, home-based caregivers conducted health education that is very broad and incorporates numerous health issues. The most common health issues, though, were HIV/AIDS and TB, and education was given both on prevention and protection. The approach of the South African government to HIV/AIDS is prevention through health education, therefore education is the key vehicle used to curb the scourge. The home-based caregivers were also used to conduct health education on the importance of the use of drugs such as antiretroviral therapy and TB drugs on HIV/AIDS in general. They were also used to conduct education on mother to child HIV/AIDS transmission, and breast feeding.Home-based caregivers are used to reduce the patient medication defaulter rate through health education by ensuring that patients take their medication as required by the Department of Health. There is a very high medication defaulter rate, especially among TB patients  and homeThe home-based caregivers support communities tremendously by identifying families and patients that do not have any source of income. They mobilise donors to donate food to those families and refer patients to health care facilities that offer the required care. Home-based caregivers are used extensively by the Department of Health to trace TB cases, to communicate with the public, to relay vaccination programmes, etc. The home-based caregivers literally work as ears and eyes for the Department of Health. They also do a lot of referrals, where they refer community members who required treatment to the appropriate health care facilities.Based on the results, on average caregivers visit between three and four houses a day. Each house visited has on average two patients. The majority of the patients are illiterate and very poor. Patients prefer to be nursed by caregivers because they are often humiliated and abused by nurses in clinics and hospitals. The abuse by nurses occurs because socio-economic differences between nurses and patients are huge . FurtherThe results indicate that services offered generate health care risk waste. Therefore, the increased workload increases the amount of health care risk waste. Health care risk waste generated is a mixture of items used for nursing patients and contaminated protective clothing. This generated healthcare risk waste is mostly unaccounted for.Health and Safety Act (1993) [Protective measures are items such as specialised clothing that is used to protect both home-based caregivers and the patients they are treating. The protective clothing prevents cross-contamination by micro-organisms and communicable diseases. It is the protective clothing that becomes contaminated during the treatment of patients instead of the health care personnel. All health care personnel must wear protective clothing when treating patients because they have to be protected from anything that endangers or causes harm to their health . The homt (1993) , during t (1993) . The carThere were, however, home-based caregivers  who indicated that they had protective clothing at the time data was collected, but the provision thereof was not reliable, it was done randomly. Hand sanitiser is used by almost 100% of home-based caregivers because they buy the sanitiser themselves. Any disposable protective clothing used is regarded as infectious and becomes health care risk waste because it is often contaminated with blood and or other body fluids . The disThe amount and composition of the health care risk waste generated by caregivers is dependent upon the number of patients nursed and the services provided. The caregivers indicated that on some days they generate aprons and gloves, but not every day because they sometimes did not have them to wear when providing nursing care to patients. They sometimes have to improvise by wearing plastic bags for protection. Another form of medical waste is a syringe, although caregivers indicated they are not authorised by the Department of Health to administer injections. The syringes are used by diabetic patients and caregivers only assist these patients when they administer the injections themselves. They do, however, assist patients to take medication orally and in the process may use syringes for accurate measurements. The syringes are recycled, meaning they are used several times, before they are discarded and are therefore not generated daily as health care risk waste. The medical containers and expired medication are not generated every day either. Some caregivers indicated that they generate soiled linen and plastic bags, which they use as protective clothing. The generated health care risk waste is typically contaminated with fecal matter and body fluids such as urine, blood, vomit, pus, sputum and phlegm. There is also waste water generated from personal and household care of the patients and also from cleaning containers used to contain sputum, phlegm and vomit from patients with nausea and TB. The different types of generated health care risk waste were not weighed because the caregivers weighed all health care risk waste together daily.The quantity of generated health care risk waste indicated by caregivers is not enormous, about 1.5 kg a day see . HoweverThis has resulted in limited information on health care risk waste generated by home-based caregivers, which causes the precise estimate of the waste to be unknown. However, desk top studies indicate that it is quite substantial and increasing sharply ,36,37,38Health care risk waste, regardless of the quantity, has a potential to cause severe damage to the environment and the health of individuals ,41. FurtOnly 10% of caregivers managed health care risk waste in a proper manner. They took the generated waste to the nearest healthcare facility to be stored, collected, treated and disposed of safely. The majority of the