The international community and governmental organizations are actively calling for the implementation of One Health (OH) surveillance systems to target health hazards that involve humans, animals, and their environment. In our view, the main characteristic of a OH surveillance system is the collaboration across institutions and disciplines operating within the different sectors to plan, coordinate, and implement the surveillance process. However, the multisectoral organizational models and possible collaborative modalities implemented throughout the surveillance process are multi-fold and depend on the objective and context of the surveillance. The purpose of this study is to define a matrix to evaluate the quality and appropriateness of multisectoral collaboration through an in-depth analysis of its organization, implementation, and functions. We developed a first list of evaluation attributes based on (i) the characteristics of the organization, implementation, and functionality of multisectoral surveillance systems; and (ii) the existing attributes for the evaluation of health surveillance systems and OH initiatives. These attributes were submitted to two rounds of expert-opinion elicitation for review and validation. The final list of attributes consisted of 23 organizational attributes and 9 functional attributes, to which 3 organizational indexes were added measuring the overall organization of collaboration. We then defined 75 criteria to evaluate the level of satisfaction for the attributes and indexes. The criteria were scored following a four-tiered scoring grid. Graphical representations allowed for an easy overview of the evaluation results for both attributes and indexes. This evaluation matrix is the first to allow an in-depth analysis of collaboration in a multisectoral surveillance system and is the preliminary step toward the creation of a fully standalone tool for the evaluation of collaboration. After its practical application and adaptability to different contexts are field-tested, this tool could be very useful in identifying the strengths and weaknesses of collaboration occurring in a multisectoral surveillance system. After dividing and categorizing knowledge into disciplines for years, the growing concern around complex health hazards urges us to reconsider the need for systemic and holistic approaches to better face these new challenges . This isAlthough there is currently no consensual definition of OH surveillance, collaborative efforts across sectors and disciplines are at the heart of definitions found in the literature –8. HowevDespite the fact that collaboration is a key factor in the implementation of OH surveillance, no evaluation method currently focuses on (i) the quality of multisectoral and interdisciplinary collaboration, or (ii) the measurement of impacts and benefits resulting from collaborative surveillance as compared to a juxtaposition of isolated sectoral surveillance components. The current evaluation tools for surveillance systems do not consider collaboration in depth . FurtherThe quality of the information produced by a surveillance system depends on the quality of its organization . Hence, The aim of this study is to develop a matrix with which to evaluate collaboration in multisectoral surveillance systems, where collaborative efforts are deployed across institutions operating in several sectors, but equally across diverse disciplines, decision-making scales, and professions, to address complex health hazards. Based on a literature review and expert-opinion elicitation, we first identified a list of attributes and indexes that characterize the organization, implementation, and functionality of collaboration taking place in any multisectoral surveillance system. Then, we developed a scoring grid to obtain evaluation results for these attributes and indexes.The evaluation matrix for collaboration taking place in a multisectoral surveillance system was developed in two main phases: the identification of evaluation attributes and indexes, followed by the development of the scoring method to obtain semiquantitative evaluation results.The identification of evaluation attributes for collaboration taking place in a multisectoral surveillance system was based on three sources of information: (i) a conceptual framework to characterize the organization and implementation of OH surveillance systems, (ii) existing OH evaluation frameworks, and (iii) existing surveillance system evaluation tools.Our starting point was the conceptual framework for the characterization of collaboration in a OH surveillance system, proposed by Bordier et al. . Figure This framework sets down the core characteristics for the organization and implementation of collaboration at governance and implementation levels, as well as the contextual factors that influence them, and identifies core functions for a successful multisectoral surveillance system.Information provided within this framework was then compared with evaluation attributes for surveillance systems used in EvaTool  and OasiA back-and-forth process between the different information sources was carried out to identify specific attributes that must be considered in order to accurately evaluate collaboration taking place within a multisectoral surveillance system.The list of attributes for the evaluation of collaboration within a multisectoral surveillance system was validated by a panel of international experts in a two-round process.For the first round, expert opinions were elicited using an electronic questionnaire developed with the Surveymonkey™ tool. Selected experts were the authors of articles related to OH surveillance or had been involved in research consortiums working either on integrated surveillance evaluation (Risksur project) or on OH evaluation (NEOH). A total of 256 experts were contacted by email to take part in the study by answering the online questionnaire. Primary recipients were asked to freely forward the questionnaire to anyone in their network with an interest in OH surveillance. The questionnaire was also advertised on LinkedIn. The questionnaire included three main sections: (i) personal information, (ii) characterization of OH surveillance, and (iii) evaluation of collaboration. Only the first and third sections of the questionnaire were considered for this study. In the first section, participants were asked to provide information on their working institution, academic background, and expertise and experience in OH surveillance. In the third section, they were asked if they considered all proposed evaluation attributes for collaboration to be relevant and if they could identify any missing attributes. Participants had to answer yes/no questions and justify their choice in an open box. The questionnaire was tested through two pilot interviews to assess the questions' clarity and was freely accessible online from March 9 to 30th, 2018. Experts' answers were then uploaded into an Excel spreadsheet, in which each row corresponded to a participant identified by his/her name and IP address, and each column to their answer for each question. A descriptive study was conducted on experts' backgrounds and opinions on the list of attributes (relevant or missing). Open comments and justifications regarding attributes were analyzed and categorized.Based on experts' answers and comments, the initial list of evaluation attributes was refined. A second round of expert-opinion elicitation was then organized with a restricted number of experts who had expressed detailed comments during the first elicitation round. The objective was to discuss, through a video conference, certain specific points that were highly commented during the first round and for which we wanted feedback on the way we proposed to address them, namely: (i) information sharing and system knowledge, (ii) leadership, and (iii) functional attributes for collaboration. The meeting took around 90 min. The discussion was recorded for further analysis and the resulting conclusions were used to validate or refine the list of attributes and their definitions.Along with the identification of evaluation attributes, we developed indexes that provide an overview of the general organization of collaboration. In contrast to attributes, which relate to a specific organizational characteristic of collaboration, indexes aim at reflecting the collaboration's organization at a macro level.Our reasoning was based on the process approach to quality management in companies, including testing laboratories- The operation process, which represents activities that generate the product or the service;- The support process, which represents activities that ensure the smooth operation of the company, such as financial and human resources, training, communication, etc.;- The management process, which represents activities implemented to ensure the company meets its goals.A surveillance system can be conceptualized following the same approach. It can be represented as an organization whose goal is to provide surveillance results in accordance with stakeholder demands and expectations, through the implementation of surveillance activities (operation process). The model can be restricted to collaboration taking place in a multisectoral surveillance system, where inputs are stakeholders' expectations regarding collaboration and outputs are the results obtained thanks to the collaborative effort.We created indexes to measure the level of satisfaction of all activities contributing to each process.The scoring methodology was largely inspired by that used in the Oasis tool, in which assessment criteria are scored to semiquantitatively measure evaluation attributes and critical control points .Once specific attributes and indexes for collaboration were defined, we singled out the necessary criteria to support their evaluation. To this end, we identified specific elements included in the definition of attributes and indexes and formulated them as criteria for the further evaluation of the latter. A semiquantitative four-tiered scoring scale was established to score each evaluation criterion depending on the level of fulfillment achieved by the collaborative situation under evaluation. Four grades were defined: grade 3 indicates that collaboration complies fully with the criterion, while grade 0 indicates a total absence of compliance; grades 2 and 1 are intermediate grades depending on the level of compliance. In some cases, the value “Non-relevant” can be used if the criterion is not relevant to the multisectoral surveillance system under evaluation. For each grade, a scoring guide was developed to describe the situation in which they should be awarded.Grades of attributes and indexes are obtained by combining grades awarded to the criteria supporting their definition. “Non-relevant” values, if there are any, do not impact the final grade.Based on the analysis of the three information sources, we first identified 38 attributes relevant to the evaluation of collaboration in a multisectoral surveillance system. These attributes were categorized into five groups: governance , operatiEach group of attributes focused on the evaluation of a different aspect of collaboration: governance and operation