Neonatal mortality currently accounts for 41% of all global deaths among children below five years. Despite recording a 33% decline in neonatal deaths between 2000 and 2009, about 900,000 neonates died in India in 2009. The decline in neonatal mortality is slower than in the post-neonatal period, and neonatal mortality rates have increased as a proportion of under-five mortality rates. Neonatal mortality rates are higher among rural dwellers of India, who make up at least two-thirds of India's population. Identifying the factors influencing neonatal mortality will significantly improve child survival outcomes in India.Our analysis is based on household data from the nationally representative 2008 Indian District Level Household Survey (DLHS-3). We use probit regression techniques to analyse the links between neonatal mortality at the household level and households' access to health facilities. The probability of the child dying in the first month of birth is our dependent variable.We found that 80% of neonatal deaths occurred within the first week of birth, and that the probability of neonatal mortality is significantly lower when the child's village is closer to the district hospital (DH), suggesting the critical importance of specialist hospital care in the prevention of newborn deaths. Neonatal deaths were lower in regions where emergency obstetric care was available at the District Hospitals. We also found that parental schooling and household wealth status improved neonatal survival outcomes.Addressing the main causes of neonatal deaths in India – preterm deliveries, asphyxia, and sepsis – requires adequacy of specialised workforce and facilities for delivery and neonatal intensive care and easy access by mothers and neonates. The slow decline in neonatal death rates reflects a limited attention to factors which contribute to neonatal deaths. The suboptimal quality and coverage of Emergency Obstetric Care facilities in India require urgent attention. Neonatal deaths account for a major proportion of the world's paediatric deaths. Global neonatal mortality declined from 32 deaths per 1,000 live births in 1990 to 23 in 2010 – an average of 1.7 percent a year, much slower than the fall in the under-five mortality rate of 2.2 percent per year. Consequently, the proportion of deaths in the neonatal period rose from 38% (4 million) of total deaths in 2000 to about 41% (3.3 million) in 2009 District Level Household Survey (DLHS-3) to analyse the links between neonatal mortality, household's socio-economic characteristics, and access to health infrastructure and appropriately skilled neonatal healthcare workers.In this paper we use data from India's 2008 nationally representative India presents a unique context to study neonatal mortality for several reasons. First, despite the rapid economic growth that has occurred there over the last two decades, neonatal deaths fell modestly from 1.3 million in 1990 to 875,000 in 2010, and India currently accounts for nearly 28% of the global deaths among newborn children However, in India prematurity and low birth weight, infections and birth asphyxia accounted for 78% of all neonatal deaths in 2005 Janani Surakhsha Yojana (JSY) and “Home-based New Born Scheme” to improve maternal and child birth outcomes, their impact on reducing neonatal deaths has been limited Recent research shows that in high mortality settings, access to emergency obstetric care has the greatest effect in improving neonatal survival outcomes, and that lack of access to emergency obstetric care services in low-income countries is a serious constraint in improving pregnancy outcomes etalSaksham (Empowered) in Uttar Pradesh, India's largest state which accounts for a quarter of all newborn deaths in India. The project was supported by a well-functioning emergency obstetric care system that included dedicated obstetricians, neonatologists, culturally and technically competent community health workers and nurses who organized the referral system from communities to respective district hospitals. Their analysis found that within 18 months of the program's commencement, neonatal deaths dropped by 58%. Therefore, the evidence from the medical literature suggests that while post-neonatal survival outcomes can be influenced by socio-economic factors and access to vaccinations and other public health measures, access to emergency obstetric and neonatal services is critical in order to reduce neonatal deaths.These findings confirm an earlier analysis by Kumar For India, the links between neonatal-specific care such as access to emergency obstetric care and health infrastructure on neonatal survival probability remains understudied at the national level. A key contribution of our paper is to address this gap in the literature using a large nationally representative dataset that quantifies the role of access health facilities on neonatal mortality outcomes, in a model that also controls for household's socio- economic characteristics.India's Public Health system has been developed over the years as a 3-tier system, at the primary, secondary and tertiary level of health care. A typical Indian state is divided into a number of districts and the districts in turn are divided into Blocks. The district health system is the fundamental basis for implementing various health policies, delivery of healthcare and the management of health services for a defined geographic area In relation to neonatal mortality prevention, skilled workforce entails adequate quality, quantity and distribution of neonatologists, obstetricians, anaesthetists and midwives. Good emergency obstetric care requires improving the availability, accessibility, quality and use of services for the treatment of complications that arise during pregnancy and childbirth As at 2011, there was a 64% shortage of specialist health workers in rural health facilities nationally, including a 66% shortage of Obstetricians and Gynaecologists, and 74% shortage of paediatricians relative to requirements for existing infrastructure District Level Household Survey (DLHS-3), collected by the International Institute for Population Sciences (IIPS), Mumbai on behalf of the Ministry of Health and Family Welfare (MoHFW), Government of India. The DLHS-3 provides a large sized 5-year retrospective collection of statistical records on maternal and child health practice and outcomes, along with demographic and economic information on both individual mothers and their respective households. There were separate questionnaires for Primary Health Centres (PHC), Community Health Centres (CHC) and District Hospitals (DH), which broadly include questions on infrastructure and human resources.The analysis in this paper is based on the 2008 The survey used two-stage stratified random sampling in rural and three-stage stratified sampling in urban areas of each district. The information from the 2001 Census was used as a sampling frame for selecting primary sampling units (PSUs). For the first time, a population-linked facility survey has been conducted in DLHS-3.The data on neonatal deaths comes from the ever- married women's questionnaire, with detailed information on the pregnancy history of women, if any child was born alive but died subsequently, information on the age and sex of the child at the time of death, and information on maternal access to prenatal and postnatal care, and details regarding the place of delivery. This questionnaire also contains detailed information on the socio-economic, demographic and labour market characteristics of the respondent's household. Similarly the village questionnaire collects data from the village head on village infrastructure and the access of the village to health facilities. The DH, the PHC and the CHC questionnaires similarly contain detailed information on infrastructure and health workforce availability and the skills available at each of these health institutions. We linked this detailed mother-level data to information on availability, access and services to health infrastructure, using the Village questionnaire, the DH questionnaire, the PHC questionnaire and the CHC questionnaire.Our analysis is based on 99,735 rural women who gave birth in the last 5 years, and for whom data is available on all our variables of interest. We focus on the last pregnancy since information on birth related characteristics is only available for the last birth. –Similarly we restrict our analysis to the rural sample since data on village-specific characteristics is only available for the rural sample, as 75% of the Indian population live in rural areas, neonatal mortality rates are higher in rural than in urban areas of India and finally, access to health infrastructure is likely to be a bigger constraint in rural areas.In Comparing the full sample with the sample of children who died in the neonatal period, we observe that 84% of the full sample had access to a delivery room in the district hospital, but the figure is slightly lower at 82% in the neonatal death sample. Similarly, a higher proportion of the households (83%) had access to emergency obstetric care in the full sample, compared to the sample of neonatal deaths (80%).We control for household characteristics such as the household head's religion, the mother's age at birth, and the birth-order of the child, such as whether the child was the first, second or third and higher parity birth. The dataset does not have any information on the household's income, wages or expenditure. Hence, we use the wealth index that is available in the dataset. We used the wealth index which was available in the dataset. The wealth index was constructed using household asset data, and is divided into five population quintiles. Notably children from the poorest wealth quintile are over-represented in the sample of neonatal deaths, compared to the full sample.Turning to the role of parental education, in general we observe that education levels are low for mothers. The schooling for fathers albeit higher, shows some disparity between the full sample and the sample of neonatal deaths. While only 45% of the mothers have ever attended school in the full sample, the figure is 71% for the fathers in our study. Among children who died in the neonatal period, only 39% of the mothers have ever attended school. It is also noteworthy that relative to the full sample, a higher proportion of children who died in the neonatal period were also more likely to have had health problems during childbirth.We estimate the probability of a child dying in the neonatal period using a reduced form binary choice probit model as below:i's village, whether there is a delivery room at the DH, the availability of trained health personnel at the DH, in particular the availability of emergency obstetric care (24-hour gynaecologist/obstetrician), and the availability of a paediatrician at the DH. We assume that household i can only access health facilities in their district.Our key explanatory variables include socio-economic variables and an array of health infrastructure