home-based caregivers managed the generated waste in an unsafe manner that can potentially endanger health and pollute the environment. Some caregivers discarded the waste in open spaces, some burnt the waste, some flushed or discarded it in a pit latrine, and some included the waste with domestic waste. However, all generated health care risk waste should follow a specific process after generation, the waste management process, the term management referring to the storage, treatment and disposal of the generated health care risk waste . The proOver 90% of caregivers do not separate the generated health care risk waste at source but include the waste with domestic waste. However, all generated health care risk waste should be separated at the point of generation and placed in correct colour-coded containers with the international infectious substance symbol  to facilAs the caregivers did not separate the generated waste at source, it was included with the domestic waste and stored in either domestic waste containers or plastic bags. The containers used by caregivers are those supplied by Durban Solid Waste for general waste and are not designed to store health care risk waste. Also, the plastic bags referred to are not the colour-coded plastic bags recommended by the South African National Standards (SANS) 10248 , but thoThe majority of health care risk waste generated by caregivers does not have proper storage facilities and is stored for the same period as the general waste generated by the household. In formal settlements the duration of storage of waste is a week as it is included with the general waste, and Durban Solid Waste collect the general household waste once a week.Waste collection differs considerably between formal and informal households. For the formal settlements, waste is collected by or on behalf of Durban Solid Waste. For the informal households, the residents do not have appropriate means of disposing of either domestic waste or human waste. Waste collection is irregular and random. The residents are often without options when it comes to waste disposal. Some residents take generated waste to a common waste receptor. Sometimes weeks go by without the garbage being collected. Waste in these receptors often overflows and scatters on the ground. The wind blows the waste or it is dragged by domestic animals and spread all around the community. Some residents resort to illegal practices of waste disposal such as disposing waste along the roadside, nearest forest, bush or vacant plot, while others bury it in shallow pits or burn it in their backyards. The shared sanitation facilities are sometimes vandalised, and are usually distant from the homes. The human waste such as urine, sputum, and vomit is discarded in open yards that are accessible to the public, children and domestic animals. Health care risk human waste is discarded in toilets and transported by the municipal sewer system to the waste water treatment plant by Durban Solid Waste vehicles. These vehicles are designed to transport domestic waste and not health care risk waste. The drivers are not trained to handle and transport health care risk waste and are not equipped to deal with emergency situations such as preventing or controlling spills or leakages.The only health care risk waste that is treated is the waste that is taken by the 10% of caregivers to the nearest health care facility. It enters the health care risk waste stream to be collected by Compass Waste, as all the health care risk waste emanating from the Department of Health care facilities in Umlazi Township is collected by Compass Waste to be treated before disposal. Different methods, such as incineration, autoclaving, chemical disinfection, and microwave irradiation are used by Compass Waste to treat the health care risk waste.Most of the generated health care risk waste is disposed of in an unsafe manner, either being discarded in open dumps, incinerated or collected by Durban Solid Waste.The factors contributing to health care risk waste mismanagement range from ignorance, lack of capacity and resources, attitude, cultural beliefs, lack of support, and irregular waste collection by waste collectors. The most significant contributing factor is ignorance because caregivers do not receive adequate training and do not have adequate knowledge of health care risk waste management. Some of the health care risk waste knowledge by caregivers is self-taught and such training is usually not accurate. Caregivers are not provided with training specific to health care risk waste. Some of the training received by caregivers incorporated aspects of health care risk waste but were not specific to health care risk waste.Mismanagement of health care risk waste has a direct and indirect impact on health and the environment. The indirect health impact generally occurs from needle stick injuries and transmission of infectious agents . These iRecommendations for efficient and effective health care risk waste management practices by home-based care givers. The study offers a list of recommendations made to improve the working procedures and conditions of care givers. A health care risk waste management plan after an intense consultative process with all relevant stakeholders is required. The recommended plan needs to be detailed, explaining how the generated health care risk waste will be classified and separated at source from the domestic waste. It first needs to describe the activities of care givers that generate health care risk waste. Thereafter, explain how the generated health care risk waste will be quantified and effectively managed, including handling, storing, and disposal. It has to specify the roles and responsibilities of the all the stakeholders in the proper management of health care risk waste and accountability and punitive