Sri Lanka has witnessed a series of dengue epidemics over the past five years, with the western province, home to the political capital of Colombo, bearing more than half of the dengue burden. Existing dengue monitoring prevention programs are exhausted as public health inspectors (PHIs) cope with increasing workloads and paper-based modes of surveillance and education, characterizing a reactive system unable to cope with the enormity of the problem. On the other hand, the unprecedented proliferation and affordability of mobile phones since 2009 and a supportive political climate have thus far remained unexploited for the use of mobile-based interventions for dengue management.To conduct a needs assessment of PHIs in Colombo with respect to their dengue-related tasks and develop a new mobile-based system to address these needs while strengthening existing systems.One-on-one in-depth interviews were conducted with 29 PHIs to a) gain a nuanced, in-depth understanding of the current state of surveillance practices, b) understand the logistical, technological and social challenges they confront, and c) identify opportunities for mobile-based interventions. Quantitative analysis included simple descriptive statistics while qualitative analysis comprised textual analysis of 209 pages of transcripts (or nearly 600 minutes of conversations) using grounded theory approaches.Current paper-based data collection practices for dengue surveillance involved a circuitous, time consuming process that could take between 7-10 days to officially report and record a single case. PHIs confronted challenges in terms of unreliable, standalone GIS devices, delays in registering mosquito breeding sites and lack of engagement from communities while delivering dengue education. These findings, in concert with a high motivation to use mobile-based systems, informed the development of Mo-Buzz, a mobile-based system that integrates three components – digitized surveillance, dynamic disease mapping and digitized dengue education – on a common platform. The system was developed through an iterative, evolutionary, collaborative process, consistent with the Spiral model of software development and is currently being used by all 55 PHIs in the CMC system.Given the entrenched nature of existing paper-based systems in PHIs’ work habits, we expect a gradual adoption curve for Mo-Buzz in the future. Equally, we expect variable adoption of the system with respect to its specific components, and specific PHI sub-groups (younger versus older). The Mo-Buzz intervention is a response to multiple calls by the global mHealth community for collaborations in the area of mobile interventions for global health. Our experience revealed that the benefits of this paradigm lies in alleviating country-specific public health challenges through a commonly shared understanding of cultural mores, and sharing of knowledge and technologies. We call upon future researchers to further dissect the applicability of the Spiral Model of software development to mHealth interventions and contribute to the mHealth evidence debate from theoretical and applied perspectives. Dengue, the vector borne disease that threatens the lives of millions of people in tropical countries, has severely affected Sri Lanka in the past 2 decades. In 2014, the country reported nearly 40,000 dengue cases, a level of burden that has been consistent over the past few years [Given that the severity of dengue outbreaks has failed to abate, Sri Lanka, and more specifically, the capital city of Colombo, grapples with an exhausted dengue outbreak management system. Dimensions of the systemic fatigue are sporadically highlighted in the mainstream media, such as the case of the public health inspectors (PHIs)—the last mile in Sri Lanka’s public health delivery system—who are overtly burdened to an extent of one PHI covering a population of nearly 50,000 citizens . Beyond Sri Lanka has witnessed an unprecedented growth in the penetration of mobile services after 2009 when the civil war ended. Currently, Sri Lanka boasts one of the most affordable rates of mobile services across the world, with penetration rates higher than most developing countries . HoweverIn other developing countries in tropical regions, technological interventions for bolstering dengue surveillance have mainly focused on the use of geographical information systems (GISs) and other surveillance systems to facilitate early notification or warnings of potential outbreaks. For instance, Chang and colleagues  used GooOn the basis of the previously mentioned review of literature, our exploratory study was guided by the following aims: (1) to gain a comprehensive understanding of the epidemiological process of identifying, reporting, and recording dengue cases in Colombo, (2) to understand the PHI’s logistical, technological, and social risks and challenges in the processes identified in (1), (3) to identify opportunities for technological intervention based on existing beliefs about and familiarity with mobile technologies among PHIs, and (4) to develop a technological intervention that can address the most critical gaps in their existing workflow to enhance the overall efficiency of the dengue management system in Colombo.paper-based dengue information system. The final section culminates with a discussion of study findings, implications of such a system for the larger public health infrastructure in Colombo, and potential future research.Our paper is presented in 3 main sections. First, we present results from a mixed-methods technological needs assessment of PHIs in Colombo. Second, we present a detailed description of a social media–based system, called Mo-Buzz, which we developed to address the most critical bottlenecks in the current To assess the dengue-related informational and technological needs of the PHIs in Colombo, we conducted a series of in-depth interviews with them that would allow us to gain a nuanced, multifaceted perspective in the issues of utmost concern to them. Each interview was preceded by a simple quantitative survey. We next present details of each of the survey and the in-depth interviews.The survey was designed to obtain a demographic profile of the PHIs; examine their technological habits, usage, and preferences in the dengue context; and generally assess their readiness to move forward and adopt and use the technology. The questionnaire comprised sections on measurement of demographic variables such as age, ethnicity, education, income, and years of experience as a PHI. We then captured technology use through a simple yes or no question asking whether they have previously used the Internet, simple mobile phone, a smartphone, mobile apps, and a tablet. Descriptive analyses were conducted using univariate statistical techniques on SPSS, v. 21 .The in-depth interviews complemented the survey and were aimed at getting a deeper, more detailed, and nuanced perspective on the PHIs role in the public health system, their specific functions related to dengue prevention and management, and their beliefs on the potential for technological interventions in their dengue-related duties. An interview guide facilitated the flow of the conversation across the following themes: (1) roles and responsibilities of the PHI, (2) perspectives on the dengue burden in Colombo, (3) data collection and information flow pertaining to dengue monitoring and surveillance and challenges in this process, (4) health educational activities related to dengue, (5) technology use and preferences, (6) ideas for technological intervention, and (7) perspectives on client  interaction, client trust, and client satisfaction. All interviews were conducted in Sinhalese or Tamil . All interviews were digitally recorded and later translated into English by an experienced translator.Data were collected through a series of detailed one-on-one interviews with the PHIs at the office of the Colombo Municipal Council (CMC). All interviews were conducted with the permission and approval of the Chief Medical Officer of the CMC who also assured access to the PHIs. The Chief Medical Officer briefed the cadre of PHIs about the interviews (before the commencement of the study) and set up a schedule where every PHI would be scheduled to attend a 30- to 45-minute time slot at the interview venue based on their schedule. At the start of each session, the research staff described the aims and purpose of the study to the PHI and obtained their signatures on an informed consent form after explaining the terms of the study including data confidentiality. Each study comprised a short 10-minute quantitative component followed by an in-depth interview  that lasted between 30 and 60 minutes.Qualitative data analysis was conducted through grounded theory approach in 2 ways. First, analysis proceeded as data were collected, thereby allowing early findings to influence later inquiries. For instance, when we observed that the first few participants alluded to contextual constraints associated with dengue-related data collection on the ground , we gradually introduced this theme into subsequent interviews to explore this area even more. Second, emergent findings and a review of the transcripts were used to design a preliminary coding guide that was further refined as coding and analysis proceeded. Two researchers coded each transcript independently, and then arrived at a final code after discussing their codes with an adjudicator. The final codes were then processed through NVivo, a software that helped to summarize qualitative data using visual and tabular formats, analyzing frequency and prominence of topics discussed by the PHIs. Eventually, the research team coded 585 minutes of interviews spread over 5 days and coded 209 pages of interview transcripts.As seen in Our descriptive analysis revealed a healthy history of technology use with nearly 86% (24 of 28) of the PHIs having used the Internet and 90% (25 of 28) having used simple mobile phones. Of these, only 62% (17 of 28) of them had used smartphones previously, and a mere 28% (8 of 28) had prior experience with tablets. Finally, nearly 35% (10 of 28) of the PHIs were familiar with mobile apps.An analysis of the constructs  revealedIn this section, we first present a description of the existing paper-based surveillance process as reported by the PHIs and then examine specific issues of interest to our technological development process.We obtained a comprehensive understanding of the flow of dengue-related information between different agencies involved in the dengue surveillance programs in Colombo. As shown in We now examine specific issues of interest. The interviews revealed that the most complex and challenging sub-processes from the process .