Poor accessibility of healthcare facilities is a major barrier for people with disabilities when seeking care. Yet, accessibility is rarely routinely audited. This study reports findings from the first national assessment of the accessibility of primary health care facilities, undertaken in Brazil. A national accessibility audit was conducted by trained staff of all 38,812 primary healthcare facilities in Brazil in 2012, using a 22-item structured questionnaire. An overall accessibility score was created (22 items), and three sub-scales: external accessibility (eight items), internal accessibility (eight items), information accessibility (six items). The main finding is that the overall accessibility score of primary care facilities in Brazil was low  of 0.21, on a 0–100 scale). Accessibility of different aspects of the healthcare facilities was also low, including external space , internal space  and accessibility features for people with other visual or hearing impairments . Scores were consistently better in the least poor regions of Brazil and in facilities in larger municipality size (indicating more urban areas). In conclusion, large-scale accessibility audits are feasible to undertake. Poor accessibility means that people with disabilities will experience difficulties in accessing healthcare, and this is a violation of their rights according to international and Brazilian laws. Globally, there are approximately one billion disabled people, equating to one in seven people worldwide . People Solutions are therefore needed to improve healthcare access for people with disabilities, and these must be targeted at overcoming the barriers faced. Improving accessibility of facilities is clearly a key need  and is sMany countries have laws or policies in place that mandate that certain access standards are met in healthcare provision . These rules are ineffective if they are not monitored. Accessibility audits can be used for monitoring purposes to understand whether facilities are adhering to certain standards, and a wide variety of tools are available . Many of these tools are complex, requiring measurement of slopes of ramps and widths of doors, and so on. As a consequence, few large-scale accessibility audits have been conducted, and almost all available data on accessibility of healthcare facilities is from high income settings and focusses on physical accessibility alone ,8,9. DatFortunately, there is also a strong commitment not only to accessibility of healthcare services, but also to data collection and accountability in Brazil, as a result of the efforts by the Ministry of Health (MoH) in recent decades. The MoH has created a national monitoring framework for healthcare, which includes assessment of accessibility of facilities ,19,20. TThis study used secondary data obtained from the External Evaluation of the Brazilian National Program for Improving Access to Primary Care–PMAQ-AB. The first cycle of the PMAQ-AB was carried out in 2012 across 5543 cities . It included the completion of a census of the structure and organization of PHC services ,22. ThisBetween May–October 2012, PMAQ-AB made a census of the health facilities infrastructure of 38,812 public PHC facilities in Brazil, where the PHC was functional and the PHC manager agreed to participate in PMAQ-AB. A public primary health facility is defined by Brazilian Ministry of Health as a public building or mobile space, where an individual or a legal entity performs primary health care actions and services, and which has a technical, personnel and infrastructure compatible with its purpose.The audit was undertaken by experienced researchers from 45 universities, hired by the Brazilian Ministry of Health. The researchers received a 20 h-long training by the universities, with a focus on the questionnaires, the possible difficulties that could arise during fieldwork and how to approach the research participants.The researchers visited each public primary healthcare facility, and undertook an audit which included investigation of the building accessibility  and the availability of healthcare personnel trained in disability-related issues. This assessment was undertaken with a 22 item (yes/no) electronic questionnaire and was completed through on-site observation .By default, the data were transmitted directly online to a central dataset in the collaborating universities. When there was no internet access in the field, the data were stored on the electronic devices and transmitted to a central dataset at a later date. The data were obtained from the MoH by request in November 2019. Due to the MoH webpage overhauling, the data were not available freely in the internet.We used a 22-item questionnaire to develop a total accessibility score . For eacA priori we hypothesized that primary health care facilities in urban areas, richer regions and with a higher number of professionals would have better accessibility. We therefore took account of these factors in the analyses. The total number of professionals employed in the units (work force) was estimated by the sum of the professionals  registered to the units. The number of professionals was not known for some facilities ), in which case we attributed the mean of the number of the specific health professional, considering the size and region of the municipality. The municipalities were classified according to their size into major , large , medium  and small cities . Regions were ranked by poverty level based on Gross Regional Product (in USD billion in 2016): North (97.2), Central-West (175.7); Northeast (257.1); South (305.5), Southeast (981.4). p-value less than 0.05. We used pseudo-Poisson regression models with robust confidence intervals in order to calculate the magnitude of relationship between the Overall Accessibility Score and the aforementioned characteristics [Data analysis was conducted by cross-tabulating accessibility outcomes with key characteristics of the primary health care facilities . The statistical significance of the difference between the proportions was calculated by Tukey’s ‘Honest Significant Difference’ method, using a cut-off of a eristics . Crude aThe regression equation is as follows:Submission to a research ethics committee was not required for this secondary analysis of openly-accessible data. Furthermore, data was not included on individuals and was not of a sensitive nature.In total, in 2012 there were 38,812 primary health facilities spread over more than 99% of the municipalities in the five regions of Brazil . The proThe accessibility of the external area of primary health care facilities was generally low and varied by region and municipality size . Fewer tThe patterns for accessibility of the internal space were similar to those of external spaces . AccessiAccessibility features of primary healthcare facilities for people with visual or hearing impairments were worst of all . Almost Brazil has made a great commitment to the achievement of Universal Health Coverage, through the establishment in 1989 of Sistema Único de Saúde (SUS), a national publicly funded healthcare system . The BraExisting assessments of accessibility of healthcare facilities in Brazil are consistent with our findings in showing that there are important issues facing people with disabilities. According to Albuquerque et al., analysing data from the Pernambuco state PMAq, only one among 2019 facilities audited presented accessibility features for people with visual or hearing impairments . They asStudies from other LMICs are sparse but are consistent with our findings for Brazil. A physical accessibility audit was undertaken in a district in Southern India . ExternaEnsuring the accessibility of healthcare facilities for people with disabilities is non-negotiable, enshrined in national and international law . The UNCThere are costs to improving accessibility, but these will be minimised if we ensure that facilities are accessible at the design-phase, as retrofitting can be expensive. Accessibility standards themselves may need adjustment as they are often a minimum of what needs to be achieved, rather than what is necessary to achieve true access. Besides financial costs, advocacy and educational investments are needed towards health care professionals, policy makers, managers and society as a whole, in order to sustain a people centred paradigmatic shift in health care. The right to health to people with disabilities implies that services respond to peoples’ needs, covering both the geographic and social organizational dimensions of accessibility . IdeallyThere are important strengths and limitations to our study, which must be considered when interpreting the findings. This study is the first example of a national comprehensive assessment anywhere in the world, including all public primary health care facilities in Brazil. The large scale allows consideration of variation in accessibility by region, municipality size and facility type. A broad assessment of accessibility was taken, incorporating physical accessibility of the internal and external areas, but also consideration of other features of accessibility. Furthermore, a standard objective checklist-tool was used across all facilities, and this was undertaken by trained staff. By contrast, previous assessments have been far smaller, generally more focused on physical accessibility only, and more geographically-focused. However, reliability and validity data were not available for the scales used. All primary healthcare units were included, and so a precise estimate of accessibility was achieved, with narrow confidence intervals. There are also limitations. The audit was undertaken in 2012, and so may not fully reflect today’s situation. The Brazilian law on the Inclusion of Persons with Disabilities was passed in 2015 and so there may have been further initiatives to improve accessibility since the audit. Each accessibility feature was scored as yes or no, yet there may be variation in accessibility  and so nuances would be missed. Data was collected by researchers from 45 universities, which may have led to variations in reporting. Furthermore, some key aspects of accessibility were not assessed, including the accessibility of equipment. Accessibility of transport to the healthcare facility was not included, even though this presents an important barrier for many people with disabilities ,4. The aThis national assessment of the accessibility of healthcare facilities in Brazil shows that it is feasible to undertake these audits on a large scale and these audits should be repeated in other settings. It highlights important gaps in accessibility, increasing the risk of the violation of the right to health of people with disabilities. The assessment also uncovered structural socioeconomic inequalities among regions and cities in the country which reinforces those gaps. Future work should focus on updating accessibility audits in Brazil and undertaking large scale audits in other settings. There is also a need to develop and trial approaches to overcoming the gaps identified in the audits, whether through incentives or penalties .


