Proponents have promoted sexuality education as a means of empowering adolescents, yet it has been thwarted in many low and middle-income countries. Nigeria represents an exception. Despite social opposition, the government in 1999 unexpectedly approved sexuality education policy. Since then, implementation has advanced, although efficacy has differed across states. We draw on theory concerning international norm diffusion to understand Nigerian policy development.We find that a confluence of international and national norms and interests shaped policy outcomes, including concern over HIV/AIDS. A central dynamic was an alliance of domestic NGOs and international donors pressing the Nigerian government to act.We argue that theory on international norms can be applied to understand policy dynamics across a variety of health and population areas, finding value in approaches that integrate rather than juxtapose consideration of (1) international and national influences; (2) long and short-term perspectives on policy change; and (3) norms and interests. Adolescents face considerable reproductive risks. Globally, seventy thousand die each year due to complications from pregnancy . In 2015The reproductive health and rights of adolescents are a growing global priority. The Sustainable Development Goals include explicit mention of adolescents, and the United Nations has produced a global strategy for women’s, children’s and adolescents’ health . ProponeThis paper, part of a larger research project on managing the politics of sexuality education, examines these political dynamics in Nigeria. Nigeria is a revealing case for several reasons. It has one of the largest populations of at-risk adolescents in the world . In addiIn studying this case, we draw on international relations and sociological scholarship pertaining to the power of international norms to shape national policy-making. Some scholars find extensive influence . Others In the sections that follow, we consider scholarship on norm adoption that forms the theoretical backdrop for this study. We then describe the study’s methodology. Thereafter we present a historical narrative on the political dynamics of adoption and implementation of sexuality education policy in Nigeria. We organize the narrative by phases of the policy process: agenda-setting, formulation, implementation and evaluation. In the discussion, we identify the factors that have shaped the Nigerian policy trajectory, drawing on theory pertaining to international norm diffusion and adoption. We argue that this body of theory and the debates it has stimulated are useful for understanding policy dynamics for a variety of health and population issues that low and middle-income countries face. We also identify principles that emerge from the Nigerian case relevant for managing the politics of sexuality education in other socially conservative settings.The influence of international norms on national policies is a central concern in international relations and sociology scholarship. Norms are collective expectations for proper behavior among actors with a given identity . They apThese debates are directly relevant to understanding the political dynamics of sexuality education policy in low-resource settings. Do those governments that adopt policy do so based primarily on judgments of appropriateness  or on assessment of national interests ? And is the cross-national spread of school-based sexuality education a product primarily of advocacy by champions, or of the diffusion of a global culture that privileges rights and rationality?The interests versus norms debate has pitted rationalists against constructivists. Rationalism in the form of neorealist theory views the international system as anarchic: a self-help world with states pursuing security and power above all else . ConstruThe structure versus agency debate has taken various strands in international relations scholarship, and has been heavily influenced by sociological treatment of this subject (see for instance ). Among The international-local debate concerns the power of international norms to alter local belief systems . Severalconstitute the interests of some actors.While few scholars take absolute positions in these debates surrounding international norms, many have distinct standpoints, emphasizing the power of interests rather than norms, structure rather than agency, international rather than local influences—or vice-versa. Some scholars have reacted to these strong positions by seeking ways to bridge differences. Sil and Katzenstein , for insSexuality education in Nigeria represents, prima facie, a hard case for theories claiming strong influence of international norms on national policy-making. Conservative social values are widespread in Nigeria, and sexuality education touches on highly sensitive issues, including adolescent sexuality and marriage. For these reasons, we might expect international initiatives to have little influence on national policy. On the other hand, particularly since the 1994 International Conference on Population and Development (ICPD) in Cairo, initiatives to advance reproductive health in low-income countries have gathered momentum, putting pressure on national governments to move on these issues. There are reasons, therefore, both to question and to expect international normative influence in this case.In the sections that follow, we examine the historical trajectory of sexuality education in Nigeria, considering the case with reference to these arguments. We ask why Nigeria adopted a sexuality education curriculum when social norms mitigated against school-based delivery. In doing so, we consider whether the origin of sexuality education in Nigeria is best understood in terms of national interests, norms, or some mix; if policy evolution was primarily a product of structural forces, agentic, or interactions between the two; and whether the forces that have shaped sexuality education in the country were predominantly global, local, or an amalgam.This is a historical case study, conducted with the aim of understanding the evolution of sexuality education policy in Nigeria. We selected a case study methodology because it considers a phenomenon in its real-life context, thereby giving it the capacity to reveal underlying causal mechanisms and processes .In 2014 we conducted 52 interviews  with peoStudies in Family Planning, Social Science and Medicine, Health Policy and Planning, African Journal of Reproductive Health and International Perspectives on Sexual and Reproductive Health. Third, we asked our key informants for documentation pertaining to sexuality education policy processes in Nigeria. They possessed some of these documents and referred us to others, which we secured through online searches. Fourth, we gathered documents from a resource center on young people’s sexual and reproductive health, maintained by Action Health Incorporated . We visited the resource center in Lagos, Nigeria and gathered hard copies of documents there. We also downloaded available online documents from that center. Finally, we collected newspaper and media reports via ProQuest Newsstand, as well as through specific national and local newspaper online archives.In addition, we gathered and analyzed more than 300 documents pertaining to sexuality education in Nigeria and globally Table . They weWe analyzed interview notes and documents to piece together a historical narrative of the development of Nigerian sexuality education policy. We coded and excerpted relevant information into a document, organizing it chronologically and by potential causal factors shaping policy dynamics. We adopted a process-tracing methodology , examiniTo minimize bias, we employed several recommended techniques , 28. FirOne limitation of this study is its focus on just one country. This feature constrains us from drawing broader inferences on the power of international norms and on factors driving sexuality education programs in other contexts. We are therefore cautious in making claims, recognizing that considerably more research on the politics of sexuality education in other settings is necessary to assess the generalizability of our findings. Another limitation is the fact that the funder of this study, the John D. and Catherine T. MacArthur Foundation, has promoted sexuality education in Nigeria, potentially introducing bias in our interpretation of findings. We sought to guard against such bias by (1) relying on sources beyond those provided by the Foundation to document its role in the history of sexuality education in Nigeria; and (2) securing the Foundation’s agreement that this study constitutes independent research, and that the authors have complete control in the reporting of results.The history of school-based sexuality education in Nigeria can be divided into three phases outlined in Table As early as the 1970s in Nigeria, sexuality education was included in teacher training curricula, but many teachers were embarrassed to implement it, and it often fell by the wayside . During I attended a boarding school which was co-educational. We had pit toilets. And in the toilets, I saw fetuses, although I never knew then they were fetuses. Nobody spoke to you about getting pregnant.Recognition by domestic champions of the dangers Nigerian adolescents faced from pregnancy, HIV and other issues connected to sexuality and reproduction sparked the process leading to national adoption of school-based sexuality education. One of these champions recalls her own school years (Interview (I) 8):These formative experiences and subsequent observations of the adverse conditions Nigerian adolescents faced, led two of these individuals to establish Action Health Incorporated (AHI) in 1989, an NGO whose mission is to improve the health of Nigerian adolescents. A major break for the organization came in 1992, when AHI secured a grant from the MacArthur Foundation for a three-year work program on adolescent reproductive health . MacArthThe connection of AHI’s co-founder to the MacArthur Foundation facilitated a crucial encounter that shaped subsequent developments for sexuality education in the country. In 1992, she traveled to Cuernavaca, Mexico, where the Foundation had organized a small meeting of grantees  , 35. TheShe subsequently initiated a process that led to the development of Nigerian guidelines , 35. WitThe 1994 ICPD facilitated her efforts by providing domestic legitimacy for this agenda. Attended by a sizeable contingent from Nigeria, the ICPD was a watershed, helping to reshape global norms away from population control and toward the right of individuals to make their own choices surrounding reproduction . The govIn 1995 the Task Force revised the SIECUS guidelines to make them appropriate for the Nigerian context, in the process considering controversial subjects such as abortion and sexual orientation . On OctoIn a simultaneous but separate process, another Nigerian NGO moved the country toward national adoption of sexuality education. The Ibadan-based Association for Reproductive and Family Health (ARFH) was founded in the same year as AHI (1989). Its Life Planning Education program began in Ibadan in 1994 in response to concerns about rising incidence of unwanted pregnancy and adolescents dying from septic complications of abortion (I21) . ARFH seOther NGOs also participated in the coalition that drafted the Guidelines and developed state-level programs . Among tThe creation of the National Guidelines on Sexuality Education set the stage for the Federal Government’s forward movement on sexuality education, including the adoption of the Guidelines and their subsequent implementation in schools. Several national and international developments shaped this decision: rising national concern over HIV/AIDS; the entry of the Ford Foundation into adolescent sexual and reproductive health in Nigeria; and, especially, advocacy by domestic champions.Teenage pregnancy was a major issue but we had not gone far before HIV came into the picture... HIV now necessitated talk about sexuality. If a girl dies, it’s not an issue. But if a boy dies, yes.Over the period 1986 to 2001, prevalence of HIV in Nigeria rose to 5.8% . The natBeginning in 1997, Ford Foundation support facilitated the process of national policy adoption for sexuality education in Nigeria. It made available additional resources and technical expertise to domestic NGOs, including AHI in Lagos, ARFH in Ibadan, AHIP in Kano, GPI in Calabar, Inter-gender in Jos and Life Vanguards in Osun.With the availability of new resources, the existence of the National Guidelines on Sexuality Education, growing concern over HIV/AIDS, and the five-year anniversary of ICPD on the horizon, domestic champions began strategizing on how to further the cause of adolescent reproductive health and to bring coordination to disparate initiatives across the country. They hit upon the idea of a national conference on adolescent sexuality and reproductive health (I8), which would also serve to operationalize the government’s commitments from the 1995 National Adolescent Health Policy . DrawingThe