attributes on its organization; effectiveness attributes on its impact on surveillance performance in each sector covered by the multisectoral surveillance system; functional attributes on the qualities of core collaboration functions required for an effective multisectoral surveillance system; and value attributes on its impacts, benefits, and cost.The initial list was submitted to expert-opinion elicitation. In total, 84 experts accessed the questionnaire. Only the 39 respondents who fully completed the questionnaire and filled in the section related to evaluation attributes were considered for the study. Most of them were epidemiologists (74%) and/or veterinarians (72%), working mainly in research institutes, universities, or expertise agencies (54%), intergovernmental agencies (21%), or national authorities (18%). Remaining respondents worked in the private sector (13%) or in non-governmental organizations (1%). Respondents' main fields of expertise included epidemiology (95%), veterinary public health (77%), public health (67%), and food safety (61%). Most participants had substantial experience in health surveillance (56%) and in the OH concept (66%). Most of them (85%) demonstrated at least 1 year of experience in OH surveillance. All proposed attributes were considered relevant by 67% of the respondents, and 43% of them answered that no attributes were missing. We did not receive comments on the proposed list from 24% of the respondents. However, we received 61 comments from experts that were related to missing attributes (49% of comments), the need to prioritize attributes (16%), the need to clarify certain attributes (13%), non-relevant attributes (13%), and the need to distinguish attributes related to collaboration from those related to surveillance (8%).Among the 19 experts contacted to take part in the second round of opinion elicitation, 9 were able to participate in a video conference. Participants were mostly epidemiologists (89%) and veterinarians (89%), mainly working in research institutes, universities or expertise agencies (67%), national authorities (22%), or intergovernmental agencies (22%). One participant worked in the private sector. They mainly had more than 1 year of experience in surveillance (89%), and all had at least 1 year of experience in the field of OH. Globally, 89% of the respondents have at least 1 year of experience in surveillance and OH.Based on expert inputs, we made major amendments to the initial list of evaluation attributes, of which the main ones are described below.Regarding organizational attributes at the governance level, “Information” was renamed “Information and communication” to address how the information concerning and produced by the multisectoral surveillance system is stored and communicated to surveillance actors and end-users. Additionally, we split the “Mechanisms” attribute into three attributes to distinguish the different governance mechanisms, namely, steering, coordination, and technical and scientific support. At the operational level, where attributes were defined to evaluate the operationalization of collaborative modalities, the attribute related to data exchange was split into two attributes to distinguish the sharing of raw data from the sharing of surveillance results. Indeed, these two modalities are possible and independent from each other, and must therefore be distinguished in the evaluation process.Deep changes were also brought to the functional attributes to avoid any ambiguity regarding the fact that they were specific to collaboration only and to focus on core characteristics of functional collaboration. Four attributes were discarded, namely, “Simplicity,” “Portability,” “Interoperability,” and “Data completeness and correctness,” as they were not considered to be core collaborative features. Conversely, six attributes were added to the list, to address key functions of collaboration: “Relevance,” “Operationality,” “Resources,” “Inclusiveness,” “Shared leadership,” and “System knowledge.” Finally, three attributes were renamed and their definition slightly refined: “Sustainability” was replaced by “Stability,” “Acceptability and engagement” by “Acceptability,” and “Adaptability and flexibility” by “Adaptability.” These attributes are highly interdependent and contribute to the effectiveness of the multisectoral surveillance system.Finally, attributes related to effectiveness were not retained as they did not specifically evaluate collaboration but rather the entire surveillance system, including sectoral surveillance. Additionally, value attributes were discarded from the study as their evaluation required additional data and information, which were not available at this stage of the evaluation matrix's development.The final list of attributes, including 23 organizational attributes (13 for governance and 10 for operation) and 9 functional attributes, is presented in Along with the development of collaboration attributes and based on the process approach for quality management, we defined three indexes that support the macro-evaluation of the organization of collaboration.- The operation index, which refers to collaborative activities throughout the surveillance process (from surveillance planning to results dissemination) that generate the relevant collaborative outputs to meet the collaborative objective.- The support index, which refers to elements intended to ensure the smooth operation of collaboration: resources allocation, training, information and communication, technical, and scientific support.- The management index, which refers to elements that contribute to the management of collaboration: existence and formalization of a collaborative strategy; governance mechanisms for steering and coordination; and performance monitoring and evaluation.Based on the identification of elements required to characterize the 32 attributes and the 3 indexes, we developed 75 criteria to evaluate them. The same criterion can be used to evaluate several functional attributes. On the contrary, each organizational attribute and index is evaluated with a set of specific criteria without any overlap. These criteria were refined following changes in attributes brought by the expert-opinion elicitation and to capture certain experts' comments.Certain notions were particularly underlined during the expert-opinion elicitation and we paid specific attention to their evaluation.First, we introduced the notion of “feedback loop” for which we developed a specific criterion. This notion refers to the fact that the outputs of the surveillance system and lessons learnt  are routed back to the governance mechanisms where they are used as inputs to inform decisions and to adapt to changes. Criteria related to the existence of a functional feedback loop firstly assess how governance mechanisms evolve and make decisions based on collaborative outputs or contextual changes. Secondly, the criteria assess the capacity of the surveillance system to feed information on the operationalization and impacts of the surveillance back to its leaders and thus the capacity of the latter to adapt.Second, we worked in depth on evaluation criteria related to information sharing and communication. We introduced the notion of institutional memory, which refers to all information concerning and produced by the multisectoral surveillance system, and we created a criterion to assess its accessibility to surveillance actors and end-users. Evaluation criteria were also added to evaluate the relevance of the information produced by the collaborative surveillance system regarding the collaborative objective(s), as well as the appropriateness of its communication (both in terms of content and means).Finally, we introduced criteria to address the required sharing of collaboration leadership among stakeholders in a multisectoral surveillance system. We assumed that leadership is evaluated through the existence and operationality of governance mechanisms for the steering, coordination, and technical and scientific support of collaboration. To evaluate if leadership is appropriately distributed across stakeholders, we introduced specific criteria focusing on the representativeness of stakeholders taking part in the governance mechanisms and whether they have an “appropriate voice.” This last term is used to define the active participation of stakeholders in these mechanisms and the fact that there is a simultaneous empowerment of each participant whose respective power is recognized by all . There sThe evaluation matrix is a spreadsheet composed of four sheets.The first sheet contains the scoring grid for the 75 evaluation criteria . For eacThe second sheet displays the numerical results of evaluation for each attribute and index. The same formula is used for all of them.xi: grade awarded to a criterion contributing to the definition of the attribute/index.n: the number of criteria contributing to the definition of the attribute/index and relevant to collaboration under evaluation.3: the highest score obtained by the criterion when the ideal situation is met.If some criteria are deemed non-relevant during the evaluation, then they are not included in the scoring of their corresponding attribute or index.Once the scoring is done, the spreadsheet automatically produces three graphical representations of the evaluation results in the third sheet. Different chart types help to differentiate easily the three levels of evaluation obtained: organization at a microlevel; organization at a macrolevel; and functions. The experience of the OASIS tool using the same principles shows, after more than 25 assessments of surveillance systems, that this option is practically efficient.The first display represents the evaluation results for the 23 organizational attributes . The result for each attribute can be visualized in a pie graph. This graphical format was considered the most appropriate graphical representation to display many individual results (up to 23) and to distinguish easily the attributes evaluated from the ones that were not. Each colored area within a pie chart represents the attribute's level of compliance regarding an “ideal” situation where all evaluation criteria are fully completed. This display provides a visual representation of the level of satisfaction for the organizational attributes, both at the governance and operational levels. It allows to identify easily the weak parts of the collaborative organization . The matThe last sheet contains all the formula to obtain the scoring of attributes and indexes, as well as the graphical representations of the evaluation results.The matrix is available in the The proposed matrix is a semiquantitative evaluation matrix developed for an in-depth analysis of the organization, implementation, and functionality of collaboration taking place in a multisectoral surveillance system.This is a first step in the creation of a fully standalone tool. To this end, guidance must be developed to help evaluators to collect the information needed for scoring criteria, and to guide them through the scoring process and the interpretation of the graphical outputs of evaluation results. Furthermore, the most relevant constitution of the evaluation team