Vehicle ownership modeling and prediction is a crucial task in the transportation planning processes which, traditionally, uses statistical models in the modeling process. However, with the advancement in computing power of computers and Artificial Intelligence, Machine Learning (ML) algorithms are becoming an alternative or a complement to the statistical models in modeling the transportation planning processes. Although the application of ML algorithms to the transportation planning processes—like mode choice, and traffic forecasting and demand modeling—have received much attention in research and abound in literature, scanty attention is paid to its application to vehicle ownership modeling especially in the context of small to medium cities in developing countries. Therefore, this study attempts to fill this gap by modeling vehicle ownership in the Greater Tamale Area (GTA), a typically small to medium city in Ghana. Using a cross sectional survey of formal sectors workers, data was collected between June–August 2018. The study applied nine different ML classification algorithms to the dataset using 10-fold cross-validation technique/s and the Cohen-Kappa static/statistic to evaluate the predictive performance of each of the algorithms, and the Permutation Feature Importance to examine the features that contribute significantly to the prediction of vehicle ownership in GTA. The results showed that Linear Support Vector Classification (LinearSVC) classifier performed well in comparison with the other classifiers with regards to the overall predictive ability of the classifiers. In terms of class predictions, K- Nearest Neighbors (KNN) classifier performs well for no-vehicle class whiles Linear Support Vector Classification (LinearSVC) and GaussianNB classifiers performs well for motorcycle ownership. LinearSVC and Logistic Regression classifiers performed well on the car ownership class. Also, the results indicated that travel mode choice, average monthly income, average travel distance to workplace, average monthly expenditure on transport, duration of travel to workplace, occupational rank, age, household size and marital status were significant in predicting vehicle ownership for most of the classifiers. These findings could help policies makers carve out strategies that would reduce vehicle ownership but improve personal mobility. Individual mobility is an essential part of any transportation system, which is significantly influenced by the availability of public transport and private vehicle ownership and usage. Furthermore, controlling the rise in private vehicle ownership, and increasing quality and access to public transportation is an indispensable part of any sustainable transportation planning strategy , 2. HoweAs a result of these drawbacks and coupled with the advancement in Artificial Intelligence (AI), Machine Learning (ML) algorithms are becoming an alternative or a complement to the statistical models. In contrast to the statistical models, ML models do not require a predefined relationship with the dependent and independent variables; instead, it learns complex relations between the dependent and independent variables by automatically developing a mapping function given an input data. In other words, ML algorithms learn a target function that best maps the input variables to the outcome variables without necessary predefining the mathematical structure. The advantage of the ML algorithms lies in its ability to detect the general trend and patterns within a given data to predict the target variable. It also has the ability to deal with missing data, outliers and multicollinearity among the feature variables –9. AlthoDespite the inability of some of the ML algorithms to provide inference for the model results, its usefulness has been demonstrated in many fields of research including the transportation domain as a complement or replacement/alternative to existing statistical models. For instance, at the city-scale transportation level, ML algorithms have been applied in estimating traffic speeds –13, trafIn terms of mode choice modeling, Hensher and Ton  exploredApart from ANN, other ML algorithms have been successfully applied to mode choice modeling. Zhang and Xie  demonstrAlthough the modeling framework of both mode choice and vehicle ownership using the traditional statistical approach, especially when using disaggregate data, are similar as both commonly use the theory of utility maximization for the formulation of the mathematical structure for parameter estimation , 30, theThe above review of modeling vehicle ownership with ML techniques indicates that only limited studies have applied ML. Also, these studies have used a limited set of ML algorithms, although the number of available algorithms are many. Additionally, these studies produced different results in terms of the best performing algorithms, making the application of ML algorithms case-specific. Therefore, this study seeks to expand on the literature of using ML techniques to model vehicle ownership especially in the context of small to medium city in a developing country like Ghana where disaggregate data on individual vehicle ownership are usually inadequate for disaggregate vehicle models. Consequently, this study aims to evaluate the use of machine learning techniques in modeling and predicting vehicle ownership levels in Ghana using Greater Tamale Area (GTA) as the case study and to identify the factors that are significantly influencing vehicle ownership levels. The results of this study will provide critical information to policymakers as to the most influencing factors affecting vehicle ownership levels and to carve out policies that would help reduce vehicle ownership but improve personal mobility. Additionally, it will add on to the limited literature on the application of ML to vehicle ownership especially in the context of a small to medium city in a developing country.The rest of the article is structured as follows. In addition to the introduction presented in section one, we present a brief description of the study area and the transportation system in section two. This is followed by a discussion on the dataset and modelling framework in section three. In section four, the model estimation results and discussions are presented whiles section five present the conclusions and recommendations.2. The city is centrally located within Northern Ghana and doubles as the capital city of the Northern Region. It is also the third largest city in Ghana after Accra and Kumasi. As a result, GTA host many government offices, private companies, research, and educational institutions.The geopolitical boundaries of the Tamale Metropolitan Assembly (TaMA) and the Sagnarigu Municipal Assembly, which was carved out of TaMA in 2012 for easy administration and deepening of local government as a result of remarkable expansion of the city of Tamale over the years, is what is referred to as the Greater Tamale Area in this paper. It has an estimated population of about 468,318 as at the end of 2018  and a laGTA also has a unique transportation system and infrastructure that is entirely different from the southern part of Ghana. Shared-Taxis and Shared-Tricycle-Taxis dominate the public transportation system for intracity transport. The mini-buses known as ‘trotro’ that is usually used in the country’s big cities for intracity commuting purposes rather provide intercity transport services in GTA. As a result, commuters are left with the choice of either using this form of public transport (i.e. Shared-Taxi or Shared-Tricycle Taxis) or using personal means of transport for their daily commuting needs.Additionally, the road network in GTA is such that all the principal streets and some linking roads in the city is/are provided with segregated bicycle and pedestrian lanes with most linking roads also having side lanes for both pedestrians and cyclists; making GTA a non-motorized transport friendly city. However, the share of the non-motorized means in the city is switching to motorized means like motorcycles and cars in contrast to the situation in the early 1990s and 2000 where cycling was the most common mode of transport in GTA with its use not only limited to the poor but as well as the well to do . ConsequThe dataset for this study was gotten from a structured revealed preference survey conducted on a cross-section of formal sector workers within GTA from June to August, 2018, using KoBo Toolbox an online open-source suite of tools for field data collection developed by the Harvard Humanitarian Initiative, Brigham and Women’s Hospital and Kweyo with support from other organizations. This group of workers were selected because they have a stable monthly income making them easy targets for banks/financial institutions or vehicle dealers in the country to offer them vehicle loans or high purchase agreements for vehicles, thereby, contribute significantly to the overall private vehicle ownership within the country.The survey was conducted on both public and private institutions. The Public institutions included Government Departments and Agencies (GDA) that included the Department of Urban Roads, Metropolitan Assembly, Survey Department, Land Commission, Ghana Water Company, Tamale Technical University (TaTu), University for Development Studies-Tamale Campus (UDS), Tamale Central Hospital (TCH), Tamale Teaching Hospital (TTH) and Ghana Education Service (GES). The private institutions included Tecno Mobile, Vodafone Ghana, and Ghana Developing Communities Association (GDCA). These institutions were selected for the study because they employed a substantial number of Formal workers in GTA and located on different parts of the city. Majority of their staff also depend on either private or public means of transport to get to work.The survey solicited information on socio-economic characteristics of respondents like age, household size, gender, job rank, level of education, monthly income as well as travel characteristics like level of vehicle ownership, average travel time to work, average travel distance to work, choice of mode to work, reasons for choosing a particular mode and average monthly expenditure on transport. In terms of transport infrastructure, respondents were asked as to whether the road network had enough provision for non-motorized transport and whether they would be willing to switch to either walking or cycling. Also, respondent’s willingness to switch from their current mode of choice to work to a Metro Bus Service if it was available and the reasons for willingness to switch or not were also solicited. For spatial and population density, respondents living within 2km radius from the CBD were taken as living in a dense area.The survey was conducted directly at the selected public and private institutions using three android tablets. Before entry into each institution, permission was sought from institutional and departmental heads. For each institution or department, an introductory letter was given to the researcher by the heads explaining, among other things, the aims, and procedures of the research to prospective participants. In addition, a written consent, implied by agreeing to complete the study questionnaire, was obtained from each participant. No intervention or treatment was administered to any participant, and there was no manipulation of any participant or study environment. All participants were assured of anonymity and privacy and informed of their rights to withdraw from the study anytime without any adverse consequences. A secure online data collection tool (KoBo Toolbox), also available offline, was used for data collection. The data was downloaded later unto a password-protected computer accessible only to the research team members. The procedures of the study were approved by the Ethics and Research Review Committee of the Tamale Technical University. In all, a total of 441 respondents were used.Three levels of classification for vehicle ownership were identified; “does not own a vehicle”, “motorcycle” and “car”, for the reason that “more than one motorcycle”, “more than one car”, and “both car and motorcycle” ownerships were less than ten