measures to be taken against mismanagement of health care risk waste.Results from the research indicate that the generated health care risk waste by home-based care givers enters the general waste stream. The main reasons for this practice are traceable to ignorance and unavailability of resources to handle the generated health care risk waste adequately. The work of care givers needs to be monitored closely to identify activities that generate health care risk waste. This can assist with the monitoring of waste produced by care givers. The monitoring will help with resource allocation and will further support the generation of prevention and protection measures of the public and the environment.Management of health care risk waste by home-based care givers needs to be allocated financial and human resources. Suitably qualified people should be employed so that they can ensure that waste generated by care givers is managed effectively. The type of storing of health care risk waste separately from domestic waste suggested by the 2005 World Health Organisation guidelines require appropriate resources .Significant health and environmental catastrophes may be experienced if current health care risk waste management continue. The irreversible damage caused by improper management of health care risk waste has already been done especially to the environment. It can, however, be stopped from getting worse. The policies should stipulate the correct procedures for health care risk waste management so that everyone may have common and standard health care risk waste management procedures. They should also include the manner in which management practices will be monitored and evaluated and invoke consequences for failure to comply.Government departments should work in a cooperative and transparent manner with one another in order to have a good working relationship primarily on issues of health care risk waste. The government departments must work together to promote the health of care givers, waste workers, and the community by ensuring that they do not get injured by the generated health care risk waste. They should also prevent environmental degradation and pollution by ensuring that the environment is protected from the generated health care risk waste. All departments within the health sector are essential in health care risk waste management. However, the agencies that may play a critical role are the environmental health practitioners, waste management experts, and infection control practitioners. These departments have insights into the current challenges resulting from the mismanagement of health care risk waste. They can also assist with community education, and offer adequate support for the care givers in proper health care risk waste management.Training on health care risk waste should be offered to all care givers, patients and the community at large, however such training should be mandatory. Different platforms such as public meetings and gatherings can be used to educate the public. Over and above being trained, the community must always be reminded of health care risk waste management issues. The following media can be used to remind the public: aggressive marketing on billboards and transport systems, radio and television advertisements, handing out pamphlets and fliers, doing campaigns, etc. Training will ensure that both the care givers and the community have an in-depth understanding of the implication of health care risk waste mismanagement on the health of the people and the environment.Ongoing education of the community on health care risk waste management and the impact of mismanagement health care risk waste on human health and the environment is important. Aspects of health care risk waste must not be the responsibility of the care givers only, but the patients receiving nursing services from care givers should take the same amount of ownership, if not more. The community as a whole should also take full responsibility because they will also be affected by the mismanagement of health care risk waste.Assessments and auditing of health care risk waste generated by home-based care givers should be carried out to carry it out regularly. Assessment and auditing would be important for the verification of the quantities of health care risk waste generated and disposal of the generated health care risk waste by the care givers. The reports from assessments and auditing will enable the management to assess their capacity to manage the health care risk waste appropriately. This would prevent the current situation of health care risk waste generated by care givers being unaccounted for.There has been very little research conducted on health care risk waste in developing countries, and the available research is inadequate. In South Africa there is a dearth of information regarding home-generated health care risk waste, especially health care risk waste generated as a result of home-based care activities. There is therefore a need for further research on home generated health care risk waste. This may result in proper planning and resource allocation for health care risk waste management so as to protect the health of individuals and the environment. There is also a need for further research on the impact that health care risk waste generated by home-based care givers has on waste employees that collect and dispose of domestic waste, waste handlers that recycle the waste, and waste scavengers. There is also a need for further research on the accurate impact that health care risk waste generated in homes has had on the health of people and animals that may be exposed to the waste and the environment.The study found that the current South African Health Care System, especially because of the quadruple burden of diseases, are inadequate to manage the health