Maternal mortality is a global public health problem. Statistics show that in 2013, 289,000 women died from complications during pregnancy, childbirth or the postpartum period worldwide. Between 2010 and 2015, there were 10,075 maternal deaths in Brazil, 3,522of which occurred in the Northeast region. The aim of this study was to investigate the actions taken by primary health care (PHC) professionals to reduce maternal mortality.This was a cross-sectional, descriptive field study with a qualitative approach. The sample comprised 81 graduate-level professionals working in PHC in the state of Ceará, Brazil. Data were collected from January to March 2016 using structured interviews, which were digitally audio recorded and transcribed. The results were organized using collective subject discourse and analyzed according with the relevant literature.The PHC professionals took both individual and joint measures to reduce maternal mortality. These activities included home visits, health education, active searches, prenatal care consultations, referrals to specialized care and outreach. The challenges that must be overcome to prevent maternal mortality include poor care and ineffective public policies that are associated with a lack of managerial support.Interaction among professionals in the health care network is critical to the development of cross-sectoral projects that improve the quality of women’s health care. Prenatal care is a key factor in reducing maternal death and enables the identification and classification of the risks to which pregnant women may be exposed and the implementation of early actions that can ensure a safe and uncomplicated delivery. However, all of these actions require effective public policies and managerial support. Maternal mortality rates have been high for many years. At the beginning of this century, representatives of 189 countries met and created a set of quantifiable objectives and targets known as the Millennium Development Goals, and they stipulated deadlines for achieving these goals. The fifth goal, “improve maternal health”, proposed a 75% reduction in maternal mortality within 15 years (2000–2015) [The World Health Organization considers a maternal mortality rate (MMR) of 20 maternal deaths per 100,000 live births acceptable. The MMR is calculated by multiplying the total number of maternal deaths in a given period by 100,000 and dividing that number by the total number of live births in the same period [The MMR data for 2013 reveal the following: in South Asia and sub-Saharan Africa, there were 510 deaths/100,000 live births; in Latin America, 77/100,000; in Ireland, 9/100,000; in Canada, 11/100,000; in Afghanistan, 400/100,000; in Haiti, 380/100,000; and in Brazil, 69/100,000 [According to a public database, from 2010 to 2015, Brazil had an MMR of 57.3/100,000 live births. The Southeast region had an MMR of 54.5/100,000 live births, while the Northeast region had an MMR of 70/100,000 live births [In Brazil, public health needs are met by a unified health system (UHS), which aims to provide free and public care for all citizens regardless of their social, demographic or ethnic characteristics. This system was instituted in 1990 with the creation of Organic Health Law No. 8088, which established conditions for the promotion, protection and recovery of health and defined the organization and functions of the corresponding services .The UHS is organized according to doctrinal and organizational principles. Its doctrinal principles are universality, equity and comprehensiveness; its organizational principles are regionalization, hierarchy, resolvability, decentralization, user participation and cooperation with the private sector .The UHS is part of the Brazilian social security system. Social security guarantees health, welfare and social assistance and prioritizes universal coverage and treatment for the entire population. Its health services integrate a regionalized and hierarchical network organized at each level of government  according to the principles of decentralization and integrated care. Such actions and services promote curative and preventive measures and ensure community participation through health councils and conferences .The UHS has the responsibility for resolving public health issues, and reducing maternal mortality is one challenge that the system faces. Thus, in 2011, the Brazilian government adopted strategies to reduce maternal and infant mortality rates by means of Ordinance No. 1459, the Mother and Child Network, known as the Stork Network. This network provides care designed to ensure the rights of women, such as reproductive planning and humanized care during pregnancy, childbirth and the postpartum period, and to protect the child’s right to a safe birth and healthy growth and development .The Stork Network is part of the health care network and provides support to primary health care (PHC) services. It is the preferred entry portal for prenatal health care services, and it connects pregnant woman with the maternity hospital responsible for their childbirth. The portal is also responsible for postpartum care and for providing comprehensive health care for the child .In the UHS, women’s PHC is the responsibility of the Family Health Strategy (FHE) and the Support Center for Family Health (SCFH). The FHE was established in 1994 to restructure the UHS and move it away from the hospital-centered model of health care. Its aim is to make health more accessible to families to improve the population’s quality of life. The SCFH was introduced in 2008 by Decree No. 154 to support the inclusion of the FHE in the service network and expand its range, resolvability, territorialization and regionalization [According to reports available in a public database, 80.40% of the population of the Northeast region was covered by the FHE at the end of 2017, and 82.5% of the population in the state of Ceará was covered during the same period. These data reflect the monitoring of access to PHC services and the strengthened planning of actions undertaken at this level of care .It is important to associate the prevention of maternal mortality with social determinants of health, such as income, education level, unplanned pregnancy and abortion, which are among the main determinants of a higher MMR. These issues should be analyzed in the context of the maternal health-disease process.In Brazil, abortion is legal in only a few situations: when it is the only way to save the life of the pregnant woman, when the pregnancy is the result of rape or incest, and (in some cases) when the fetus has a congenital malformation . HoweverIn this context, the questions guiding this study were based on the acronym PICO: P –population , I –intervention , C –comparison , and O –outcome . As a result, the following questions were raised: What actions do PHC practitioners take to reduce maternal mortality? What types of training and skill development are available to them? What challenges do they face in reducing maternal mortality?Given the high MMR in Brazil, particularly northeastern Brazil, it is important to address these questions to promote pregnant women’s health and prevent mortality during pregnancy and childbirth. The aim of this study was to investigate the actions performed by PHC professionals and their capacity, aptitude and challenges related to reducing maternal mortality.This was a cross-sectional and descriptive field study with a qualitative approach. It was performed in southern Ceará, a northeastern Brazilian state. The purposeful sample comprised graduate professionals working in the FHE and SCFH, including physicians, nurses, dentists, social workers, physical educators, pharmacists, physiotherapists and psychologists.2, and it comprises nine states. It has a population of approximately 53 million inhabitants and a population density of 32 in habitants/km2. Its Human Development Index is 0.659, which is considered average. The gross domestic products BRL 848,532 billion, which represents 14.2% of the gross national product [Northeastern Brazil has a warm climate for much of the year. It is the third largest region in Brazil, with a territory of approximately 1,558,196 km product .Data collection took place from January to March 2016 in a municipality with 70 FHE teams and 7 SCFH teams, for a total of approximately 240 professionals. The study included 81 of these professionals; 42 declined to participate, and the rest did not meet the inclusion criteria described below. Among the professionals who participated, 6 did not want or know how to respond regarding their actions to reduce maternal mortality, and 4 did not indicate what challenges they faced in doing so. The professionals in the sample met the following inclusion criteria: a) having worked on an FHE or SCFH team for at least six months, b) working on an FHE team that engaged in SCFH activity, c) performing usual-risk prenatal care and, for mothers who met the criteria for high or medium risk, providing coordinated care between the PHC and a specialized service, and d) fully exercising their activities during the data collection period.A structured form was used to collect data during interviews. The interviews were audio recorded digitally and transcribed to allow the researcher flexibility in obtaining additional important information to meet the proposed objectives.To verify that the questions contained in the form were significantly likely to meet the study objectives, a pre-test that included 5 randomly chosen PHC professionals who volunteered to participate was carried out. After reading each item, the professionals were asked to describe their understanding of what was being asked in their own words. When the purpose of the question and the professionals’ understanding was consistent, the item was kept on the form; if they diverged, the item was reformulated according to the professionals recommendations. To evaluate the content of the form, two experts in women’s health and maternal mortality were consulted. After the experts’ analysis, 5 open questions that met the study’s proposed objectives remained on the form.Data collection occurred during the work hours of the FHE professionals. First, each professional was contacted to explain the purpose of the research and to confirm his/her availability to participate in the study. If the professional was available at this point, the interview was conducted; otherwise, it was scheduled according to the participant’s availability.The data collected in the interviews