conference was held at the Sheraton in Abuja in January 1999 , 43 (I9)The problem of HIV was there but the Ministry did not know where to start from in terms of talking about sex vis-à-vis HIV/AIDS.Aside from these public efforts, the AHI founders also sought adoption of a curriculum throughout the country . Toward that end, they approached an official in the Ministry of Education who supported its policy-making bodies. The official immediately took to their ideas on sexuality education, noting that (I4):Teaching our girls about their bodies and how to say no to immorality…how to handle those who would want to spoil them, and not to succumb to pressure to anybody who wants to pollute you.The official advised the AHI founders to prepare a memorandum, which the official then herself presented to education officials. While some education commissioners from more conservative northern states expressed concerns that such a curriculum would corrupt girls, the official and her superiors in the ministry worked hard to convince them of its value. She assured them that it was not about sex, but rather about its prevention (I4):At a 1999 meeting of the National Council on Education, the Ministry’s highest policy-making body, education officials from each state approved a proposal for including sexuality education in schools (I4) , 44. TheAt its 48th session in Enugu in August 2001, the National Council on Education formally approved the curriculum for use in Nigerian schools , 43, 47.The Weekly Trust, after talking to Islamic clerics and the Anglican Archbishop of Kaduna, published an editorial highly critical of the curriculum, claiming it promoted immorality throughout the country (I27). Shortly thereafter, at a meeting in 2002 in Kaduna involving Federal Ministry of Education officials and State Commissioners of Education, the curriculum came under threat. Most of the commissioners from the more conservative northern states objected to the idea of such a curriculum and to its content . Alerted of this possibility, the AHI founders traveled to the meeting, where, behind the scenes, sympathetic ministry officials kept them apprised and consulted them on negotiations. As they noted (I8):We had prior information that the northern governments had agreed they would not have the document so we tried to get the middle-belt states out of the clutches of the core northern states. The southern states were on our side.Not long after approval, resistance to the curriculum emerged  , 48. In Eventually ministry officials and the commissioners reached a compromise, but one that significantly diluted the content of the curriculum to abstinence-only . MentionFollowing national government approval of the curriculum, proponents sought to ensure its implementation across the country. They have had variable success. In Lagos, Oyo and several other states, most junior secondary students (mostly in the 11–16 age range) received sexuality education. In many other states, few students are exposed to the curriculum.Implementation proceeded slowly after adoption of the curriculum. Seven years after being instructed to do so, nearly a quarter of Nigeria’s 36 states had yet to introduce the curriculum . A 2008 In 2010, a new attempt was made to implement the curriculum on a national scale. In that year the Global Fund to Fight AIDS, Tuberculosis and Malaria approved a grant to ARFH to support FLHE implementation across Nigeria . The FedImplementation results have varied by state. Implementation in Lagos has proceeded further than in most. All the state’s 320 public junior secondary schools have taught the curriculum . A UNESCImplementation in Oyo state has also been relatively effective compared to other states, largely due to the ARFH-led Life Planning Education program. ARFH partnered with the state government to carry out the program , securinKano presents a contrast to Lagos and Oyo. Despite donor funding to the effective local NGO, AHIP, that has consistently championed the cause, efforts to scale-up FLHE have encountered considerable resistance . Local champions for FLHE have found themselves in life-threatening situations. A Ministry of Education official estimates that the proportion of schools covered may be as low as 10% (I44). One reason for the low coverage is that Kano’s social and cultural environment is much less conducive to promoting sexuality education than that of Lagos and Oyo. Conservative forms of Islam have been central to the social and political life of the people for more than two centuries , 59, andImplementation has also been variable across the rest of the country. A study by researchers at the University of Ibadan found that the percentage of secondary schools within states implementing FLHE ranged from 13.5 to 100%, and most states have no budget line for the program . A studyScholarship concerning the influence of international norms on national policy-making helps to identify factors that shaped the adoption and implementation of sexuality education policy in Nigeria. Debates in this body of work pertain to the relative influence of norms and interests, agentic and structural forces, and local and global factors in shaping national policy processes. Much of this scholarship emphasizes the influence of one or the other element of these binaries. The Nigerian case, however, reveals interactions among rather than the dominance of any particular element.Norms shaped policy adoption: government officials came to accept the appropriateness of the idea that adolescents should have information on sexuality, and responded by developing and approving national sexuality education curricula and programs. However, interests also influenced their decisions: the national government prioritized sexuality education only when officials became alarmed about the spread of HIV. Moreover, sexuality education advanced not only on the power of ideas, but also on the availability of material resources: the willingness of international donors, and a few Nigerian state governments, to provide funding.Agency mattered: moved by their concern about the reproductive risks that Nigerian adolescents faced, domestic champions promoted the cause of sexuality education. This entrepreneurship may be the single most powerful factor behind the advance of the agenda. However, these champions did not develop their ideas in isolation. They participated in global gatherings such as the ICPD, interacted in international meetings with donors, and joined global movements for sexual and reproductive health and rights. These champions were shaped by a world culture they did not create—an international social structure that privileges rights and modernity and that produced the conditions for the emergence of global initiatives on reproductive rights.Local and national norms shaped the policy process: in places such as Kano, the beliefs that school-based sexuality education is a Western imposition and fosters adolescent sexual experimentation posed considerable barriers to implementation. In addition, suspicion by northern state commissioners of education about sexuality education led to dilution of the national content of the curriculum, resulting in an abstinence-only program. However, international norms also heavily influenced policy development. Most notably, the very idea of school-based sexuality education came from abroad.constitute their interests.Findings from the Nigerian case are in line with claims and approaches that emphasize theoretical integration. Sil’s and Katzenstein’s  appeal fWendt’s ideas on structuration  that intIntegrative analytical approaches undoubtedly are relevant and worth employing for understanding the influence of international norms on many health and population policy areas, including refugees, HIV/AIDS and family planning. For instance, norms and interests intersect in refugee policy: a humanitarian imperative to protect populations at risk confronting national concerns over identity and security. They do so as well in HIV/AIDS policy: the norm of right to treatment, the stigmatization of affected groups, and the fear by governments of cross-national contagion and social disruption all shape national policy responses. Agentic and structural forces help to explain the diffusion of policy on family planning: for instance, the power of national champions in places such as Indonesia, Bangladesh and Iran, all participating in a world culture advancing the idea of fertility control as an element of modernity.We offer three ideas on how integrative approaches from scholarship on international norms might be applied usefully to the analysis of health and population policy—one idea drawn from each of the three large debates. First is the value of attentiveness, when conducting health and population policy analysis, to forces both internal and external to countries. In political science scholarship, comparativists have typically focused on internal forces. One consequence, as Finnemore  and MeyeMany important social processes take a long time…to unfold…, [which is] problematic…in areas of inquiry where individual strategic action has become the central vantage point for framing questions and answers about social life.Second is to adopt both long and short-term perspectives on health and population policy change. Kim and Sharman , drawingOn this point, one might consider patterns in national policy responses to the HIV/AIDS pandemic, best understood over the course of decades rather than at any given moment in time. Yet Pierson himself, in making this critique, also points to the opposite difficulty: an “overly deterministic picture of social processes” (p. 185). Detecting contingency requires attention to agency. Moreover, this agency may have long-lasting effects. A structurationist approach  that empThird is the idea that in investigating the motivations of political and social actors surrounding health and population policy, it may be worth setting aside, at least temporarily, the impulse to label these quickly as grounded either in ‘norms’ or ‘interests.’ In explaining the same act—say a head of state’s public support for or condemnation of legalized abortion—a constructivist may be inclined to identify it as motivated by a principle-based concern; a rationalist to point to the interest that drives it. Yet the motivations may be multiple, intertwined and unclear even to the actor him or herself. The analyst might best direct his or her effort to detecting the complex motivations at work without prejudging which category these fall under. Finnemore and Sikkink argue in their 1998 piece  that, “IUnderstand that national proponents are the core actors. External actors including international donors and United Nations agencies may offer financial and technical resources needed to support the issue. However, without local champions committed to the issue, knowledgeable about the social context and savvy about how to negotiate the political environment, sexuality education may not advance far.Anticipate opposition. Even in the most favorable social environments, some opposition to school-based sexuality education is to be expected as it gives rise to fears that adolescents may be encouraged to engage in sexual experimentation. Presumably, proponents will be most effective when they anticipate the emergence of such opposition, actively seek to understand the objections, and identify strategies to address these concerns and neutralize opposition.Take advantage of policy windows. Political opportunities to promote sexuality education arise unexpectedly. For instance, the alarm caused by the spread of HIV/AIDS in Nigeria presented an opportunity for proponents to advance sexuality education as part of the solution. Proponents are more likely to make progress on the issue when they are attentive to these political opportunities and are ready to act when these windows appear.Recognize sub-national variation. Contexts vary not just nationally but sub-nationally, shaping prospects for implementation. In Nigeria, for instance, the conservative social context in Kano State was much less conducive to sexuality education promotion than that of more cosmopolitan Lagos—impeding progress in the former. Proponents need to consider this sub-national contextual variation and adapt strategies accordingly.Aside from implications for scholarship on the influence of international norms on national policy-making, the case study also points to several principles on managing the politics of sexuality education in socially conservative settings. Our knowledge of how to manage these politics would benefit considerably by comparative studies that consider and critically examine these principles. Among these principles are , 65:UndeWhile the case of sexuality education in Nigeria is unique, these findings indicate its relevance to broader questions on the influence of international norms on national policy-making—specifically the value of adopting integrative rather than binary perspectives. The case study also suggests strategies likely to be helpful to proponents of sexuality education working in other socially conservative contexts.