needs of the people. And yet the services provided by the home-based caregivers will continue to be a necessity in the near future. As mentioned, caregivers play a significant role in improving the lives of people and promoting their health. It is only appropriate that their working procedures be re-evaluated and changed so that they do not harm the environment and people’s health. As has been revealed by this study, a considerable amount of health care risk waste generated by caregivers is managed in a manner that endangers the environment and the lives of all those exposed to the waste. Findings of this study show that the health care risk waste management of home-based caregivers is not practiced in accordance with best practices as approved by the Department of Health.The offered recommendations by the study are to improve the working procedures and conditions of caregivers to protect health, preserve the environment, and comply with the law. Suggested recommendations include: having a health care risk waste management plan, monitoring the generated health care risk waste, resource allocation, development of policies and guidelines, government and departmental collaboration and cooperation, community education, training of caregivers on health care risk waste, and continuous assessment and auditing. However, the most important suggestion is the need for further research that will shed light on the areas of focus and the best way for dealing with the management of health care risk waste.


With the rapid development of urbanization in China, a vast number of subway projects are under construction and planned in many cities. However, the complexities of the environment in subway construction inherently bring about many uncertainties and risk factors. Understanding the inherent properties of the critical success factors (CSFs) will contribute significantly to the subway construction. From this perspective, this paper aims to identify the CSFs for safety management in subway construction. This study screened preliminary CSFs through a literature review and in-depth interviews with experts in China. Based on the data gathered and subsequently analyzed from the questionnaire surveys, a final total of 24 CSFs were identified. Then, interpretative structural modeling was employed to ascertain the interrelations among them. The result showed that the factors concerning the engineering survey and design not only occupy relatively higher scores in the questionnaire survey but also contribute significantly latent impacts on other factors. In addition, the creation of a reasonable schedule and the investment of the safety measures were also found to have a fundamental impact on the safety management of subway construction. This research guided the safety managers in determining the most important safety factors they must face and provided them valuable information that could promote safety performance and decrease the number of accidents over the course of subway construction. One of the major objectives and tasks for the 13th Five-Year Plan 2016–2020) period in China is to increase the urbanization level from the current 56.1 to 60%. In order to deal with urbanization pressures such as increasing traffic volume and growing demands for land, a vast number of subway projects are under construction and planned in many cities. As a result, as of 31 December 2017, up to 44 cities in China had been approved for the construction of subway systems, and 35 cities had already been operating subway systems. However, the complexity of the environment in subway construction inherently leads to many uncertainties and risk factors, which may lead to accidents [016–2020 Safety is the system property or quality, which is necessary and sufficient to ensure that the following construction activities. . AccordiSince the beginning of modern project management in 1960s, academic researchers have sought to identify a definitive list of Critical Success Factors (CSFs), the key things that project managers must get right in order to deliver a successful product . PreviouMost prior studies concentrated on exploring CSFs for safety management in construction, with fewer studies aiming to consider the interrelationships among the CSFs in subway construction. To address this knowledge gap, a method for ascertaining the interrelations among CSFs was proposed. The objective of this paper is to provide a reasonable method to identify the CSFs for safety management in subway construction in order to enhance safety performance. The research objectives include: (1) determining the CSFs for safety management in subway construction; and (2) evaluating the relative importance of CSFs as well as the interrelations among them. The paper is organized and presented in the following structure: The research goal of this paper is to explore the CSFs for safety management in subway construction in order to enhance safety management performance. To achieve this purpose, collecting the factors was a critical process of the research, which provided a foundation for the following analysis. This paper puts emphasis on extracting common elements for safety management factors from the activities and processes in subway construction. In order to establish a comprehensive list of factors, the factors for safety management in subway construction should be considered from different views. As a construction project always starts with planning and design, followed by a construction stage, decisions made upstream have inherent influences on other stages . Other rThe following two typical options were adopted for the selection of factors. First, a literature review was used to identify the original factors. Second, preliminary factors were selected based on in-depth interviews with experts. Code of construction safety