respondents. As a result, the car ownership class exclusively included the few respondents who had both cars and motorcycles whiles the motorcycle ownership also exclusively included respondents who had more than one motorcycle. Also, the motorcycle class included all types of motorcycles like mopeds, scooters and motorbikes whiles the car class is all types of vehicles used as a personal means of transport.Based on the survey data as shown in On average, respondents travelled about 6km to get to their work destinations with an average travel time of 20 minutes. Also, about 60% of the respondents lived more than 2km from the CBD and spent about GHȼ180.00  out of an average monthly income of ȼ1580.00 ($392.17) on transport. In terms of demographic characteristics, majority of the respondents were males (69%) and married (62%), with an average family size of 4.2. Additionally, the majority of the respondents were between the ages of 20–40, an indication that the sample is more youthful and represented by age as defined by Ghana Statistical Service (GSS) .Scikit-Learn , an effiSupervised classification ML algorithms were used in this experiment for the reason that the output or target (i.e. vehicle ownership level) variable in our dataset is a labeled categorical variable with three possible outcomes . Details of the dataset and the feature descriptions are shown in 2 regularization and converges faster for high dimensional data. The probabilities describing the outcome of a single trial is based on the logistic regression function. However, it must be noted that this does not follow the behavioral specification or the Random Utility Models specifications in the statistical approach. Instead, features are taken uniformly for all target outcomes as a single weight trained for each feature for each target class [Logistic regression which is known as the maximum-entropy classification, is a type of linear model used for the classification of dependent categorical variables based on one or more independent features. It can handle both binary and multiclass outcomes with options for regularization which penalizes the model in order to prevent overfitting . The ‘neet class .The stochastic gradient decent algorithm is another linear model that is used to classify dependent categorical outcomes using a regularized linear model with the gradient loss calculated on each sample to reduce the decreasing strength schedule (learning rate). It can be estimated on either dense or sparse data sets and can allow mini-batch learning . It suppSVM is one of the most popular and versatile machine learning algorithms that is used for supervised learning for both classification and regression tasks. It can analyze both linear and non-linear relationships between the target variable and the independent features by using the principle of structural risk minimization . It consLike SVMs, Decision Trees are also multipurpose non-parametric supervised learning algorithms that can implement classification and regression tasks, and even multi-output outcomes. It uses simple decision rule to learn from the data features that can predict the outcome of the target variable. The merits of this algorithm lie in its simplicity and the ability to produce interpretable models. However, it is prone to overfitting the data thereby reducing the generalizability of the model and can also be unstable if there is a small variation to the data . SeveralThe ensemble learning methods is one of the popular learning algorithms that are applied in many disciplines to make predictions of data. It aggregates the predictions of many base estimators to produce a single estimator that is more robust and a better generalization of the data. It is categorized into two methods, averaging methods which average the predictions of the base estimators to reduce the variance and boosting methods which try to remove the bias of the combined estimator . For thiThe NB supervised learning classification algorithms are based on the Bayes theorem which state that the likelihood of a target outcome corresponding to a group of features is conditionally independent of each other; thus, considering all features to contribute independently to the probability of the target outcome. Therefore, the model predicts its probability condition on several independent features. The parameters in the algorithm are estimated using the maximum likelihood method. The different NB classifiers differ mainly due to the assumption regarding the probability distribution function . For thiThe KNN is an instance-base-learning algorithm that stores the instances of the training data by computing each point using majority vote of the nearest neighbors and assigned the target class with the most representative nearest neighbors. It does not actually construct a model to make predictions. Instead, predictions are made base on the largest proportion of k-nearest point, as a result it is often called a lazy classifier . The stuAs was pointed out in the introduction, one major challenge of ML algorithms is the inability of some of the algorithms to produce interpretable results. However, other algorithms have some attributes that can be used as a form of interpretation for the model results. For instance, algorithms with the ability to produce feature importance or feature ranking relative to the target variables can form the bases for some form of interpretations. The feature importance or ranking is the amount of contribution an input variable has on the overall predictive ability of the ML model relative to the outcome. For this study, the Permutation feature importance is used to evaluate the feature importance for each of the classifiers. This method was chosen because it can handle biases from categorical variables with many categories preferred. Permutation feature importance is the reduction in model score when the value of a single feature is arbitrarily shuffled. In other words, it is the measure of how scores of an estimator reduce when a feature is excluded from the model estimation. A reduction in the model scores indicates how important this feature is, in the overall performance of the model , recall, accuracy, precision, sensitivity, and specificity. A typical sample of a confusion matrix is shown in To prone down the number of features so as to reduce overfitting the algorithms to the data set and to assess the level of contribution the features in predicting the vehicle ownership classification in GTA, permutation feature important is apply to the selected algorithms as shown in On the other hand, the highest recall of 94% is achieved by the LR, LinearSVC and GaussianNB classifiers whiles the lowest precision of 88% is attained by LR classifiers, and a lowest recall 91% is attained by the DT, SGD, RT, Adaboost and KNN classifiers. The motorcycle ownership class recorded the highest precision of 97% by the LR, LinearSVC and GaussianNB classifiers, and recall of 97% by the Adaboost classifier whiles the car ownership category achieved the highest precision of 90% for LR and LinearSVC classifiers and recall of 93% for ERT, GaussianNB and LinearSVC classifiers respectively. The lowest precision and recall for the motorcycle ownership class of 93% was achieved by the KNN and GaussianNB classifiers respectively, whiles the car ownership class attained a lowest precision of 83% by the DT classifier, and lowest recall of 86% for the Adaboast, SGD, DT and RT classifiers.With regards to the Cohen-Kappa static, the highest performing classifiers in terms of prediction agreement to the actual class labels is the LinearSVC with a kappa static of 0.90 whiles the least performing classifier is the DT classifier having a kappa static of 0.86. LR, ERT, Adaboost and GaussianNB produced a kappa value of 0.89 whiles SGD, RT and KNN had a value of 0.88, respectively. Overall, all the classifiers performed well in terms of motorcycle ownership prediction with the least precision and recall of 93% recorded for the KNN and GaussianNB classifiers respectively and performed west for the car ownership prediction with the least precision and recall of 83% and 86% recorded for the DT classifier and the Adaboast, SGD, DT and RT classifiers respectively.The best performing classifiers over all the possible classification threshold for the ROC curve as shown in Vehicle ownership modeling and prediction is one crucial task in the transportation planning processes which traditionally uses the statistical modeling techniques in the modeling process. However, with the advancement in computing power of computers and AI, ML algorithms are becoming an alternative or a complement to the statistical models in modeling the transportation planning processes. Although the application of ML algorithms to the transportation planning processes; like mode choice, traffic forecasting and demand modeling have received much attention in research and abound in literature, scanty attention is paid to its application to vehicle ownership modeling especially in the context of a small to medium cities in developing countries.Therefore, this study attempts to fill this gap by modeling vehicle ownership in GTA, Ghana; using a cross sectional survey of formal sectors workers collected in June–August 2018. The study used LR, SGD, LinearSVC, DT, RF, ERT, Adaboast, GaussianNB and KNN ML classification algorithms to model the dataset. The performance of each classification algorithms was evaluated using accuracy, precision, recall, ROC, and Cohen-Kappa static. Additionally, permutation feature importance was used to determine the features that are significant in predicting vehicle ownership in GTA.The results show that LinearSVC is the best performing classifier in terms of accuracy of predictions whiles LinearSVC, RF, ERT, GaussianNB and KNN are the best classifiers base on ROC. The best classifier with regards to the Cohen-kappa static is LinearSVC. Therefore, based on accuracy, ROC and Cohen-kappa static, LinearSVC is the best classifier for the dataset. For predictions based on class performance, KNN performs well for no-vehicle class whiles LinearSVC and GaussianNB performs well for motorcycle ownership. For the car ownership category, LinearSVC and LR performs well in comparison with the other classifiers.The results also indicated that individual mode choice (car or motorcycle), average monthly income, average travel distance to workplace, average monthly expenditure on transport, duration of travel to workplace, age, household size and marital status were significant in predicting vehicle ownership for most of the classifiers. However, provision of non-motorized infrastructure, density, and willingness to switch from current transport mode to work to Metro Bus Service if available were less significant in predicting vehicle ownership for all the classifiers. Our results also demonstrated that ML can also be applied to small to medium cities in developing countries like Ghana.The findings in this study throws more light on vehicle ownership in the context of a small to medium urban city in Ghana which is mainly influence by the respondents travel characteristics and average monthly income. This finding is largely in agreements with the studies by Ha et al. , KaewwicBased on the most significant features in predicting the vehicle ownership level in GTA, policy makers should look at ways to reduce individual mode choice but, improve the public transportation such as the development of structural public transportation projects such as Bus Rapid Transit, Light Rail or simply a network of regular buses instead of the current informal public transportation (Shared-Taxis and Shared- Tricycle Taxis), which could potential drive down the vehicle ownership level in the city.S1 Data(IPYNB)Click here for additional data file.S1 File(CSV)Click here for additional data file.S2 File(CSV)Click here for additional data file.S3 File(CSV)Click here for additional data file.S4 File(CSV)Click here for additional data file.S5 File(CSV)Click here for additional data file.S6 File(CSV)Click here for additional data file.S7 File(CSV)Click here for additional data file.S8 File(CSV)Click here for additional data file.