Despite their potential benefits, many electronic health  innovations evaluated in major studies fail to integrate into organizational routines, and the implementation of these innovations remains problematic.The purpose of this study was to describe health care professionals’ self-identified perceived barriers and facilitators for the implementation of a Web-based portal to monitor asthmatic children as a substitution for routine outpatient care. Also, we assessed patients’ (or their parents) satisfaction with this eHealth innovation.Between April and November 2015, we recruited 76 health care professionals . During a period of 6 months, participants received 3 questionnaires to identify factors that facilitated or impeded the use of this eHealth innovation. Questionnaires for patients (or parents) were completed after the 6-month virtual asthma clinic (VAC) implementation period.Major perceived barriers included concerns about the lack of structural financial reimbursement for Web-based monitoring, lack of integration of this eHealth innovation with electronic medical records, the burden of Web-based portal use on clinician workload, and altered patient-professional relationship (due to fewer face-to-face contacts). Major perceived facilitators included enthusiastic and active initiators, a positive attitude of professionals toward eHealth, the possibility to tailor care to individual patients , easily deliverable care according to current guidelines using the VAC, and long-term profit and efficiency.The implementation of Web-based disease monitoring and management in children is complex and dynamic and is influenced by multiple factors at the levels of the innovation itself, individual professionals, patients, social context, organizational context, and economic and political context. Understanding and defining the barriers and facilitators that influence the context is crucial for the successful implementation and sustainability of eHealth innovations. In the last decades, the use of information and communication technology (ICT) in health care, also known as electronic health , has rapidly evolved. It is widely used as a tool for improving health care, it delivers health care to geographically remote areas, it has the potential to reduce costs, and it improves health-related behavior and long-term management of chronic diseases. -3 DespitThe barriers and facilitators for successful implementation have been the topic of several review papers -10, and In 2011, a Web-based portal to monitor asthmatic children was developed with the aim to change current pediatric asthma care and to (partly) substitute routine outpatient visits by Web-based monitoring. This Web-based portal, also called the virtual asthma clinic (VAC) for children, consisted of an information module, a forum for peers, a communication module, and an individual treatment plan for patients. Initially, we focused on providing evidence for a positive impact of this eHealth innovation on clinical endpoints. After 16 months of follow-up, the number of symptom-free days and the degree of asthma control improved in children who received care using the VAC, and we concluded that routine outpatient visits could partly be replaced by monitoring asthmatic children using eHealth. .With this evidence of the impact of the VAC on clinical outcomes, the logical next step in the organizational process was the effective implementation of the VAC in a larger number of Dutch hospitals in order to become an integral part of current pediatric asthma management.The main factor that complicates implementation is either human or organizational -16. OfteBased on this model, we conducted a qualitative survey study with the aim to identify barriers and facilitators experienced by Dutch health care professionals and patients (or their parents) when implementing eHealth in routine pediatric asthma care. In addition, we summarize our lessons learned in recommendations that we consider relevant for successful implementation and sustainability of eHealth in general.This qualitative survey study utilized data collected from health care professionals including pediatricians, pediatric pulmonologists, nurse practitioners, pediatric (respiratory) nurses, and children or their parents . We condThe 8 hospitals originally participating in the randomized controlled trial (RCT)  were appThe VAC for children is a Web-based portal for children with asthma. It consists of a general information module and a secure private section where children (or their parents) can log in to communicate easily with their asthma team, download or consult their individual treatment plan, and complete a validated questionnaire for Web-based monitoring of their asthma control. Implementation of the VAC in pediatric asthma care included the use of the VAC in daily practice without a fixed protocol for the use of this innovation. Despite the existence of a national guideline for pediatric asthma management in The Netherlands, subtle differences between hospitals and health care professionals may exist . In addition, use of the VAC was tailored to local  preferences, for example, whether a nurse practitioner was involved in the use of the VAC or which professional was primarily responsible for contact with the patient. No restrictions were made about the frequency of outpatient visits or Web-based monitoring per patient.Before implementation of the VAC, a 2-hour introductory visit was planned in each hospital, accessible to all participating professionals. These introductory visits were given by the same person (LvdW) and were aimed at adequately informing professionals about the purpose and details of the study and practical use of the VAC. The information provided was semistructured in each hospital. This visit included a real-time demonstration of the VAC and the different functions within the innovation. Further, questions by professionals were answered, and contact information and user manuals for patients and professionals were provided. Patients (or their parents) were informed about the use of the VAC by their asthma team and also received a written instruction manual. During the implementation process, all professionals could contact the help desk in case of existing problems.Successful implementation was defined as using the VAC on a regular basis in daily pediatric asthma care, patients using the VAC regularly, and a positive attitude  toward continuing the use of the VAC in the future.Information about barriers and facilitators for successful implementation were collected by structured Web-based questionnaires (closed survey), which were completed by all professionals at the start of implementation and after 3 and 6 months using the same questionnaire at these different time points. Participation was voluntary, and health care professionals and patients could withdraw from the study at any time for any reason. No incentives were offered. Participants had 1 month to complete the questionnaire before the survey was closed.Questionnaires were based on the model of Grol and Wensing, proposing that barriers and facilitators could be examined at 6 different levels: innovation, individual professional, patient, social context, organizational context, and economic and political context . QuestioIn case of missing questionnaires, an automatically generated reminder was sent after 1 and 2 weeks. When a professional did not complete the questionnaire after 2 reminders, the link to the questionnaire was closed, and the questionnaire was considered missing. Only completed questionnaires were analyzed (as it was not possible to close the survey when items were missing).Barriers and facilitators for implementation of the VAC in daily practice were identified from the open-ended questions and assessed using qualitative analysis. Barriers and facilitators were divided into different categories and organized into themes using the adapted model for understanding change at different levels of health care . Two autDescriptive statistics were used to analyze the multiple choice questions .After 6 months, health care professionals were asked to send a questionnaire on patient satisfaction to their patients (or parents) via the VAC. The researchers had no influence on how many patients were reached because they had no access to local clinical data for medicolegal reasons. Therefore, no information was provided about the severity of their asthma and current medication or treatment regimes. Questions were addressed pertaining to the different modules of the VAC , the innThe study was approved by the local medical ethics committee (Commisie Mensgebonden Onderzoek Nijmegen-Arnhem), which waived written informed consent.The characteristics of all participating hospitals, including the number of participating health care professionals and whether implementation was successful or not, can be found in Characteristics of the participating professionals, covering a wide range with respect to age and experience, are shown in The mean age of all professionals was 47 (SD 8) years, and the mean work experience was 14 (SD 8) years. The majority of the professionals  had no experience with eHealth in daily practice at the start of the study.Almost 70% (35/51) of the professionals were present at the introductory visit and received detailed information about the study and the use of the VAC. The other professionals were informed about the VAC by colleagues. Only 2% (1/51) did not receive any information before starting to use the VAC. All participants concluded that information provided at the introductory visits and the instruction manual were clear. Only 18% (9/51) of the professionals read the instruction manual thoroughly.Implementation of the VAC was unsuccessful in 29% (4/14) hospitals. In 1 hospital, this was due to insufficient staff; just 1 pediatric pulmonologist was available for the implementation of the VAC, and