management is a significant part in literatures, which is summary of construction safety management after years’ experience. Therefore, code reading and review is an effective way to acquire factors see . Though According to the literature review, 28 related original factors were found. There were some similarities between the 28 related original factors, so in-depth interviews were then conducted to ensure the reliability of those dimensions and factors. There were some similarities among the 28 related original factors. As a consequence, the experts came to the consensus that the original factors should be reduced to 24 preliminary factors. Finally, a summary of 24 factors are presented in In-depth interviewing is a qualitative research technique, which conducting intensive individual interviews with a small number of respondents to explore their perspectives on a particular idea, program, or situation . In ordeQuestionnaire surveys, is widely used method for extracting or identifying key factors ,45. The In total, 600 questionnaires were distributed and 182 of them were collected from project employers, contractors, designers, contractors, and government regulators. Interpretative structural modeling (ISM) was first proposed by Warfield in 1973, with the aim of analyzing complex systems . Wang etThe ISM process is an interactive process in which a group of both directly related and different elements are organized into an all-inclusive systematic framework . In virtStep 1: Identify the system factors set. A set of variables affecting the system is defined. The factors for safety management in subway construction were generated using literature review, in-depth interviews, and questionnaire surveys, as shown in (1)For the relationships (2)If there are strong mutual influences between (3)When Step 2: Construct the adjacency matrix. The adjacency matrix is employed to demonstrate the relationships among the factors in ISM, The adjacency matrix A is as follows:Step 3: Generate the reachability matrix. The reachability matrix is used to represent the extent to which different nodes in a directed graph can reach  each other through certain channels. LetStep 4: The analysis of the reachability matrix. According to the reachability matrix, the reachability sets and antecedent sets of every factor must be determined. In the Step 5: Draw the ISM relationships diagram. In accordance with the results of partitioning the reachability matrix, the top-level factor is positioned at the top of the hierarchy and the second level factor is placed just below the top level. This process is repeated until the bottom level factors are placed at the lowest position in the hierarchy.A flowchart of the overall methodology combining the questionnaire survey method and the ISM process adopted here is presented in Reliability analysis was performed on the 161 valid questionnaires, with the results indicating a high reliability (Cronbach’s α = 0.847). Shen et al. noted that the threshold value of Cronbach’s α for a reliable questionnaire is 0.70 .The scores and rankings of the 24 factors were examined by descriptive statistics . If the Based on the questionnaire survey data gathered and the comprehensive analysis of the data, 24 factors were identified as the CSFs for safety management in subway construction. After calculating and analyzing the questionnaire survey data, it was found that the total effects of the dimension layers on safety management in subway construction ranged from 3.57 to 4.27. Given that four out of the 10 top factors were located in the engineering survey and design dimension , it is bThe adjacency matrix and reachability were obtained as per the steps and rules discussed in ISM methodology According to According to Step 4 for the level partitioning of matrix In accordance with the results of partitioning the reachability matrix, the reachability matrix was rearranged, and the hierarchical structural structure diagram for the safety factors was drawn as a five-layer hierarchy, shown in Knowing what safety factors influence and how these factors influence subway construction is necessary to promote and improve safety performance level. With the assistance of in-depth interviews and questionnaire survey, a final total of 24 CSFs was identified. Through the analysis of all of the indicator scores, shown in Surveying surrounding buildings and municipal pipelines (F3), design scheme constructability review (F5), engineering geological condition analysis, and the disturbance of groundwater (F1) ranked first, third, eighth, and ninth, respectively. Considering that subway constructions through dense urban areas increase the unpredictability of tasks and the relationships of this unpredictability to safety, the above factors represent the crucial tasks in subway construction . The manThe ISM model  revealedFive superficial factors in the upper level have a direct impact on subway construction safety: the supervision of special operations (F10), guaranteeing temporary power use safety (F16), workers’ safety awareness (F19), workers’ potential safety hazard insight (F20), and emergency rescue measures (F24). Once an accident occurs, emergency rescue measures would be undertaken by the experienced project managers according to the accident type and characteristics. Therefore, F24 is isolated from the other factors. These factors will directly affect subway construction safety and cannot influence other factors. Moreover, it is worth noting that workers’ potential safety hazard insight (F20) is influenced by five factors in the middle levels, which means the abilities of the workers to find the potential safety hazards without warning have the most significant impact on reducing accidents in construction ,65.The factors in the middle levels ( hazards .The Resilience-based Early