Civil strife has long been recognized as a significant barrier in the fight against vaccine preventable diseases in several parts of the world. However, little is known about the impact of the ongoing civil strife on the immunisation system in the Northwest (NW) and Southwest (SW) regions of Cameroon, which erupted in late 2016. In this paper, we assessed the effect of the conflict on key immunisation outcomes in the North West and South West regions of Cameroon.Data were obtained from the standard EPI data reporting tool, the District Vaccine and Data Management Tool (DVDMT), from all the districts in the two regions. Completed forms were then reviewed for accuracy prior to data entry at central level. Summary statistics were used to estimate the variables of interest for each region for the years 2016 (pre-conflict) and 2019 (during conflict).In the two regions, the security situation has deteriorated in almost all districts, which in turn has disrupted basic healthcare delivery in those areas. A total of 26 facilities were destroyed and 11 healthcare workers killed in both regions. Reported immunisation coverage rates for key antigens including, BCG, DPT-3 and MR, witnessed a dramatic decline between 2016 and 2019, ranging from 22% points decline for BCG in the NW and to 42% points decline for DPT-3 in the SW. Similarly, the proportion of districts with DPT-3 coverage of at least 80% dropped from 75% in 2016 to 11% in 2019 in the NW. In the SW this proportion dropped from 16% in 2016 to 0 % in 2019.Our data demonstrates the marked negative impact of the ongoing civil strife on key immunisation outcomes in the two regions and the country at large. This decline could amplify the risk of vaccine preventable diseases vaccine preventable diseases outbreaks in the two regions. Besides the ongoing actions to contain the crises, effective strategies for reaching children in the conflict zones as well as the internally displaced population are needed. There is also the need to rebuild destroyed facilities as well as to protect health facilities and staff from targeted violence. There is increasing recognition from the global health community that the goal of equitably extending the benefits of immunisation to all infants is far from being achieved . One undThe death toll is often high because civil strife habitually creates conditions that increase susceptibility to VPDs, while also damaging immunization systems. Civil strife can lead to mass displacement of people, overcrowding, and limited access to food, water, hygiene and sanitation services , which iAlthough the devastating effect of conflicts on the immunisation system has been documented in many countries, little is known about the influence of the ongoing civil strife on Cameroon’s immunisation system. Cameroon has enjoyed decades of peace until late 2016 when armed violence erupted in the NW and SW regions . The conThe study was conducted in Cameroon, which is politically divided into ten regions: eight of which are French speaking and the remaining two are English speaking. This dichotomy can be traced back to World War I, when France and Britain joined forces to attack and seize Cameroon, which until then was a German colony. Following the seizure, the German colony was split into two entities and 83% of the territory was awarded to France by the League of Nation and the remaining 17% to Britain . Each ofBoth regions are divided into Health Districts (HD), which in turn are divided into health areas. Each health area has a leading health facility, which is generally public, but can be private in some health areas. The leading facility coordinates the distribution of vaccines and supplies and reports coverage rates for all facilities, both public and private, within the health area. Prior to the crises, the SW had 18 functional health districts, and 308 health facilities, of which 255 (83%) were offering immunisation services . The NorOne dose of Bacillus Calmette-Guerin (BCG) at birth or on first contact by a health worker, three doses of diphtheria, pertussis and tetanus containing vaccines  and 13-pneumococal conjugate vaccine (PCV-13) at 6, 10 and 14 week, four doses of oral polio vaccine  at birth, 6, 10 and 14 weeks, two doses of rotavirus vaccine at 6 and 10 weeks, one dose of inactivated polio vaccine (IPV) at 14 weeks, and one dose of yellow fever and combined measles and rubella vaccine (MR) at 9 months . According to standard practice, this tool is updated on a monthly basis with data from health facilities in each district. Regional EPI heads used a predefined questionnaire to abstract key variables, including the security profile of the health districts, service delivery, vaccine logistics, and others. These data were extracted for 2016, when the conflict first started, and 2019, after more than 2 years of continued conflict, in order to evaluate the impact of the conflict on these variables. Following data collection, the regional EPI heads returned the completed forms to the central level, where they were screened for accuracy and completeness before data entry. We resolved any identified data discrepancy by directly calling the regional head or the district medical officer. We then analyzed the data using Excel 2016 and used summary statistics to estimate the variables of interest individually for the years 2016 and 2019.Figure Figure Table Figure Similar declines were observed with immunisation service delivery. In the NW, the proportion of fixed-post immunisation sessions dropped by 27%, falling from 8947 sessions in 2016 to 6523 sessions in 2019. Similarly, the proportion of outreach sessions declined by 75%, falling from 8362 sessions in 2016 to 2092 sessions in 2019. In the SW, the proportion of fixed-post session dropped by 46%, decreasing from 8952 sessions in 2016 to 4808 sessions in 2019. Likewise, the proportion of outreach sessions declined by 65%, dropping from 3657 sessions in 2016 to 1292 sessions in 2019.The consequences of the ongoing civil strife in the NW and SW regions of Cameroon (or the “Anglophone crises”) have been enormous. Over 3000 people have been killed in direct fighting or died from war related conditions such as gunshot wounds, starvation or poor hygienic conditions . In addiThe goal of this study was, therefore, to assess the effect of the conflict on the immunisation system in these two regions, with particular focus on the effect on coverage for key antigens and other variables. Overall, we found a dramatic decline in coverage for all antigens in both regions. For instance, between 2016 and 2019, coverage for DPT-3 dropped by 28 and 42 points in the NW and SW respectively. A similar trend was observed for antigens against measles, poliomyelitis, pneumococcal and rotavirus (Fig. The observed decline in coverage and equity can be attributed to the direct effect of the conflict on the immunisation system. Indeed, the number of facilities offering immunisation services have dramatically declined as the conflict intensifies. For example, by November 2019, the number of facilities offering immunisation in the NW and SW declined by 53 and 30% respectively. This decline was a direct consequence of facilities closing down because of the rising level of insecurity, which caused many healthcare workers to flee from their duty stations. In a handful of cases, facilities were openly burnt down, destroyed, or looted by arm groups . With a The challenge of immunizing infants from these regions extends beyond reaching infants in the conflict regions. As mentioned previously, the conflict has created a mass of internally displaced people, the majority of whom are women and children. Although official reports indicate that half a million people from these regions have fled to the neighboring regions, there is limited clarity on the specific destination of these population sub-groups. This leaves open the question on the geographic denominator to which they will now belong. It is highly possible that these displaced populations are not being adequately included in population denominators in their new locations, which in turn would mean that coverage figures in other regions could actually be lower than currently reported. This challenge highlights the need to sensitize facilities and healthcare workers in districts where these populations are likely to be found so that these displaced individuals and their children are properly captured into the health system in their new locations.In our study, the reported violence against health facilities and health staff has been devastating. Burning down, destroying, and looting of facilities, coupled with fatal attacks on health staff, undermine the effectiveness of life-savings public health programmes, including immunisation. As seen in this conflict, these actions clearly disrupt service delivery and engender a demoralized workforce. Although there is a global consensus on “zero tolerance” of violence against health facilities and workforce during conflicts , mechaniTo our knowledge, this study is the first to systematically report the impact of the ongoing civil strife on immunisation systems in the NW and SW regions of Cameroon. But despite this merit, there are several limitations of this study that are worth highlighting. First, the primary data for this study were collected under volatile conditions, which could have introduced bias into the data, especially the data for 2019. Secondly, the primary denominator, which was used by districts to calculate coverage data for 2019, was assigned by the central level and the denominator was based on projections from the 2005 national census. Using centrally assigned denominators may likely result in inaccurate coverage estates for the districts in these regions, primarily because of massive migration of people from these regions. Third, the regions have suffered from prolonged internet and transport shutdowns, which invariably affected data transmission to higher levels. This later challenge suggests that the data from the two regions were often incomplete most of the time. Notwithstanding, we strongly believe that our study sets the scene for preliminary understanding of the impact of the ongoing crises on key immunisation outcomes and child health in general, in these affected regions. We hope that our findings will stimulate future research needed to document the vaccination status of infants in the crises zones as well as that of internally displaced infants. In addition, further research will be needed to establish effective strategies for reaching children as well as determine appropriate actions to prevent violence against health facilities and health care workers.Our study findings suggest a considerable negative effect of the Anglophone crises in the North West and South West Regions of Cameroon on immunization outcomes. The dramatic decline in coverage and equity between 2016 and 2019 suggests that many infants in these regions remain susceptible to VPD. The sharp decline in coverage and equity seems to be a direct consequence of the armed conflict on the healthcare system, including disruption of supply lines, destruction of facilities and decimation of healthcare workers. The prevailing situation in these regions has also affected the national coverage for all antigens, which have also witnessed a sizable decline. This situation is already putting the entire country at risk of VPD outbreaks, as evident by the ongoing massive measles outbreak. Our results humbly represent a call to action to rapidly immunize children from these regions, both those residing in conflict zones and the internally displaced. In the short term, there is the need to identify effective strategies and mobilize resources for reaching these children and protecting health facilities and health workers from violence. In the long term, there is the need to rebuild the infrastructure that was destroyed and to re-establish the systems and the supply lines that have been disrupted. Above all, peace needs to return to these regions to ensure permanent improvement in immunization coverage and prevention of deaths from vaccine-preventable diseases.