for this physician, the time investment was too much in addition to his regular work. No specific reasons for unsuccessful implementation in the other 3 hospitals could be assessed due to missing questionnaires at follow-up. No further follow-up was done with the hospital representatives who initially agreed to participate.At the end of the study, 66 parents completed the voluntary questionnaire to provide information about the VAC. Most of their children were male  with a mean age of 10.1 (SD 2.5) years. On average, these parents used the VAC for 7.6 (SD 4.7) months. There were 10 children with asthma who completed the questionnaire.Barriers and facilitators were divided into 6 categories and organized into themes using the adapted model for understanding change at different levels of health care . Table 2innovation, we mean “the eHealth innovation (or the object) of the implementation process,” in this study, the VAC. There were 4 categories related to this theme: (1) attractiveness; (2) amount of information; (3) (dis)advantage; and (4) accessibility and usability.By attractiveness of the innovation as a facilitator, as the innovation was clear, easy, and user-friendly. Also, the innovation provided bundled, reliable, and age-adjusted information about asthma for children and their parents.Several professionals stated the advantage of the VAC to substitute routine outpatient visits as a major facilitator. However, other professionals defined restrictions in the use of the innovation. For example, their assumption or cognition was that Web-based monitoring only based on the asthma control test, which is sensitive to confounding factors, is not an adequate substitution for these visits. They also stated that the missing integration between the VAC and electronic medical records (EMRs) was a barrier for the use of the VAC in daily practice, as this resulted in an extra workload to keep both systems up-to-date.Professionals also mentioned the accessibility of the innovation. The accessibility of the innovation was also facilitated by the available user manual and  support service during the study. Both items were central facilitators in helping professionals to use the eHealth innovation in daily practice. Other professionals had some concerns about the privacy of patient data when using eHealth and concerns about the usability of the innovation when ICT problems occurred.Interactive educational methods , enthusiasm, and motivation of those responsible for the innovation were considered important contributors to the There were 3 categories defined: (1) knowledge and awareness of eHealth; (2) attitude of health care professionals toward the innovation; and (3) professional skills.knowledge about the VAC and for whom it was intended. Almost 40% (20/51) did not know what was expected with regard to working with the VAC, and 8% (4/51) had doubts about its use in daily practice.At the start of the study, 20% (10/51) of the professionals concluded they had insufficient positive attitude toward the use of eHealth seemed the most important facilitator for easy and quick implementation of the VAC in daily practice. By using the VAC, professionals experienced eHealth as an enrichment of their work. They were more able to customize care to the individual patient, and this “personalized eHealth” matches the needs and wishes of both professionals and patients. Besides this, the use of the VAC was reported to facilitate the provision of asthma care according to current guidelines. Also, they emphasized the accessible contact, the improvement of the patient-doctor relationship, and the fact that they had more time for complex patients.The professionals’ commitment toward eHealth appeared to be of great importance for the successful implementation of an eHealth innovation. A were not convinced of the added value of the eHealth innovation, successful implementation of the innovation was unlikely despite all efforts. As reasons, professionals mentioned the risk of losing sight of patients and the fact that Web-based monitoring could never substitute face-to-face contacts due to, for example, the missing interpersonal relationship. Additionally, other professionals saw the VAC as a possible barrier for professionals’ own development due to fewer patient contacts.In contrast, when professionals “it is part of health care”). They stated that with the use of the VAC they had a great opportunity to start using eHealth in daily practice in a structured, solid, and easy way.Nevertheless, most professionals had a positive attitude about eHealth overall  knowledge or a lack of (computer) skills. Further, they stated that there was no time to explore the VAC adequately and improve their skills. The majority of the professionals mentioned that they wanted to spend more time using the VAC to continue to improve these skills in order to take full advantage of all the various features of the innovation. However, they lacked time due to their work and the responsibilities of taking care of patients.At the level of the patient, professionals mentioned several facilitators and barriers for the implementation of the VAC, which were divided into 3 categories: (1) (dis)advantage for the patient; (2) patient satisfaction and compliance; and (3) accessibility and usability.main advantages reported by patients were fewer routine outpatient visits and, as a result of this, less absence from school and work (parent-related). Professionals experienced high patient satisfaction. Further, they stated that patients’ compliance, self-management, and knowledge were promoted by the use of the VAC. With the use of the VAC, patients can easily and proactively participate in the treatment of their own disease, and asthma management is more based on shared decision making. Also, Web-based monitoring resulted in less focus on the illness of the child.The accessible for all patients. However, in The Netherlands, over 96% of the Dutch households had access to the internet in 2016.Notably, for other professionals, this last argument was not a facilitator but a barrier. They mentioned that Web-based monitoring emphasized the confrontation with asthma, as a result of the monthly questionnaire. The fact that the VAC is not suitable for all patients was found to be another barrier to implementation according to professionals. For example, patients with poor perception of their asthma symptoms were not considered suitable for Web-based monitoring as a substitution for routine outpatient visits. Therefore, they emphasized that less contact with professionals is not always feasible or wise. A potential risk of Web-based monitoring via the VAC is the patient compliance: how can professionals ensure continuous use of the innovation by patients? Compliance may be influenced by patients’ motivation, symptom burden, and cognitive abilities. With a patient’s lack of motivation for completing the assessment tool, Web-based monitoring as a substitution for outpatient visits is impossible and will not result in proper asthma care. Another potential barrier mentioned by professionals was the concern about a lack of access to the internet for some patients, resulting in selection bias and the innovation not being The majority  of the parents concluded that the VAC had added value to current daily pediatric asthma management. Parents were satisfied with the attractiveness, usefulness, and user-friendliness of the innovation. Further, the C-ACT questionnaire was found to be an adequate tool for Web-based monitoring of disease deterioration. Because of the frequent follow-up by C-ACT, most parents were more aware of their child’s asthma symptoms. They concluded that this eventually led to better asthma control. The perceived threshold to communicate through the VAC was low, communication was easy, and they concluded that the asthma team responded within the agreed timeframe (of 2 working days) most of the time. The majority of the parents experienced more control of the asthma of their child, felt to be more independent, and experienced better cooperation with the physician by using the VAC. Security was no issue for 96% (58/60) of the patients or parents, as they trusted that personal information on the VAC was safe. Only 10% (6/60) of the parents missed out on the personal or face-to-face contact with professionals. Overall, the majority of the parents  concluded that the VAC had additional value to current daily pediatric asthma management and wanted to use the VAC in the future. The VAC was scored an 8 or higher  by 78% (47/60) of the parents. Similar scores were reported by the children completing the questionnaire.There were 3 categories defined at the level of social context: (1) (lack of) sufficient interprofessional collaboration; (2) substitution of tasks or care by health care professionals; and (3) care according to current guidelines.sufficient interprofessional collaboration, most professionals stated that the use of an eHealth innovation like the VAC improved the collaboration between professionals. However, this was only the case when all participating professionals adjusted their tasks before starting to use the VAC. When the asthma team did not adjust or coordinate tasks accordingly, professionals experienced a lack of sufficient interprofessional collaboration resulting in inadequate use of the eHealth innovation.First, regarding substitution of tasks between professionals. For example, nurse practitioners completed the individual care plan for all patients instead of the pediatrician. The latter reported to spend more time on more complex patients.Second, the use of the VAC facilitated current guidelines. The layout of the individual care plan was based on the content of the national pediatric asthma guideline, including treatment goals, medication, information, and an action plan in case of an asthma exacerbation.Third, a major facilitator for the implementation