Warning Indicators (REWI) method was applied to provide early warning to avoid major accidents and to improve the organization’s resilience through the selected set of Contributing Success Factors . The REWThe promotion of safety management in subway construction is complex, as it involves many uncertainties and a mass of risk factors. Understanding the inherent properties of the CSFs for safety management in subway construction is conducive to retaining a high level of safety performance. This paper provides a comprehensive list of CSFs influencing subway construction safety management in China, based on literature review, in-depth interviews, and questionnaire survey. After calculating and analyzing the questionnaire survey data, it was found that the engineering survey and design phase in subway construction is a vital factor of successful safety management. In addition, surveying surrounding buildings and municipal pipelines, safety training, design scheme constructability review, ensuring the investment of the safety measures, and foreman’s safety attitude were identified as the most important factors for safety management in subway construction; these were the top five factors, indicating that these factors played vital roles in safety management.Many researchers have tried to identify critical safety factors to effectively prevent construction accidents, while minimal efforts have been made to investigate the relationships and interactions among the CSFs in subway construction. To address this knowledge gap, the interrelations among factors are illustrated by utilizing the proposed ISM method. As the ISM model analysis shows, the engineering survey and design factors, such as surveying surrounding buildings and municipal pipelines, the disturbance of groundwater, and engineering geological condition analysis not only occupy relatively higher scores in the questionnaire survey but are also located at the deepest hierarchy of the interpretative structural model. In addition, the factors of creating a reasonable schedule and ensuring the investment of the safety measures occupy relatively higher scores and are also located at the bottom of the ISM structure. As such, more attention should be paid to these factors. It is also concluded that the factor of workers’ potential safety hazard insight is a critical superficial factor in the upper level, which will directly affect subway construction safety. In general, this research contributed to the improvement of subway construction safety management in China. This research guided the participants in determining the most important safety factors to be addressed and provided them with valuable insights into the perception of and knowledge about subway construction safety. Although this study obtained very useful findings regarding safety management in subway construction, more factors should be gathered from construction sites to avoid deviations. Moreover, the research has been raised based on the factors, and their interaction regularity is not quantitatively analyzed, which should be clarified by further research. Meanwhile, subway construction involves many activities and these activities involve many processes, and it is encouraged to apply the proposed approach to analyze the particular activities in future research.


The Shenkursk Injury Registry (SHIR) was established in the Shenkursk District, Northwestern Russia in 2015 for the purposes of primary prevention. The SHIR covers all injuries (ICD-10 diagnoses from S00 to T78) for which medical aid is given at the Shenkursk central district hospital and includes data about injury circumstances. We used the SHIR data to assess the quality of the SHIR as an evidence basis and for the local preventive applications.Completeness, representativeness, and reliability of the SHIR data were assessed using a sample of 1696 injuries which have occurred in July 2015–June 2016. Chi-square tests were used to assess differences between the registered and missed cases in the registry and Cohen’s kappa were applied to assess the agreement between independent data entries.The completeness of the SHIR with respect to the coverage of cases treated at the Shenkursk central district hospital was 86%. There were no differences between the registered and the missed injuries by sex, ICD-10 codes, weekday of admission, but there were differences in their distribution by attending physicians. Also, higher proportions of child injuries and injuries in the summer time were among the missed cases. Signs of lower injury severity (different distribution by ICD-10 codes and lower proportion of traffic injuries) were observed among injuries in rural areas which were not covered by the registry because of treatment at rural primary health care units without referrals to the central hospital. Two independent data entries from standard paper injury registration forms showed a 79–99% agreement, depending on the variable considered.With consideration of possible insubstantial overestimates of the average injury severity, the SHIR data can be considered sufficiently complete, reliable, and representative of the injury situation in the Shenkursk District. Therefore, SHIR is an adequate evidentiary basis for planning local injury prevention. Injuries are the third leading cause of death in the European region, after diseases of the circulatory system and neoplasms , 2. The International evidence shows that good-quality injury data are a prerequisite for effective prevention –6. ThereIn Russia, injuries, poisonings, and other consequences of external causes are registered by the receiving hospitals. For an injury, the hospital information systems record the code according to the International Statistical Classification of Diseases, 10th Revision (ICD-10) –13. ThisA number of countries have gone a