…50% there is a delay, mostly in the sending of reports. When we get the report the breeding places may not exist anymore (and) maybe the patient might have been relocated after getting better even  devices. The PHIs would thus be required to carry these devices with them in addition to the rest of the paperwork, and after detecting the particular locality’s geographical coordinates, note it down on their paper forms. Although these devices provided partial reprieve to the PHIs, this intervention started triggering its own set of unique technical challenges. For instance, inconsistencies in recording the geographical locations were bound to occur, as each MOH (overseeing multiple PHIs) was equipped with only one device, resulting in a situation where not all PHIs could be uniformly equipped with the system. Furthermore, the density of the terrain comprising uneven housing patterns, unplanned road layouts, and slum colonies meant that the GPS device was, in many instances, unable to procure the signal required to display the precise coordinate of breeding sites. PHI 9 explained the situation thus:Sometimes I can’t get GPS points. … Sometimes, we have to go like 50 meters away in order to get a significant difference in the GPS coordinates...In addition, the back-end data management system for the GPS device was set up in a way that required the coordinates captured to transmit through multiple points before finally getting recorded, thereby causing inordinate delays in the data collection process. Pointing out the disadvantage of such delays to breeding site surveillance efforts, PHI 14 noted:When we give GPS points they form clusters on the central map. Then we can pinpoint breeding places on the map. When we do this in the current system the data has to go here and there and the delay may take days and the breeding place will have served its purpose already.Commenting on the inability of the existing GPS systems to equip the PHIs with visual maps that can inform them about where dengue outbreaks are occurring, PHI 21 said:…we don’t know how mapping must be done exactly. If it’s with us then we can know which areas are more prone to cases. But it’s just that we refer record books. We don’t get the mapping information. Although we get the waypoints, we don’t get the resulting mapped data. That does not come to us. We have no feedback from this.Public health regulations in Sri Lanka allow for legal action to be taken against offenders who fail to address the problem of breeding sites in and around their homes or construction sites (in case of faulty builders). Although the current arrangements allowed the PHIs to record and report the geographical coordinates of errant offenders, the PHIs were unable to provide photographic evidence that would bolster the implementation of such punitive actions. Although some PHIs on their initiatives used their phone camera to capture pictures of breeding sites, these images were seldom allowed as official evidence in the court. Compounding the problem was the fact that not all PHIs were equipped with camera phones, thereby potentiating a situation of inconsistent evidence from the health authorities to the courts.Despite serving as the last and most critical mile of the public health care system in Sri Lanka, PHIs invoke a range of reactions from the communities they serve during client visits. Ranging from fear and caution to resistance and apathy, these reactions can sometimes stymie the efficiency and speed with which they implement their tasks, as it influences the quality of interaction between the PHI and the client in different ways. At the entry stage, when the PHIs have arrived at the clients’ residence and are introducing themselves, they are used to being met with a range of responses. Some clients immediately request the PHIs to take a seat and are keen to share all the information that the latter need so that their disease can be cured, whereas others could make the PHIs feel unwelcome. As PHI 14 says, over time PHIs have developed their own strategies to smoothen their interaction with the client.After we go to a patient we can’t suddenly start to fill the form. We must become friendly with them. Then only can we get the correct answers from them.The PHIs’ affable approach can yield limited results especially when clients are requested for their income as part of the demographic assessment in the forms. The PHIs concur that while this question is casually dealt with by residents in lower income neighborhoods; clients in higher income neighborhoods are more cautious and are thus reluctant to share such information. According to PHIs, client attitudes come into the fore especially when it comes to communicating to them about the actual risks of dengue.PHI 24 shared his experience thus:sic).” They take the leaflet and just throw it somewhere. They don’t want to read or they don’t like it. They think it’s a joke, what we’re doing.Sometimes, when I tell the truth it’s like a joke to them. When we come they say “here comes the dengue  unit directly from the site, including the breeding site information and location I think it would be very useful to us since the report would have come through immediately. Then we can quickly identify areas which could prove to be severe in the following months.In addition to quicker transmission of field reports, other capabilities of mobile phone technologies, such as reminders, could enable PHIs to be reminded of a new patient report that they would be required to follow-up on, thereby allowing them to plan their workdays in advance and in a more time-efficient manner. Many PHIs suggested that one of the main advantages of such technologies would be in delivering dengue education sessions to clients and other community members. PHIs felt that the use of such technologies would be regarded as a social novelty, which, in turn, would arouse curiosity among community members eventually leading to greater engagement. Apart from obtaining a more detailed awareness of dengue, PHIs believed that these technologies bore greater appeal from a social persuasion perspective and could thus help to transform positive attitudes to behavioral performance.PHI 12 said:Yes, it’s more effective definitely. People like it better if we can show them instead of just reciting orally. Even in a school if we demonstrate to the children via a drama for example it becomes more effective.Finally, PHIs’ delivery of dengue education was stymied by outdated modes of communication such as pamphlets and dated movies. However, the PHIs seemed open to and enthusiastic about an Internet-enabled mobile technological intervention albeit some cautious signals from the older PHIs. Overall, the sentiment we gleaned from the interviews seemed to suggest a number of advantages to such an initiative and the PHIs offered concrete ideas that we could built into our innovation, the details of which are presented in the following section.In summary, our assessment revealed that the current systemic practices surrounding dengue surveillance and prevention were beset by a number of challenges, some of which could be partially addressed with the aid of mobile technologies. Foremost, we found that the workflow surrounding PHIs’ client visits was weighed down by unreliable procurement of clients’ addresses, lengthy paper-based form filling prone to environmental risks, and variable accuracy of geographical coordinates recorded by existing GPS devices. After collecting data, the process of transmitting and processing it through various reports was time consuming and adversely affecting the timeliness of surveillance operations. The needs assessment helped to identify the key gaps and constraints in the existing dengue information flow and also opportunities to address these using mobile social media. The challenge was to facilitate easier and more efficient exchange of information between actors without changing the existing workflow that has been established according to national guidelines. Instead of digitally transforming the information flow in its entirety, the priority for our innovation would be to address the bottlenecks in steps 8 and 9 identified in Our approach to developing a social media–based solution for addressing the dengue prevention gaps in Colombo was inspired by the Spiral Model of software development -21. Thisdetermining objectives and identifying constraints, as has been accomplished by our needs assessment. Second, risks in the context of a technology-based solution dengue surveillance and prevention in Colombo—a context where PHIs have minimal exposure to smartphones—might pertain to slow or gradual adoption of the technology by PHIs, the delay involved in managing both, the paper-based forms and tablets for a period, and the accuracy of the new technology’s reading of the geographical coordinates of a location. Third, involvement of multiple stakeholders in the process of developing this technological solution was imminent as any system developed by the research team based in Singapore would need to incorporate the local technical nuances of Colombo, insights that we could best gain by collaborating with institutions such as the CMC, Mobitel (the second largest telecom operator in Sri Lanka), and the University of Colombo School of Computing. Finally, the evolutionary nature of technological development was expected because of 3 factors: (1) the system would undergo multiple iterations as PHIs’ comfort and familiarity with the technology increased with use over time, (2) the PHIs would receive feedback from their clients on an ongoing basis, which would need to be incorporated into system refinements, and (3) given that the new system would be developed in parallel to the existing system, we would first need to replicate the existing workflow