and the method used to score evaluation criteria must be determined. Indeed, some criteria might be scored very differently across stakeholders and end-users with various backgrounds, perceptions, and expectations. Nevertheless, the use of the scoring guide is limiting this risk of lack of standardization. The current matrix design is currently very close to that of the OASIS tool, and this proximity to a familiar tool could potentially make the matrix easier to use for evaluators, especially if deployed in synergy with the OASIS tool to globally evaluate the multisectoral surveillance system. To assess its practical application, the tool should be field-tested across different multisectoral surveillance systems targeting various hazards, in different epidemiological and socio-economical contexts, and under various governance and institutional organizations of collaboration.Although the matrix can be used independently if there is a need to focus on collaboration only, it can be combined with surveillance attributes within existing evaluation tools for an overall assessment of the multisectoral surveillance system.In its current form, the matrix has three main limitations. First, the evaluation is based on a semiquantitative method to score criteria; this is undoubtedly marked by subjectivity despite the development of the scoring guide. Second, the current matrix does not evaluate the effectiveness of collaboration, nor its impacts and cost, which are crucial parameters for decision-makers , 17, 18.In a multisectoral surveillance system, the collaborative process may occur in several cross-cutting dimensions , as described by Bordier et al. . All theThe central objective of the matrix is to evaluate collaboration; therefore, some attributes might not be specific to multisectoral surveillance systems, as collaboration can occur in other types of surveillance. For instance, governance attributes related to communication and information sharing are relevant to any surveillance system. However, they are of particular importance in a multisectoral surveillance system due to the multiplicity of stakeholders involved and thus the diversity of background, knowledge, and expectations. Furthermore, issues around the multiplicity of data sources and data ownership are more complicated , 20 and The evaluation matrix focuses on the quality of collaboration and does not evaluate the performance of the multisectoral surveillance system. However, the evaluation of collaboration cannot be completely disconnected from sectoral surveillance organization and performance, as certain collaborative characteristics are impacted by the settings and capacities in the different domains covered by the multisectoral surveillance system. Therefore, certain collaborative attributes support the evaluation of collaboration within its context. For instance, any evaluation of information generated by collaboration must equally consider the information produced by the sectoral components constituting the multisectoral surveillance system, as it may impact the quality and relevance of the information produced by collaboration regarding the collaborative objective. To evaluate the quality of collaborative activity outputs in terms of its capacity to reach the collaborative objective, the evaluation criteria must also focus on sectoral capacities. Indeed, collaborative activities might be hampered by poor sectoral capacities or by a sectoral organization that is not tailored to support collaborative modalities. For instance, in a multisectoral system where the agreed collaborative modality is that of joint data analysis, the collaborative output might not be achieved because of a lack of comparability across data sets, due to the poor quality of data produced by one sector, or as a result of the inappropriateness of surveillance design in one sectoral component.a priori consideration, to determine if the collaborative modalities are appropriate and well-operationalized enough to meet the pursued objective in a given context.The evaluation matrix does not aim to evaluate the degree of integration achieved in a given multisectoral surveillance system. The aim is to qualify the degree of integration that the multisectoral surveillance system seeks to achieve, to assess if this is coherent with the collaborative context, and whether the collaborative modalities and activities designed and implemented are appropriate to achieve it. For instance, in a multisectoral surveillance system, separate institutions may independently supervise surveillance components in their respective jurisdictions and may decide to restrict the collaborative effort to the sharing of information on surveillance results to keep each other updated. Although this modality can be considered as a low level of collaboration, it might be the most relevant to the expected collaborative objective and the epidemiological and socio-economic context. The evaluation matrix will help, without However, the aim of any collaborative surveillance system is to integrate different areas of knowledge, competencies, and type of expertise, to improve the effectiveness of the surveillance compared to the effectiveness of several surveillance components operating in silos. Consequently, the matrix enables the evaluation of this integration through the assessment of the existence and relevance of the information produced and of the way it is shared and communicated internally. Furthermore, if some collaborative modalities have been planned for the sharing of surveillance results or data, and/or for the integration of different surveillance data sources for joint analysis, then specific operational attributes can be used to evaluate whether this integration is relevant and appropriate for meeting the collaborative objective. All the criteria related to the quality and integration of information are used to evaluate the functional attribute “System knowledge.” However, at this stage, our evaluation matrix does not allow the evaluation of the impact of this information, as discussed previously.The expert-opinion elicitation allowed the revision and validation of attributes. The methodology was simple and based on an online questionnaire for the first round, followed by video conference with a selected panel of experts for the second round. Hence, it does not strictly follow established expert-opinion elicitation methodology, which pays specific attention to reducing the bias linked to experts, namely by validating the data they provide before its usage. However, in our study, we considered that the validity of information obtained from experts relied mainly on the diversity of relevant opinions retrieved, which depended on (i) the number of respondents; (ii) their expertise in OH surveillance; and (iii) their representativeness in terms of disciplines, professions, and working organizations. The response rate of the questionnaire was quite low: 39 people answered the questionnaire as compared with the 256 who were contacted in the first instance and asked to disseminate it through their network. This is partly compensated, however, by the fact that 85% of these respondents declared they had strong expertise in the field of OH and surveillance. The major concern is the bias of the study toward respondents' backgrounds and disciplines, as most of them declared they were veterinarians and epidemiologists. The original selection process was supposed to limit this bias by selecting the experts through the articles identified by the systematic literature review  the collaboration's organization at a microlevel with regards to attributes relating to specific collaborative characteristics; (ii) the collaboration's organization at a macrolevel with regards to indexes encompassing a wide range of elements contributing to the same process; and (iii) the collaboration's functions with regards to attributes reflecting core collaborative functionalities. The evaluation attributes have been validated by a group of experts in the field of OH surveillance, and converge with those defined as characterizing collaboration in other activity fields, such as inter-professional collaboration in health care facilities. Indeed, collaboration is not specific to multisectoral surveillance systems, and the attributes developed for the purpose of this matrix could be efficiently used to assess collaboration in other surveillance settings and, after adaptation, even in other multistakeholder systems.The tool still needs to be finalized through field-testing and the development of a detailed framework to standardize its application. Once these steps are completed, the tool will enable the evaluation of a collaboration's capacity to achieve its goal in a multisectoral setting, as well as its strengths and weaknesses in terms of organization, implementation, and functionality. Evaluation results could then be used to support the development of recommendations to improve the quality and appropriateness of collaboration.MB and CD designed and coordinated the study, analyzed the results, and drafted the manuscript. DN participated in the collection and analysis of data. FG and PH initiated the study, participated in its design and coordination, and contributed to the analysis and interpretation of results, and have equally contributed to the drafting of the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In 2003, the United States (US) Institute of Medicine of the National Academies recommended that all undergraduate students have access to an education in public health to assist with diversifying the public health workforce and ensuring an educated citizenry on public health issues. In line with this recommendation, and that of the Consensus Conference on Undergraduate Public Health Education, Georgia State University established a Bachelor of Science in Public Health (BSPH) program in 2016, with the mission of advancing health through leadership, scholarship, research, and service, to better the human condition and to promote the common good, especially for urban communities in the US and for global populations. Using integrative approaches that encourage student empowerment, self-development, integrative thinking, and reflective learning, the Georgia State University BSPH program currently offers a range of generalist introductory public health courses to over 400 students. This review seeks to examine student perceptions of integrative practices utilized by Georgia State University faculty in the BSPH program and to investigate the extent to which student perceive these integrative educational practices as preparing them to use insights gained in the classroom and from the field, to question, modify, connect, and integrate material learned in the academic setting, to real-life public health challenges. It also seeks to identify which of the integrative educational practices have the highest impact of helping students integrate the knowledge and skills gained to public health issues. Georgia State University is an urban public research institution located in Atlanta, Georgia. Established in 1913, the university has seven campuses throughout metro Atlanta with over 51,000 students of diverse backgrounds, enrolled in over 250 degree