step further and created injury registration systems which aim to prevent injuries. Such injury registries and databases have played an important role in lowering injury incidence, injury-related mortality and disabilities , 14, 15.The aims of this study were to assess the quality of the SHIR data for use as an evidence basis and for local preventive applications.n = 5073) is the administrative center of the district and its only urban settlement [The Shenkursk District of the Arkhangelsk Region, Northwestern Russia Fig.  had a pottlement . It is sHealth care in the district comes from two sources: the central district hospital and rural primary care units. The central district hospital is located in the town of Shenkursk and has in-patient departments (62 beds) as well as adult and pediatric outpatient units. The rural primary care units include two out-patient departments and 23 feldsher-midwife stations. Records of treatment at all of these locations are held at the hospital information system of the Shenkursk central district hospital, according to Russian national healthcare standards.The SHIR was created using the translated manual for the Harstad Injury Registry , 15, 17.The SHIR is intended to cover all injuries (ICD-10 diagnoses from S00 to T78) for which medical aid is given at the Shenkursk central district hospital. The data are initially collected using paper-based IRFs - two-page sheets with sections for recording patients’ socio-demographic characteristics , information about time and place of the injury, alcohol consumption in the 24 h before injury, use of protective equipment, and optional sections for descriptions of road traffic and sport injuries. The IRF also has a free-text field for recording a verbal description of how the injury occurred. This field is supplemented by three supportive questions to facilitate such descriptions: “What were you doing?”, “What went wrong?”, “How were you injured?”. This is consistent with the concepts of pre-crash, crash, and post-crash described by Haddon  as well Physicians who provide treatment for injuries at the Shenkursk central district hospital or in its ambulance cars are instructed to offer the IRF to each treated patient at their first outpatient or ambulance visit, or within few days after hospitalization. Patients complete the IRFs, often with the assistance of accompanying relatives, a nurse, or a physician. If a patient does not complete the IRF due to a severe condition or other reasons, injury registrars (the two trained nurses) complete the form retrospectively, using data from routine medical records  as well as information obtained from the attending physician.Once the IRF is completed, its data is manually entered into the SHIR database (based on Epi Info 7)  by the tOne year of the SHIR data  was used for assessments of the data quality, i.e. data completeness, representativeness, and reliability. The completeness in terms of coverage of injuries treated at the Shenkursk central district hospital was assessed by linkage of the SHIR records to those of the hospital information system, assuming that the latter included all injuries. Record linkage of the SHIR and the hospital system was performed using names , dates of birth, and dates of injuries.The representativeness of the SHIR data for the Shenkursk District was assessed by comparing registered injuries to those treated at the Shenkursk central district hospital but not registered in the SHIR. As the second step, registered injuries that occurred in rural areas  and were treated at the Shenkursk central district hospital were compared to rural injuries that were treated at primary care units, and thus have fallen outside the SHIR’s coverage. These comparisons were performed based on variables that are present in the hospital system: age, sex, ICD-10 code, and time variables for initial hospital visit . Chi-square tests were used to assess differences between the compared groups.Data reliability in the SHIR was assessed as agreement between the routine data entry from IRFs performed by the two injury registrars; and a second entry that was independently performed by the first author. This second entry included independent coding of original text descriptions of injury circumstances, following the same coding lists and procedures. Variables used for reliability assessments were sex, age, ICD-10 code, date of injury, mechanism of preceding activity, accident mechanism, injury mechanism, factors involved in each of the mechanisms, alcohol consumption in the 24 h before injury, generalized injury cause, AIS , and hosAll statistical analyses were performed using SPSS, version 24 .According to the hospital information system, there were 2305 injuries in the Shenkursk District between July 2015 and June 2016  and external cause (V01-Y98) codes, or weekday of admission  . On the This study has shown that the completeness of the SHIR with respect to the coverage of cases treated at the central district hospital was 86%, which is lower than that reported from several other registries. For example, Thailand has a provincial injury surveillance system that covers injuries from five large hospitals and has a reported completeness of 98.8% , and theThe approach we used to assess completeness of the SHIR assumed that the hospital system covers all injuries treated in the central district hospital. However, we identified a number of injuries in the SHIR that were treated in the hospital but were missing in the hospital system for unknown reasons. That may indicate that our estimates may be slightly underestimated.The imperfect completeness of the SHIR may be primarily explained by the difference between missed and registered injuries in their distribution by attending physicians, which reflects unequal efficiency of physicians to collect IRFs from