Background: Domestic violence is a traumatic experience that can lead to physical consequences, mental disorders and financial damage. Over 18 cases per 100,000 inhabitants were reported in Brazil between 2013 and 2014. The ministry of health poses a mandatory notification of all cases of domestic violence, which is essential, bearing in mind its systemic relation to various social issues and the extensive regional differences and high socioeconomic inequalities present in Brazil.Aim: To analyze the characteristics of the notification rates of domestic violence and investigate the correlation of these with health and socioeconomic characteristics of large Brazilian cities.Methods: Retrospective data on notifications of domestic violence was collected from the National Information System for Notifiable Diseases for Brazil, 2017. Dependent variables were collected from the Brazilian Institute of Geography and Statistics and Ministry of Citizenship. Inclusion criteria were: cities larger than 100.000 habitants and that had at least 20 reports, totaling 68.313 reports in 259 cities. These were stratified by age, race and sex of victim, type of violence used, violence perpetrator, place of occurrence and means of aggression. Proportional number of notified cases was calculated for each city to expose different characteristics of reports. A multiple linear regression model was used to investigate the correlation between report rates and different socioeconomic and health variables.Results: The analysis showed a high proportion of repeated violence, use of body strength and over 50% were perpetrated by a partner or boyfriend. Report rates were higher for women, black individuals and children under four, highlighting subgroups of the population that were more vulnerable. Indeed, these groups were correlated differently with socioeconomic variables. Poverty, assessed as Bolsa Família investment, was correlated with domestic violence report rates across vulnerable groups.Conclusion: The study showed that black women and children are more vulnerable to domestic violence, highlighting deleterious effects of patriarchy and structural racism within Brazilian society. Altogether, we suggest that reducing poverty, patriarchy and structural racism could lead to fewer cases of domestic violence. Domestic or intra-family violence is defined as violence that happens between intimate partners or family members, especially at home, although not necessarily. The perpetrator of such violence can make use of various forms of aggression, such as: physical, psychological, sexual, financial violence and torture and it can be against children, the elderly, women or men . While mGiven that domestic violence is a traumatic event, intensive research effort has been made to elucidate factors that may contribute to the occurrence of domestic violence—and therefore identify efficient ways to decrease cases of domestic violence. It is perceived that multiple aspects are involved, such as social-psychological  and cultural (such as patriarchy and racism) aspects . AlthougFrom 2003 to 2012, in the United States, domestic violence accounted for 21% of all violent victimizations . In paraIn Brazil, over 18 cases of domestic violence per 100,000 inhabitants were reported in the years of 2013 and 2014. This was over three times higher than what was observed in 2009 and 2010 . The theSince it is often difficult to identify cases of domestic violence, due to its invisibility , 19, theThe notification of domestic violence is an important measure, given its association to social issues and the extensive regional differences and high socioeconomic inequalities present in Brazil . In thisThis is an observational retrospective study in which we used stratified sampling to analyze data notifications of domestic violence that occurred in the year of 2017 provided by the Brazilian Government through its national database, SINAN. Dependent variables used in correlation analyses were collected from the Brazilian Ministry of Health, the Brazilian Institute of Geography and Statistics (IBGE) and Ministry of citizenship. All data collected was from the year of 2017, except for population and demographic data, which were from 2010. This was due to the lack of estimates for population stratified by sex, race and age beyond the last census of 2010. Therefore, notification rates are likely overestimated in this study. All of the databases are public and free to access. Descriptive information and definition of variables are provided in Domestic violence was the dependent variable used throughout the study and was defined as any type of violence perpetrated by: father, mother, stepfather, stepmother, brother, sister, partner/spouse, boyfriend, girlfriend, daughter or son; occurred at any site, but most likely at home. This definition is the same coined by Minayo .In Brazil, the notification system is centralized by the ministry of health through the public database of the National Information System for Notifiable Diseases (SINAN). Currently 48 diseases or other incidents, including domestic violence, are of mandatory reporting. The notification forms must be filled by healthcare professionals in any health service, public or private and should contain sociodemographic data of the patient/victim and characteristics of the incident. In cases of violence, there are fields regarding information on the victim, the event, the aggressor and about the care provided. Those forms are sent to the municipal health department, where they are analyzed to feed the SINAN database, made public through TabNet, which is a tool of the Brazilian National Health System Information Technology Department (DATASUS). It is a public domain generic tabulator that allows anyone to generate information from the SINAN database , 25.On the brazilian notification system, there are different rules for each disease or incident. When the incident is a violence, the healthcare professionals must report it whenever they suspect a violence is occurring, or whenever a victim has reported to suffer violence. Since it is not the role of healthcare professionals to investigate cases of violence, there is no follow up for notification purposes, only for improving the health of the victim. The information registered by the healthcare professional is confidential. It is not passed on to the police or publicly disclosed without going through health surveillance analysis of the municipal health department . TherefoNotified cases of domestic violence were collected for cities with more than 100.000 habitants and that had more than 20 reports, totaling 68.313 reports in 259 cities. This was done to ensure data of higher quality and to decrease skewing of the data due to low number of reports. These were stratified by age, self-reported race and sex of the victim, as well as type of violence used, perpetrator of violence, place of occurrence and means of aggression. Proportional number of notified cases was calculated for each city. In order to calculate notification rates, the number of notified cases for each city was multiplied by 100,000 and divided by the population of that same city, according to the 2010 census. Data on notification rates as well as characteristics of the victim, aggressor, place of occurrence and means of violence used were analyzed through paired non-parametric Wilcoxon test for two variables , and Friedman test with Dunn's multiple comparison test for graphs with more than two variables, since data did not pass normality test. Bar graphs express mean ± S.E.M for 259 observations, comprehending 259 cities.After initial assessment of which subgroups were reported to have higher notification rates, we conducted an ecological study to investigate the association of socioeconomic and health variables with the notification rate of domestic violence in vulnerable subgroups. Therefore, a multiple linear regression model was used. The model can be written as:Y is a single column vector of the report rate, B is Gross Domestic Product (GDP) per capita in R$ per 100.000 inhabitants, C is demographic density in person per km2, D is number of health places per 100.000 habitants, E is deaths due to assault per 100.000 inhabitants, F is Bolsa Família investment in R$, G is number of family health strategy teams per 100.000 inhabitants and ε is the error. All variables were log transformed, thus the coefficient should be interpreted as how a percentage change in x (dependent variables) affects the percentage change in y (notification of domestic violence). GraphPad Prism 8.0 software  was used for the statistical analysis.Where This research included data publicly available from the Brazilian Ministry of Health. The subjects' identities were not revealed to the researchers, and the data was obtained by healthcare professionals on duty, since the notification of domestic violence in health services is mandatory in Brazil. Therefore, written consent from the participants and ethical review and approval was not required for this study. This is in accordance with the Brazilian legislation and institutional requirements.pardo (black ethnicity). Most victims had <8 years of formal schooling. The report rate of domestic violence for each of the 259 cities included in this study is shown in There were 68,313 notified cases of domestic violence in large Brazilian cities in 2017. There are several aspects entailing domestic violence, such as the type of violence used, means of aggression, place of occurrence and characteristics of the perpetrator. To examine the most common characteristics of notified cases, we conducted a paired analysis of the proportion of each subcategory of the above-mentioned aspects of domestic violence . Over 60To analyze aspects of the victims, we calculated the report rates of domestic violence for different subgroups of the population for each of the 259 cities analyzed. As exhibited in Bolsa Família investment was inversely correlated for total population, women and black individuals. Interestingly, the strength of the association between Bolsa Família investment and notification rates was similar for the total population, women and black individuals (around −0.15% change per 1% change in notification rate). This indicates that richer cities tended to have higher report rates for domestic violence and poorer cities tended to have lower report rates. Curiously, there was an inverse correlation between domestic violence notification