and then attempt to abbreviate and enhance the process in subsequent versions. The conceptual alignment of the Spiral Model with our goals for this study are clear as will be demonstrated by an explanation of the model’s founding ideas. First, the model recommends that the software development process commence by Our system is built on open source technologies and is mainly purposed for mobile and Web-based application which can be accessed through an Android platform  or a Web browser. The Android solution forms part of the main application by running as an agent on mobile devices. The PHIs and MOH can report information in various forms (photo or text) using mobile devices. The Web-based solution is designed mainly for the management as it offers an interactive system for geospatial visualization, reports for reported DIF, summaries and graphs, and Web forms for other details. The solution is developed using Java-related technologies. The server side of this system is supported by Apache, Tomcat, and MySQL.The Mo-Buzz system digitizes 3 main functions of PHIs and presents the capability on handheld mobile devices and Web interfaces: (1) capturing, storing and recording visual, textual, and geographical information from patient visits and house or area inspections, (2) staying updated of dengue spread patterns in the Colombo region on a real-time basis, and (3) providing dengue education to the public in an engaging format that will retain their attention and interest.As seen in In contrast to the CMC’s existing manual pin-maps that can only be updated at the end of every case reporting cycle, the Mo-Buzz system offers a live real-time dengue map that is updated as and when PHIs submit a DIF form to the system. This allows the CMC’s public managers to obtain real-time updates of dengue spread and allocate dengue prevention and management resources strategically and efficiently. This component also automatically draws information from the geotagged breeding site reports and represents this information visually in a map format so that the MOH and their respective PHIs can plan their prevention activities accordingly.To increase engagement between the PHI and their clients, the Mo-Buzz system offers a tablet-based health education component. This has been done in the backdrop of mounting evidence that suggests positive outcomes resulting from mobile-mediated health education modules for health workers in other contexts. The first version of the health educational module includes digitized versions of the CMC’s dengue education materials that the PHI presents to his clients complemented by verbal explanations of dengue prevention concepts. We have enhanced the contents with more graphical elements presented in 3 languages  to create awareness among communities with varying levels of linguistic proficiency. For future versions, we are taking the information we gathered to build enhanced graphics, animations, and tailoring capabilities into the health education component.Mo-Buzz was developed through a series of iterative steps carried out in continuous collaboration with the CMC management, PHIs, and Mobitel. Consistent with the spirit of the Spiral Model, we chronicle the 3 main “risks” that we encountered and explain how these risks were gradually alleviated in subsequent iterations of the system.The major challenge for the Mo-Buzz system design was the adoption by its target user-base. Most staff members in CMC have not had an experience with digital devices. At the same time, the daily information collection need was substantial.Our final system was developed through several versions and tested with stakeholders. Each version's initial scope was selected based on feedback from younger PHIs. The rationale was engaging younger staff members as early adopters and eventually ambassadors before extending to older staff.User interfaces were designed based on CMC's standard documents and followed similar format for simpler forms to help PHI's to get familiar. They were designed to minimize the navigation depth, reduce tedious typing, and all contexts were grouped according to usage patterns of PHIs. The system was introduced with task-oriented trainings, selecting small groups of staff members based on their roles.Despite the enthusiasm for mobile technology–based solutions expressed by PHIs and their self-confidence in the ability to handle such solutions, we anticipated challenges in terms of adoption given that our intervention would be completely new to the PHIs’ context. As expected, we gradually discovered that while some PHIs displayed lesser technological skills than we expected, the senior PHIs (by age) were resistant to adopt this new system after years of using paper-based methods. We addressed this risk through a 3-pronged, ongoing strategy. First, the research team constantly consulted with PHIs in the process of development, thereby enhancing their familiarity with the system’s capabilities, and softening their resistance to adopt it. Second, the research team, in collaboration with the CMC management, conducted a number of training sessions that ingrained in PHIs the advantages of the system, and the mechanisms by which our solution could address their daily dengue surveillance concerns. Third, the previously mentioned 2 strategies allowed us to identify specific resistance points within the technology—for instance, the number of fields in the DIF—that we collaboratively managed to reduce over time, maintaining only the most critical informational fields.The technical configuration of our initial system—such as information transfer rate and connectivity strength—was based on our understanding of the strength of mobile technological infrastructure in Colombo, as gleaned from our conversations with experts from CMC and Mobitel, and industry reports. When this version was tested in the controlled environment of Mobitel’s offices, we found minimal inconsistencies with our technical expectations. However, when we used the technology in the field , we discovered a number of issues that needed to be ironed out including weak transfer rates and intermittent mobile connectivity. To overcome these problems in a context where PHIs could least afford to lose data from the field, we developed a simple mechanism that would enable them to save completed DIF forms in case they were unable to immediately send it to the CMC due to network connectivity issues. The system would give them options to retry sending or save temporarily and automatically synchronize at a later time when network connectivity was more stable. Similarly, we discovered that it became challenging to send reports of breeding sites with pictures (in an unstable network connectivity environment) as the images comprised large file sizes. The subsequent iterations of Mo-Buzz involved a mechanism that would automatically resize the images to fit the device’s screen dimensions without severely compromising on picture quality while reducing file size.In its incipient stages of development, the Mo-Buzz system comprised digitized versions of existing paper-based health education materials, as desired by the CMC and PHIs. Over time, it became clear that this strategy needed to be revised on account of the simple reason that the multimedia capabilities of tablets were left unused. In subsequent iterations, we collaborated with a team of designers to develop infographics-based health education materials, now available in English, Sinhala, and Tamil and are in the process of incorporating an animation-based dengue education video that the PHIs can show to their community members. We are also in the process of further developing the educational module in a manner that will offer PHIs informational cues and/or alerts in case they fail to cover any important subtopics related to dengue during their interaction with client communities.We chronicled a range of other risks including issues of linguistic proficiency, range of supported devices, incorporating informational requirements of the CMC management, but have restricted our discussion to 3 risks in the interest of parsimony.Recognizing the severity of the dengue situation in Sri Lanka, our study aimed to identify specific gaps and challenges in surveillance and prevention efforts and use this understanding as the foundation to build an mHealth intervention for PHIs in Colombo. Although our effort was inspired by emerging global efforts using the power of mobile technologies to address public health concerns in developing countries, our objective was to integrate the affordances of multiple solutions and offer them on a common platform, in the form of Mo-Buzz, thereby generating a holistic solution.Previous studies ,23 invesRecently Labrique et al  respondeThe Mo-Buzz intervention was first soft launched in June 2013 among a small group of PHIs chosen by the CMC management following which the project team worked on multiple iterations over the next year and half. The system has been fully adopted by the CMC in early 2015 for use by all PHIs. Even so, we expect a gradual adoption curve given the entrenched nature of existing systems in PHI’s work habits. Equally, we also expect variable adoption of the system with respect to its specific components and specific PHI subgroups (younger vs older).The Mo-Buzz intervention is a response to multiple calls by researchers and the policymaking community for collaborations in the area of mobile interventions for global public health. Our experience revealed that the benefits of this paradigm lies in alleviating country-specific public health challenges through a commonly shared understanding of cultural and ethnic mores and sharing of knowledge and technologies. In the next phase, the research team plans to conduct a theoretically informed, mixed-methods evaluation to assess adoption effectiveness and system performance and its effects on dengue program management metrics of the CMC. We also plan to quantitatively compare the user experiences of the Mo-Buzz system with its paper-based predecessor. We call upon future researchers to further dissect the applicability of the Spiral Model of software development to mHealth interventions and contribute to the mHealth evidence debate from theoretical and applied perspectives.