programs in 100 fields of study, including public health  utilized by Georgia State University faculty in the BSPH program, and the extent to which students see these HIPs as preparing them to use insights gained in the classroom and from the field, to question, modify, connect, and integrate academic material to real-life public health challenges. It also seeks to examine HIPs that have the greatest impact.Students pursue a college education for several reasons, prime among them being the need for financial well-being and the ability to engage in leisure activities . As collSeveral studies have established a significant association between good educational practices and student college outcomes. Chickering and Gamsons assert that contact between students and faculty, reciprocity and cooperation among students, active learning, and prompt feedback are practices that can aid this process . These pHIPs have been found to contribute to student increased academic engagement, knowledge, resolve, and general academic success . These eThe BSPH program has over 400 racially and economically diverse students enrolled in the public health major, and caters to both traditional and non-traditional students. The program is a 4-year degree that places special emphasis on urban and global health issues, and has a curriculum that focuses on elements of life and biological sciences, social sciences, and the humanities. The goal of the program is to provide students with an interdisciplinary understanding of public health, using a broad spectrum of approaches and course work. Students enrolled in the program acquire knowledge and skills needed for graduate school, and for careers in a wide range of public health and interdisciplinary professions.We used a cross-sectional convenience sample of current and graduated BSPH students to assess student perceptions of the extent to which six HIPs implemented by Georgia State University's BSPH program faculty, impact undergraduate student cumulative learning, academic success, and career outcomes. Undergraduate course work and assignments, service learning/community-based learning, collaborative projects, study abroad, undergraduate research, and signature experience were the HIPs examined.Students in the BSPH program were informed about the study and its purpose, through faculty announcements, emails, the BSPH general learning management system (iCollege), and were invited to take the survey. Completed survey questionnaires were collected on a daily basis using Qualtrics. All students associated with the program were given an equal opportunity to participate in the study.To assess the impact of BSPH HIPs, data was collected on the amount of time students purposely devoted to course work and assignments, the extent of student interaction with peers and faculty on course work, and student opportunities to receive guidance and on-going feedback from faculty on their course work and assignments. Data was also collected on student's confidence in their ability to apply public health knowledge situations both in and outside the classroom.The study was exempt from the Georgia State University IRB review process because, it was conducted in an established or commonly accepted educational setting that specifically involved normal educational practices that did not adversely affect students' opportunity to learn required educational content. The study was further exempt from IRB approval because it sought to research the effectiveness of or the comparison among instructional techniques, curricula, or classroom management methods.The HIPs survey comprised a 23-item questionnaire containing closed-ended questions on a six-point Likert scale ranging from “strongly disagree” to “strongly agree.” The questionnaire was pilot-tested with randomly selected BSPH students for accuracy and consistency of measures. The questions assessed HIPs on six domains; (1) undergraduate course work and assignments, (2) service learning/community-based learning, (3) collaborative projects, (4) study abroad, (5) undergraduate research, and (6) signature experience. The survey questionnaire also asked for demographic and academic information.The demographic and academic variables of the survey included academic status ranging from recent graduate to freshman, and the sex of students. The undergraduate course work and assignments variable focused on the amount of out of class time students devoted to course work and assignments, the availability of faculty to provide continuous feedback on course work and assignments, and student confidence in their ability to apply course material to real-life public health situations both in and outside the classroom. The service learning and community-based learning variable focused on career and occupational skills development, preparation for professional employment, and the application of classroom knowledge to service and community-based learning activities. The collaborative projects variable focused on working with peers, enhanced understanding of course material, and integrating and merging of knowledge from other courses with team members to produce a high quality academic product. The study abroad variable focused on decisions for postgraduate education and the acquisition of additional skills for a future career. The undergraduate research variable focused on student ability to research public health issues and their ability to present at conferences, and the final variable, signature experience, focused on the ability of students to create faculty reviewed academic products that were pertinent to their experience.The data collected in Qualtrics were cleaned and exported to SPSS for analysis. Univariate analysis was conducted to summarize and describe data. Missing data were excluded from calculations. Univariate, bivariate, and multivariate data analyses were conducted using SAS 9.4 and Stata 11. Univariate analysis was conducted to obtain descriptive statistics for the six HIPs domains, sex, and educational status. Bivariate data analysis was conducted to determine the relationship between academic status, sex, and the six domains. At the multivariate level, we conducted an ordinal logistic regression to determine whether there was a relationship between academic status and the six HIPs domains and adjusted for sex. The 95% confidence interval was used to provide an estimated range of values for each of the HIPs variables measured.All 436 students currently enrolled in the BSPH program and the 19 students who have graduated from the program were invited to participate in the survey. One hundred and five students currently enrolled in the program and nine students who have graduated from the program, completed the survey. The majority of students (93.8%) are still enrolled in the program, and 88% of the respondents self-identified as female. Regarding undergraduate course work and assignments, 58% of students said they devoted a minimum of 3 h per day to their course work and assignments, 52% said they met with BSPH faculty outside of class for guidance on course work and assignments, and 66% said that they received feedback from BSPH faculty on their course work and assignments. Over half of the students surveyed (58%) said that they were confident that they could apply material from various courses offered by the program to public health issues both in and outside the classroom. Undergraduate BSPH courses include Health Equity and Disparities and Introduction to Public Health.Forty-eight percentage of students in the BSPH program said service learning and community-based learning was an important part of their BSPH experience, and 49% said the experience helped them to develop career and occupational skills. Fifty-two percentage of students indicated that they were able to apply their classroom knowledge to the service and community-based activities they engaged in. Fifty-six and 54% of students, respectively, said that their participation in service and community-based activities gave them a sense of personal achievement and prepared them for professional employment opportunities. Forty-seven percentage of the students surveyed disclosed that they were able to integrate their classroom work into their service and community-based activities.On the issue of collaborative projects, 45% of students stated that working with peers was an important part of their BSPH experience, while 8% did not think so. Forty percentage of students stated that collaborative projects helped them to better understand course material. Less than half of the students surveyed (40%) said group projects inspired them to do their best on assignments, and 42% of students indicated that group projects allowed them to integrate the ideas and knowledge they acquired from various program courses, with that of their peers to create good academic products .A little more than a third (36%) of students reported that their study abroad experience motivated them to consider pursuing graduate studies, and allowed them to acquire additional skill sets for their future careers. Less than half (39%) of the students neither agreed nor disagreed that it influenced their decision to enter the public health workforce or pursue graduate education.Undergraduate research is one of the most requested opportunities from the student body. Forty-two percentage of the respondents took a course that required them to do some research. As a result, 43% of these students were able to use their research skills to develop oral and poster presentations delivered both on and off Georgia State University's campus.Given that the BSPH program is only in its third year of development, and the signature experience courses are taken when the predominance of the major coursework is completed, most of the respondents in the program have not taken the signature experience course yet. Of those who have, 42% stated that they were able to integrate and apply what they had learned in the classroom to their signature experience, and 42% said that enrolling in the course exposed them to experiences they would otherwise not have gained in the classroom. Forty-two percentage of students who took the signature experience course indicated that, with guidance from faculty members, they were able to produce good final academic products.p = 0.0357) and signature experience (p = 0.0085) with regards to the question, I am/was able to apply what I learned in the classroom to my signature experience. When it came to BSPH graduates and seniors, we also found statistically significant relationships for collaborative projects (p = 0.0456) regarding the question, Working on group projects collaboratively helps/helped me to integrate my ideas with those of others in the group to produce a good product; for study abroad (p = 0.0331) with regards to the question, Participating in the BSPH study abroad program allowed me to acquire additional skill sets for my future career and signature experience; and for signature experience (p = 0.0379) in relation to the question, I was able to apply my undergraduate research skills by presenting at a conference. Concerning seniors and juniors, we found statistically significant relationships for undergraduate course work and