variables guided by the medical literature on services critical to neonatal care in India. The term The vectors CHC and PHC include variables at the lower referral hospital. As with the DH, to capture information on the availability of health personnel, we include two variables- the average number of gynaecologists and the average number of paediatricians available at Block-level CHCs. We also include dummy variables indicating the availability of operation theatres at the CHC and at the PHC. Since the PHC acts as the first point of referral, we create a variable PHC_ref_del indicating the average number of referrals to the DH as a ratio of the number of deliveries performed at the PHCs within a Block. There is no information in the household dataset on the specific CHC or PHC that the household may visit, we assume therefore that the household has access to all the CHCs and PHCs in their Block, and accordingly include the average number of the health personnel and infrastructure of all CHCs and PHCs in the Block. A full description of all the health infrastructure variables included in the analysis is provided as Households may also potentially have access to private health facilities such as private clinics and hospitals. Given that the DLHS does contain information on health infrastructure and personnel in private health facilities, we include a variable indicating the average distance between the nearest private health facilities to the respondent's village.Socioeconomic refers to household characteristics such as the wealth quintile, a dummy variable for whether or not the child's mother and father have attended school, and variables to indicate the household head's religion and caste.The term Birth includes the child's birth-specific characteristics such as their gender, their birth-order, whether the child is part of twin births, dummy variables for specific birth-related complications such as whether it was a breech delivery, whether the labour was prolonged, etc., and mother-specific variables such as her age at birth. We also include dummy variables for states to control for time in-variant state-specific unobserved heterogeneity, and finally The term The source of identification in our sample is the cross-sectional variation across Blocks and districts. The data on PHCs and CHCs are available at the Block level, and DH data are available at the district level, and thus vary only across districts, although we note that some of the districts have more than one district hospital, in which case we have assumed that the mother would go to the nearest DH.The health facilities that we have included among our explanatory variables are fairly exogenous to the health-seeking behaviour of households. All the household specific socio-economic and birth-related characteristics are also exogenous to household decisions. However, one can argue that some unobserved health attributes may lead to the household being in a higher wealth quintile and also the probability of having a healthy baby. We have included the household's wealth rather than income given that it is less likely to be endogenous.Furthermore, there are variables in the questionnaire on whether the mother received antenatal and post-natal care, if skilled health personnel were present at the time of delivery, whether the child's birth was at an institutional facility, whether the mother received any assistance from government health-related programs (such as JSY). These variables are likely to have a direct bearing on neonatal death. However, these decision variables are the outcome of an interplay between supply-side variables , child-specific birth characteristics, and also the household's socioeconomic characteristics which we have already included in the regression model. In the presence of both supply and demand-side variables, variables relating to care, skilled personnel and program participation become redundant as the former influences the latter. Similarly, regional unobservable characteristics have the potential to confound the impact of supply side variables, and as discussed the inclusion of state level dummy variables control for state-specific unobserved heterogeneity.Our estimation results are presented in The dependent variable neonatal mortality is an indicator variable  for the probability of a child being born alive, but dying in the first month. We report marginal effects and robust standard errors.Our analysis indicates a statistically significant and negative association between variables relating to district hospitals and neonatal survival outcomes. For both full sample and the backward states sample, the variable distance to DH was statistically significant and positive. Specifically, according to However, distance to PHC is found to be negative and statistically significant for the full sample result. In other words, an increase in the distance between the respondent's household and PHC reduces the probability of neonatal death. Although this result may appear counter intuitive, the negative association may simply imply that if the PHC is closer, the mother may choose to deliver at home or take the child to the PHC which is ill-equipped to deal with neonatal care, and the probability of a child dying in the neonatal period increases. This result is consistent with evidence that these PHCs are not well equipped to deal with complications in neonatal care.The availability of emergency obstetric care (measured using the variable 24-hour availability of obstetrician/gynaecologist) is not statistically significant when state level dummy variables are included. This maybe because it is unclear from our dataset whether it is the obstetrician or the gynaecologist who is available for 24 hours, and they perform different roles. Moreover, the state dummy variables may capture state-specific observed and unobserved characteristics that affect neonatal death such as the quality of health care service. While other measures of health facilities only capture the number of health professionals in the facilities, the emergency obstetric care variable captures whether these health professionals are available for 24 hours. The above results highlight the fact that access to services at the DH, particularly access to emergency obstetric care is crucial in reducing neonatal deaths, particularly in India's less developed states. Although the lower level hospitals such as the CHC and PHC might have a role in referring cases to the DH, they do not appear to have any direct influence.With regards to child characteristics, the results broadly accord with those found in the literature. In particular, relative to a female child, a male child has a significantly higher probability of dying in the first month. The child's birth order is also statistically significant. Relative to a first-born child, higher birth order children have a significantly lower probability of dying in the neonatal period. This may be because more experienced mothers may be in a better position to pick the danger signs during pregnancy. These results hold both for the full sample and in the sample of backward states. Similarly, a child who is part of a twin has a significantly lower probability of survival compared to a singleton birth. We also include variables relating to whether the birth was complicated, and our results show that the probability of neonatal death is significantly increased when there was excessive bleeding and breech presentation at the time of the child's birth. Both conditions are considered to be common causes of birth asphyxia, a known risk factor for neonatal death.Not surprisingly, having a mother who has some schooling relative to none significantly lowers the probability of neonatal death. Our results also show that relative to a child from the lowest wealth quintile, children from the highest three wealth quintiles have a significantly lower probability of dying in the neonatal period. Mother's age has a non-linear relationship with neonatal mortality, indicating that the probability of neonatal morality increases with mother's age. The variables religion and schedule caste/tribe are not statistically significant. This may be because the wealth quintile captures much of these differences and also the Government of India has already introduced a number of programs such as JSY that improve access to health services for disadvantaged people.Finally, we have included controls for states to account for state-specific differentials in neonatal mortality. The full set of results are not presented in We test the robustness of our results to alternative specifications. First, previous research has suggested that the likelihood of neonatal mortality is highest in the first week of birth Therefore, as a first robustness check we re-estimate a model where the dependent variable is defined as the probability of a child dying in the first week of birth, using the same set of explanatory variables as in the previous regressions  and the Our results show that the distance to the DH is statistically significant and positively signed for this sample, albeit the size of the marginal effects are small. This result holds for all the three robustness tests.As a final robustness check, we considered if there was a link between the nearest health facility, health personnel and infrastructure. To assess this, we include two interaction dummy variables between distance and health facilities  and distance and health personnel . The interaction terms are not significant in any of our specifications and we have chosen not to report them due to space considerations. These results are however presented in Janani Surakhsha Yojana and “Home-based New Born Scheme”), but these initiatives have not succeeded in significantly reducing deaths in the neonatal period. The medical literature has highlighted the importance of emergency obstetric care in reducing neonatal mortality. In this paper, using nationally representative data we examined the links between neonatal mortality and access to health infrastructure, particularly focusing on the role of distance various health care facilities. Our results show that the probability of neonatal death is lower if the household lives closer to the DH, which is the only health facility with emergency obstetric care. Access to lower level health facilities such as CHCs and PHCs, are shown to be insignificant in influencing neonatal mortality outcomes.India accounts for the largest number of global neonatal deaths with 900,000 of 3.3 million neonatal deaths in 2010. Despite high economic growth rates over the last two decades and declines in child mortality rates, neonatal mortality rates remain high and have increased as a proportion of child mortality rates. Since 1995, the Indian government has instituted two major public health programs to improve maternal and child survival outcomes Click here for additional data file.Table S1Probit estimation results: Dependent variable- Probability of child dying in the neonatal period.(DOCX)Click here for additional data file.