There is consensus among stakeholders in Cameroon on the need to develop and strengthen human resource capacity for nutrition. This study was conducted to provide a comprehensive mapping of the current capacity for tertiary-level human nutrition training in Cameroon.Participating institutions included university-level institutions offering dedicated nutrition degree programs or other programs in which nutrition courses were taught. A semi-structured questionnaire administered during in-person interviews was used to collect data on existing programs and content of training curricula. Nutrition curricula were reviewed against the following criteria: intended objectives, coverage of nutrition topics, and teaching methods.In total, five nutrition degree programs (four undergraduate programs and one master's program) were identified. Three additional programs were about to be launched at the time of data collection. We did not find any doctorate degree programs in nutrition. All the undergraduate programs only had little focus on public health nutrition whereas the master's program in our sample offered a good coverage of all dimensions of human nutrition including basic and applied nutrition. The predominant teaching method was didactic lecture in all the programs. We did not find any formal documentation outlining the competencies that students were expected to gain upon completion of these programs. Nutrition courses in agricultural and health schools were limited in terms of contact hours and scope. Public health nutrition was not covered in any of the health professional schools surveyed. We found no institution offering in-service nutrition training at the time of the study.Based on our findings, we recommend that nutrition training programs in Cameroon be redesigned to make them more responsive to the public health needs of the country. Cameroon is a Central African country with a population of approximately 23 million . It is dImportant efforts have been made over the past years to raise the profile of nutrition to a high priority in Cameroon. The country joined the Scaling Up Nutrition (SUN) movement in March 2013 , with nearly 1 million under-five children being affected . In addi%, with nCameroon faces an acute shortage of human resources in the health sector and in their equitable distribution across the country . The lacDeveloping a workforce capacity will not address all capacity gaps in a sustainable manner because capacity development goes beyond workforce development and the training of individuals , 16. As The paper also highlights existing gaps and challenges in current approaches to nutrition training in the country and proposes practical solutions to address them. The study was commissioned by the Government of Cameroon , with the support of UNICEF, Helen Keller International, and other partners.There were two levels of selection. First, we screened a set of institutions based on a preliminary list that was provided by the Ministry of Public Health, the Ministry of Higher Education, and key in-country informants. These institutions were contacted by telephone or email to check their eligibility. Then, we enrolled those institutions found to run dedicated nutrition degree programs or those offering other programs in which nutrition courses were taught .An official letter was sent to all targeted institutions by their respective line ministries to explain the objectives of the assessment and request their participation. In-person meetings were then scheduled with the representatives of the institutions to gather information about existing nutrition programs or courses. During the meeting, the objectives of the assessment were further explained to the respondents. Interviews were conducted either in French or English.There were two rounds of data collection for this assessment. The first round, which took place in 2013, was conducted in four regions . The second round, which took place in 2014, also covered the West region and three other regions . In total, seven of the ten regions of the country were covered .The data collection method used was similar to the one used to assess the capacity for nutrition training in West Africa as described elsewhere –15. DataOutline of the objectives of the programs (skills and knowledge to be taught).Coverage of nutrition topics in the curriculum. Three main categories were defined to characterize the areas of nutrition emphasized in the curriculum: basic nutrition, clinical nutrition, and public health nutrition. Basic nutrition was defined as the application of nutrition principles at cellular or organ level and clinical nutrition as the application of nutrition principles at the individual level in clinical settings. Public health nutrition was defined in the context of this study as the use of health promotion approaches and the application of public health principles to nutrition at the population level to prevent nutrition-related diseases, promote health, and improve overall health outcomes , 18.Training design and teaching method. The prevailing teaching methods were categorized as didactic method (focus on the acquisition of knowledge), problem-based learning , and a holistic, integrated approach  .Existing academic nutrition programs in the country were reviewed against the following criteria:In total, four undergraduate programs in nutrition were available in three regions in Cameroon at the time of data collection. These programs were found in Bamenda, Buea, and Yaoundé . The UniAll the programs were established during the 5 years preceding the survey. The program in Bamenda was run by a government-supported institution, whereas the programs in Yaoundé and Buea were run by private institutions. None of the programs was involved in international collaboration for nutrition training or research.The Yaoundé and Buea programs award a higher national diploma (HND). The Buea and Bamenda programs award bachelor-level degrees. The language of instruction in Buea and Bamenda is English whereas that in Yaoundé is French.The admission requirements for all the undergraduate programs are a technical or general college education with a science background or any other equivalent qualifications as accepted by the Ministry of Higher Education of Cameroon. The full-time duration of the bachelor degree program in Buea is 3 years whereas that of Yaoundé and Bamenda is 24 months and 60 months, respectively. The HND in Nutrition and Dietetics offered in Buea is of 24 month-duration.The teaching format for all the programs was didactic with little practical training. The program in Bamenda was heavy on basic nutrition and food science, although it included some courses on community nutrition and clinical nutrition. In contrast, the curricula of the Buea and Yaoundé programs emphasized dietetics and applied nutrition. The nutrition courses offered were mainly on food, nutrition, and dietary planning. None of the programs emphasized public health nutrition, or the ongoing nutrition transition in the country, or the attendant rise in NCDs as a key area in their curricula. Furthermore, none of them adequately covered the national protocol for the management of acute malnutrition. The detailed curricula are available upon request.We did not find any formal documentation outlining the competencies that students were expected to gain upon completion of these programs.The University of Ngaoundere was the only institution offering a graduate program in nutrition in Cameroon at the time of data collection . The 2-yThe curriculum offered a good coverage of the key dimensions of human nutrition . The curThe University of Maroua and the University of Bamenda, two state-owned universities, were also about to launch master's programs related to nutrition at the time of data collection .Although we did not find any doctorate degree programs in nutrition in Cameroon, we noted that there were some Ph.D. holders who had obtained their degrees in nutrition abroad.All the nursing and midwifery schools surveyed used a standard nutrition curriculum that was designed by the Ministry of Public Health of Cameroon . NutritiUnlike medical schools where nutrition was embedded in other clinical courses, nutrition instruction was delivered mainly as a stand-alone course in nursing and midwifery schools. As with the undergraduate nutrition degree programs, the teaching method for nutrition training in the health professional institutions was mainly didactic, with little opportunity given to students to apply the basic principles of human nutrition to public health practice.The training content in nursing and midwifery schools was heavily oriented toward basic nutrition. The nursing programs included three courses on food and food groups, nutritional requirements, and nutritional disorders . Some ofSeveral university-level institutions in Cameroon offered nutrition courses as part of the curricula for other programs . These iNutrition was also taught in some programs offering degrees in agriculture and related areas. These included master's programs in animal production , Master's in Crop Production (University of Dschang), and an Agricultural Engineering degree (University of Bamenda).There were limited opportunities for continuing professional development in nutrition. There were no short-term nutrition training programs available in the country at the time of the study.In this study, we provided a detailed assessment of the current academic nutrition programs in Cameroon. We found that university-level nutrition training was not common. We identified only eight nutrition degree programs in the country, five of which were less than age 5 and three were about to start. Contrary to study findings in West Africa , we did The study revealed several weaknesses in the existing nutrition training programs in terms of the opportunities to acquire competencies for nutrition career practice, teaching methodology, the scope of topics covered, alignment with national priorities, and engagement in international collaboration. Overall, the findings of this study are consistent with recent observations about nutrition training programs in West Africa , and in We did not find any formal documentation outlining the competencies that students were expected to gain in any program. The need for competency-based nutrition training in Africa has been stressed by many experts , 22. To We also found that public health nutrition was only marginally covered in both dedicated nutrition degree programs and in health professional schools. The need to focus on public health nutrition to improve nutrition outcomes in a sustainable manner is of paramount importance. A lack of trained professionals in public health nutrition is one the factors hindering the implementation of nutrition interventions , 24.Unlike the situation in West Africa, we found no short-term professional nutrition courses in Cameroon. Continuous professional education programs or in-service training are important because they can provide the opportunities for updating knowledge, skills, and competencies in nutrition. However, this approach will only be effective if the basic training of beneficiaries is adequate and sufficient time and resources are allocated to it. Although the capacity for supervisory training, mentoring, and on-the-job nutrition training in Cameroon was beyond the scope of this study, there is also a need to document and improve current practices because most organizations in the country use these strategies to build the capacity of their staff on nutrition.Even more importantly, individual capacity development efforts need to go beyond training staff from the health sector. Non-medical staff, especially those from agriculture and WASH  sectors, need to be equipped with adequate knowledge on nutrition to help accelerate the delivery of nutrition-sensitive interventions. Training curricula in agriculture schools also need to be reviewed to strengthen the linkages between agriculture and nutrition and provide a platform for scaling up nutrition-sensitive interventions .Our results also revealed that collaboration and networking between training institutions in Cameroon were not well established and need to be strengthened. Enabling closer ties between training institutions inside the country could foster the mobility of students and faculty members across the country . HoweverThere are several limitations for this study that should be noted. First, our inventory may not have been exhaustive as we covered only seven out of ten regions. However, these were the regions that contained the largest universities, where tertiary-level training was likely to be located. In spite of our best efforts to provide a comprehensive assessment of the current academic nutrition offerings in Cameroon, some programs may have been omitted. However, we believe any gaps are unlikely to significantly affect our findings. Secondly, we do not sufficiently discuss the steps that need to be taken to improve the quality of nutrition training in Cameroon. We are planning to conduct a workshop in Cameroon during which the key results of this study will be discussed with the Government of Cameroon and all stakeholders. This will ultimately pave the way for the development of a consensual action plan that will help to upgrade existing programs and develop new programs that are of high quality.This study is a first step toward the strengthening of human capacity for nutrition in Cameroon. Our findings highlight the need for a shift in paradigm for nutrition training in Cameroon to be more responsive to the public health needs in the country. Nutrition training programs could be improved by making them more comprehensive in the coverage of all dimensions of human nutrition , designing more practical-based training, emphasizing competencies, and harmonizing nutrition curricula to ensure that a minimum set of competencies are present in the workforce. It is also vital to enhance in-service nutrition training for health professionals in the country and support the establishment of new nutrition degree programs to enable an expansion of a nutrition workforce across the country. The Government of Cameroon, through the Ministry of Higher Education and the Ministry of Health, should also take steps to establish standards for systematically monitoring the quality of nutrition training programs to ensure that they are aligned to national nutrition priorities.