their patients. Practically, injuries with uncompleted IRFs are largely detected by injury registrars through regular checks of the registry against the hospital system. In such cases, the registrars complete the IRFs retrospectively, using available medical documentation and information obtained from physicians. In order to assess the proportion of IRFs competed by registrars, in 2017 the SHIR was added by a variable specifying who completed the IRF. In 2017, 59% of IRFs were completed by patients or accompanying relatives, and 41% were filled in by registrars. This reflects the registrars’ substantial efforts to achieve the highest possible completeness, although the results are still imperfect. Based on that and in order to improve the completeness of the SHIR, the administration of the hospital was advised to enhance physicians’ motivation to ask their patients to complete IRFs.According to the information in the hospital information system, there were no substantial differences between registered and missed injuries in the SHIR by sex, weekday of admission, diagnostic and external cause categories, but missed injuries showed a higher proportions of children (34% vs. 24%) and higher proportion of injuries occurring in summer time (46% vs. 27%). The increased probability of failure to register injuries in summer may be explained by the vacation period, when a part of the staff is absent and those remaining must deal with a higher volume of prioritized medical tasks. The higher proportion of missed injuries among children may also be due to higher underregistration in summer time, when children have holidays and are more likely to get injured.As the proportion of missed injuries in the SHIR was 14% and the missed cases showed only minor differences from those registered, the imperfect completeness of the registry should not substantially affect its representativeness for total injuries treated at the central district hospital. However, there are some underestimates of injury risks among children and in summer time, which should be taken into account when using the data for preventive purposes.n = 13,530). This implies that sampling of specific injuries for research purposes may take a long time, or confidence intervals may be broad. However, the primary aim of the SHIR is to identify circumstances, mechanisms and involved factors of the most frequent injuries in the Shenkursk district for planning targeted district-level prevention. Studies of these injuries are expected to have good levels of statistical power. And, the longer the registry is run, the more cases are generated.The population covered by the SHIR is rather small  are more commonly referred to the central district hospital, while minor injuries are more often treated at primary care units. The described differences between the two groups were significant but not decisively substantial, so the SHIR data can be considered fairly representative of all injuries in the district. Although, a notation of some overestimations in overall injury severity has to be made.The difference in coverage of urban and rural injuries by the SHIR also creates difficulty in estimating the incidence. On one hand, not all cases appear in a numerator if we calculate the incidence for the whole district, thus leading to an underestimate. An alternative way can be to limit the numerator to cases in the town, and use the town’s population in denominator. But this reduces statistical power and does not represent the situation in the entire district with large rural component. This data deficiency can be compensated by calculating the incidence using the information of hospital system, which covers all rural and urban cases. This would lead to more precise incidence estimates by sex, age or ICD-10, while the registry provides valuable information about typical injury circumstances.Another limitation is the non-inclusion of prehospital fatal injuries. The reason for that is that such fatalities are referred to a forensic department outside the hospital. Thus, the SHIR cannot be used to estimate the burden and describe the characteristics of fatal injuries. This weakness has to be considered when using the SHIR data for preventive applications, but its elimination would unlikely affect the registry-derived priorities for preventive interventions as fatal injuries constituted, for example, only 2.1% of the total injuries in the Shenkursk District in the study period from July 2015 to June 2016.In the present study, we expressed data reliability as percentage of agreement between two independent raters. The data value was considered reliable if it was the same for the two raters. According to the classification by Landis and Koch, the agreement was “almost perfect” for variables resulting from simple data entry from IRFs into the SHIR  . For varThe presented data reliability assessments referred to the stage when the data is transferred manually from paper-based IRFs into the electronic registry, but the reliability of IRF data can scarcely be assessed. Potential deficiencies were addressed during staff training and in the design of the form. For example, the correct indication of injury severity according to the AIS in the medical part of the form requires a physician to be familiar with this scale. To prevent possible errors due to lacking knowledge of the AIS, the IRF itself contains a detailed description of the AIS, in order to facilitate proper ranking by physicians.This study has demonstrated that the SHIR can be considered sufficiently complete, accurate, and representative of the injury situation in the district. With a notation of a possible insubstantial overestimate of the average injury severity in the district, it forms a suitable evidence basis for local preventive activities and can be used for injury research.