assignments (p = 0.0065) regarding the question, Faculty in the BSPH program provide/provided feedback on my coursework and assignments; for service learning/community-based learning (p = 0.0464) with respect to the questions The BSPH service-learning experience will help/helped with the development of career/occupational skills and I am/was able to apply classroom knowledge to my service learning activities; and for collaborative projects (p = 0.0324) concerning the questions, Collaborative group projects helps /have helped me to better understand course material and “Working collaboratively on group projects inspires /inspired me to do my best in an assignment., undergraduate research. Concerning seniors and juniors, we also found statistically significant relationships for undergraduate research (p = 0.0224) regarding the question, I participated/was able to participate in undergraduate research opportunities as a requirement of a class that I took in the BSPH program; and for signature experience (p = 0.0448) in relation to the question, The BSPH signature experience caused me to produce a final product that was evaluated by a faculty member.We conducted bivariate analysis for sex, academic status  by all the six HIPs domains. We found no statistically significant relationship between sex and the six HIPs domains, but we found statistically significant relationships between BSPH graduates and juniors for collaborative projects .Results from the study provide baseline data of the effectiveness of HIPs utilized by the BSPH faculty to educate and prepare students for real-life public health challenges. The results also indicate that students perceive the HIPs implemented in the program as effective in impacting their learning and preparing them for real-life public health challenges.Our study revealed that most students in the BSPH program (58%) devote more than 3 h per week per semester on undergraduate course work and assignments. This is consistent with the National Survey of Student Engagement's (NSSE) findings, that the average student spends about 17 h per week on course work including homework, reading, and assignments. For the majority of students responding to the survey, interaction with faculty outside classes provided additional guidance on how to do their coursework and assignments. Previous research indicates that student-faculty interactions can have several positive influences. Indeed, Pascarella and Terenzini found that student-faculty interaction generally have a positive influence on the cognitive growth and development of college students . They alService learning affords students the opportunity to apply knowledge gained in the classroom to practical community-based projects. It also allows students to make real-life connections between what they learn in the classroom and what actually happens in practice. Close to half (48%) of the students who responded to our survey found service learning/community-based learning to be beneficial. This statistic is modest and may be because of the infancy of the BSPH program and the fact that not many students are at a point where they can engage in the practice. We found that participating in service learning activities was a catalyst to student development of skills for future employment, increased personal insight, cognitive and social development, and created a sense of personal and academic achievement. This is consistent with earlier research findings by Austin et al. , Yoiro eThe goal of collaborative undergraduate projects is to help students learn to work and solve problems in the company of others, and to sharpen their understanding by listening seriously to the insights of others, especially those with different backgrounds and life experiences. Unfortunately, not as many BSPH students (40%) found this HIP to be helpful in increasing their understanding of course material. These results are consistent with the findings of a previous study conducted by Premo et al. which found that, collaborative projects by themselves are not enough to promote increased student achievement . Group pBrazil, The Dominican Republic, China, India, and Uganda are the five countries where students in the BSPH program have had the opportunity to visit and explore different cultures, worldviews, and life experiences. Led by full-time faculty from the SPH, as well as faculty from geosciences, criminal justice and communications, students who took the survey indicated that studying abroad enabled them to acquire additional skills sets such as critical thinking, problem solving, communication, leadership, professionalism, and intercultural fluency that they need for their future careers. These competencies are consistent with the National Association of College and Employers (NACE) key career competencies . All BSPEven though the number of students who indicated that they were able to participate in undergraduate research was <50% of those who responded, 43% reported that their understanding of how to conduct research, increased their ability to write papers and to present at conferences, both on and off campus. This is consistent with Lopatto's  findingsThere is no other extracurricular activity that undergraduate students at Georgia State University request more, than doing research with faculty. Students focused on continuing their education beyond the baccalaureate degree, know that learning how to conduct public health research with experienced faculty can enhance their graduate school applications considerably. Thus, in the 3 years that the BSPH program has been in operation, opportunities for students to participate in undergraduate research has continued to increase. In the spring of 2017, just one semester after the program was inaugurated, a faculty member agreed to work with two undergraduate students on a funded research project to examine the impact of mindfulness on tobacco cessation in low-income communities. Since that spring, in each semester, additional faculty have worked with more and more undergraduate students in the program. As of the fall 2018 semester, four faculty members are working with more than 10 students on research projects related to health policy, water quality, nano-particles, and health promotion and behavior. Additionally, the lead author of this paper has started a research club to work with students to develop manuscripts based on primary and secondary data analysis and the systematic reviews of the literature. Within a week of the faculty member announcing the launching of the club, over 20 students had signed up.All students at Georgia State University are encouraged to complete at least one signature experience. Utilizing experiential strategies, signature experience courses give students the opportunity to apply course content to real-life situations. While signature experience courses are highly encouraged across the university, they are not a required course in any program of study except in the BSPH program. In this program, students entering their senior year of study register for PH 4991 (Signature Experience 1–Prospectus) and PH 4992 (Signature Experience–Capstone). Both courses are offered every semester in a 7-week mini-mester, so both courses can be taken in one semester. This increases the odds for students to progress to graduation in any given semester. The prospectus course (4991) is the first of a two-course sequence required to meet the area H requirements of the BSPH program of study. Students have the opportunity to integrate, synthesize and apply their public health knowledge through cumulative and experiential activities. In this course, students complete a variety of projects, and written assignments designed to assess student acquisition of the required public health competencies covered within the public health major. Mastery of these competencies is required to receive the BSPH degree.Forty-two percentage of students indicated that participation in the signature experience course exposed them to things that typically do not occur in a traditional classroom, and that they were able to integrate what they learned in the classroom into the course, and were able to produce quality, culminating artifacts that were evaluated by their faculty. This finding is consistent with that of Fitzpatrick et al.  who asseWhile the results from the assessment are promising, it would have been good to have more BSPH graduates complete the survey. To address this challenge, faculty will ensure to create awareness among BSPH students of the importance of participating in such surveys in the future.The study assessed six HIPs utilized by Georgia State University BSPH faculty and the extent to which integrative educational practices prepare students for the labor force and for further education. It also sought to identify integrative educational practices that have the highest impact of helping students integrate knowledge and skills gained in the classroom to public health issues. Results from the study provide invaluable baseline data for the assessment of future integrative educational HIPs utilized by Georgia State University faculty in the BSPH program.EAr-M and KR-W wrote the draft manuscript, finalized, and edited the final manuscript. EAl-M performed the statistical analysis. All authors reviewed and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Gingival recession refers to the exposure of the tooth's surface by an apical shift of the gingiva. The aim of this paper is to present a clinical case of an adult patient with a skeletal Class I and clinically deep gingival recession in the mandibular left central incisor. A preadjusted appliance with 0.022 in × 0.028 in slot was placed in both arches. Rectangular arches were used, with the addition of root lingual torque, specifically in the left lower central incisor. Class II and vertical intermaxillary elastics were used throughout the active treatment to obtain intercuspation of the posterior teeth. The orthodontic movement with the application of a localized biomechanics system of forces into the mandibular left central incisor delivered good dental and functional occlusion and, mainly, gingival and periodontal health. The follow-up showed stable results with the periodontium within normal limits and an improved occlusal interdigitation. Gingival recession refers to the exposure of the tooth's surface by an apical shift of the gingiva . NumerouAlthough there is controversy in the literature as to whether it is possible to have spontaneous improvement in gingival recession after orthodontic movement , recessiThe relationship between tooth movement by orthodontic treatment and the improvement of recession must be discussed because it has just been related in the literature to one of the multiple factors of recession etiology. Thus, the objective of this article is to present the clinical case of a patient who sought orthodontic treatment with the lower incisor showing localized and severe recession and a specific application of biomechanics with good results.A female patient at the age of 21 years and 6 months sought orthodontic retreatment by appointment with her dentist who was concerned with the gingival recession of the left lower central incisor and with the