The culture of New Public Management has promoted the diffusion of strategic management tools throughout Public Healthcare Organisations (PHOs). There is consensus that better strategic planning tools are required to achieve higher levels of organisational performance. This paper provides evidence and understanding of the emergent uses and scope of strategic planning in PHOs, in order to answer three research questions: (i) has the New Public Management approach changed the organisational culture of PHOs in terms of how they adopt, diffuse, and use strategic planning documents? (ii) how coherent are strategic planning documents in PHOs? and (iii) what are the main purposes of strategic documents in PHOs?An analysis was carried out in three Italian Local Health Authorities. We analysed the number and types of formal strategic documents adopted between 2004 and 2012, evaluating their degree of coherence and coordination, their hierarchy, their degree of disclosure, and the consistency of their strategic goals. A content analysis was performed to investigate overlap in terms of content and focus, and a qualitative analysis was carried out to study and represent the relationships between documents.The analysis showed that a rich set of strategic documents were adopted by each PHO. However, these are often uncoordinated and overlap in terms of content. They adopt different language and formats for various stakeholders. The presence of diverse external drivers may explain the divergent focus, priorities and inconsistent goals in the strategic documents. This planning complexity makes it difficult to determine how the overall goals and mission of an organisation are defined and made visible.The evidence suggests that PHOs use a considerable number of strategic documents. However, they employ no clear or explicit overarching strategy currently, and strategic planning appears to be externally oriented. All the documents communicate similar topics to different stakeholders, although they use different language to answer to the different expectations of each stakeholder. Therefore, strategic planning and plans seem to be driven by neo-institutional approaches, as they are means to build consensus and negotiate ground for strategic actions, rather than means to identify strategic choices and priorities. This paper provides evidence of the manifold uses and scope of strategic planning in Italian public healthcare organisations (PHOs). We analyse the features and scope of formally adopted strategic documents that Italian PHOs are expected to produce, or that they autonomously decide to develop.There is some consensus in the literature that - especially in turbulent and complex contexts - strategic tools are required to achieve higher levels of performance ,2. This The formulation of strategy in the public sector requires a disciplined effort to take the fundamental decisions and actions that shape and guide what an organisation is, what it does, and why it does it, all within a legal framework ,6.It is clear that political discourse often lies behind the success or failure of efforts to strategise in public contexts, in which a number of diverse actors come together to define goals and implement actions. As suggested by the strategy-as-practice approach, the formulation of strategy in PHOs is often the result of the interplay between organisational discourse and politics in the public sector.In fact, strategic decision processes in PHOs suffer from the effects of the public nature of these organisations, beside the effect of the peculiarities of the healthcare sector. The public nature, according to the published literature, has clear effects on the organisational environment ,8:• Complexity. Public organisations generally have a variety of stakeholders to refer to. Often, the requirements of the various external constituencies  are in conflict. Public organisations are expected to contribute to the general development of the community, while simultaneously pursuing their primary goals.• Permeability. Public organisations are ‘open systems’ that are easily influenced by external events, especially with regard to making services responsive to emergent public needs. This pushes constituents’ daily influence and delays the formulation of long-term policies and the implementation of processes.• Instability. Political constraints result in frequent policy changes and the imposition of short time horizons on public managers. The political cycle often creates pressure to achieve results rapidly or makes it extremely difficult to pursue medium-term projects that need continuity to be implemented successfully.Second, the concept of publicness affects the goals of organisations. It has been frequently disputed that public organisations have distinctive goals such as equity and transparency that do not exist in the private sector.Third, the internal characteristics of public organisations are considered to be distinctive for many different reasons: public sector organisations have more formal procedures for decision making and are less flexible and more risk-averse than their counterparts in the private sector; the existence of weighty procedures and regulations implies a counter-productive obsession with rules and processes, rather than a concern with results and outcomes; managers in public organisations have less freedom to act and react according to their personal views of the circumstances that they face; public managers experience the impact of hierarchy (bureaucratic rules and regulations) without its benefits (the freedom and power to manage their subordinates); and the level of organisational commitment is believed to be lower in the public sector, largely because of weak links between performance and organisational rewards.The healthcare sector is a complex environment, where strategy and decision-making are defined by the intersection of different cultures , values  and interests . Furthermore, management in the healthcare sector is becoming increasingly more difficult, as every system is subject to the same structural trends: a demographic shift toward the elderly, the skyrocketing pace of technological innovation and rising consumer expectations, all of which impact heavily on rising costs.Consequently, strategic documents may not be used as they were originally intended, because they often end up responding more to the constraints of institutional isomorphism than they do to the primary need to formulate strategy.The backdrop to the present study is more than 15 years of managerialisation in the Italian health service , which wIn order to formulate our three research questions, we began by assessing evidence of whether PHOs adopt strategic plans concurrently. We then investigated the following research questions:1. Has the NPM approach changed the organisational culture of PHOs in terms of how they adopt, diffuse, and use strategic planning documents?2. How coherent are strategic documents in PHOs ?3. What are the main purposes of strategic documents in PHOs?PHOs are pluralistic organisations with diffuse structures of governance, and the process of agreeing strategic decisions can therefore be difficult. We designed our study to explore the presence, consistency and scope of PHOs’ strategic documents. Our findings are discussed with reference to two theories: the political environment framework and the garbage can framework.In the political environment framework, the public sector is seen as a number of parallel but separate strategy-making processes that are politically driven, ambiguous in their goals, and not well formalised. Mintzberg  argued tThe garbage can framework suggests that public organisations lack formal long-term planning processes. Their strategies are instead developed gradually through disjointed incrementalism, learning-by-doing, and the recognition/formalisation of emergent strategies. Moreover, in the real world, decisions, including strategic ones, arise from the accidental or random confluence of four streams ,13. ThesOur hypothesis complements the theoretical frameworks presented above. We propose that, in a complex environment characterised by a number of sources of pressure on Italian PHOs, strategic planning documents are often the result of the interplay between key stakeholders, and these documents are internally inconsistent because they are drafted to meet different external expectations. Strategic planning documents can be used to build consensus and could be a means of satisfying the informational needs of different stakeholders. This could create a space for actual strategic decision-making outside the remit of official planning documents.Strategic planning documents can have a bureaucratic origin, since they can represent an administrative constraint imposed by law or by a higher level of government, or they can represent an internal managerial resolution to steer the organisation. External legal constraints do not impose logical links between strategic documents, or the attainment of specific overall goals. Each document can explicitly pursue different objectives, and the differences between documents are often the result of legislative stratification or of a fragmented geography of power in the public network. In light of this framework, the authors focused on understanding the degree of coherence between different documents from the same LHA.Therefore, the aim of the present study was to answer the three research questions, posed in Section 1, by analysing and understanding the scope and overall degree of coherence of all the strategic documents taken into account.In order to answer the first question, we analysed a number of different formal strategic documents for each PHO and interviewed their top managers.In order to answer the second research question, we evaluated the degree of coherence and coordination between strategic tools, or the existence of a clear hierarchy between them, by considering both their timing and their focuses. The underlying assumption is that a high degree of integration and a clear time sequence are indicators of a clear strategy aimed at effective organisational guidelines. By contrast, if the language use in strategic documents is uncoordinated and no overarching strategy can be discerned from them, this implies a weak internal commitment to formalise a strategic design.In order to answer the third research question, we analysed the degree of disclosure and the consistency of the strategic goals expressed in the different documents. A high level of disclosure and consistency implies that the PHOs concerned intend to share strategic goals with internal and external stakeholders, as well as the actions necessary to implement them. By contrast, if there is no real attempt to satisfy the informational needs of stakeholders or to provide clear and visible results, there is a low level of consistency. The presence of quantitative service targets and future resource allocation is a strong indicator of disclosure, while the presence of only qualitative suggestions for the future can be considered the opposite.Sistema Sanitario Nazionale). The Italian SSN is a Beveridge-like national healthcare system that includes 140 local health authorities (LHAs) that are the basic purchasers and providers of the system, and 80 independent hospital trusts that represent the most specialised third-level providers. PHOs in the SSN have average annual budgets of 480 million Euros, and have an average of 3 000 employees. In Italy (population 60 million), the SSN is managed by 21 regional governments. The LHAs in each region show different degrees of development in managerial terms, even though each region acts as a public holding and applies the same external constraints to all PHOs. For this exploratory qualitative research, we used a multiple case study approach [Data were collected from the Italian SSN , because it is one of the most innovative Italian regions from a managerial point of view . Emilia-We selected three LHAs for the present study, namely Parma, Reggio Emilia, and Cesena. Since the early 1990s, these three LHAs have distinguished themselves by their ability to introduce managerial innovations [In order to analyse the number and types of formally adopted strategic documents (first research question), representatives