rates for women and number of health places . Finally, notifications in children were positively associated with demographic density, which was not present in other population groups. Thus, it is likely that different subgroups within the population are affected differently by socioeconomic factors.In order to examine whether report rates for domestic violence were correlated with socioeconomic factors, we performed multiple linear regression models . These wBolsa Família investment, was negatively correlated with domestic violence report rates across vulnerable groups, that is, poorer cities tended to present higher rates of domestic violence notifications. Thus, we show that black women and children are more vulnerable to domestic violence and suggest that improving household size, reducing poverty and structural racism would be an effective way to reduce cases of domestic violence.Data herein presented underlie associated factors of domestic violence reports in large Brazilian cities in the last year available, 2017. We show that there was a high proportion of repeated violence , that the majority of cases involved physical violence with the use of body strength and that over 50% were perpetrated by a partner or boyfriend. There were higher rates for women, black individuals and children under four, highlighting subgroups of the population that were more vulnerable. Indeed, these groups were correlated differently with socioeconomic variables. Poverty, assessed as Women accounted for 70% of the victims of reports and had a report rate two times higher than men. This, coupled with a high proportion of partners, boyfriends and fathers as perpetrators of the violence indicates a historical relation of power between men and women. This reinforces the deleterious impact of patriarchy within the Brazilian society, since it has been shown that patriarchy is systematic and institutionalized in western culture –28. ThisBecause the perpetrators are often family members, these have close contact to the victims, as well as a power-based relationship. A reoccurrence of the violence would be expected . This hiThe most common means of aggression and type of violence were body strength and physical violence, which are in consonance with the literature , 28. PhyWe found a positive correlation between GDP per capita and report rates in women and total population. It is possible that richer cities have more structured health systems  that areBolsa Família investment as a proxy for poverty, given that this cash-transfer programme targets families below the poverty line. From this analysis, we found a negative correlation between Bolsa Família investment and report rates in women, black population and total, meaning that cities with less poverty report more cases of domestic violence. The lack of correlation between GDP per capita and report rates in black individuals may suggest this population does not access city-level economic growth. This reinforces the idea of a social hierarchy in which black individuals  are at the bottom of the social hierarchy , involved physical violence and were perpetrated by a partner or boyfriend. There were higher report rates for children under four, women and black individuals, emphasizing subgroups of the population that were more vulnerable. This highlights deleterious effects of patriarchy and structural racism within the Brazilian society. Domestic violence report rates across vulnerable groups were associated with poverty, assessed as ications . TherefoData is available upon reasonable request to the corresponding author.MP and RG designed the study, analyzed data, drafted the manuscript, reviewed, and approved the final version of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


N = 200 per country per format) from Brazil (Portuguese), China (Mandarin Chinese), India (Hindi or English), Spain (Spanish), and the USA (English). The results of this survey should provide more understanding of the differences and similarities in distribution of data for the four scale formats. Also, the translations and findings of this survey can guide marketers, sensory scientists, product developers, dieticians, and nutritionists when designing future consumer studies that will use these question formats.Question formats are critical to the collection of consumer health attitudes, food product characterizations, and perceptions. The information from those surveys provides important insights in the product development process. Four formats based on the same concept have been used for prior studies: Check-All-That-Apply (CATA), Check-All-Statements (CAS), Rate-All-That-Apply (RATA), and Rate-All-Statements (RAS). Data can vary depending on what question format is used in the research, and this can affect the interpretation of the findings and subsequent decisions. This survey protocol compares the four question formats. Using a modified version of the Eating Motivation Survey (EMS) to test consumer eating motivations for five food items, each question format was translated and randomly assigned to respondents ( To improve the health of people in our communities, it is important to understand the motivations that drive food choices, the perceptions of foods, such as liking or sensory qualities, and consumer’s reactions to products such as their emotional or attitudinal responses. This information is essential to nutritionists and dietitians as they develop sustainable meal plans for their communities. It also is beneficial to product developers, sensory scientists, and marketing researchers, as it guides them in producing and promoting food products that meet the needs of consumers. Various formats of questions have been used in consumer surveys to collect food product characterizations based on perceptions, opinions, beliefs, and attitudes of target group consumers ,5,6,7,8.With CATA, consumers are asked to check all items that are of importance from a list of options ,19. The As the CATA question asks the respondent to check all items that apply, it would then be expected that the unmarked items are not important or do not apply. However, it is also likely that respondents who are undecided on whether a particular item applies could opt not to check the item. This lack of a neutral option in the CATA question format could impact on the accuracy and reliability of the collected responses that are intended to guide decision making when developing products. Also, whether intentionally or unintentionally, some items may remain unchecked by the respondent. It is possible that some unchecked items were not seen by the respondent as they speedily answered the question ,18 or itThis, however, highlights the fact that a typical CATA question demands less cognitive effort from the respondents as compared to other question variations, such as the CAS, and other diagnostic rating questions such as Just-About-Right (JAR) ,10,22. CEven more, a tendency for respondents to mark items that appear at the top of the list more than items that appear in the middle or at the bottom of the list (primacy bias) has been associated with print and online surveys  and centIn phone interview surveys, a different question format that is known as the Check-All-Statements (CAS) has been used extensively . This quThomas and Klein  showed tIt is worth noting that the CAS question format can be limited by the tendency of respondents to select affirmative or positive responses more frequently (acquiescence bias) . HoweverIn some cases, knowing that an item is important or applies is not enough and researchers want to gain more understanding of the level of importance or “how much” the item applies to the study question. To do this, researchers sometimes use the Rate-All-That Apply (RATA) question format where, if the item is checked as applying, respondents are then asked to rate how much the selected items apply based on a given scale. Usually, a Likert type scale  can be used for example; a 5 pt scale anchored at “Not at All Important” and “Extremely Important” can be used to rate the applicability or importance of each selected CATA item. More discrimination in product liking was realized by Jaeger et al. ,29 in a However, Vidal et al.  refuted Another CATA format is the Rate-All-Statements (RAS) where instead of having the respondents check all items that apply and subsequently rate how much the selected items apply; they are directly asked to rate all CATA items. A similar Likert-type scale for RATA is usually used. This question format may collect more detail as compared to either CATA or CAS or RATA. The RAS question format would be expected to require a higher level of thought process and likely would result in longer mean survey duration as compared to the other aforementioned three question formats. Little literature was found on RAS as applied to consumer product characterizations in sensory analysis surveys and study questionnaires. Thus, there is a research gap for exploration into the results and distribution of responses collected by these four question formats  across different survey questionnaire fielding platforms . Also, there is little research on the impact of demographic aspects such as age and gender and location on CATA data.The overall objective of this survey was to compare the CATA, CAS, RATA, and RAS question formats. The specific questionnaire used for the comparison was an on-line eating motivations survey. Specific objectives for the questionnaire comparisons were to (a) compare the number (percentage) of items identified as positively motivating the eating of specific foods by either of the four formats; (b) the length of time taken to complete questionnaires in the four formats; (c) compare liking and just about right questions for the four formats of questionnaires; and (d) compare completion rates for the four formats. Specific objectives for the eating motivations survey were to use results from the surveys to determine specific eating motivations that can guide marketing, sensory, product development, and nutrition intervention for each country. This writing provides a step-by-step description of how and what materials, methods, and protocols were used during the preparation and fielding stages of the on-line survey in five languages.The Eating Motivations Survey (EMS) was developed to compare four question formats  across five food groups in five countries. The questions investigated the respondents’ motivations for eating or not eating