indication of a gingival graft.In the dental aspect, she presented Class II, division 1, left subdivision malocclusion, 2 mm of overjet and 30% of overbite, presence of all permanent teeth, except the 3rd molars, good profile, general resorption of alveolar bone ridges, discrete periapical bone thinning in the apex, and clinically deep gingival recession in the left lower central incisor. It was possible to note that this tooth was slightly more extruded than the other teeth, with interference of the lower lip frena in the most apical region of the gingival recession. The moderate curve of Spee and parabolic dental arch form. The maxillary midline deviation was 1 mm to the right .The tomography showed no facial cortical bone of the left mandibular central incisor in the apical thirds of the root, with a slight hypodensity in the apical region. Lingual, mesial, and distal cortical bone of the central incisor was maintained .The following objectives of the orthodontic treatment were established: (1) to move the root of the inferior central incisor left to lingual; (2) wait for physiological coverage of the vestibular root face of the same center; and (3) obtain Class I of canines and molars in the left hemiarch.Alternative 1: start with orthodontic treatment: aligning, leveling, lingual root torque in the left lower central incisor, and frenectomy. In the maxilla, to obtain intercuspation of the teeth of the left side moving all distally, TADs were used to optimize such movement. Gingival grafting was performed on the labial surface of the left lower central incisor after orthodontic completion.Alternative 2: the same biomechanical procedure for the movement of the left lower incisor, however, keeping the left teeth side as they are, in Class II molar relationship.Before the orthodontic treatment was started, the patient was referred to her general practitioner and the periodontist for routine clinical procedures. All treatment alternatives were explained to the patient, and alternative #1 was selected. It was explained, and she understood the little predictability in the reversal of gingival and periodontal health of the left lower incisor.Full fixed preadjusted appliances with 0.022 in × 0.028 in slots were placed in both arches . AlignmeThis was followed with coordinated maxillary and mandibular finishing arches, with the maintenance of root lingual torque in the left lower central incisor . Class IAfter 20 months, the fixed appliance was removed and the superior wraparound-type retention and a fixed canine-to-canine retention were bonded.Complementary examinations showed that the treatment goals were achieved, with maintenance of right molar and canine Class I and Class I relationship of molar and canine on the left side, as well as normal overjet and overbite . There wTomography revealed in the axial, sagittal, and coronal views a significant change in the facial apical third of the root of the left mandibular incisor with bone formation. There were no signs of root resorption or bone loss near the mandibular incisors . RetentiThe etiology of gingival recession is multifactorial. However, researchers have concluded that if orthodontic treatment is performed inaccurately, it can lead to gingival recession . The patThe radicular exposure resulting from the gingival recession, besides the esthetic impairment, poses multiple problems for the individual, such as the occurrence of radicular hypersensitivity, difficulty in brushing in the affected region with the ease of biofilm retention, and greater susceptibility to developing root caries .In the illustrated clinical case, a third-order bend inserted in a differentiated manner was used for the correction of sagittal positioning of a left lower central incisor recession.According to Sifakakis et al., unexpected movements of the mandibular incisors after treatment can have many causes. Some movements may be provoked either by an active component in the retainer caused by the clinician during construction or bonding or by the masticatory forces deforming the wire .Machado et al.  used a cIn the present case, the treatment of the recession was performed by doing individual torque of the recessive teeth, followed by frenectomy. After the orthodontic retreatment and placement of the tooth within the bony housing, the patient was referred for a gingival graft, but she did not undergo the procedure because she was satisfied with the gingival health.The absence of periodontal pockets was verified by probing after treatment and at 1 year after treatment, also increasing the good prognosis in the long term. This periodontal result after treatment may also result from good gingival width on the buccal surface of the mandibular anterior teeth and good hygiene, without inflammation during and after treatment.The spontaneous improvement of root coverage in this patient was in contrast with Deng et al.  who statThe sagittal tomographic images in the occlusal view showed bone formation into the bone defect in the apex region, probably caused by the movement of the root through the cortical bone that carried the cortical wall lingually in the mandibular central incisor, thus improving the prognosis of the tooth, but Garlock et al. stated that although pretreatment cortical bone thickness, ridge width thickness, and specific tooth movements all play roles in what happens to the bone during treatment, incisor inclination was not correlated with alveolar bone height changes .Orthodontic movement is not a determining factor to result in gingival recession, but when associated with thin gingiva, thin bone board, dehiscence, bone fenestration, direction of orthodontic movement, presence of inflammation, or trauma of brushing, it creates a favorable environment for the development of gingival recession. Tanaka et al. successfully advocated the grafting of subepithelial connective tissue of the palate prior to orthodontic movement, restoring the clinical crown (from 9.0 mm to 5.0 mm) on the vestibular face of the right lower central incisor .The main purpose of the preadjustable bracket system is to minimize the need to introduce folds in the orthodontic wires. However, even using a preset apparatus, in certain cases, it is necessary to insert third-order folds (torque) into the rectangular arch to achieve a good orthodontic finish .Antelo et al. used a versatile bracket on the lateral incisor that was bonded in an inverted way, with a rotation of 180° to express a negative torque of –10° in a clinical case with the maxillary lateral incisor for palatine and in anterior crossbite, and biomechanics was efficiently expressed without the insertion of torque in the orthodontic arch , and thiTherefore, even with the use of preadjusted brackets and versatility feature, the professional must have biomechanics knowledge and technical ability with a clinical capacity of an interdisciplinary team, composed of the orthodontist, periodontist, and patient commitment.The orthodontic treatment of a young woman, with severe gingival recession of the left lower central incisor, was carried out, with the application of a localized biomechanics system of forces that delivered good dental and functional occlusion and, mainly, gingival and periodontal health. The 1-year follow-up showed stable results with the periodontium within normal limits and an improved occlusal interdigitation.


A recent symposium and workshop in Khartoum, the capital of the Republic of Sudan, brought together broad expertise from three universities to address the current burden of communicable and non-communicable diseases facing the Sudanese healthcare system. These meetings identified common challenges that impact the burden of diseases in the country, most notably gaps in data and infrastructure which are essential to inform and deliver effective interventions. Non-communicable diseases, including obesity, type 2 diabetes, renal disease and cancer are increasing dramatically, contributing to multimorbidity. At the same time, progress against communicable diseases has been slow, and the burden of chronic and endemic infections remains considerable, with parasitic diseases  causing substantial morbidity and mortality. Antimicrobial resistance has become a major threat throughout the healthcare system, with an emerging impact on maternal, neonatal and paediatric populations. Meanwhile, malnutrition, micronutrient deficiency and poor perinatal outcomes remain common and contribute to a lifelong burden of disease. These challenges echo the United Nations (UN) sustainable development goals and concentrating on them in a unified strategy will be necessary to address the national burden of disease. At a time when the country is going through societal and political transition, we draw focus on the country and the need for resolution of its healthcare needs. The Republic of Sudan is undergoing dramatic political and societal changes which have potential to both improve and harm the health of the population.Poverty-associated endemic infectious diseases, nutritional deficiencies and poor perinatal outcomes cause a huge burden of ill health.An increasing burden of chronic non-communicable disease, and communicable diseases pose major challenges for to the healthcare system.Antimicrobial resistance is widespread and threatens all aspects of the healthcare system.Improvements in population health require improvements in multi-sector infrastructure and better data to prioritise the use of resources.Sudan has long held a fascination to the outsider, right from the Biblical days of the Kingdoms of Kush and Nubia, through the Ottoman Empire to the Victorian era, where there was joint rule as a Condominium by the United Kingdom and Egypt, until independence in 1956. At independence, the country was considered the breadbasket of Africa and irrigation schemes made the country rich in cotton and other agricultural products. However, decades of mismanagement, the harsh climate and political difficulties have meant that this is now all but vestigial. Notably, a long-standing war of separation between the South and the North led to the splitting of Africa’s largest country, when the Republic of South Sudan was born after a UN-approved referendum in 2011Schistosoma haematobium infection.Though steady progress has been made, communicable diseases are still estimated to cause 30% of deaths in Sudan  to whole populations has been proposed as an intervention to reduce malaria transmission.Schistosoma haematobium and chistosoma mansoniS are present, and being water-transmitted infections, their epidemiology is strongly associated with proximity and exposure to natural freshwater sources.S. haematobium infection was 5.2%, and S. mansoni 0.06%, but ranged much higher in East Darfur state where S. haematobium prevalence reached over 25%.S. haematobium, 5.9% S. mansoni and 4.4% mixed infection).While malaria may cause the greatest acute health burden, schistosomiasis is believed to be the most prevalent parasitic infection. Indeed, one of the first ever treatment trials for this disease was conducted in Khartoum.Leishmania major, whereas visceral disease is caused by Leishmania donovani, with recent serological studies indicating that there may be different strains