of the study LHAs participated in an intensive two-day training seminar. This seminar introduced the definitions and theoretical frameworks discussed in Section 1, in order to begin the process of ‘naming’ and ‘framing’ the problem. Then we interviewed three top managers of each PHO in the sample, including one of the senior managers , the chief controller, and an operations manager. Finally, we jointly selected the most relevant strategic planning documents, which had been formally adopted between 2004 and 2010 in each PHO.Second, we assessed the selected strategic documents in order to evaluate their principal focus. The following five planning focuses were considered: (1) the vision statement, (2) the planned service mix and portfolio evolution, (3) future resource allocation, (4) planned organisational developments, and (5) accountability content and modes to external stakeholders. Using content analysis, each document was analysed to determine the number of times that key words appeared in the text relative to the overall number of pages of the document, in order to create an index to capture the document’s focus. The indicators represent how frequently the key words of each focus appear in the whole document. The numerator is expressed as the total number of times that the key word linked to a specific focus was present in the document, while the denominator is expressed in terms of the total number of pages, in order to make documents with different lengths comparable. The index helped us to establish the focus, or focuses, of the document, where a high number associated with an indicator corresponded to a high relevance of that focus. Average frequency of relevant words per page for each focus was also considered to evaluate the relevance of a single focus within a document.We also carried out an in-depth analysis by reading all documents and recording their details in a database. In order to control for classification errors during the analysis process, a number of rules of evaluation were agreed. The authors worked independently, and discrepancies in the entries of the researchers were discussed before agreement was reached. We then adopted the sequence of a rational planning framework, first defining the vision statement and planned strategic position, then selecting the service portfolio and resource allocation, and ending with organisational development and stakeholder accountability ,20,21 inThe adoption date and planned implementation period of each document and its focus allowed us to observe the logical interactions between the different planning stages. We represented these interconnections graphically in order to capture an overarching view of adoption times and strategic focuses, and compared them with the ideal model obtained from previous studies of rational planning and the legislative framework. The aim of this step was to evaluate the degree of coherence and coordination between different strategic documents .Finally, we tabulated the major goals of each strategic plan in order to evaluate their consistency, contradictions, and redundancies . Our aim was to assess whether there was a general consistency and disclosure in terms of the objectives and the allocation of resources in the documents, and to understand the purpose of the strategic documents. For this reason, we selected four main targets from the first documents adopted by each PHO between 2004 and 2012, in order to assess how each goal was linked to the contents of the succeeding documents. We used five defined levels of consistency in order to evaluate, for each LHA, the overall consistency of goals among strategic documents. The aim of this step was to categorise each LHA in terms of level of consistency, based on the connection between documents. The five levels were defined as follows:1. LEVEL 1: General goals are clearly stated and easily detectable in the first strategic document;2. LEVEL 2: General goals are clearly stated and easily detectable in the first document; and corresponding variations in the level of services are detectable in the succeeding documents;3. LEVEL 3: General goals are clearly stated and easily detectable in the first document; corresponding variations in the level of services are detectable in the succeeding strategic documents; and variations in the level of resources/investments are directly linked to the specific goal;4. LEVEL 4: General goals are clearly stated and easily detectable in the first document; corresponding variations in the level of services are detectable in the succeeding documents; variations in the level of resources/investments are directly linked to the specific goal; and there is a clear link between all documents for each single specific goal;5. LEVEL 5: General goals are clearly stated and easily detectable in the first document; corresponding variations in the level of services are detectable in the succeeding documents; variations in the level of resources/investments are directly linked to the specific goal; there is a clear link between all documents for each individual goal; and all documents are designed using similar language, layout, and articulation of goals.All five levels are logically linked and the achievement of a higher level implies the attainment of the previous level. If the characteristics of a lower level are not met, it is not possible to reach a higher degree of overall consistency between documents.From the data analysis, the first point of interest was the breadth of the strategic documents adopted by the three LHAs in the short study period. Generally, no single comprehensive strategic document exists. Instead, there is a series of plans defining similar items in different ways, proposing different content, focussing on different priorities, and adopted at different times. Each LHA selected more than one document that they defined to be ‘strategic’ . This breadth of strategic documents differs from the findings of previous authors, who have tended to depict the strategic planning process as coordinated and linear, articulated in rational stages, and resulting in the creation of one overarching strategic document ,20. FurtThe presence of multiple strategic documents, instead of an overarching strategic plan, can only be justified by the different focuses of each document. Using the content analysis approach described in Section 2, we clearly demonstrated that several documents had more than one focus and that these focuses are repeated in multiple documents for each LHA Table . For insThe documents and their sequence were partially determined by the legislative framework defined by the regional government of Emilia-Romagna. Given the sequencing of legislation, which suggests the use of a rational strategic approach ,20, it mThe present study analysed the logical correlations between the planning tools for each PHO and their coordination in terms of date of adoption and time sequence. Although adoption dates usually are clearly shown in public documents, some documents still required careful reading of their introductory paragraphs in order to understand the time horizons involved. In some cases, the date of approval was after the formal planning timeframe, highlighting the first source of incoherence. By analysing the chronological order and focuses of the documents, we aimed to establish whether there was a high degree of overall coherence and a clear time sequence, implying a rational approach to strategic planning and a desire for effective organisational guidelines.As shown in Tables There does seem to be general compliance with the Italian legislative frameworks in terms of the adoption of formal documents. From this perspective, the effect of NPM culture on LHAs is reconfirmed. With regard to the theoretical framework presented earlier, strategic planning documents seem to comply with the general rules that govern their adoption and are a means to relate and account to stakeholders.The analysis in Table In general, it was difficult to find a strong overall consistency between documents, and impossible to determine how each general goal translated into concrete actions with a clear allocation of resources and funding. In most cases, the general objectives tended to be more specific in later documents; however, no explicit evidence of the available resources for a specific project or the types of investment was shown. Indeed, this analysis emphasises that, even in the presence of a logical correlation between documents, there is a significant lack of consistency, and goals are ambiguously presented.In general, the content of the documents presents an incomplete picture of goals and targets. All the strategic plans featured a vast amount of historical data on the context and results achieved in the organisation concerned, followed by vague qualitative statements about future strategy, and missing or incomplete definitions of quantitative targets and resource allocations.The only targets stated were improvements to particular services, usually without any quantification of the expected improvement. Moreover, these services are often peripheral activities. In addition, no reductions in services are ever described, and changes in the allocation of resources are usually unavailable. Although each LHA produces its own formal balance sheets, these are not embedded or summarised in its strategic documents. Indeed, the strategic documents seem to focus on the reconstruction and analysis of past performance and results, and on the promotion of a qualitative vision of service orientation and organisational development. However, relevant or systematic data on future strategy are rarely provided.Public organisations rarely define clear targets, even in their formal plans, leading to uncertainty as to which social target has been prioritised and which have been partly or totally excluded . HoweverThis problem of quantification is consistent with traditional Weberian bureaucracies, which engage in planning using an input-based approach in order to discern all the issues related to the financial statements, but hide information about user targets, included and excluded social clusters, outputs, service standards, and equity.The aim of the current study was to analyse the role played by strategic documents in PHOs given their degree of overall coherence. Using three case-study LHAs, we analysed the logical correlations between the different strategic documents adopted by individual PHOs in order to understand their degree of coherence, coordination and disclosure, and the role they play in management steering the organisation and accounting to stakeholders.The results show that NPM prescriptions had an impact on the PHOs in our sample, since there is a diffused strategic culture and planning tools are widespread. Formally adopted strategic plans are embedded and capture health sector complexity, trying to analyse and regulate a wide portfolio of issues and to dialogue with a rich arena of stakeholders.There is a multitude of formal strategic documents in place, although they are often uncoordinated and have inconsistent content. There is often no logical sequence between strategic documents, even though all of them are consistent with different stakeholder needs and perspectives. Almost every strategic document has an external focus because of the bounds set by regional regulations or government policy, as well as by stakeholder expectations.The strategic documents of LHAs are the main tools for communicating with diverse stakeholders that use different languages and varied processes of negotiation. As such, LHAs must use their influence to alter language, format, processes, and timeframes in order to meet stakeholder needs . AlthougOfficially adopted strategic plans offer vague and qualitative targets for steering complex PHOs. Although a rich diversity of quantitative reports is available, these reports are always related to past performance, and analytic and clearly stated future goals are not in place. Future strategies are described using only a qualitative and narrative approach . StakehoThese considerations all belong to a complex and multi-actor model of social bargaining that focuses on sense-making and political representations rather than on quantitative planning . PHOs arTherefore, in highly pluralistic