of the VAC was the fact that this eHealth innovation makes it possible for professionals to easily optimize and individualize care for the patients to There were 3 categories related to this theme: (1) organization of care processes or organizational structure; (2) time; and (3) ICT infrastructure.organization of care by the use of VAC was considered an important driving factor for successful implementation. For example, the easy and accessible way of communicating with patients via the VAC gave professionals the possibility to contact the patients at a time during the day that was beneficial for them. Despite some professionals experiencing lower workload through the use of the VAC, others emphasized the extra workload and time due to the extra administration for completing all information in the individual treatment plans.A better more time on the use of the eHealth innovation.Contrastingly, the involvement of the medical management at an early stage of the implementation made it easier for professionals to change work processes and, at the beginning of the implementation, spend the lack of interoperability  between the VAC and current EMRs. For medicolegal reasons, professionals have to include all patients’ contacts in their personal EMR. Due to the missing link between the VAC and current EMRs, professionals had to complete both portals, which was time-consuming and not workable in daily practice. A sustainable integration is necessary to keep both systems up-to-date easily. Local ICT problems caused minor barriers, for example, firewall blocking the website.A major barrier was mentioned by almost all health care professionals, namely lack of structural financial reimbursement for Web-based monitoring. When Web-based monitoring substituted 50% of the routine outpatient visits, professionals were only reimbursed for 50% of these visits. However, they had to invest time in the use of the VAC  and were encouraged to reduce the number of routine outpatient visits.Only 1 category was defined in this theme: financial arrangements. The most important barrier for successful implementation of the VAC was the Major perceived barriers found in this study included concerns about lack of interoperability of this innovation with other systems, the lack of structural financial reimbursement for Web-based monitoring, the burden of eHealth use on professionals’ workload, and a changing patient-professional relationship (due to less face-to-face contact).Major perceived facilitators included training and support, a positive attitude of professionals toward eHealth, the advantages for the patients, and the possibility to tailor care to the individual patient , to substitute tasks between professionals, and to easily deliver care according to current guidelines by using the VAC.We identified these barriers and facilitators for the implementation of a Web-based portal to monitor asthmatic children as a substitution for routine outpatient visits among a group of health care professionals, patients, and parents in 14 hospitals. These barriers and facilitators were arranged in 6 themes as described by Grol and Wensing: the innovation itself, individual professionals, patients, social context, organizational context, and political and economic context . Althouglack of interoperability is perhaps one of the greatest organizational obstacles to the long-term integration of eHealth infrastructure in health care [The lth care ,22,23. Alack of structural financial reimbursement of Web-based monitoring [The other significant obstacle for further diffusion of our eHealth innovation is the nitoring ,24. To dthe burden of eHealth use. Otherwise, they experience an extra workload and a time constraint, which are major impediments to implementation [eHealth innovations have to fit the workflow of professionals to minimize entation ,16,25,26entation .The main methodological limitation of this study is that the data were collected using 3 consecutive questionnaires over a period of 6 months. In-depth interviews to assess more detailed information about the barriers and facilitators perceived by professionals were not used. Further, we had developed a questionnaire based on the model of Grol and Wensing, which was not validated and tested for reliability. However, no valid questionnaire to assess barriers and facilitators for implementation has been published or validated. In addition, we were not able to specify similarities and differences between respondents and nonrespondents as we did not have any data of the latter. Therefore, we cannot rule out some bias. Nevertheless, we consider the response rate  as quite acceptable and therefore assume that a bias may be minimal.For the collection of parents’ and patients’ data, we were dependent on health care professionals sending this questionnaire via the VAC because we were not allowed to have access to patients’ data. This may have influenced the response rate of this questionnaire, as it is possible that professionals did not send this questionnaire or sent it too late. Also, it would be interesting to compare the responses of the health care professionals and patients or parents in future research since their perceptions or viewpoints may be different. Another limitation could be the fact that all 3 questionnaires for professionals were sent in a time period of 6 months after starting to use the VAC. This means that patients monitored over the Web using the VAC were only seen once during this period. This could make it difficult for professionals to develop an objectively based opinion about the importance of the VAC for their daily practice. We could not objectively assess possible changes in time, differences between hospitals, or type of professionals. Also, it is possible that the time period of the study (6 months) was too short to identify all key barriers and facilitators. Nevertheless, most findings were in line with earlier studies.An overall strength of the VAC is the involvement of health care professionals and patients from the beginning of the project. Participants’ wishes and possible objections against the VAC were used for its development, and after the RCT their feedback was used to update the VAC to optimize their use before wider implementation. Ongoing involvement of key stakeholders  in the design and development of eHealth technologies helps to ensure that systems are likely to be valued and used by professionals (intrinsic motivation) and should be considered as a way of overcoming barriers and facilitating implementation ,28-31.Quality of care  is a major facilitator for the implementation of an eHealth innovation and appears to be relevant for the adoption of eHealth. Therefore, this should be assessed before implementation of the innovation in daily practice.Besides health care professionals and patients, other stakeholders  should be included as early as possible in different development and implementation phases.Involve end-users in the design and development of an eHealth innovation to make them develop feelings of ownership toward the innovation and to achieve a positive perception of the innovation’s usefulness and user-friendliness. Use their feedback to optimize the innovation.Maximize the use of and adherence to eHealth applications by developing and modifying the eHealth app from the patient’s point of view: only when a clear advantage or incentive is perceived, eHealth may sustain. The lower frequency of outpatient clinic visits is probably a major incentive in the case of the virtual asthma clinic.Provide adequate training and support  during and after the implementation process to optimize use of the innovation.Aim for a transition period for users. This period can be used to become familiar with and learn how to use the eHealth innovation and thereby facilitate the implementation process.Even the best eHealth system will fail if users do not have the right knowledge and skills to use it effectively.Standards for technology should be optimized before or during the implementation process .Sufficient financial reimbursement needs to be arranged to support sustainable implementation. Chances of finding reimbursement increase with evidence of efficacy, superiority, and cost-effectiveness.Guarantee the privacy and safety of patients’ data.Implementing eHealth and sustaining it are very different ventures. After implementation, ongoing monitoring, evaluation, and adoption of the system are needed to ensure intended goals are being met and to identify ongoing barriers.Another strength of this implementation study is that the questionnaires were based on factors identified by qualitative research, the model of Grol and Wensing , and theBased on the barriers and facilitators found in this study, we propose a list of recommendations when implementing eHealth innovations . These cTherefore, the suitability of the innovation in its context is essential for an innovation to become successful. Professionals can be seen and approached as key holders to achieve change and successful implementation of the innovation . HoweverImplementation of an eHealth innovation is a complex, dynamic process influenced by multiple factors at the levels of the innovation itself, individual professionals, patients, and the social, organizational, and economic and political context. Understanding and defining the barriers and facilitators that influence the context appears to be important for the successful implementation and sustainability of an innovation.Despite serious concerns about structural financial reimbursement and the lack of interoperability of the system, health care professionals, patients, and parents generally expressed enthusiasm about the VAC in our study. In the majority of the participating hospitals, this innovation became part of regular asthma care for children and is it used as a  substitution of traditional outpatient care for children with asthma.