of L. donovani in distinct geographical regions.Cutaneous leishmaniasis is widespread with 93% of the population considered at risk, but visceral disease is more geographically restricted to southern, eastern and central regions, with about 25% of the population considered at risk.Escherichia coli clinical isolates have been reported to be multi-drug resistant.Prevention strategies are key to the control of the emergence and spread of AMR. These include vaccination, access to water and sanitation (discussed earlier) and effective infection prevention and control procedures. Inadequacies across the healthcare system hamper prevention efforts. Furthermore, there is limited published literature on AMR surveillance or antibiotic use from Sudan.Infections in maternal and neonatal and paediatric surgical pathways are an additional concern. Female genital mutilation is widely practiced, and this practice leads to severe complications during delivery, often requiring deinfibulation, carried out by non-medical healthcare professionals.Governmental support and commitment for initiatives to target AMR is are necessary for implementation and sustainability. In July 2017, Sudan became one of the first countries in Africa to draft a National Action Plan (NAP) for AMR.Despite the division from South Sudan in 2011, Sudan remains one of the largest countries in Africa with a population just over 40 million.Like other major non-communicable diseases, the prevalence and burden of cancer in Sudan appear to be increasing.While many outsiders equate Sudan with traditional practices of female circumcision and accompanying high maternal and neonatal mortality rates, childhood malnutrition remains a significant issue not only in displaced people from war and conflict but also in many rural communities, where there is limited access to medical care. Rates of adverse perinatal outcome and associated disability are high in Sudan, as in many countries in sub-Saharan Africa.A 2013 publication described Sudan as having ‘made insufficient progress to achieve Millenium Development Goal 4 and having levels of child and infant mortality that are among the highest in the region and the world’.Maternal health and nutrition are also important for foetal neurological development, and the high prevalence of iodine deficiency in SudanThis paper provides a summary of the proceedings of a 3-day scientific symposium and does not represent a systematic review of the existing research in the themes included. However, the symposium brought together extensive academic and clinical expertise and provided a unique perspective on the current challenges and gaps in the Sudanese healthcare system.The burden of disease in Sudan is affected by poverty and is complicated by geography, politics, armed conflict and not infrequently, mismanagement. At a time when the political landscape is in transition, the burden of communicable disease in the country remains high, and non-communicable diseases look set to increase. The problems, however, are not all intractable. The symposium and workshops held in Khartoum in November 2018 highlighted strategies to improve the situation with relatively limited resources. Many of these have the common theme of collecting high quality and nationally representative data to better understand the problems and prioritise the use of scarce funding, and the need for achieving governmental support to implement improvements in healthcare.The WHO Sustainable Development Goals should be achievable despite previously poor implementation and organisation of WHO directives. The developed world needs to work with Sudan, not only at a governmental level but also through professional bodies to support the well-qualified healthcare workforce and foster capacity building for research and development through partnerships with external funders and academic institutions across the world. There are also opportunities for bi-directional learning from other LMICs. The Khartoum conference highlighted opportunities for collaborations and workforce development to engender sustained change. The current situation in Sudan and how it unfolds will be critical in determining the evolution of healthcare distribution and also engineering societal change in the future of the country. We remain hopeful that global politics does not hinder the fundamental transformations that are needed for the current and future health of the nation.


Background: Recognition of the dominant dietary behaviors with respect to gender and specific age groups can be helpful in the development of targeted and effective nutritional education. The purpose of the study was to analyze the prevalence of the selected eating behaviors  among Polish adolescents. Methods: Data on the nutritional behaviors were collected using a questionnaire. Body mass status was assessed based on weight and height measurements. Results: 14,044 students aged 13–19 years old from 207 schools participated in the study. Significant differences were found in the nutritional behaviors depending on age, gender and nutritional status. Favorable nutritional behaviors corresponded with each other, the same relationship was observed for adverse behaviors. The frequency of the majority of healthy eating behaviors decreased with age, whereas the incidence of adverse dietary behaviors increased with age. Underweight adolescents more often consumed sugared soft drinks, sweets and fast food compared to their peers with normal and excessive body mass. Conclusions: A significant proportion of adolescents showed unhealthy nutritional behaviors. Showing changes in the incidence of nutritional behaviors depending on age, gender and body weight status, we provide data that can inform the development of dietary interventions tailored to promote specific food groups among adolescents on different stages of development to improve their diet quality. The health of children and adolescents is dependent upon food intake that provides sufficient energy and nutrients to promote optimal physical, cognitive and social growth and development ,2,3. HowAlthough correct nutrition is important throughout the life span, it is possible to distinguish particularly critical periods, i.e., the first 2–3 years ,15. DramAlthough nutritional knowledge does not always translate into proper nutritional behavior , some daIn Poland, there are many studies on nutritional behaviors of adolescents ,9,11, buThe presented study is a part of the research and education program Wise nutrition—healthy generation granted by The Coca-Cola Foundation, and addressed to the secondary and upper secondary school youth, their parents and teachers. The main objective of the program was to educate the secondary and upper secondary school students regarding the importance of healthy nutrition and physical activity in the prevention of the diet-related diseases. The research part of the project included assessing the selected dietary behaviors and parameters related to physical activity of the students and performing anthropometric measurements to assess their nutritional status. Those with diagnosed abnormal body mass were invited to the dietary counseling program . The diagram presenting the overall activities within the project is provided in the This paper focused on the results concerning nutritional behaviors of students . The proTo examine the selected nutritional behaviors and nutritional status of Polish teenagers, participants were recruited from schools participating in the project. To ensure a representative selection of students, these schools were randomly selected using the stratified sampling method from all of the 2058 enrolled institutions. The sampling was stratified by province and location , as well as the type of school (secondary and upper secondary). Secondary schools  are compulsory for all adolescents aged 13–16 years, and are located close to the students’ place of residence. Upper secondary schools  include, depending on the type, youth from 16 to 20 years of age. As in the case of secondary schools, students typically live with their families and commute to school. Within the selected schools, as the next step, students were randomly selected from the class registry. Exclusion criteria included: Diagnosed disease that required the use of a special diet, pregnancy or lactation in girls or lack of written consent. All the personal data of participants were fully anonymized. The schools, and consequently, students came from all over Poland, therefore the research was of a nationwide character. In total, 207 schools of the 2058 institutions were enrolled (~10%), and finally 14,044 students participated in the study, including 7553 (53.8%) girls and 6491 (46.2%) boys. The age categories for the studied group were adopted in accordance with the HBSC methodology .The assessment of the body weight status of the examined individuals was based on anthropometric measurements (body weight and height) conducted by a trained dietitian. All the measurements were carried out with the equipment provided by The Polish Society of Dietetics: Digital floor scales  and a steel measuring tape (0–200 cm). All dieticians conducting the measurements were specially trained and followed the same procedures according to Anthropometry Procedures Manual by National Health and Nutrition Examination Survey (NHANES)  to minimWeight of the individuals was measured twice to the nearest 0.1 kg, and the mean value was recorded. Measurements were conducted on individuals dressed in basic clothes  and without shoes. From the final result 0.5 kg was subtracted (predicted weight of the basic clothes).For height measurements individuals stood on a flat surface in an upright position with their back against the wall, and the heels together and toes apart (without shoes and socks). They were asked to stand as tall as possible with the head in the Frankfort horizontal plane . The hei2, normal body weight for BMI between 18.5 and 24.9 kg/m2, overweight between 25 and 29.9 kg/m2 and obesity ≥30 kg/m2 [Based on the body height and weight data, body mass index (BMI) value was calculated. BMI was calculated as body weight in kilograms divided by the square of height in meters. Depending on the age of the subjects different criteria for assessing the body weight status were used. For individuals aged 13–18 years old, calculated BMI value was plotted on gender BMI centile charts for age (with an accuracy of one month) . The pern = 50) was conducted to examine whether the questions were understandable to the respondents. The questionnaire was validated: Repeatability was verified by determining the correlation coefficient between the results obtained in the same group  twice; correlation coefficients for individual questions were on average 0.76 (95% CI = 0.71–0.83) and ranged from 0.18 to 0.96.Data on the selected nutritional behaviors were collected prior to the anthropometric measurements and dietary counseling. The paper questionnaire containing questions about the selected nutritional practices, physical activity and self-esteem satisfaction (data not included in this article) was carried out in individuals by a dietitian. This provided the opportunity to clarify possible doubts or ask additional