contexts, participatory strategy approaches are more effective than rational ones. Scholars agree that strategy-making in these organisations requires collaborative decision-making processes involving the plurality of actors playing distinct but tightly-knit roles .In summary, no clear or explicit overarching quantitative strategy is available and all strategic planning documents seem to be externally oriented: they communicate similar topics to different stakeholders, each of whom use a different language, and have a different negotiation process and informational needs. From this point of view, strategic planning documents represent a means of gaining and developing a protected space for ‘hidden’ decision-making, which might be necessary in order to allow PHOs to take autonomous managerial decisions without the involvement of the external stakeholders who were involved in the formal process of drafting these documents. This is a consequence of the complexity of PHOs, and public managers in the healthcare sector should be aware of and not victim to this complexity. As a consequence, management should base strategic decision-making on an awareness of the different purposes of each planning document, assigning it the most appropriate role in the overall planning decision process. There can be many different purposes for these documents: communicating the organisation’s values, being accountable to internal or external stakeholders, presenting a long-term vision, planning the tools for managing the PHO. Documents’ titles are not always consistent with their content and the real meaning they have in managing the organisation and its relationship with the external context. Managers should use the various planning documents to govern the healthcare organisation and, at the same time, create favourable conditions for exchanges and consensus building with the external contexts and all stakeholders.The evaluation of the extension of this strategic space, to be created by healthcare sector managers, and the explanation of how this can be effectively achieved through organisational autonomy without breaking stakeholder trust and social contracts, is a broad avenue for future research in this area.LHA: Local Health Authority; NPM: New Public Management; PHO: Public Healthcare Organisation; SSN: Sistema Sanitario Nazionale .The authors declare that they have no competing interests.All authors contributed equally to this work.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/13/5/prepub


Mortality in the period 1995−2002 was studied for 63 single or grouped causes at the municipal level by computing: crude rate, standardized rate, standardized mortality ratios (SMR), and SMR adjusted for an ad hoc deprivation index. Regional populations were used as references for SMR calculations and 90% CI accompanied SMR values. The deprivation index was constructed using 2001 national census variables for the following socioeconomic domains: education, unemployment, dwelling ownership, and overcrowding. SENTIERI results will allow the priorities setting in remediation intervention so as to prevent adverse health effects from environmental exposure. This paper's objective is to present the rationale, methods, advantages, and limitations underlying SENTIERI project and to describe data and resources required to apply a similar approach in other countries.SENTIERI project  studied mortality in the sites of national interest for environmental remediation . SENTIERI described mortality of residents in NPCSSs, and it specifically focused on causes of death for which environmental exposure is suspected or ascertained to play an etiologic role. The epidemiological evidence of the causal association was classified  Human health is intimately connected to the surrounding environment. This is particularly the case of the health of people living in contaminated site(s) (CS) which is affected by the legacy of past industrialization and current industrial activities, often in absence of environmental remediation.European Community legislation addresses the concept of CS only in the context of the Thematic Strategy for Soil Protection  and the According to 2007 estimates, soil contamination requiring clean up is present in approximately 250,000 sites in the European Environment Agency (EEA) member countries . AlthougThe term CS can have different meanings. A general definition, following the public health perspective, is “areas hosting or having hosted human activities which have produced or might produce environmental contamination of soil, surface or groundwater, air, and food chain, resulting or being able to result in human health impacts” . Given tad hoc collection of data and aims at describing the health profile of populations documenting ascertained or suspected associations with local environmental risks and the potentiality to provide efficient answers. More detailed analyses can be carried out, at a higher level of definition, by collecting specific data on health outcomes and/or on exposure [There are several approaches and methods for assessing the health impact of National Priority Contaminated Sites (NPCS). On the one hand, one can apply risk assessment techniques, where available data on the degree of contamination  are used to quantitatively estimate the risk of occurrence of health endpoints causally associated with the agents; on the other hand, epidemiological approaches applicable to NPCSs involve the inclusive collection of available health information of resident population, and various agents and exposures. In these assessments, a first descriptive level is based on epidemiological tools that do not require an exposure . SENTIERI project  , 7 is anThe methods proposed under the approach exemplified by SENTIERI can be generalized and applied to other NPCSs. This paper's objective is to present the rationale and methods underlying SENTIERI project and to describe data and resources required to apply a similar approach in other countries. When studying how the environment can adversely affect human health, it is usually very difficult to identify clear cause-effect relationships because they are characterized by multicausality with different strengths of association. In addition, these relationships are influenced by individual factors  that can also have a role on both exposure level and disease development. SENTIERI project was developed to deal with this complex scenario. It describes the health profile of residents in contaminated sites through small area analysis by applying the multistep procedure described in the following sections. A selection of epidemiologic terms are defined in Glossary to facilitate the reading of the paper.As a first step, NPCSs to be studied should be chosen, and the criteria adopted to define NPCS/NPCSs are clearly indicated. The NPCS selection will depend on the aims of the study to be undertaken, on the availability of the NPCCs-related information, and on any other consideration researchers would make and consider appropriate. In many instances, NPCSs to be studied are chosen by third parties, such as an environmental authority, by public concern, and media pressure. It is advisable that the criteria used throughout this phase are clearly stated.In most instances NPCSs are characterized by the presence of numerous and different environmental sources of contamination possibly leading to human exposures. All the available NPCS data should be collected and described in a standardized, homogeneous way. Geographical characteristics, extension of the contaminated area, and demographic information about residents potentially affected should be listed. Detailed description of contamination characteristics should be included as well as the presence of industries and all other human activities that have contributed to the environmental deterioration of the NPCS. Researchers will specify the sources used for this task: scientific reports, acts, and so on.Criteria to define populations affected by contamination may vary. Populations at risk can be identified as people living in the neighborhood of NPCSs sources or living in areas defined as contaminated. Typically, the distance from the areas affected by contamination is used, but also dispersion modelling results are used. In the latter case, the definition of the areas most affected by contamination, and the consequent identification of at-risk populations, depends on the accuracy of the model. There are several models used to evaluate the areas affected by contaminants; their implementation and improvement depend on the available information on several parameters. For example, in the case of emissions into the air from oil refineries, the parameters to be considered should be characteristics of emission sources: for example, height, flow rate, composition of emissions, exit temperature, local orography, and meteorological conditions . Areas cFor the reference population the same data of the area units under study are needed: cases and populations stratified by gender and age categories.The reference population should be selected considering two different needs: (1) it should be comparable to the studied populations for factors that can affect the health profile with the exception of the contamination at study—the differences in the health profile between the compared populations should be ideally due only to the differences in environmental exposures, namely, to the contamination; (2) it should be sufficiently numerous to obtain stable reference rates also for rare diseases. These two needs have opposite requirements, as the first one is usually negatively correlated with the dimension of the population, while the second one is positively correlated with the dimension of the population. The reference populations should be selected balancing these two needs. Usually one or two populations among the following are selected as reference population: national, and regional, local .The aims of the study will imply a sound outcomes selection to include the ones for which environmental exposure/s  is suspected or ascertained to play an etiologic role. The possible health impact from environmental exposures is measured in terms of mortality, morbidity, incidence of neoplastic diseases, and so forth. General considerations about the quality of available information and data as well as intrinsic limitations of the selected outcome measures should be described and discussed.Health indicator characteristics should be carefully examined and multiple aspects considered taking into account the inherent uncertainty. Sources of national or local routinely collected data, spatial and temporal coverage, and quality aspects are all of extreme importance for the validity of study results and their usefulness in terms of general knowledge and public health relevance.An appropriate length of the period under study will make research results and conclusions more informative for diseases with long latency times; precision of the epidemiological parameters will also improve with a longer study period. Small-area studies investigate the role of neighbourhood level . The speThe smallest territorial unit that can be used in small area studies depends on data availability that may vary in different countries. For example, in Italy small area studies can be carried out at the census tract (average of 200 residents) and municipality levels. In 2001 about 70% of the Italian municipalities included less than 5,000 residents; this compares with Great Britain, where small area studies can be carried out at the following levels: enumeration districts—400 residents, electoral wards—5,100 inhabitants, and postcode sectors—6,600 people .ad hoc Deprivation Index was built and applied to the SMR estimates.In geographical studies of environment and health, confounding from social and economic factors may occur. To control such confounding effect, standardisation techniques have been extensively used since the mid-1990s. To account for possible confounding from socioeconomic factors in SENTIERI project, an Deprivation can be defined as “a state of observable and demonstrable disadvantage relative to the local community or the wider society or nation to which an individual, family, or groups belong” . Deprivaa priori from the epidemiological evidence