The climate variables that directly influence vector-borne diseases’ ecosystems are mainly temperature and rainfall. This is not only because the vectors bionomics are strongly dependent upon these variables, but also because most of the elements of the systems are impacted, such as the host behavior and development and the pathogen amplification. The impact of the climate changes on the transmission patterns of these diseases is not easily understood, since many confounding factors are acting together. Consequently, knowledge of these impacts is often based on hypothesis derived from mathematical models. Nevertheless, some direct evidences can be found for several vector-borne diseases.Evidences of the impact of climate change are available for malaria, arbovirus diseases such as dengue, and many other parasitic and viral diseases such as Rift Valley Fever, Japanese encephalitis, human African trypanosomiasis and leishmaniasis. The effect of temperature and rainfall change as well as extreme events, were found to be the main cause for outbreaks and are alarming the global community. Among the main driving factors, climate strongly influences the geographical distribution of insect vectors, which is rapidly changing due to climate change. Further, in both models and direct evidences, climate change is seen to be affecting vector-borne diseases more strikingly in fringe of different climatic areas often in the border of transmission zones, which were once free of these diseases with human populations less immune and more receptive. The impact of climate change is also more devastating because of the unpreparedness of Public Health systems to provide adequate response to the events, even when climatic warning is available. Although evidences are strong at the regional and local levels, the studies on impact of climate change on vector-borne diseases and health are producing contradictory results at the global level.In this paper we discuss the current state of the results and draw on evidences from malaria, dengue and other vector-borne diseases to illustrate the state of current thinking and outline the need for further research to inform our predictions and response.The online version of this article (10.1186/s40249-019-0565-1) contains supplementary material, which is available to authorized users. Please see Additional file “Climate is traditionally defined as the description in terms of the mean and variability of relevant atmospheric variables such as temperature, precipitation and wind. Climate can thus be viewed as a synthesis or aggregate of weather.” according to Goosse et al. . These aOver the past 50 years, the earth’s climate has been affected by global warming, with an increase of surface, air and ocean temperature, resulting in the melting of glaciers and the rise of sea levels . The incThe insect vectors that transmit pathogens become infectious mainly after the ingestion of the pathogen through a blood meal on an infected host, followed by the pathogens amplification/circulation in the insect’s body, before the vector become infectious . In the Other climatic variables that strongly influence VBDs transmission are water-related, such as rainfall period, duration and abundance, and the humidity of the environment . AlthougAedes aegypti mosquitoes will amplify and transmit dengue viruses only if exposed to temperatures within the range of 20 to 35 °C [Ae. albopictus is present and active [To better understand which climatic variables are affecting the VBDs ecosystem and how, the literature was searched firstly on PubMed with the words “climate” and “mosquitoes” and “diseases”, than the word “diseases” was replaced by the name of specific diseases such as “malaria”, “dengue” and other diseases names. From all publications available, only those presenting direct evidences which were facts and situations with proof of relationships between vectors/diseases outcomes and climate changes, were selected to be included in the discussion. From the selected literature, further publications were sometimes referenced. The objective of this review was not to be exhaustive in referring to all existing direct evidences, but more to show which mechanisms were at work and how the changes/trends of the climatic variables are currently influencing the different vector-borne diseases systems. As an example, the cycle of a mosquito-transmitted pathogen is divided into two parts, one part is in the vector and the other part is in the host(s). In the host, the pathogen will find stable and suitable temperature conditions, since the host is regulating its own temperature. On the other hand, in the vector, the pathogen will find the suitable temperature conditions only if the mosquito vector is exposed to a favorable environment. As an example, the to 35 °C . These sd active . Furtherd active . This cod active . Vector When environmental conditions are changing because of climate change, the genetically determined vector competence will not be affected, but the vectorial capacity may dramatically change and provide conditions that are more favorable to outbreak transmission. The vectorial capacity is a function of vector density, which is strongly related to rainfall patterns in the case of mosquitoes , of vectAnopheles arabiensis in the slope of Mount Kilimanjaro, resulting in a subsequent change in malaria distribution [Anopheles species in Iran [An. gambiae in Madagascar [One of the first pieces of evidence relating climatic warming to an increase in malaria incidence was reported from Rwanda in 1994, showing that an increase in the mean minimum temperature explained 80% of the variance in the monthly malaria estimates in high altitude areas . This firibution . The sam in Iran  and for dagascar . To confdagascar . Variatidagascar . In tempdagascar . ConsequRainfalls and extreme flooding have also been found to have an impact on malaria transmission such as in Uganda, where an extreme flooding event resulted in an increase of malaria risk of 30% . In ZambThe moving distribution of malaria vectors, as well as the fluctuations in malaria incidence are challenging vector control activities and impacting upon the malaria elimination targets in some countries. The evidence of changing patterns in malaria affected areas are not easily correlated to climate changes alone, since they take place in an overall changing situation, with modifications of land-use, water-management and human activities exposing different populations to different transmission patterns . FurtherAe. aegypti. Urban temperatures are changing in a drastic way due to the warming climate and consequently they are enhancing, among other factors, dengue transmission and outbreaks, due to higher diurnal temperature range [The monitoring of how climate changes are affecting some vector-borne diseases has not been performed systematically over long periods of time . This isre range . The comre range . This rere range  The firsre range , and sinAe. aegypti mosquitoes, because of increased water storage [In Vietnam a similar study looking at the impact of rainfall and increased humidity on dengue in the northern coastal city of Haiphong showed that dengue outbreaks are correlated to an increase of both climatic parameters. For each 50 mm rainfall increase and 1% humidity increase, the risk of dengue outbreak increases of 1% . These r storage . This is storage . Other c storage . Extreme storage . The imp storage . The cha2 [Other VBDs diseases are affected by climate change and the example of the human African trypanosomyiasis (HAT) or African sleeping sickness is very informative. This disease is linked to the presence of the tsetse flies vectors, which are very reactive to temperatures and rainfall patterns. The decrease in rainfall in the sahelian border of Western Africa since the 1950s has led to the displacement of the tsetse flies to the southern parts within the 1200 mm rainfall limit per year. Consequently the HAT has also moved from north to south and most of the remaining foci of HAT in the 2000s were found in the southern countries such as Ivory Coast, Ghana and Liberia . Further2 . This st2 . More re2 , with a 2 . Again, 2 . Consequ2 , and the2 . The fir2 . The imp2 .Culicoides imicola, transmitting the bluetongue virus, and on the contrary are also related to low survival of tsetse flies and a subsequent decrease of animal trypanosomiasis [Although it is not fully understood how climatic variables, changes in trends, extreme events and climate variability are directly affecting the transmission of vector-borne diseases, much evidence can be found to confirm that increasing temperatures due to global warming have an impact on these diseases. This evidence includes contrasting effects with increasing disease incidence in some situations and decreasing disease incidence in other situations. The same effects are also reported for livestock diseases, which have been studied more intensively because of their economic outcomes. For example, the increase in temperature is related to the expansion of some vectors and consequently of the diseases they transmit such as somiasis . The conBorrelia burgdorferi which are migrating northward and creating favorable conditions for Lyme disease transmission to extend to northern locations [One of the most common effect of climate change on VBDs is the change in vector and disease distribution found not only for malaria and dengue, but also for other diseases such as HAT, Leishmaniasis and the Japanese Encephalitis, now emerging as a human and livestock disease on the slopes of the Himalayan highlands . Even inocations . These cThe impact of climate changes on VBDs is complex and the occurrence of opposite effects makes general predictions almost impossible. In order to provide recommendations, based on evidences that can be transformed into policies the impact of climate change has to be investigated at the very specific and local scale. Further integrated approaches are needed because of several confounding factors, which include the host behavior and human population dynamics . Nevertheless, the consequences of these changes already have an impact on Public Health, and the health systems need to be prepared to face epidemics and to mitigate these threats. Preparedness should be based on multi-sectorial concepts and framework, include a deeper understanding of the biological phenomenon as well as a plan for strengthening health systems to respond to different levels of emergency. The development of mitigation measures is needed at all levels, from the global to the local and should co-ordinate and take advantage of push to achieve the Sustainable Development Goals .Additional file 1:Multilingual abstracts in the five official working languages of the United Nations. (PDF 378 kb)