questions. After its completion the questionnaire was collected by a dietician. Due to the large sample group and direct methods of data acquisition, it was decided that the questionnaire has to be short, and must contain questions about the critical determinants of teenagers diet quality. Taking into account the health behavior in school-aged children (HBSC) questionnaire  concerning nutritional behaviors , and ava©StatSoft, Inc, 1984–2014, Cracow, Poland). Data were analyzed in the total group, according to age, gender and body weight status. Statistical significances for nominal  variables were determined using the Pearson’s chi-square test. Additionally, contingency coefficient Cramér’s V was used to indicate the strength of association between categorical variables. Quantitative data was tested for normality of distribution; in the case of its absence the Mann–Whitney test was used for comparisons of independent groups. The correspondence analysis was used to study the relationship between dietary behaviors. The differences were considered significant at p ≤ 0.05.Statistical data processing was performed using Statistica version 13.1  in the whole group and separately for girls and boys are presented in The frequencies of examined nutritional behaviors in the total group, and for girls and boys separately are presented in Breakfast was regularly consumed by seven out of 10–13 year olds but only by half of 19 year olds. There was a statistically significant  effect of age in the total group, and separately for girls and boys. Boys were more likely to eat breakfast in comparison to girls, and differences were particularly noticeable in the younger age groups. The frequency of eating at least one serving of fruit per day also decreased with age. A statistically significant  effect in the total group, and separately for girls, and boys was noted. Girls were more likely to include fresh fruits to the daily diet in comparison to boys. There was a significant effect of age on the consumption of vegetables in the total group. Half of the 13-year-olds consumed at least two servings of vegetables a day, but the frequency of consumption decreased to 43% for the group of 19-year-olds. Similarly, the influence of age was observed in the group of girls, and boys. Girls consumed at least two servings of vegetables daily more often than boys in all age groups, except for 18-year-olds. The consumption of milk or milk beverages decreased with age. Significant age effects were observed throughout the total group, and among girls, and boys. In all age groups fewer girls drank milk and fermented milk beverages compared to boys. With age, the proportion of teenagers consuming whole grain bread in everyday diet decreased. However, age effects were not observed for girls, and neither for boys, separately. Considering gender, in all age groups, the greater percentage of girls consumed whole wheat bread in their usual diet. No significant effect of age was observed on fish consumption, neither in the total group, nor in girls, and boys. However, significant gender effects were observed: A greater percentage of boys consumed fish at least one a week in all age groups compared to girls. The effect of age was observed in regards of drinking sugared soft drinks a few times a week, for the whole group, and for both genders. The proportion of adolescents drinking sugared soft drinks increased with age. A higher percentage of boys consumed sugared soft drinks compared to girls in all age categories. Less than half of the students declared consuming sweets more than once a day. No age effects were observed, neither for the whole group, nor for the girls. A small effect of age was found only among boys. On the other hand, a relationship with gender was observed: In all age groups, a higher percentage of girls declared such behavior compared to boys. There was a significant relationship between fast-food consumption and age. The percentage of adolescents consuming fast food more than twice a week increased with age, and an analogous relationship was observed for girls and boys. In all age groups, a higher number of boys declared such nutritional behaviors comparing to girls.The data on the prevalence of examined nutritional behaviors depending on the nutritional status  are presented in Analyzing the prevalence of selected nutritional behaviors in the whole group of adolescents depending on the body weight status, significant relationships were observed for all eating behaviors except for consuming vegetables. Regular consumption of breakfast was more often declared by adolescents with normal body weight and underweight in total group and both for girls and boys. The percentage of subjects consuming at least one portion of fruit was the smallest in the underweight group, and the largest among the obese adolescents. Consumption of milk and milk beverages was declared by a higher percentage by overweight adolescents, whereas in the smallest percentage by underweight individuals. At the same time, no relationship was observed between this nutritional behavior and the nutritional status separately for girls and boys. The frequency of regular consumption of whole-grain bread increased with the category of body weight in the whole group and in the case of girls. The relationship between fish consumption and the nutritional status was observed only in the whole group. As in the case of bread, the frequency of declared fish consumption increased with the BMI category. In the case of the last three nutritional behaviors: Drinking sweet beverages, eating sweets and fast foods, the incidence of these behaviors decreased with the BMI category, both in the whole group and among girls and boys .Since adolescence is a time of tremendous biological, psychosocial and cognitive changes, nutrition interventions need to be tailored not only to the developmental stage, but also to the nutritional needs of individuals . Based oBased on the analysis of correspondence, it can be noticed that regardless of age or sex, beneficial (or adverse) nutritional behaviors cluster together. Thus, individuals who, for example, do not consume breakfast, more often show other adverse nutritional behaviors . A typical breakfast in Poland includes bread or cereals, dairy and/or meat products as well as vegetables and/or fruit. Thus, omitting breakfast may lead to a reduction in the supply of these products in the overall diet. Our results suggest that if one irregularity is found in a teenager’s diet, it can be assumed that the overall diet quality is low. Interestingly, consuming (or not consuming) sweets, sugared soft drinks and fast food cluster together, but did not correspond to other determinants of the quality of the diet. It may suggest that such products might be consumed together as a meal . It may also suggest the need for educational activities aimed at these products, regardless of the general education about healthy nutrition.n = 4487, 2–16 years). Moreover, individuals who eat breakfast had significantly higher intake of calcium and folate, and significantly lower intake of total fat than breakfast skippers, which indicates the important role of breakfast not only in maintaining a healthy body weight but also in the quality of the diet. Our results indicate a strong need to increase education activities promoting the regular breakfast consumption, especially among older girls and students with abnormal body mass status.In our study, the frequency of regular breakfast consumption decreased with age, both among boys and girls. In addition, girls significantly less often declared eating breakfast compared to boys. Our observations are consistent with data from the HBSC study  where olRegular fruit and vegetables consumption is linked to many positive health outcomes . The WHO1, B2 and B12 [Dairy products, especially milk and milk beverages, contribute to a healthy diet by providing energy, protein, and nutrients such as calcium, magnesium and vitamins B and B12 . Regular and B12 ,40. Howe and B12 , which r and B12 . We alsoAs in the case of vegetables and fruits, consumption of whole grain products is associated with a lower risk of many diet-related diseases, e.g., cardiovascular disease and stroke, hypertension, insulin sensitivity, diabetes mellitus type 2, obesity and some types of cancer . PapanikRegular intake of fish, particularly fatty fish, has positive health outcomes, especially in the long term. It reduces the risk of CHD mortality and ischaemic stroke . Fish coSugared soft drinks, sweets and fast foods are the sources of empty calories that contribute to a substantial share of the total energy intake in children and adolescents . Intake The strength of the study is the sample size. To our knowledge there is no research on such a scale covering all age categories over a large geographic area. With such a large sample, the advantage is also the way of obtaining data. All questionnaires were filled in by a trained dietician who could explain the respondents’ doubts on an ongoing basis. Moreover, all anthropometric data were obtained through measurements conducted also by a dietician, which ensured obtaining reliable results and minimize the bias.Respondents for our study were recruited from schools participating in the project, which can be a certain limitation. However, the number of schools allowed a random selection of the sample taking into account different types of institutions and their geographic location. The small number of questions with the very limited possibilities of answers in the questionnaire may also be a certain limitation. However, the questions have been developed on the basis of large, international studies on the nutritional behaviors of school-aged children ,26, and By analyzing the differences in nutritional behaviors between age and gender groups, we provide data that can inform the development of dietary interventions tailored to answer the needs of adolescents at different stage of development and to improve the quality of their diet. We observed significant changes in the frequencies of analyzed eating behaviors depending on gender as well as on age. Furthermore, we have shown that the incidence of undesirable eating behavior is higher among underweight adolescents compared to their peers with an excessive body mass. Information on the most frequent nutritional errors on every stage of adolescents might be used to determine the type of educational messages given when counseling this challenging group, e.g., education activities regarding regular breakfast consumption should be intensified in older age groups, as the percentage of young people who eat breakfast decreases with age. On the other hand, education on the adverse effects of consumption of sweets, sugared soft drinks and fast food should be directed not only to adolescents with excessive body weight, but mainly to those underweight, as the consumption of these products is more frequent in this group. Moreover, regardless of age and sex, both favorable and adverse nutritional behaviors corresponded with each other. The present findings can be used both for the development of educational programs and for educational activities carried out by teachers at the school level.