of their association with selected environmental exposures. This is the basic key aspect of the SENTIERI approach.When performing epidemiologic studies, there is a risk for researchers to become data-driven. This can be the case when commenting results for causes showing an increase, possibly on the basis of statistical significance. As an example, SENTIERI dealt with the complexity of the relation between area contamination and health effects. For each NPCS studied the project focused on those causes identified It is suggested that researchers use environmental contaminants information considering the available level of details. In SENTIERI possible relevant exposures were abstracted from Legislative Decrees, that is, administrative sources defining NPCSs boundaries and coded on a productive sectors basis . The choice was made because NPCSs had heterogeneous level of environmental characterization. While for some NPCSs information on specific chemical contaminants was available, for others only productive plants were listed. This is to point out that researchers should be able to adapt this approach to their specific situation.When studying factors that determine changes in the occurrence of a given health condition or its predictive factors, it should always be kept in mind that most diseases have a multiple etiology. Therefore also exposures different from those specifically present in NPCSs should be considered, as well as every known cause or risk factor, such as smoking habits, alcohol consumption or other sources independent from those at study, that is, socioeconomic factors and occupational exposures, and air pollution due to combustion of fuels for transport activities and domestic heating. The latter aspects are particularly relevant when studying complex industrial settings close or overlapping to urban highly populated areas.Once the environmental exposures of interest identified, researchers should examine the updated scientific literature to evaluate the associated health effects. This apparently easy task is in fact quite demanding, because by browsing the literature different kinds of publications are collected: handbooks, original articles, letters to scientific journals, multicentric studies, editorials, reviews, meta-analyses, and so on. Therefore, the first decision to be taken is about the “relevance” to give to the collected material and how to use it to define the strength of the association between the specific health outcome and the environmental exposure/s that characterize/s the NPCSs. SENTIERI study group defined a hierarchy in the literature sources. Sources expressing the epidemiological community consensus, evaluating scientific evidence by means of standardized criteria, and weighting the study design and the occurrence of biased results were considered most important . They were followed in the hierarchy by quantitative meta-analyses. Multi-centric studies, systematic reviews, and single investigations were also considered. Consistency among sources was a criterion used to classify the strength of the causal association. a priori evidence evaluation).This process was performed considering not only the environmental exposures, but also those risk factors previously mentioned . Literature sources were presented in the final report in a tabular form to let the reader follow the entire process of evaluation for each cause combined with different exposures. On the basis of explicit criteria the strength of the causal association for each cause-exposure combination was classified . In SENTIERI the production activities and sources of contamination listed in the Decrees defining the sites' boundaries were used as a proxy for environmental residential exposures; they are coded as chemical industries, petrochemicals and refineries, steel plants, power plants, mines and/or quarries, harbour areas, and asbestos or other mineral fibres, landfills, and incinerators. For each NPCS contamination data were collected, both from the national and local environmental remediation programmes.The study population comprised residents in 44 NPCSs; each one included one or more municipalities, a total of 5.5 million inhabitants in the 44 NPCSs, about 10% of the Italian population at the time of 2001 Census.In SENTIERI project the Italian 2001 standard population was used as a reference to calculate crude and standardized rates. Regional populations were used as reference in the indirect standardization.Mortality for 63 causes (or group of causes) for the period 1995–2002.a priori evaluation should be built. Each outcome can be considered usable for the SENTIERI approach if its validity is previously verified, and appropriate epidemiological parameters can be estimated.SENTIERI approach can be applied considering different health outcomes. Each outcome and cause analysed should be characterized to define its specific contribution in evaluating the possible health impact of contamination. For this aim, mortality, morbidity , cancer incidence, and congenital malformations prevalence could be of major interest. As described in the previous section, for each outcome a matrix of ad hoc deprivation index (SMR ID).Briefly, SENTIERI studied mortality in 44 NPCSs using data at municipality level (1995–2002), calculating indicators such as crude and standardized rates  and standardized mortality ratio (SMR), using regional comparison rates, both crude (SMR) and adjusted for an ad hoc Deprivation Index was built and applied to the SMR estimates in SENTIERI project (SENTIERI DI). The deprivation index was constructed using the 2001 national census variables representing the following socioeconomic domains: education, unemployment, dwelling ownership, and overcrowding.To control for confounding from social and economic factors an a priori epidemiological evaluation of the strength of the causal association for each combination of selected outcome and environmental exposure. For details concerning the a priori evaluation see The epidemiological evidence was examined on the basis of explicit criteria to build a matrix of the  Firstly a multidisciplinary group of researchers (see the previous section) draws up the list of causes to be submitted to the evidence evaluation. Secondly, the epidemiologists classify the strength of the causal association of each outcome/exposure combination.The procedure to develop such matrix can be summarized as follows.To complete this phase in SENTIERI project, the epidemiologists developed a procedure to examine the epidemiological literature published from 1998 to 2009 on the health risk of populations living in NPCSs. For details refer to The epidemiologists examined each cause of death/exposure combination  in terms of strength of causal inference. “Environmental exposures” were distinguished from “other exposures” in NPCSs. The former were fixed on the basis of the possible sources of contamination in NPCSs listed in the Decrees that defined each site boundaries ; the “other exposures” were the environmental, lifestyle and occupational most important known etiological factors: air pollution, active and passive smoking, alcohol intake, occupational exposures, and socioeconomic status. The procedure finally led to classify the evidence of the causal association into three categories: Sufficient to infer the presence of a causal association, Limited to infer the presence of a causal association, and Inadequate to infer the presence or the absence of a causal association.The criteria adopted for the classification are reported in a priori evidence about the strength of each outcome-cause/environmental exposure or outcome-cause/“other exposure” causal association was prepared ; (b) previous studies carried out in the investigated area; and (c) a conclusive paragraph with suggestions for further scientific and/or remediation priorities as well as recommendations for public health interventions. SENTIERI study group prepared a form to present each NPCS at study. It included a summary description of population and contamination data: specific sections dedicated to (a) results by gender . For example, a role of emissions from refineries and petrochemical plants was hypothesized for the observed increases in mortality from lung cancer and respiratory diseases in two NPCSs; a role of emissions from metal industries was suggested to explain increased mortality from respiratory diseases in two other sites. In six NPCSs an etiological role of air pollution in the raise of congenital anomalies and perinatal disorders was suggested, and a causal role of heavy metals, PAH's, and halogenated compounds was suspected for mortality from renal failure in six sites.According to the 2001 Census, the NPCS Sassuolo-Scandiano includes 6 municipalities with a 102,811 overall population.The perimetration Decree of this NPCS lists the presence of pottery manufacturing plants, an environmental exposure that SENTIERI qualifies as “C” .a priori Sufficient or Limited evidence of causal association with the environmental exposure in this NPCS, an excess for respiratory diseases and asthma was observed in men , SMR ID = 168 (90% C.I. 117–234)) and similarly in women (SMR = 110 (90% C.I. 69–167), SMR ID = 110 (90% C.I. 69–166)). A hypertension excess was pointed out for both genders (men: SMR = 192 (90% C.I. 166–221), SMR ID = 190 (90% C.I. 164–219); women: SMR = 206 (90% C.I. 184–230), SMR ID = 196 (90% C.I. 176–219)).In conclusion, data acquisition for the appraisal of the present lead environmental pollution and occupational exposure is suggested. Individual epidemiological investigations are recommended to study asthma prevalence.a priori Sufficient or Limited evidence of causal association with the environmental exposure showed, for the period 1995–2002, 3,508 excess deaths for all causes, corresponding to 439 deaths/year; the number of excess deaths was 1,321 for respiratory diseases, 898 for lung cancer, and 588 for pleural neoplasms. When considering excess mortality with no restriction to causes of death with a priori Sufficient or Limited evidence of causal association with the environmental exposure, the number of excess deaths for all causes was 9,969 ; the excess was 4,309 for all neoplasms (about 538 excess deaths/year), 1 887 for circulatory system diseases, and 600 for respiratory system diseases.SENTIERI project assessed also the overall mortality profile in all the NPCSs combined. The mortality for causes of death with a priori evaluation of the epidemiological evidence as carried out in SENTIERI reinforced the findings and strengthened the case of an etiological role to some environmental exposures. This has varying degrees of persuasiveness for example, an increased lung cancer and respiratory disease risk was observed in sites hosting refineries and petrochemical plants, suggesting the need for further studies; the ascertained exposure-disease association between pleural neoplasm mortality and asbestos was confirmed in sites with documented presence of asbestos and asbestos-like fibres [The ecological approach used in SENTIERI does not allow to draw firm conclusions on the causal relationships between residential exposure and health status in residents in a contaminated site; furthermore, the causal inference might be complicated for causes with multifactorial etiology in areas with multiple sources of different pollutants and concurrent presence of air pollution from urban areas. Notwithstanding these difficulties, in a number of instances, the e fibres . Anothere fibres .The value of an ecological study like SENTIERI should be measured, as recently suggested , againstExposure ascertainment is a key phase in ecological environmental investigations; the exposures affecting the study population should ideally be described in detail, while in practice a number of limitations affect this crucial aspect in most studies.In some investigations the exposure/s is a time-bound event in a limited geographical area, leading to a point source emission of a limited number of contaminants whose nature has been identified and whose toxicological properties can be partially known. Events such as the explosion of Seveso in 1976  and BhopAnother limitation in exposure ascertainment lies in the implicit assumption that all residents in the area under investigation experience