Opabinia was the first to highlight how some of the Burgess Shale animals differ markedly from those that populate today's oceans. Categorized by Stephen J. Gould as a ‘weird wonder’  Opabinia, together with other unusual Burgess Shale fossils, stimulated ongoing debates about the early evolution of the major animal groups and the nature of the Cambrian explosion. The subsequent discovery of a number of other exceptionally preserved fossil faunas of Cambrian and early Ordovician age has significantly augmented the information available on this critical interval in the history of life. Although Opabinia initially defied assignment to any group of modern animals, it is now interpreted as lying below anomalocaridids on the stem leading to the living arthropods. This commentary was written to celebrate the 350th anniversary of the journal Philosophical Transactions of the Royal Society.Harry Whittington's 1975 monograph on  Whittington's redescription of Opabinia heralded the presence of very unusual creatures among those under investigation from the Burgess Shale, a deposit in which, remarkably, soft-bodied forms were fossilized 4] startess Shale .3.Smithsonian Miscellaneous Collections. Walcott described his work as preliminary but, even following his death in 1927, there was relatively little research activity on the specimens [Proboscicaris, now known to be part of the anomalocaridid Hurdia, at this time [Walcott discovered the Burgess Shale in 1909 and published a series of descriptions of the fossils he collected in the pecimens . The bulhis time . When Arhis time . In addiTreatise on invertebrate paleontology, which grouped the Burgess Shale arthropods alongside trilobites in Trilobitomorpha, was that their appendages at least were trilobite-like [In the mid-1960s, the Geological Survey of Canada (GSC) embarked on a project to map the area of Yoho National Park, including Walcott's Quarry, and Whittington [ite-like . Whittin4.inter alia, had attracted him to Harvard 17 years earlier. Whittington's expertise and focus was arthropods, and he started his work redescribing the Burgess Shale fauna with Marrella [Marrella is the most abundant arthropod in the Burgess Shale by a significant margin, and Whittington used it to work out the mode of preservation of the Burgess Shale fossils showing that they, albeit flattened, retain some three-dimensionality and are oriented in a variety of attitudes to bedding owing to the way they were transported prior to burial [Before Whittington had even completed his Burgess Shale fieldwork, he had accepted an offer to succeed Oliver Bulman FRS in the Woodwardian Chair at the University of Cambridge. Thus, the nascent Burgess Shale project crossed the Atlantic with its leader who was returning to his English origins but with a rather different research focus to the silicified trilobites that, Marrella , which, o burial .Yohoia, which differed from Marrella particularly in the possession of a pair of grasping appendages (which Whittington referred to as the anterior great appendage) at the front. A second species of Yohoia described by Walcott turned out to lack these appendages and had a bivalved carapace, so Whittington assigned it to a new genus which he named Plenocaris. He investigated the limbs of the trilobite Olenoides [Opabinia. When Whittington showed a preliminary reconstruction at the Palaeontological Association conference in Oxford in 1972, the audience responded with loud and spontaneous laughter [Opabinia is relatively rare, so it is not clear why it attracted Whittington's attention so early in the sequence of Burgess Shale papers. Such decisions were made well in advance; specimens had to be borrowed and mailed across the Atlantic. But there is no sign that Whittington changed the order in which he planned to research the taxa from the Burgess Shale in response to any development in his overview of the fauna. I doubt that he could have predicted that Opabinia would become a talisman for the Burgess Shale project as a whole.Abundance may have been a criterion in determining how Whittington prioritized taxa for reinvestigation, at least initially . Thus, the next arthropod that Whittington  tackled lenoides  for the laughter , an indiOpabinia paper [Opabinia in detail—eight from the Smithsonian Institution National Museum of Natural History and one each from the Yale Peabody Museum and the GSC. All except the last, which was found during the GSC excavation of 1967, were collected by Walcott's expeditions. Whittington had access to a further 18 specimens from the Smithsonian collections.Whittington's ia paper  is a comia paper ), and seia paper . Whittinia paper . He achiMarrella and Yohoia appeared in the Bulletin of the Geological Survey of Canada; the original plan was that the Survey would publish the results of the reinvestigation of the Burgess Shale. The Opabinia monograph was the first of 12 descriptions of Burgess Shale animals to be published in the Philosophical Transactions by Whittington and his colleagues; others were published in other journals. This shift in publication strategy marked a recognition that the output of what was, by then, a team working under Whittington's guidance, would be too much for the Survey publication programme. Whittington's 1971 election to the Fellowship of the Royal Society may also have contributed to the change—the Philosophical Transactions became more accessible to him as a vehicle for monograph-length treatments.Whittington's papers on 5.Opabinia. The morphology and affinities of this animal have generated significant controversy. Walcott's preliminary description was based on four specimens, two of which he figured [Opabinia as a crustacean and compared it with the living anostracan branchiopod family Thamnocephalinae, which have large clasping antennae [Opabinia are ‘very suggestive of an annelidan ancestor’.Whittington's was not the first, nor the last, technical description of  figured . He regaantennae . He concantennae  noted thOpabinia and the lobopod Aysheaia early in his career, in a paper published in 1930, shortly after he joined Yale University. Hutchinson [Opabinia as an anostracan branchiopod and suggested that the proboscis might represent the fused internal branches of the antennae. He interpreted the trunk limbs as foliaceous with setae. Hutchinson provided the first reconstruction of Opabinia, showing the animal swimming ventral side up in the manner of a living anostracan (a). He regarded Opabinia [Opabinia and other extinct taxa, which he interpreted as early specialized marine anostracans predating the migration of the group to fresh water. Hutchinson illustrated two specimens of Opabinia from the Smithsonian collections that were not figured in Walcott's original description. Both were figured and described by Whittington [The great ecologist G. Evelyn Hutchinson considered both tchinson  acceptedostracan a. He regOpabinia , p. 10 aOpabinia [Leanchoilia and Yohoia, and his reconstruction of Opabinia (b) is reminiscent of those great appendage arthropods and very different from Hutchinson's anostracan-like version. Simonetta [Opabinia with a bifid proboscis, short antenna-like appendages, just two large compound eyes, a dorsal exoskeleton with lateral projections (pleurae) and biramous trunk appendages with a long segmented inner branch. Whittington [Opabinia in search of the jointed limbs that should surely have been present if it were an arthropod. While the specimens show only limited evidence of preparation (a), Whittington's deep understanding of the way the Burgess Shale fossils split into part and counterpart ensured that he knew where to look for any potential segmented endopod and was confident they were absent.Alberto Simonetta, a professor of zoology at the University of Camerino and primarily a specialist on birds, was the first to recognize that Walcott's fossils merited a major reinvestigation. He began a comprehensive review of the arthropods in the Smithsonian collection in 1960, in part with his colleague Laura Delle Cave. Unlike Whittington and his team, however, Simonetta did not prepare the fossils, indeed, he may not have been permitted to do so. His description of Opabinia  was inclOpabinia b is remiimonetta  depictedttington  describeparation a, Whitti6.Opabinia, Whittington generated a reconstruction that looked quite different from those of Hutchinson and Simonetta, and did not closely resemble any living or fossil arthropod (c). It was clear that Opabinia did not belong with the trilobites (in Trilobitomorpha) nor could it be accommodated in any modern taxonomic group. To what was this strange creature related? It would probably be fair to say that he was flummoxed! Whittington turned for advice on the affinities and mode of life of Opabinia to one of the leading authorities of the day on living arthropods, Sidnie Manton FRS (1902–1979) of Queen Mary College and the Department of Zoology at the Natural History Museum ) London, who was writing her 1977 textbook The Arthropoda: habits, functional morphology and evolution and was, in turn, relying on Whittington for advice on fossil arthropods [Opabinia’ (clearly implying uncertainty in her mind about its nature) in which she suggests that Opabinia is ‘an annelid worm of an extinct group’. Whittington's letter to Manton on 22 April 1974 asks ‘is there any reason why it should necessarily be annelid in affinities, or should I merely suggest it is an extinct worm-like creature?’ . When Whittington finally submitted his paper to the Philosophical Transactions on 6 August 1974, he noted [Having drawn and interpreted the most instructive specimens of rthropod c. It wasnton FRS 02–1979 oOpabinia lent itself to an interpretation within this framework, which he had absorbed through reading Manton's work and discussing her ideas with her: the concept of separate phyla was a logical extension of Manton's view. In her 1973 synthesis, Manton [Origin of major invertebrate groups [Manton's lifetime of investigations of the comparative functional morphology of living arthropods, together with the results of research by the Australian embryologist Don Anderson on arthropod development, led her to espouse a polyphyletic origin of the arthropods ,21. Whit, Manton  argued te groups . Manton e groups , p. 488!7.Opabinia were being published his graduate student Simon Conway Morris FRS was describing a selection of Burgess Shale animals that Walcott had overlooked: Nectocaris, Odontogriphus, Dinomischus and Hallucigenia. These too were difficult to ally with any living group. Opabinia was the first, but these other taxa also raised the possibility that taxa of high rank had evolved during the explosion of diversity that characterized the Cambrian, only to go extinct. Opabinia's iconic status rests not only on its remarkable morphology, but the fact that it was the first newly described Burgess Shale animal that apparently could not be assigned to a living phylum. This concept of ‘taxa of uncertain affinity’ was seized upon by Gould [Wonderful life, where he characterized them as ‘weird wonders’. The giant predator Anomalocaris (b), which Whittington and Briggs described in 1985 [Opabinia paper as representing a conceptual leap in our understanding of the Cambrian explosion—tangible evidence that Burgess Shale taxa might represent a riot of experimental morphologies that are not represented today [Opabinia … will stand as one of the great documents in the history of human knowledge’. Hyperbole surely but not, perhaps, if Whittington's Opabinia paper is viewed as a proxy for the Burgess Shale project that he led.While Whittington's contradiction of Walcott's (and others) views on by Gould  in his balocaris b, which  in 1985 , was alsed today . Gould [ed today , p. 136 Wonderful life [Opabinia. Gould's book inspired attempts to quantify morphology, independently of numbers of taxa, and to determine how much variation appeared and how quickly during the Cambrian. Such analyses showed that disparity evolved rapidly in the Cambrian but to an amount that was not significantly greater than at any time later in the history of life [Hallucigenia, for example, turned out to be a spiny lobopod. At the same time, the use of cladistic methods for determining the relationships of fossils, which palaeontologists had been slow to adopt, was on the rise, and such an approach would ultimately help to clarify the relationships of Cambrian animals to those of today.Whittington's fundamental insight led to a reconsideration of the relationships and significance of the Burgess Shale animals. It was Gould's ful life , however of life . In the  of life . Halluci8.Opabinia, the affinities of these extinct forms were likely to be obscured. Whittington was not convinced of the value of numerical methods, much less cladistics, relying instead on experience and a deep knowledge of morphology to identify species and genera and determine their systematic position. In this, he was not unusual among trilobite specialists or other palaeontologists of the time. The validity of genera relied on their establishment by an expert on the group, and taxonomy was based, for the most part, on authority. The first attempt to use statistical methods to analyse the relationships of Burgess Shale organisms was a collaboration between Whittington and me, as one of his former graduate students [Cladistics uses shared derived characters as a key to relationships between taxa, whereas considerations of disparity emphasized differences and, by implication, ‘weirdness’ compared with the more familiar creatures of today. As long as Whittington's team dwelt on the peculiarities of Burgess Shale animals like students ,27. We pstudents . Thus, tOpabinia or Anomalocaris. In 1987, Briggs & Whittington [Opabinia  with the arthropods. Graham Budd, Professor at the University of Uppsala in Sweden, started his career as a graduate student of Simon Conway Morris, working on another exceptionally preserved Cambrian fauna, from the Lower Cambrian of Sirius Passet, Greenland. He described a remarkable new arthropod, Kerygmachela, with lobe-like limbs and gill-like structures [Opabinia. He presented the first cladogram showing these animals , a de facto acknowledgement that Opabinia is an arthropod. Budd formalized this idea in 1996, interpreting Opabinia as having lobe limbs and placing it [Anomalocaris. This is not so far removed from Whittington's pre-cladistic view that Opabinia is representative of an ‘ancestral group of segmented animals' [Opabinia occupies  thatructures ,33, draw animals , with thacing it  as an ofanimals' ,34 were animals' . Budd's animals'  on the poccupies , althoug9.Opabinia were difficult to interpret from the outset. Walcott considered them limbs, but Whittington, well versed in trilobites and other arthropods, wondered if they might be pleurae . He eventually determined that the flaps were appendages, but unusual in having separate gill filaments on their outer surface  and Euarthopoda, went in search of the second limb branch (endopodite) [d) that they are represented by the triangular reflective areas that Whittington interpreted as gut extensions. Zhang & Briggs [Opabinia was equivocal and interpreted the gill filaments as extensions of the rear margin of the flap immediately to the anterior, resulting in a more familiar arthropod limb structure (e). More importantly, Zhang & Briggs agreed with Budd's placement of Opabinia on the arthropod stem [The flaps along the trunk of aridids: ). This uopodite)  that Whiopodite) , p. 71. & Briggs  showed ttructure e. More ipod stem , which dOpabinia further [d), returned to Whittington's view that the gill-like structures are attached to the flap-like limbs dorsally  [Opabinia emphasizes the potential importance of this animal in determining the sequence of events in the evolution of arthropod limbs. At the same time, Opabinia has also captured the imagination of the public. A Google search for Opabinia images yields artwork, cartoons, T-shirts, jewellery and even soft toys—impressive, even if only a fraction of the number of hits for Tyrannosaurus!Ever tenacious, Budd, with his then graduate student Alison Daley, investigated  further , includi further  (figure aridids) . They alaridids) ) may ref10.Extraordinary fossil biotas: their ecological and evolutionary significance [Opabinia, reveal combinations of characters that are not represented in the modern biota. The biota today is a winnowed sample—many of the intermediate forms have suffered extinction. These extinct intermediates are critical to unravelling how morphology evolves, and in analysing the relationships of even the modern groups. The Burgess Shale project stimulated huge interest in the evolutionary significance of exceptionally preserved fossils, which occur in what are commonly known as Konservat–Lagerstätten (conservation deposits). Erwin et al. [The reinvestigation of the Burgess Shale under Whittington's leadership emphasized the importance of exceptional deposits in preserving soft-bodied animals in addition to the shelly forms that make up the normal fossil record. Whittington highlighted this by organizing a landmark meeting at the Royal Society in 1985, with Conway Morris, on ificance . Conway ificance  performen et al.  enumeratOne of Whittington's first tasks was to work out how the Burgess Shale fossils are flattened in the shale, a prerequisite to interpreting and reconstructing them. Much effort has subsequently been expended in attempts to explain why the fauna as a whole is preserved and, specifically, why Konservat–Lagerstätten are abundant in the Cambrian relative to later periods of time. Burgess Shale-type fossils are preserved as carbonaceous films ,42; deca11.Opabinia, the Burgess Shale was by far the most important repository of data on soft-bodied forms from the Cambrian. Although Opabinia remains essentially unique to the Walcott Quarry, a number of new discoveries have significantly augmented the number of Konservat–Lagerstätten of Cambrian age, and increased our knowledge of the diversity of Cambrian life. The immediate area around the Walcott Quarry has yielded several new sites of exceptional preservation. A number were discovered in the early 1980s by Royal Ontario Museum expeditions led by Desmond Collins [Metaspriggina [When Whittington described  Collins , and the Collins  and a sl Collins , some 40priggina . Such neHalkieria [Myoscolex, one of the more common fossils from the Emu Bay Shale, might be Opabinia-like. The majority of specimens of Myoscolex, however, consist of phosphatized muscle blocks—the cuticle, or evidence of appendages, is rarely preserved and the nature of Myoscolex has yet to be confirmed. More recently, Van Roy et al. [Opabinia in 1975, such palaeontological riches were inconceivable.In addition to new discoveries in the area around Walcott's original quarry, many important sites yielding Burgess Shale-type fossils have turned up in other parts of the world and are the subject of major research projects. A number of sites in the USA, notably in Utah, continue to yield new soft-bodied fossils, but they are generally not as well preserved as those from the original Burgess Shale. Spectacular Cambrian fossils have been found in China , particualkieria . The Lowalkieria . Briggs alkieria  even sugy et al.  reported12.Opabinia with lobopods like Hallucigenia, anomalocaridids and the arthropods of today.Future work on the Cambrian will involve exploiting the wealth of new fossil discoveries around the world. The approach, however, is increasingly interdisciplinary. Refined methods of imaging fossils, reconstructing the original animal, analysing relationships and generating phylogenies, and dating and analysing rock sequences, open up remarkable possibilities for working out the early evolution of animals and relating it to environment and ecology. The most exciting progress, however, will come from an integration of palaeontological and biological approaches. Molecular phylogenies combined with fossil data provide a new measure of rates and steps in the evolution of clades. And relating fossil morphologies to studies of evolutionary development and how it is controlled genetically  will rev