Ecosystem services accounts are a useful tool that provides relevant information on the role of ecosystems in delivering services, and the society benefiting from them. This paper presents the accounting workflow for ecosystem services at the European Union level adopted by the Knowledge Innovation Project on an Integrated system for Natural Capital and ecosystem services Accounting (KIP INCA) - a European Commission initiative. The workflow includes: 1) biophysical assessment of ecosystem services; 2) monetary valuation; and 3) compilation of accounting tables. Supply and use tables are presented for six ecosystem services assessed so far. The supply table shows woodland and forest, followed by wetlands, as the ecosystem types with the highest monetary value per unit area. Analyses of changes between 2000 and 2012 show an overall increase of the monetary value of ecosystem services, mainly due to an increase in demand for them. We also discuss advantages and disadvantages of adopting a fast-track approach, based on official statistics, in comparison to an accounting strategy based on spatial models. We propose a novel workflow for ecosystem services accounts, focused on assessment of the actual flow of ecosystem services, making a significant contribution to further development of the technical recommendations for ecosystem services accounts. In thisThe SNA is an international standard for the systematic compilation and presentation of economic data. It provides information on how much economic sectors produce, how much households consume and save, the level of investments and the amount of trading with the rest of the world. The SNA represents the entire economy in a simplified way, through being integrated and internally consistent. The role of natural capital is not yet transparently recorded in the SNA; it needs to be complemented by ecosystem accounts. The way to integrate the natural capital domain into the SNA is through satellite accounts. In satellite accounts, the core statistical framework is applied to outputs designed to meet specific/crosscutting uses not originally contemplated in the SNA. Specifically, in this case, information related to the environment is processed, framed and reported alongside the core SNA framework. The System of Environmental-Economic Accounting (SEEA) proposed and supported by the United Nations (UN) since 1993 provides methodological guidelines for setting up satellite accounts relating to natural capital. Specifically, the SEEA Experimental Ecosystem Accounting (SEEA EEA)  targets The different modules of the SEEA EEA include accounts for ecosystem extent, condition and services, and the thematic accounts. According to the SEEA EEA, ecosystem services accounts measure the supply and use of ecosystem services in physical and monetary terms, which helps to integrating the results of ecosystem accounting with other economic indicators derived from the SNA. Supply and use of ecosystem services are specific accounting terms; they refer to the amount of ecosystem service (ES) provided by ecosystems and the amount used by socio-economic systems, also termed actual flow . While ‘In parallel with the progress made on the SEEA EEA, the European Union (EU) 7th Environment Action Programme and the EU Biodiversity Strategy to 2020 include objectives to develop natural capital accounts in the EU, with a focus on ecosystems and their services . In thisIn KIP INCA, the JRC develops, at the EU level, experimental accounts for the actual flow of a range of ecosystem services. In this paper, we present the general framework adopted by KIP INCA for ecosystem services accounts, which includes two different approaches: 1) fast-track approach based on official statistics; and 2) spatial modelling approach based on mapping of different components of ecosystem services . Providing a detailed explanation of the methods used to account for each ecosystem service is beyond the scope of this paper, since they can already be found in the literature . We prov2Six ecosystem services accounts have been developed, including two provisioning services, three regulating and maintenance services, and one cultural ecosystem service ; Annex 2Ecosystem services accounts are provided for the years 2000, 2006 and 2012, matching the years in which CORINE land cover (CLC) maps are available. For consistency with the ecosystem extent accounts carried out by the European Environment Agency, the accounting layers of CLC are used as reference data .Data gaps hampered development of the accounts for all targeted years . Where dThe KIP INCA framework for ES accounts follows three main steps : 1) biop2.1ES accounts is focused on quantifying the actual flow, which is the amount of ecosystem service effectively delivered from ecosystems to socio-economic systems . There aMore specifically, for some ecosystem services, the actual flow can be quantified by adopting a fast-track approach that relies on officially reported statistics . This isThe development of spatial models for consistent quantification of actual flow is still under debate and remains highly challenging, especially for regulating ES, due to the complexity of mechanisms generating the benefit . The modDefinition of actual flow of different ecosystem services varies broadly, depending on the way ecosystem services are perceived, how they are modelled, or the proxies used to assess them. This can largely affect the outcome of ES accounts. For this reason, the definition of actual flow is provided for each ecosystem service, to set clear limits for what is explicitly considered in the accounts . For ins2.1.1According to UN guidelines, benefits generated by ecosystem services can already be accounted for within the SNA (SNA benefit) or outside the SNA (non-SNA benefit) in satellite accounts . The firThe use of official statistics, as currently available, may be misleading since they report SNA products, which also include human inputs . The ecosystem contribution represents one of the many inputs necessary to generate the SNA products reported in statistical databases. Consequently, it is necessary to disentangle the natural input from the human input. The disentangling procedure based on official statistics, appropriately framed and justified, represents an appealing opportunity for accounting as potentially no modelling is required, and no additional data need to be created. Practitioners would in fact use official data, and eventually combine ecological information available, to extract the amount of ES flow to fill the supply and use tables. However, this procedure should be grounded in solid assumptions to assess the ecosystem contribution: the simpler the assumptions adopted, the higher the uncertainties.This fast-track approach can also be applied to non-SNA products, when ad hoc datasets are available with appropriate estimates of the ES actual flow. For instance, the assessment of global climate regulation was based on Land Use, Land-Use Change and Forestry (LULUCF) inventories .•2 flows  were tair_gge], .•Timber provision: different sets of official data  were used to disentangle the ecosystem contribution from the total value of the SNA product , was used in combination with biophysical modelling to assess the ecosystem contribution in a spatially explicit way  the ecosystem service potentialMost efforts in ecosystem services assessment have been dedicated to mapping ES potential, with significant progress in the development of mapping methods and tools . MappingUltimately, the ES potential, the ES demand and their spatial relationship will determine the amount of actual flow mobilised from ecosystems to socio-economic systems to generate the benefit. The spatial relationship between ES potential and ES demand is usually more complex than a simple overlay. This relationship can be perfectly accounted for using the spatial delineation for ‘Service Providing Areas’ (SPA)  and ‘SerIn this paper, we provide examples for three ecosystem services, each having a different type of spatial relationship between SPA and SDA . Crop poex post, in proportion to the different ES potential that each ecosystem presents •Flood control (buffer)•Nature-based recreation (information)For other ES , overuse (when occurring) modifies the initial condition for ES potential, and thus an unmet demand is generated: i.e. when land cover and use, as initial setting for the accounting period, do not meet current needs from users during the accounting period . In this2.2Monetary valuation of ES can be done using different approaches and valuation techniques. Since ES accounts represent satellite accounts for the SNA, their valuation should be in line with the exchange value principles applied in the core accounting system . In thisIn our approach, we applied valuation techniques consistent with SEEA EEA recommendations . The same approach is also applied to global climate regulation, where high-level institutions provide estimates of effective carbon rates .When biophysical modelling is used, the procedure for monetary valuation is more complex. There should be a direct connection between: (i) any change that occurs in the key variables  ruling the biophysical model; (ii) outcomes obtained in biophysical terms; and (iii) their valuation in monetary terms. Biophysical assessment cannot be ancillary information in the monetary valuation, but (as previously stated) the leading driver of the outcome in monetary terms.For some ES, such as flood control and nature-based recreation, a model is built for the monetary valuation. For flood control, estimates based on avoided damage costs are undertaken using a complex spatial processing procedure . For natGiven the experimental nature of these ES accounts, methods applied are subject to readjustments that may result in substantial changes to the values reported. For the purpose of this paper, we have applied some updates in accounting for crop pollination. In In this application, all monetary estimates are kept constant over time. This choice is justified by the purpose of highlighting changes in biophysical assessment in the trend over time. Future updates of ES accounts will apply a standard procedure to account for change in monetary values in time series, more in line with the common practice of national accounts.2.3Supply and use tables represent the accounting format for ES. Accounting tables can be built in physical or monetary terms . In the In the SNA, the use tables show the allocation of goods and services by economic sectors as intermediate consumption (i.e. used by other industries in the production of their output), and as final consumption . In ES satellite accounts, the use table shows the flow of each ecosystem service to different users . The structure of the use table remains consistent with the SNA, and uses as definition of economic sectors the Statistical Classification of Economic Activities in the European Community (NACE Rev. 2). Moreover, global society needs to be added as user of global ecosystem services such as global climate regulationex post processing is required to allocate the actual flow to the ecosystem types, considering their different potential to deliver the service (e.g. forests retain more runoff than shrubland). Since ecosystem service potential is a function of ecosystem extent and condition . For instance, the role of forest in providing recreation opportunities and flood control is higher than the role of shrubland. It follows that forest in the spatial model receives a higher score than shrubland, as confirmed by the literature and/or expert opinion. Scores assigned to the different classes of land cover are then averaged for the MAES ecosystem types (fC). The relative extent of each ecosystem type was calculated as the ratio between the extent of the ecosystem in the Service Providing Areas and the total extent of SPA. The ‘weighted potential’ accounts for the variability in the role of each ecosystem type in delivering the service, also considering the extent or amount of each ecosystem type. For instance, 1 km2 of forest retains more runoff than 1 km2 of shrubland, but 10 km2 of shrubland would retain more runoff than 1 km2 of forest. The weighted potential (i.e. extent multiplied by the correction factor) is then used to allocate the total actual flow, in relative proportion to the values obtained. In other words, if the weighted potential of forest is 10 times larger than of shrubland, the amount of actual flow allocated to forest will also be 10 times larger.For some ES, the quantitative allocation to ecosystem types in the supply table, and to economic sectors and households in the use table, is already clear from the description of the service or from the structure of the biophysical model, e.g. cropland for crop provision, forest available for wood supply within woodland and forest for timber provision. For other ecosystem services , ondition ; Fig. 2,ondition .