the same exposures, while exposure variability is likely to be substantial, due to many factors . The possible consequences of such nondifferential exposure misclassification are complex, and direction of the resulting bias is not predictable .An additional limitation in exposure ascertainment derives from the territorial size and the population dimension of the areas at study for which vital statistics are available. Whatever the administrative boundaries are, they hardly correspond to the distribution of environmental pollutants, so that the misclassification of exposure  is common.ad hoc registry data of specific pathologies  can give a better picture of the health profile of residents in NPCSs. As far as outcome measures are concerned, many studies in polluted areas consider mortality, based on death records. However, the analysis of hospital discharge records, Each vital statistics is able to provide information only about the events that is designed to record, and databases need to be validated for use in epidemiological studies.In the majority of countries death rates from all causes are unlikely to be biased because reporting the event of death is exhaustive. Therefore the overall mortality, which is an important indicator of conditions of life, can be analyzed with confidence . In ItalIn most European countries Hospital Discharge Records (HDRs) are indicators of hospital activity, and their main use is for administrative purposes : validitThe analysis of cancer incidence and congenital malformations data in environmental epidemiology investigations can be considered, subject to validity evaluation. In Italy in the context of contaminated sites congenital anomalies have been used in a descriptive study  and the Mortality statistics and hospital discharge statistics have been using the succeeding versions of the International Classification of Diseases (ICD) that guarantees homogeneity and comparability of results obtained in different places. However, particularly for cancer, the resolution power of the ICD is far lower than that of classifications based on pathological diagnosis such as the succeeding versions of the International Classification of Diseases for Oncology (ICD–O). Some associations between environmental agents and cancer are limited to specific pathological variants of the disease ; for populations served by cancer registries where the histological type of cancer is systematically recorded this problem is solved.ad hoc deprivation index (SENTIERI DI). In environmental health studies factors as socioeconomic status, occupational exposures, and individual lifestyles can have an etiologic role on the health effects under study thus possibly confounding the exposure-disease relationships. Socioeconomic status is a determinant of health and disease. Since the mid-1990s ecologic studies of environment and health in UK adjusted for deprivation using Census data; for a review refer to Pasetto 2010 . To accoOccupational exposures are potential confounders in ecological studies of environment and health; individual based studies may be needed to disentangle environmental and occupational risk. a priori evaluation of the epidemiological evidence. The main limitations of the overall approach have been listed. Its major strengths are the standardization of the mortality analysis and NPCSs classification in terms of environmental exposure which allow the study of all NPCSs in one country; the a priori evidence evaluation to comment and interpret study results is a key characterizing element of the project. Additional assets are that the mortality analysis can be updated and other vital statistics data can be analysed; also the a priori evidence evaluation can be brought up to date following the established criteria and procedures. The present paper referred as a common thread to SENTIERI project, in its main components of mortality study and The SENTIERI approach allows the description of the health status of populations living in the Italian NPCSs. Furthermore, it is suitable for an overall analysis of data from different NPCSs and comparative analysis of data from NPCSs with the same contamination sources.ad hoc data collection [The SENTIERI approach is, in its essence, a tool to describe the health profile of residents in NPCSs to document ascertained or suspected associations with local environmental risks; it does not require an llection . The appThe links between environmental exposures and health effects depend on the environmental pollutants and diseases being considered but are also influenced by factors such as genetic constitution, age, nutrition and lifestyles, occupation, and socioeconomic factors such as poverty and level of education. Identifying these relationships is therefore challenging; however, the effort is often worthwhile as it may help to redefine priorities and unlock resources .a priori evidence evaluation and mortality analysis can be updated [a priori evaluation can be carried out for environmental exposures different from the ones in SENTIERI project.Other strengths of the SENTIERI approach are that the  updated ; other h updated , morbidiNotwithstanding the remarkably laborious activities required to set up a national project such as SENTIERI, major benefits in terms of quality and quantity of findings, and a favourable cost/gain balance can be expected inasmuch as this becomes a permanent system of epidemiological observation on health of residents in NPCSs.


Heart Rhythm, the Registry investigators published the first large, multicentre series of patients with ARVC in South Africa.The Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) Registry of South Africa was established in 2004, under the auspices of the Cardiac Arrhythmia Society of Southern Africa (CASSA).What is the profile of the patient with ARVC in South Africa? The disease occurs in all racial and ethnic groups. It usually starts causing symptoms by the third decade of life. Males manifest with symptoms of the disease more often than females, with a 2:1 ratio. Most frequently, patients come to their physician complaining of palpitations, dizziness and syncope. About a third of South African patients also notice chest pain, which makes ARVC an important consideration for clinicians evaluating young people with chest pain.These young people with ARVC are regularly involved in sport, and in fact, 28% of patients in the South African cohort were professional endurance athletes at some point in their lives. Previous human and animal studies have demonstrated that, if an individual is genetically prone to ARVC, endurance exercise is an important environmental factor in determining how quickly the condition develops.Diagnosing ARVC can be challenging, though. Standard cardiology tests can be unremarkable for years during the earlier phases of ARVC, which means that a high index of suspicion and repeat evaluations, with close follow up, are needed. Even in the South African cohort, which typically represented advanced disease, 6% of subjects had a ‘normal’ resting ECG at their last follow-up visit. Some 12% of symptomatic patients had no abnormalities at all on cardiac imaging and were diagnosed based on family history, electrocardiographic abnormalities and molecular genetic testing.Make no mistake, however, this is not a benign cardiomyopathy. Several Registry participants had died by the end of the follow-up period (a median of around eight years). The annual mortality in this study was 2.8%, and the five-year cumulative mortality was 10%. Outcomes were worse than in other parts of the world; on average, patients died two decades earlier than patients in France.As a striking demonstration of the severity of ARVC, outcomes were compared with control patients who represented the general South African population. The two groups had the same survival rates. Bear in mind that South Africa is in the midst of an unprecedented increase in mortality, due in large part to the colliding epidemics of HIV/AIDS and non-communicable diseases.Despite such poor outcomes, however, there is an important silver lining to this cloud. The survival study identified the patients who were at high risk of dying suddenly, including those with a history of syncope and sustained ventricular tachycardia. Arrhythmias were the cause of death in two out of every three patients who died, although fortunately, to date not a single Registry participant who has received an implantable cardioverter defibrillator has died. From a practical standpoint, these data suggest that the early use of ICDs in patients with syncope and sustained ventricular tachycardia may prevent early mortality. Any patients with these symptoms and a diagnosis of ARVC should have top priority to be evaluated by a cardiologist.Heart Rhythm report, genetic analysis was focused on the most common culprit gene, known as plakophilin-2 (PKP2). Of the blood samples analysed, 25% had a PKP2 gene defect that caused disease. While this detection rate is satisfactory in itself, the yield of genetic testing is likely to be even higher in the future; the laboratory team is currently incorporating other ARVC-related genes into the screening technique. All physicians who care for patients with ARVC are encouraged to send blood samples to the Cardiovascular Genetics Laboratory in the Hatter Institute for Cardiovascular Research at the University of Cape Town for genetic screening.It has been known for years that ARVC is an inherited condition in a significant proportion of cases. The Registry report has made several key observations about the genetic causes of ARVC. First of all, 30% of participants in the study had a family member who was also affected. For the purposes of the PKP2 gene, Registry investigators made another observation. One of the study subjects actually had two separate defects in the PKP2 gene, and when his sister was screened, she was found to harbour the same two defects. The other family members had either one or the other defect – and in none of them was the disease particularly severe. The two siblings with multiple defects, however, had disease onset in early childhood, and its course was so severe that both siblings needed heart transplants by the time they were teenagers. Geneticists refer to this type of phenomenon as an ‘allele dose effect’, and to date, this is only the second time that such an effect has been reported in the ARVC research literature.In the process of screening the PKP2 gene. Haplotype analysis revealed that, in all likelihood, these individuals received their defective gene from a common ancestor (founder effect). The founder effect, as is the case with the allele dose effect, represents only the second time that such an effect has been reported in the ARVC literature. What is more promising, however, is the potential for better understanding how this specific gene abnormality can cause a clinically distinct form of ARVC. Since investigators have identified identical defects in several individuals, they will be able to study the effects of this particular defect on a large scale.Perhaps the most important genetic discovery, however, was that several unrelated study participants actually had the exact same defect in their To conclude, the CASSA-sponsored Registry has made important contributions to our understanding of ARVC in the South African context. It shows that ARVC has a high mortality and affects individuals in the prime of their life. Death is potentially preventable though, if the condition can be diagnosed early and high-risk individuals are promptly referred for consideration for ICD implantation. Because ARVC runs in families, it is mandatory to screen the first-degree relatives of affected individuals. Genetic testing yields an answer in one out of four cases and is available through the ARVC Registry at the University of Cape Town. Cardiologists and general physicians alike now have the chance to work together to improve the diagnosis and management of patients with ARVC, to reduce the high mortality rate associated with this condition. The ARVC Registry of South Africa is in a unique position to facilitate such advances in patient care, and doctors are encouraged to refer all suspected or confirmed cases of ARVC to the Registry coordinating centre for enrollment and evaluation.