Knowledge and skills of primary health care workers (PHCWs) in primary eye care have been demonstrated to be inadequate in several districts of Kenya, Malawi, and Tanzania. We tested whether enhanced supervision, focused on improving practical skills over two years, would raise the scores of these workers on a test of basic knowledge and skills.This was a randomised controlled trial. All primary health care (PHC) facilities within two districts of each country were enrolled and randomly assigned by district  or by health care facility (Tanzania) to receive quarterly skills-based supervision by a district eye coordinator or to continue existing routine supervision. At baseline, a test of basic knowledge and skills in five key areas was administered to PHCWs, and visual acuity (VA) charts and working torches were provided. After two years the test was administered again. Changes in test scores were compared between the intervention (enhanced supervision) and the non-intervention (routine supervision) facilities.All 137 facilities in the six districts were enrolled including 343 PHCWs. At baseline, no facility had a visual acuity chart and 18 (13%) had a working torch; the average total skills scores were 6.04 and 6.38 (maximum of 12) in the non-intervention and the intervention facilities, respectively. After two years, 16 intervention facilities (23.2%) had a visual acuity chart correctly placed and 19 (27.5%) had a working torch, compared to 4 (5.9%) and 6 (8.8%), respectively, in the routine supervision facilities. At the facility level, the change in overall test scores was +1.84 points in the intervention sites compared to +0.42 points in the non-intervention sites (p<0.001). Staff turnover included about 75% of the staff by the end of the study.The improvements in the enhanced supervision facilities were very modest and of questionable clinical significance. The low impact of the intervention may be due to the high turnover of PHCWs or high absenteeism. A better understanding of the quality of eye care at PHC facilities and influencing factors are urgently needed before continuing to invest resources in the scale up of this model of task shifting in Africa. Primary eye care (PEC) in sub-Saharan Africa usually refers to the provision of basic eye services  integrated within the primary health care (PHC) system, offered at the most basic level of the health system by general primary health care workers (PHCWs). It is estimated that only 30% of Africans have access to specialised eye care at any point and therefore, by default, most patients are attended by frontline health workers, who may not have received any training in eye care . An impoTherefore, it is often assumed that eye care services can only be made sustainable if they are integrated into the basic health services. The assumption is also made that if eye care is provided at the basic health care level it will increase accessibility for the rural poor. On the other hand, there are arguments that PEC will not be an effective way to reach the goal of elimination of blindness and visual impairment because cataract, glaucoma, and refractive errors are the most common causes for blindness and visual impairment in Africa and these conditions, unfortunately, cannot be treated at the level of primary care system in Africa; in fact it is a challenge to even diagnose them accurately without more technical knowledge and equipment than are present at the primary health care level. It should be also be considered that there might be lower quality when specialized services are delivered by general health workers. In the case of eye care, there could be many reasons for the low quality, including inadequate training and supervision, workload, and infrequent encounters with patient with eye complaints, among others. Supervision in particular has been noted to be a problem at PHC facilities in Tanzania . Ehiri sThe challenges of integrating health services have included severe shortage of human resource capacity to implement the programmes and scale up , lack ofet al[et al found unacceptably long delays in accessing specialist emergency eye care services among patients with eye trauma [et al identified an awkward and difficult referral system, lack of the right medicines at clinics, poor knowledge of eye conditions, and inadequate communication within the referral system, as problems limiting the ability of general primary health care staff to provide good primary eye care [There is a need to critically look at the available evidence of successes of existing primary eye care programs that have been integrated into PHC before further investments into PEC are made. A detailed review by Courtright et al identifiet al. He acknet al. In a ste trauma . These weye care . Late preye care . A progreye care ,18. In teye care . It is aeye care , the litThe current study was designed to test whether in comparison to “routine supervision”, “enhanced” supervision over two years  would improve the knowledge and skills of primary health care workers in primary eye care in Kenya, Tanzania, and Malawi.This was a prospective randomised cluster study. In each country, two non-adjacent districts were randomly assigned to the intervention or non-intervention arm. All government primary health care facilities within each district were included. The intervention plan and tools were developed through a tool development training workshop (intervention plan) and pilot testing. Specific relevant conditions at the facilities, and measurements of the knowledge and skills of the PHCWs there were made at baseline, using a standardize questionnaire (described below). After collection of baseline information, a torch, batteries, and a visual acuity chart were provided to both intervention and non-intervention facilities. District Eye Coordinators (DECs) were trained in “enhanced” supervisory methods, provided with supervisory monitoring forms, as well as a minimal incentive and transportation money. The training was two days and included short didactic sessions followed by interactive sessions to practice and demonstrate competence. Role play was used to gain skills in supervisory challenges. The DECs were coached and expected to demonstrate how they would teach each of five subjects included in the PEC test . They were to make supervisory visits to each health care facility every quarter; each visit included a focus on one of the five subjects. Non-intervention districts were informed of the study, asked to continue the supervision system that was already in place, and were not given any supervisory monitoring forms or extra funds to make visits.The randomization in Kenya and Malawi was at the district level. In Tanzania, randomization was by facility because the DECs felt it was not “fair” to randomize by district; special attention was given to instructing the eye coordinators in the strict need to avoid “spillover” in the supervision provided.Ethical clearance was obtained in each country: from Tumaini University in Tanzania, and the Ministries of Health in Kenya and Malawi. Consent was obtained from all health workers who participated in the study.Training of the DECs in supervision, and of the interviewers, took place in each country separately, after a meeting of principal investigators from each country to determine methods. Study coordinators in each country contacted the DECs by phone every quarter to ensure that supervisory visits were actually made.Two questionnaires were used, both administered orally by the trained interviewers (research assistants). One pertained to conditions at the facility and included questions on staffing at the facility, as well as the availability of a working torch, tetracycline eye ointment, and a visual acuity chart. This was administered to the facility in-charge and took about 15 minutes to complete. The second questionnaire was administered to individual PHCWs. It was designed to test basic knowledge and skills; 8 points were allotted to testing ability to recognize (1 point) and manage (1 point) four common or important eye conditions  presented as cases with large colour photos and a brief history for each. Questions were mixed, some with yes/no answers and others needing numerical answers  and others asking specifically what topics were taught/learnt. The last part of the questionnaire was designed to measure specific clinical skills. Photographs and histories consistent with four important eye conditions  were shown; one point was given for recognition of the condition and another point for suggesting the proper management. Four additional points could be earned from demonstrating how to check visual acuity using a Snellen chart; one point was given for each of the following: correct distance, measuring each eye separately, recording the visual acuity, and interpreting what it meant. The test was simple and designed to explore a lower threshold for competence in recognition and management, based on the experiences of the authors. A total overall score was calculated by adding the above scores, with a maximum of 12 points possible. The pre-coded individual questionnaire took approximately 20 minutes to complete.The questionnaires, which were translated into Swahili for Tanzanians and administered in English in Kenya and Malawi, were pre-tested on PHCWs in Tanzania. The questionnaires were administered by research personnel in each country, all of whom were trained to ensure standardization in data collection.Knowledge and skills were analysed at the facility level using an average of the scores of all the PHCWs present at the facility on the visit; this was necessitated by the high rate of turnover of PHCWs between baseline and follow up and also took into account the cluster effect of the supervision on individuals at one facility. All staff present on the day of the visit were sampled.Data were entered by double data entry in Epidata 3.1 (electronic software for data entry), which has inbuilt quality checks, and imported into Microsoft Excel and Stata 11.0 for analysis. We compared facilities pre-intervention using chi square or t-test. We calculated average scores for all PHCWs at each facility for recognizing and managing each condition, measuring VA, and total overall score. We analysed the change in total average score from baseline to follow up for each health centre and compared these changes by t-test between the intervention and non–intervention facilities. Changes in individual test items were analysed by a non-parametric  test.A total of 343 PHCWs from 137 health centres, 69 with enhanced supervision (intervention) and 68 with routine supervision (non-intervention), were studied. All supervisory visits to the intervention facilities occurred as scheduled except for two visits in Malawi which were not made