varying food items that belong to five different food groups  ,31 Tabl. DiffereBased on previous research, a total of 16 motivation constructs, 15 from Renner et al.  and one Additionally, the survey questionnaire included the food involvement scale   were recruited by Qualtrics, Provo, UT, USA using its or its partners existing databases. Qualtrics or its partners maintain proprietary databases of consumers in each country . The databases have a range of demographics, which can be parsed based on age, sex, purchasing habits, etc. Each survey question format  was assigned randomly to ~200 respondents per country meaning ~800 respondents per country were used in the test. Each of the 200 respondents per format were divided into 4 age groups with ~50 respondents per group for the study: (a) Generation Z (born in the years 1995 to 2001), (b) Millennials (born in the years 1980 to 1994), (c) Generation X (born in the years 1965 to 1979), and (d) Baby boomers (born in the years 1944 to 1964). Within each age, 50% were female and 50% were male. For recruiting, Qualtrics sends an e-mail to a percentage  of random members of its panel that a survey is available. Those members who volunteer to take the survey complete a screening questionnaire to determine if they qualify . If they qualify, they take the survey. If they complete the survey, they receive compensation usually based on a points system for the country they live in. If they fail to complete the survey within a specific period of time, complete the survey too fast, or answer questions incorrectly that are intended to check if the respondent is paying attention, the respondent is exited from the survey. It must be noted that although the databases are populated with consumers from a broad range of consumers in each country, only those with access to the internet are included. Although China, India, the USA, and Brazil had the highest number of internet users in 2015 and Spain had one of the highest percentages of users [This survey fielded during the summer of 2019. Respondents were required to be 18 years or older (born in 2001 or before) but not older than 75 years (born in 1944 or after). Respondents that did not meet the required age criteria were discontinued from completing soon after starting the survey. Another trigger was positioned after the completion of the demographic questions but before the start of the food involvement questions . RespondRespondents first completed questions on demographics, food involvement, health, and taste attitudes, and food neophobia. Then they were asked to complete the EMS using one of the four question format variations. The computerized randomizer tool that was used took into consideration the gender  and age group (four age groups) of the respondents in order to ensure approximately equal numbers of respondents in each gender and age group for each question format. Initially, a pilot test with about 100+ respondents was conducted to verify that the survey questionnaire was collecting data as designed. The initial responses were carefully examined to check for any missing data and identify any corrections that needed to be made before final data were collected. This is the last point at which researchers can revise questions and flow to ensure the appropriate data were being collected. In this study, for example, researchers noticed that the randomizer assigned all four question format variations to each respondent. Thus, those data were discarded, and the randomizer tool was reprogrammed to randomly present only one question format to each respondent. Incomplete or partial responses for cases where the respondent did not complete answering the entire questionnaire within 4 weeks were recorded but not included in the respective quota fulfillment. That allows comparison of survey completion rates among the question formats to provide more understanding of how each format influences the willingness of respondents to complete the survey. Such information is critical in guiding researchers when designing self-administered surveys on consumer behavior. The time that was taken by each respondent to complete the entire survey was recorded in seconds.There was no specific length of time that was anticipated for the respondent recruitment and completion of fielding phases of the survey. This can be explained by the fact that both the recruitment and survey questionnaire completion occurred simultaneously. It can further be attributed to the complexity and number of required quotas  of this survey. However, from the start of respondent recruitment to the fulfillment of all quotas, it took on average five weeks to complete fielding in each country. Survey fielding began in the USA and continued to other countries as the respective translations became available. As expected for each country, certain quotas filled up quickly as compared to others. For instance, for China, the generation X, and the boomers quotas took a longer time to fill up as compared to the quotas of the younger people.Chi-square will be used to compare the CAS, CATA, RAS, and RATA data for each food group in each of the five countries. The ANOVA will be used to assess the effect of survey format on survey liking, mean duration, and respondent JAR for EMS in each country. Percentages of completion rates for each of the four question formats will be calculated. All analyses will be run using XLSTAT .The results of this survey protocol can help to make decisions related to the best choices for determining survey question formats for future studies based on whole sample, age group and gender subsamples. The number (percentage) of items identified as positively motivating the eating of specific foods by the various formats will be compared in order to determine which format provides the most in-depth information. In addition, the completion rate and length of time respondents take to complete questionnaires in the four formats can be compared to determine if one or another format is reducing respondent participation or taking excessively long to conduct the survey. For on-line surveys, time is money; longer surveys cost more to conduct because respondent incentives must be higher. If one format takes much longer to complete than another format, the cost could be too high unless the data provides significantly more robust information. Respondent acceptance of the survey and their beliefs in it being too short, just right, or too long also can be assessed. In addition, eating motivations for various food groups in different countries with both males and females and different age groups can be determined. The questionnaires are available and translated to be used directly or with additional modification by other researchers. The research results using this protocol can be used to guide nutrition and health interventions and assist marketing, sensory, and product development professionals in each country.Based on the objective(s) and purpose of the survey, items or terms to be included in questions, target population, and other items must be identified and established as part of the survey. Buy-in from stakeholders who will use the survey results must be obtained in order to make the data useful to them. In this project we discussed the project with a wide range of stakeholders before committing to the final design. Depending on the complexity of the project this timeline could be from a few days to more than a month.Determining the questions should be done by review of available literature  a pre-test in actual field trials with 10% of the sample was conducted. The survey flowed from demographic questions to food involvement scale to health and taste attitude scale to neophobia scale and then to EMS questions . For EMSFor this study, recruitment and survey fielding was conducted simultaneously. Potential respondents in existing Qualtrics panel databases were screened, but that screening happens at different paces in various countries and cultures. In some countries where consumers of all ages regularly check computer communication  screening and testing happened quickly. In other countries or for some demographic groups, recruitment and fielding took longer. In this case, we also checked the data after “completion” of the survey and added additional respondents when needed. The initial fielding took approximately 4 weeks with checks and additional recruitment taking 2 more weeks.Responses were recorded in real-time as the respondents completed the survey questionnaire. The responses were coded and downloaded as Microsoft Excel datasets. Although simple analyses of percentage responses for items, such as positive or negative motivations and mean values of time and questionnaire acceptance, can be analyzed quickly, more in-depth analysis by gender, age group, and other survey data clusters take much longer to analyze and understand. Timing also is affected by other work streams the researchers are working on.On-line surveys only test those consumers who are on-line and accessible, an increasingly large part of the population but still only a portion of the global population. In some parts of the world such testing is impossible, and those sections are missed in on-line testing regardless of the question format used.For the large population that can use on-line testing, the complexity of surveys such as this one that have a large number of recruitment categories, numerous question items (47 positive and 20 negative), additional questionnaires used  and various survey flows for question formats, specialized computer programs are required to set up the surveys and ensure they are properly fielded. For example, for the RATA format, the Qualtrics system provided a pop-up question when respondents rated an item as important. Other survey computerized systems or survey methods  may not have the same abilities to adjust the formatting or flow of questions. Adjustments must be considered if researchers conduct similar surveys using different survey methods.Continuous, near real-time careful examination of collected responses and updates on quota fulfillment is required with this on-line survey approach. This ensures that quotas are not overfilled (increased cost beyond planned budget) but also prevents cases of unfulfilled quotas. For example, we noticed that the USA-RATA questionnaire for the female Generation Z quota had missing responses for four consumers and we were able to recruit and field additional respondents.