FDG-PET relies on higher glycolytic activity in tumors compared to normal structures as the basis of image contrast. As a glucose analog, FDG is transported into malignant cells which typically exhibit an increased radioactivity. However, different from glucose, FDG is not reabsorbed by the renal system and is excreted to thebladder. The present paper describes a novel computational methodfor the quantitative assessment of this excretion process. The method is based on a compartmental analysis of FDG-PET data in which theexcretion process is explicitly accounted for by the bladder compartment and on the application of an ant colony optimization (ACO)algorithm for the determination of the tracer coefficients describingthe FDG transport effectiveness. The validation of this approach isperformed by means of both synthetic data and real measurementsacquired by a PET device for small animals (micro-PET). Possibleoncological applications of the results are discussed in the final section.[ Although FDG is a glucose analog, there are several differences between the uptake and metabolism of FDG compared with normal glucose. Both molecules, for example, are transported into cells by the same proteins, and both are phosphorylated by hexokinase. However, FDG is trapped within the cell as a consequence of phosphorylation, and therefore it cannot be further metabolized; unlabeled glucose, on the contrary, is either stored as glycogen or rapidly metabolized. Further, at a renal level, unlike glucose, FDG is not reabsorbed by the renal tubule, and then it is excreted, which implies that there is radioactivity in the bladder. We point out that this last issue has a significant consequence as far as the effectiveness of the imaging procedure is concerned; in fact, the more radioactivity is in the bladder, the less amount of tracer is available for tumor identification.Positron emission tomography (PET)  is an imA typical way to assess the FDG excretion in the urine is to compute the average clearance defined as the ratio between the (asymptotic) activity in the bladder and the time integral of the tracer concentration in blood . In nuclAs in , 7, kidnA third compartment, the urine, is localized in the bladder and is characterized by one single input and no corresponding output. The time activity curve (TAC) describes the input of tracer in the system and is determined from regions of interest (ROIs) of the left ventricle drawn on FDG-PET maps at different time steps. Estimates of the tracer concentration for the bladder and for the two-compartment system made of parenchyma and preurine are obtained by means of ROIs including bladder and kidneys, respectively. Six exchange coefficients describe the efficiency of tracer transmission between the different compartments . The first novelty of our approach is in the kind of compartmental model adopted. Unlike the typical schemes for the study of renal physiology , 7, whicexchange coefficients or rate constants or microparameters -FDG, injected into a mouse. The time evolution of tracer concentrations inside kidneys and from kidneys to bladder has been modeled by a linear system of ordinary differential equations with constant coefficients. The time variation of the total concentration of activity inside kidneys and bladder  has been estimated through an analysis of micro-PET data. The six constant exchange coefficients, which provide information on FDG metabolism, have been regarded as unknowns. The related inverse problem has been solved by applying an algorithm based on ACO. Resulting applications to real and synthetic data have been shown and discussed also in comparison with the results provided by a Levenberg-Marquardt algorithm.This paper deals with the renal flow of a radioactive tracer, [ktp = 0. This shows that the ACO approach is also capable of recovering vanishing rate constants. More generally, our computational approach to micro-PET data analysis shows that (1) the tracer coefficients of the compartmental system quantitatively measure the effectiveness of the excretion process; (2) these parameters offer a reliable and more local alternative to clearance, providing quantitative details to a process that clearance is able to describe just in a global way; and, specifically, (3) the average clearance and the rate coefficient from blood to preurine are correlated with a significantly high correlation coefficient.The mathematical approach described in this paper provides estimates of the six unknown coefficients. Unlike techniques based on graphical analysis, it does not require any distinction between irreversible or reversible uptake of tracer nor identification of a time value after which suitable expressions evaluated from the data become linear in time . MoreoveThe physiological basis for this study relies on the broad utilization of FDG in the diagnosing and staging of cancer. In fasting patients, this tracer accurately maps the insulin independent glucose metabolism as an index of aggressiveness and growth rate of neoplastic lesions. We agree that MRglc determined by means of, for example, Patlak analysis would provide a reliable quantitative index of glucose consumption. However, these measurements imply the use of dynamic imaging whose long acquisition time (50–60 minutes) would hardly fit with the operational procedures of a PET lab. Accordingly, clinical PET imaging almost always implies the acquisition of only one image at the late (equilibrium) time. Under this condition, only tracer uptake can be measured. SUV is largely used to define cancer glucose consumption  but obvi


Energy is a major challenge for the future with important consequences on the economic and political stability, food security, water supply, energy independence, pollution, and global ecosystem. Owing to increased industrial activities and growing population, the reserve of oil and other fossil resources will become, at best, rare, and costly for extraction and commercialization.2) on the biosphere. Toward this objective, different approaches are currently under investigation based on various platforms such as water, microorganisms, plants and photovoltaic devices. Splitting of water, for example, is used to generate gaseous hydrogen using molecular catalysts such as molybdenum-oxo complex , in the same way that plants do for their own natural photosynthesis, would be an ultimate, or at least a complementary solution to other potential bioenergy alternatives, for both the production of biofuels and the reduction of CO2 levels. Figure 2 and ending by the synthesis of sugars. The synthetized sugar can then be conducted to a chamber  where it could be converted to bioethanol by fermentation. Once realized, such an approach would not only offer the advantage to save valuable lands, freshwater and crops, but also to reduce CO2 levels and make industrial activities as desirable activities rather than culprit operations, because the CO2 emitted will be recycled permanently to feed the artificial system and produce bioethanol. In other term, the more CO2 emitted by industrial activities, the more sugar synthesized, and the more bioethanol produced. To enable maximum fixation of CO2, such a system is expected to be implemented near industrial factories that emit CO2 intensively.Other alternative energy resources include nuclear and solar-based platforms. Nuclear is a highly risk adventure at local and global level, especially under unpreventable environmental disasters and uncontrollable climate change. The other safer approach is sunlight and its applications with photovoltaic devices. An ideal energy system, however, should offer the possibility to produce sustainable power while reducing COThe composition, size, chemical, and physical properties of appropriate devices and materials intended for such a technology need to be scrutinized and custom-made for the specific projected task. This will entail efforts at the interface of multidisciplinary fields including biotechnology, chemistry, physics, engineering and plant biology. Moreover, in an ideal conception, a good sustainable energy platform should combine artificial photosynthesis with photovoltaic devices to take advantages from both settings in all circumstances.2→sugar→bioethanol may result in loss of some energy efficiency. To avoid such potential losses and take advantage of a shorter way to convert CO2 to fuel, another option would be the conversion of CO2 directly to ethanol .Unlike the natural photosynthesis, whose rate is relatively low and depends on plant species and ambient conditions, the artificial system should enable better control and management of the bioenergy yield. In fact, natural photosynthesis yield is not necessarily low, but just adapted to the needs of photosynthetic organisms. Artificial photosynthesis, on the other hand, is needed to offer more flexibility on the control of the production yield and to satisfy great energy demands. Yet, one of the foremost challenges of sunlight-based technology is what to do when there is little or no sun? To address this intermittent nature of sunlight, an efficient photosynthesis system should mimic plants in their perfect absorption and tackling the light spectrum for their own photosynthesis. From hot and wet to cold and rainy environments, plants capture light efficiently and develop intense vegetation with important organic matter produced . Similarly, an artificial photosynthesis should be optimized to operate in all circumstances of light shifts and intensity. To achieve such an objective, future multidisciplinary advancements and doubled efforts will be necessary to build an effective artificial photosynthesis that could be scalable for industrial production of bioenergy. The conversion of CO2 to C6 sugars. As for any new or unexplored research areas, a substantial investment also will be needed, at least at the first stages before an optimization and automation reduces the cost and augments the sensitivity of the system. The approach will demand great versatilities and sophisticated setting with several phases. For example, to circumvent the issue of CO2 dilution in the atmosphere, CO2 can be injected into the system after either chemical or, preferably, biological production of CO2 by the system itself   Figure . If the 2 levels and to provide renewable clean bioenergy. As supplementary advantages, it is not necessary to use freshwater water nor arable lands, since artificial photosystem could be implemented anywhere. Rain water could also be collected and stored in the same setting to answer the needs of water required for the production of sugars, so an important burden on freshwater can be avoided.There is no doubt that earth's climate will change inevitably over the next decades due to intense anthropogenic activities. The negative effects of fossil energy combined to unsustainable practices in agricultural and industrial activities will continue to cause damages. To avoid such damages, it is urgent to reduce the emission of greenhouse gases at local and global levels. In the light of the depletion of fossil fuels, considerable investment is mandatory to develop safer and sustainable energy source to avert worst-case scenario. The establishment of new sustainable energies will require biologists, chemist and physicists to narrowly collaborate and examine a wide range of approaches. Artificial photosynthesis to produce synthetic sugar for fermentation and bioethanol production would be a worthy option to focus on. The apparent benefit of such an approach is to reduce COSuch an approach holds great potential to be used at least as a complementary approach to the other investigated methods. Further advantages include energy independence and new jobs created as a result of an implementation of new industry and researches for continual optimization and improvement at both basic and applied levels.