(1)Weighem types , which aAllocation of the actual flow in the use table based on demand is more straightforward, especially for some ecosystem services. When dealing with provisioning services, the SNA product generated only by the ecosystem already has a recipient: these services provide input to economic sectors to produce such as agriculture and forestry. It is a similar case for crop pollination, since the benefit generated is also an SNA product used by the agricultural sector . In fact, mapping ES demand provides the information required to allocate the actual flow to economic units in the use table. People exert a demand for nature-based recreation, becoming the users of this ecosystem service and therefore the actual flow is allocated to households in the use table. In the case of flood control, the actual flow is only calculated where there is demand for this ecosystem service: economic assets such as artificial and agricultural areas. Thus, we can directly calculate the actual flow separately for each land cover type delineating the demand, and establishing correspondence with the different economic sectors. For instance, the actual flow of flood control generated in urban fabric is allocated to households, while the actual flow being used in agricultural areas is allocated to the agriculture sector .2 emissions. However, allocation of the actual flow for this ES might go beyond the final beneficiaries and focus on the emitters of CO2 . Although there is still discussion on how to clearly frame the notion of asset in ES accounts, one attempt that puts together ecosystem types and ES and compares this new approach to the traditional resource accounts is proposed in 33.1Maps of the actual flow of ecosystem services show differences among their spatial patterns . For ecoFor ecosystem services for which actual use is derived from spatial models, the spatial distribution of the actual flow largely depends on demand. For instance, the actual flow of crop pollination is only generated in those areas where farmers decide to grow pollinator-dependent crops – according to the Common Agricultural Policy Regionalised (CAPRI) model  and consSimilarly, nature-based recreation shows high values for actual flow where there is more abundant population making use of suitable nearby areas for daily recreation . This pattern is due to the way the actual flow was quantified. For this experimental account, nature-based recreation for households covers only one part of the numerous recreation flows that could be quantified (such as the contribution of nature to the tourism sector). In this case, the actual flow of nature-based recreation estimates only visits to high-quality areas on a daily basis . As such, visits are quantified only where population lives less than 4 km from these high-quality areas (SPA). Therefore, municipalities  with a high number of inhabitants and SPA closer than 4 km show higher actual flow. Since we considered daily recreation, high-quality areas that are beyond 4 km from population centres would not be suitable for daily activity, so would not contribute to generating actual flow  as the ecosystem service with the highest monetary value, representing 40 % of the total monetary value of the six ES accounted for at the EU level .Table 3SThis result is in line with other studies  which foIn the case of In relative terms, crop pollination represents 8 % of the total value. This is because we account here for the share of crop production attributable to pollination only in areas with high environmental suitability for pollinators (i.e. in service providing areas), and where there is demand (i.e. pollination dependent crops). Pollination is also reported by The supply table relative to the ecosystem extent may be useful for comparing findings across other accounting case studies. 2 sinks  with no ES delivery. Therefore, the monetary value reported in the accounts is mainly due to the presence of green urban areas, which is the key land cover type acting as supplier of ecosystem services in urban ecosystems, as defined in the MAES ecosystem classification (Annex 1). If we considered just the extent of green urban areas, we would obtain a relative value for urban ecosystems of EUR/kmFinally, the monetary value reported per year for the ‘asset’ rivers and lakes and coastal areas should be considered with caution, since it was only assessed for nature-based recreation and the full range of services provided by these ecosystems is not properly represented.The use table shows households as the main users of ecosystem services, mainly due to the high monetary value of nature-based recreation . A higheThe agricultural sector is the second most important user, mainly for crop provision and crop pollination. We should bear in mind that the use table represents the entry point into the SNA. The agricultural sector can generate products for intermediate and final consumption by other economic sectors, both for domestic economy and international trade. The food industry is one of the key determinant sectors for the wealth of any country. Agriculture can produce raw crops thanks not only to farmer input but also to ecosystem contribution. The yearly flow of yield (from crop provision and pollination) and protection (from flood control) that the agricultural sector receives from ecosystems is estimated at EUR 31 billion. Under a scenario of reduced ES flows to agriculture, the production of raw crops  would be more expensive to farmers.3.3The accounting of ecosystem services over time shows an increase in monetary value in the actual flow of ecosystem services assessed at the EU level, except for timber provision . HoweverIn this context, the increase in the monetary value of nature-based recreation is mainly explained by an important increase in ES potential, but also by increased demand from population in need of that service . On the Interpretation of the increase in monetary value of flood control by ecosystems is more complex, since at the EU level there are practically no changes in the ES potential or demand, and the actual flow in biophysical terms even decreases . As discAnalyses of changes in unmet demand are also useful in understanding the role of natural capital in contributing to human well-being . InteresAlthough interpretation of changes over time is more difficult for ecosystem services assessed through the fast-track approach, some inference can still be drawn. The increase in the actual flow for crop provision can be interpreted as an increase in demand , which iIn the case of timber provision, the increase in the actual flow in biophysical terms is less important  from what is generated by human inputs . Most ecosystem services accounts carried out so far take SNA products (crop yield and timber) as proxy for ES flow . We claiThe second point brings attention to the suitability of spatial models for quantifying ES actual flow based on the main drivers: ES potential and ES demand. As demonstrated in our approach, the development of spatial models is suitable for accounting purposes, and it also supports connection with the supply and use tables.The third point helps to consistently identify what is an ‘asset’ in ES accounting. It is important not to mix the role of ecosystem types  with natural resources  in the SEEA framework. This concept is still under discussion in the SEEA EEA revision process. In our proposal, the sum of ES per ecosystem type represents the yearly flow provided by the ecosystem asset (as shown in the supply table).2 instead of sinks, as usually reported in the literature . Data for these ecosystem services are more easily available in official statistics. The advantage of this fast-track approach lies in the use of available information without the need to model. The disadvantage lies in the lack of underlying information to understand the changes over time and the cause-effect relationships that should be contrasted with available literature or other complementary indicators. Furthermore, for the purpose of accounting for global climate regulation, the use of the LULUCF inventories presents some limitations. Firstly, data refer only to managed land, excluding natural (non-managed) areas. This might explain why wetlands appear as net sources of COterature . SecondlThe accounting approach based on spatial models for ES provides data about the key drivers of change in the service used: ES potential and demand. This facilitates a detailed assessment of the changes in the actual flow, helping to understand the role of ecosystems providing the service and/or the role of society benefiting from it. It also provides complementary data useful for land planning, such as the maps of unmet demand that show areas where ecosystem restoration may enhance the ecosystem contribution to human well-being. For instance, in the case of nature-based recreation, statistics on real daily use of natural areas could be gathered for the adoption of a fast-track approach. However, with this fast-track approach we would not be able to understand why changes take place and what exactly is the role of natural capital in determining the service. A drawback of the modelling approach is that it requires ad hoc expertise and these models are not easily usable or accessible for practitioners or policymakers. A solution could be to develop tools in Geographic Information Systems that include the whole accounting workflow. These tools would contribute to making ES accounts more accessible to practitioners, by taking advantage of the modelling technique developed by experts, and at the same time by using their own detailed database.These different assessment procedures could contribute to building a more comprehensive tier approach in ES accounting, consistent with the already solid ES mapping tier approach  and alsoThe development of the experimental ecosystem services accounts under KIP INCA highlights the complexity of developing these accounts, both conceptually and methodologically. In this context, there is a need to develop accounts for more ecosystem services, since each of them presents very different characteristics. ES accounts cannot be generalizable, since the assessment of each ecosystem service is very different and the accounts need to be tailored accordingly.It is important to highlight that the accounts developed at the EU level present many challenges, mainly related to data availability: sometimes data do not exactly match the years assessed, or they are not available at the required spatial resolution. This mainly hampers the development of consistent accounts for a representative time series. Further developments should focus on obtaining better data suitable for accounting, for instance spatial distribution and production of pollinator-dependent crops over time for crop pollination, and temporal series for high natural value of farmland and forest for nature-based recreation.Despite the issues with data availability, the methods developed under KIP INCA are suitable for application to different geographic areas and at different spatial scales. Currently, there are a limited number of examples of ES accounts e.g.  and moreES accounts constitute a step forward in ES mapping and reporting of indicators. In this sense, ES accounts presented in this paper are the starting point to further develop a system that is truly integrated with economic accounts. In fact, integration with the SNA is essential for ES accounts to play a role in economic modelling, analysis and planning. Future releases under KIP INCA will present accounts for water purification, soil erosion control and habitat maintenance. The addition of new ecosystem services to the accounting tables may result in significant changes in the monetary value of ‘assets’ and the relative importance of each ecosystem type. Further efforts should be made in accounting for a comprehensive list of ecosystem services, allowing robust analysis of synergies and trade-off between them.