This study analyzes the regulation of and developments in blood donation in China from 1996 to 2019, and demonstrates the government’s efforts to improve blood safety.Since the implementation of the Blood Donation Law in 1998, the number of blood donors in China increased by 275% from 1998 to 2018 (from 4 million to 15 million). The principle of no-fault liability was proposed and has been applied since 2010 to the tort liability related to blood transfusion malpractice. In 2015, mutual blood donation accounted for 4.2% of the national collection. However, in some provinces of China, the percentage of mutual blood donation increased from 9.3 to 35.6% in 2016. The National Health Commission canceled mutual blood donation in March of 2018. Since 2015, nucleic acid amplification testing has become a routine test item for screening blood.The Chinese government institutionalized the voluntary non-remunerated donation principle, enacted regulations for the management of blood transfusion, and adopted advanced blood testing technology to sustain blood supply and ensure blood safety. Despite increased blood donation, blood shortages persist. The quality and safety of blood collection can be further improved through the cancellation of mutual blood donation and incentive measures for voluntary non-remunerated donation of blood, which needs facilitation by governmental legislation. From the 1980s to early 1990s, the shortage of blood and the introduction of new plasma collection technology in China created a big opportunity for paid donation, targeting the poor in rural areas. Blood with HIV/AIDS, hepatitis C(HCV), and malaria, was common then, as were frequent cross infections . Disorde2016 Global Status Report on Blood Safety and Availability, apart from increased VNRBD, the number of blood donations, and volume of blood collection, blood safety has been improved by the blood nucleic acid test (NAT) technology adopted by China; and the clinical, rational use of blood has likewise significantly improved in China [To solve the problem of blood safety, China implemented the Law of the People’s Republic of China on Blood donation (Blood Donation Law) in 1998, and institutionalized the principle of voluntary non-remunerated blood donation (VNRBD) by learning from international experience. VNRBD is an important measure for ensuring blood quality and safety. Blood safety has undergone significant changes in China since 1998. Currently, most scholars have reached a consensus regarding VNRBD and its foundation for a safe and sustainable blood supply . In 1998in China . Despitein China –18.The recent status of blood donation and transfusion in China as per data from 1998 to 2019 is presented in this study. Furthermore, improvements and developments in blood donation mode, legal framework, policy, screening technology, and government management are demonstrated. The legal framework and policies on blood donation and transfusion have shown to be effective intervention mechanisms in ensuring blood quality and safety for more than 20 years. Development of the blood donation system in China is not only a reference model for other developing countries, but also an indicator of blood donation system problems and trends to help improve blood safety and availability in China.The laws and regulations related to blood donation and transfusion that were implemented or revised from 1998 to 2019 in China were consolidated to expound on the current legal framework of blood transfusion and the roles of the government, blood stations, and hospitals in the management of clinical blood use. Documents on the laws, regulations, and notices were collected from official Chinese government websites, and the data on blood donation were obtained from official reports of the National Health Commission (NHC) from 1998 to 2019, the WHO’s Global Database on Blood Safety from 1998 to 2011, and the 2016 Global Status Report on Blood Safety and Availability. We used “blood transfusion,” “medical damage liability,” “HBV,” “HIV,” “HCV,” and “syphilis” as keywords to search litigation on the China Judgements Online Chinese court documents website. A total of 484 related cases were downloaded, and 301 of them qualified after screening.In 1998, the Blood Donation Law became a symbol of the VNRBD system in China. VNRBD, family replacement/mutual blood donation (FRMBD), and employer-organized blood donation were the three types of blood donation programs permitted by the Blood Donation Law  were implemented in 1998, the blood center was defined as a nonprofit, public welfare organization, and its establishment was thereafter managed by the health administration department of the provincial government [Blood centers serve as the main institution in the collection of blood. From 1993 to 1998, the establishment of blood centers has been consistently approved by the Red Cross Society in China . After tvernment . Blood cvernment . Blood cvernment .The medical institution is the only legal institution for the clinical use of blood. The Blood Donation Law stipulates that all blood and blood products must be tested before transfusion in medical institutions to ensure safety . Other rBefore 1998, the recruitment of blood donor volunteers was a very challenging endeavor in China. Traditional Chinese medicine holds that the loss of even a small amount of blood was harmful to health; this was also why paid blood donation was common at the time .Since the 1998 implementation of the Blood Donation Law, and encouragement of unpaid blood donation through laws and policies , the numThe proportion of unpaid blood donation, which was only 8% in 1998, increased to 95.5% in 2005. After 2009, all clinical blood came from unpaid donation . In respThrough the establishment of a multi-level alarm mechanism when blood is in short supply, and the deployment of resources in different blood centers, seasonal, regional, and partial blood donation problems have been solved to a great extent. In 2015, 1.19 million units of blood were allocated across the country, reaching 1.54 million in 2017 . In 2018Since 1998, according to Article 15 of the Blood Donation Law, patients’ family members, relatives, friends, and colleagues have been allowed to donate blood for mutual aid in emergency situations. FRMBD is a double-edged sword for blood donation. On the one hand, it can solve the shortage of blood. On the other hand, the risk of blood trade exists in mutual blood donation. The WHO has stressed that when mutual blood donation accounts for more than 5% of unpaid blood donation, there is a risk of illegal blood trade.As a specific mode of donation, it was able to relieve the shortage in clinical blood in China. FRMBD accounted for 0.41% of the national blood collection in 2009 . In 2015However, the rules for mutual blood donation in the Blood Donation Law are too wide in scope for FRMBD and leave room for criminals to sell blood illegally, thereby increasing people’s distrust regarding voluntary blood donation and lowering the quality and safety of donated blood . PrivateTo ensure the quality and safety of blood collection, the NHC issued a government order to cancel FRMBD nationwide, except for some remote areas, by March 2018 . At presBlood safety, to a large extent, depends on whether the blood source is safe. Ensuring the safety of blood collected is the first step in the process. It took the Chinese government four years to establish and strictly implement the testing procedures, and they have been continuously improving it over the past two decades.China’s commercial plasma selling emerged in the early 1980s . Since 1Finally, the Technical Operation Procedures in Blood Stations standardized donor screening, which has become an essential testing step at blood collection centers since 1997 . From thIn the following two decades, testing was strictly implemented. Equipment and technology were updated continuously. For blood group, the RhD type has been mandatorily appraised since 2012 . For serBy analyzing the litigation related to transfusion from 1981 to 2020, we found that the number of cases experienced a huge reduction, since HCV was required to be tested for in 1994 Fig. . AdverseProcess optimization and technology updates have improved blood safety directly, but the risk of blood transfusion cannot be eliminated completely for some unpredictable factors such as infections, venous thromboembolism , transfuBefore 1993, there were no regulations related to adverse events caused by transfusion. For instance, medical institutions or blood stations would not be held accountable for HIV infections caused by blood transfusion because the HIV antibody was not required to be tested for until 1993 . BetweenBetween 2002 and 2010, according to Article 33 of the Regulation on the Handling of Medical Accidents, the fault liability principle was deemed applicable in transfusion. It was found that hospitals were not responsible for no-fault transfusion , meaningTort Law of China, damage from transfusion was classified as a special no-fault liability tort. It was the first time it was clearly defined that patients could claim compensation. This principle instituted the protection of the rights and interests of patients. Although the hospital may not be at fault in the whole process, they should assume tort liability for infringing upon a civil right or interest of the patient and pay compensation. As shown in Fig. Tort Law of China. Generally, the trial process takes three to 4 years after prosecution. Basically, the patient has the right to claim compensation from the blood center or the hospital if he or she suffered any adverse event due to transfusion or infected blood.After 2010, according to Article 59 of the The management of blood donation is an essential part of the public health system and is mainly managed and supervised by the government. Laws and regulations play an important role in blood accessibility and safety. First, the legal framework of blood donation, especially the encouragement of VNRBD, assures the supply for clinical blood use. Second, the legal framework ensures blood safety for all . The rulBlood transfusion therapy is of great significance to the treatment of trauma, anemia, and blood system diseases. Every recipient’s blood group must be determined before transfusion. Application of ABO blood group positive and negative typing and cross-matching tests help avoid acute hemolytic reactions to a large extent. Hemolysis by incompatibility, due to anti-erythrocyte antibodies, remains the most frequent and serious immunological risk to the receiver, especially in a transfusional or feto-maternal context . For somThe principle of no-fault liability actually protects the interests of patients, given that they are a vulnerable group to a large extent; however, it places a huge economic burden on public service agencies such as hospitals and blood centers. The brief infectious period, before the virus is detected, cannot be completely avoided. Moreover, infection caused by transfusion is generally not detected immediately after transfusion. As a result, loss of blood samples or sample collection errors are commonly found during the investigation of infection cases , 63. In It is evident that China has made significant advancements in increasing blood donation. To achieve a self-sufficient blood supply, the WHO states that a minimum of 20 to 25 donors for a population of 1000 is essential . With 15In order to prevent blood dealers from profiting from mutual blood donation, the NHC adopted the most direct and effective strategy. Obviously, there are contradictions and conflicts between the requirements and provisions of the NHC in the cancellation of mutual blood donation. First, the cancellation of mutual blood donation has increased the burden of clinical blood shortage while reducing potential transactional crimes between donors, recipients, and blood dealers. Second, mutual blood donation is allowed and institutionalized by the Blood Donation Law; however, the NHC tried to override it by the notice issued in 2018 . The notOur study on the development of the Legal Framework on blood donation and blood safety in China is based on data collected from Chinese government websites and the WHO database. The amount of blood donation in the same year may vary according to different data sources. Regrettably, data on the volume of donations from 2002 to 2008 were not obtained because they were not publicly available. Furthermore, the judgment documents related to transfusion were collected from the website China Judgments Online. Due to the irregularity of court records in various regions, there may be some omissions in our data.The Chinese government institutionalized the voluntary non-remunerated donation principle, enacted regulations for the management of blood transfusion, and adopted advanced blood testing technology to sustain blood supply and ensure blood safety. The number of litigation cases related to transfusion has experienced a huge reduction since the legal framework and testing technology have improved. Despite increased blood donation, however, blood shortages persist. The quality and safety of blood collection can be further improved through the cancellation of mutual blood donation and incentive measures for the voluntary non-remunerated donation of blood, which need facilitation by governmental legislation.