due to unavailability of fuel. In Malawi there were 38 health facilities in total: 18 non-intervention, 20 Intervention; in Tanzania 58 in total: 29 non-intervention, 29 intervention; and in Kenya: 40 in total: 20 non-intervention, and 20 intervention.There was a high turnover of PHCWs, with only 20% of the workers interviewed at baseline still in place at the end of two years; the positions of most of those who left had been filled by others. There was also high absenteeism with approximately 1/3 of all PHCWs absent during the two visits. One supervisor in Tanzania left his post halfway through the study and was not replaced by the Ministry of Health. Data from the facilities to which he was providing enhanced supervision were analysed with other enhanced facilities. Results were very similar in all countries so we elected to present them together.A comparison of the facilities at baseline Table  shows thTable Table This study documents the persistent deficiencies in the diagnosis and treatment of common eye conditions by PHCWs in three countries, despite enhanced supervision by DECs over a two year period. A strong point of this study is that it was conducted as a randomised trial to try to ensure that potentially confounding factors were equally distributed between the two arms of the study.Our study results highlight some of the major problems with PEC, which is supposed to be provided by PHC facilities in the countries under study. At baseline, the facilities were poorly equipped to do the most rudimentary examination of an eye, although tetracycline eye ointment was commonly available and used despite this. Neither this, however, nor any other eye medicine, should be dispensed without an examination of the eye. In a companion paper we documented factors associated with scores at baseline on the test of knowledge and skills .The high staff turnover and absenteeism are indicative of the problems within the PHC systems of the countries included in our study. Failure to replace staff (such as the eye coordinator who was a supervisor) who leave for long periods of time weakens the systems. Weak systems make the provision of quality care, especially specialized care, more challenging, and also make it imperative that good quality supervision take place and include skills transfer.The fact that enhanced supervision is significantly associated with having a working torch, and having a VA chart correctly placed on the wall, suggests that supervision helps. Even so, despite having been provided with these, only about one-quarter of the enhanced-supervision facilities had working torches and correctly placed VA charts after two years.With regular supervision based on skills transfer, we demonstrated a modest increase in the ability of PHCWs to measure VA. This is a fundamental part of the examination of an eye but must be used in conjunction with history and further examination to determine appropriate management. While statistically significant, the improvements were of questionable clinical relevance and unlikely to be enough to actually lead to improved eye care in the health facilities.There are a number of limitations in this study. While we believe that these facilities and the PHCWs within them are representative of others in the three countries, this cannot be proven. The personnel who collected data were trained to do so objectively, but it was not possible to keep them from knowing which facilities received intervention and which did not; this could have resulted in some bias. In Tanzania, the loss of a supervisor halfway through the study meant that half of the intervention facilities missed the enhanced supervision they should have received; if the supervision had been effective, the scores at these facilities might have been higher post intervention. However, this weakness in the health system is a reality that must be considered when task shifting strategies aimed at providing more services at PHC level are proposed.An important consideration is the design of a good test of PEC knowledge and skills. There is no common understanding of what PEC means and thus the skills and knowledge required to provide PEC may be debated . HoweverIn summary, we demonstrated a modest improvement in knowledge and skills in PEC after two years of skills-based supervision. It might have been more effective had the staff turnover not been so high. It is possible that if such supervision were provided uniformly throughout the health system, PHCWs would benefit even when transferred elsewhere. Good supervision need not be costly and should be part of routine activities. The fact that such supervision is not routinely practiced is evidence of the poor functioning of the current PHC system and leads to the bigger question of what is realistic to expect from PHCWs in terms of delivering specialist care of any type. For now, it is not clear that PEC, focused on diagnosis and management of eye conditions, will result in quality care for patients or that will it result in decreased prevalence of vision loss in the population, even with the implementation of enhanced supervision and oversight. This is not to say that there is no role for the PHCW in providing PEC; however, it might be better limited to knowledge of where to refer people they see with eye complaints, particularly in settings where few eye patients present to PHC facilities. More evidence on the effectiveness of current concepts of PEC is required before advocating for their expansion.CI: confidence interval; DECs: District Eye Coordinators; DFATD: Foreign Affairs, Trade and Development Canada; GHRI: Global Health Research Initiative; IDRC: International Development Research Centre; KIs: village key informants; OR: odds ratio; PEC: primary eye care; PHC: primary health care; PHCWs: primary health care workers.The authors declare that they have no competing interests.KK designed and conducted the experiment, analysed data, and contributed to write up. MG, EB, and EE conducted the experiment, and reviewed the manuscript. SL designed the experiment, analysed data, and contributed to write up. PC designed the experiment, analysed data, and reviewed the manuscript.


It is therefore much faster and cheaper, being the principal advantage of DH technology in plant breeding, but not the only. Indeed, DHs are also useful for genetic mapping of complex qualitative traits, for linkage studies and estimation of recombination fractions, to unmask recessive mutants, to avoid transgenic hemizygotes, or for reverse breeding, among others  technology is a powerful tool in plant breeding to reduce the time and costs needed to produce pure lines, the cornerstone of hybrid seed production. This biotechnological alternative to classic methods allows for a reduction of the typical 7–8 inbreeding generations needed to fix a hybrid genotype to only one in vitro to induce the development of a haploid embryo, generally from the egg cell , involving both female and male gametophytes. From the female gametophyte, haploids may be produced by uniparental genome elimination and by induction of gynogenesis. Uniparental genome elimination is typically achieved by crossing two sexually incompatible species, in some intraspecific crosses when one genitor carries specific mutation(s), or through genetic manipulation of CENH3, a centromeric variant of the H3 histone  that engulf and digest cytoplasm regions, being finally released to the apoplast. They also describe the parallel formation of a callosic layer beneath the microspore intine, and the de novo formation of abnormal cell walls with altered callose and cellulose composition. All these events appear to have a dramatic impact in the developmental fate of the embryogenic microspore, including genome duplication by nuclear fusion.For all these methods, there are species where they are most efficient. This is why these species are used as experimental models to study basic aspects of the process. This is the case of onion for gynogenesis, and of barley and rapeseed for microspore embryogenesis in monocots and dicots, respectively. This Research Topic includes examples of research focused on different aspects of gynogenesis and microspore embryogenesis in these species. For example, Castillo et al. show that preconditioning or coculture with ovaries increases the efficiency of DH production and chromosome doubling in different bread wheat cultivars, being the increases higher in those most recalcitrant. Interestingly, these results are in line with those from Lippmann et al. about the role of the female parts in helping the development of microspore-derived embryos in an in vitro environment, devoid of the complex crosstalk between embryo, endosperm and seed tissues that takes place during zygotic embryogenesis. In this crosstalk, hormones play a key role. This is why Żur et al. present a review focused on the current knowledge of hormonal regulation during microspore embryogenesis. Besides the role described for the principal hormones, either when they act endogenously or when applied exogenously, this review presents new and interesting notions about their involvement in this process. A remarkable example of the application of this kind of knowledge is the study brought by Chiancone et al., which achieves an important milestone inducing for the first time the development of microspore-derived embryos in different cultivars of Citrus, a very recalcitrant fruit crop, through the use of meta-topolin, a plant hormone rarely use in microspore embryogenesis.However, not all the species respond well enough to DH technology. Indeed, many of them are still considered as recalcitrant to these treatments, including many of the most important crops worldwide. Despite the work of many groups, little is still known about how to overcome recalcitrancy. This is why it is also important to shed light on the particularities of recalcitrant species and the special conditions they need to be induced. In this Research Topic, Together, the papers of this Research Topic show some relevant advances in the understanding of the processes that lead to the formation of DH plants, and in their application to improve its performance in recalcitrant genotypes.This work was supported by grant AGL2014-55177-R from Spanish MINECO to JMSS.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.