were transcribed in full and organized using the collective subject discourse method, in which central ideas/anchors and their corresponding key expressions were obtained. This method consists of obtaining the central ideas and their corresponding key expressions,which make up one or several speech syntheses. Speech syntheses are the discourses of the collective subject, which in this case refer to the terms, actions and challenges that the professionals identified in association with efforts to reduce MMR.In the social representation created via collective subject discourse, individuals’ identities are transmuted, dissolved and incorporated into one or several collective discourses .Collective subject discourse is a discursive data organization technique used in qualitative research that enables a community to speak as if it were a single individual. The raw material used in collective subject discourse comprises thoughts expressed in discursive form. The discourses are subjected to content analysis, which begins by decomposing each discourse into its main central ideas and determining the main central ideas of the discourses as a whole; a summary that reconstitutes the discourse of the group is then created .After the data were organized using collective subject discourse technique, three themes and their respective central ideas emerged. Theme 1 was the actions that PHC professionals took to reduce maternal mortality; its central ideas were home visits, health education, active searches, consultations, referral to specialized care and outreach. Theme 2 was professional competence; its main ideas were training and skill development to reduce maternal mortality. Theme 3 was challenges in reducing maternal mortality; its central idea was effective public policies.In compliance with Resolution No. 466/12 of the National Health Committee  , the stuThe results were organized into the three above mentioned themes, with their respective central ideas and collective subject discourse. The discourse analysis was based on the participants’ reports of the individual and joint measures they took to reduce MMR, the challenges they faced in carrying out those actions and the skill development opportunities that were available to them to reduce MMR.The aim of this study was to investigate how actions directed toward women’s health care are carried out in an attempt to reduce maternal mortality. In this context, the speech synthesis revealed that home visits, health education, active searches, consultations, referral to specialized care and outreach are tools for reducing maternal mortality.The PHC professionals indicated that teamwork is important to their ability to act to reduce MMR. The speech synthesis revealed that the professionals have confidence in the activities they perform and emphasized the importance of working as a team. The analysis indicated that each professional is important in the provision of holistic care and that working individually is not conducive to satisfactory health promotion or the prevention of maternal mortality.The speech synthesis suggested possible measures to reduce maternal mortality. In particular, it highlighted the effectiveness of public policies that promote comprehensive women’s health care, and it focused on the commitment of management in PHC and care at medium- and high-complexity levels of care.Health education promotion was one of the actions taken by PHC to reduce maternal mortality. However, ascertaining the education level of the treated woman is necessary, as familiarization with the educational level of the target audience is essential when planning activities to provide knowledge and increase awareness about a particular issue.Pregnant women’s education level is an important factor to consider in the context of health care. In general, women with higher education levels tend to seek more preventive care, which contributes to a substantial reduction in maternal mortality levels .Women’s education levels can significantly affect their maternal health. Consequently, education is a social determinant of health that may enhance strategies for improving individual health because the higher the population’s education level is, the greater its demand for social and health rights that make equal opportunities available for everyone .Studies indicate that the causes of maternal mortality are not equally distributed and this inequality is attributable not only to deficiencies in the health system but to social determinants of health. Thus, the risk of maternal mortality is higher in socially disadvantaged populations since women in these circumstances are more likely to experience unintended pregnancy than women with greater financial and social resources , 19.Education, income and occupation are closely related and can determine access to assets and social opportunities; consequently, they assume an important role in the success of health actions such as reproductive planning and reducing maternal mortality. Financial dependence and inadequate income can also be determinants of unplanned pregnancy and unsafe abortion practices.In Brazil, abortion is among the five main causes of maternal mortality, and it is related to approximately 5% of all maternal deaths. For this reason, in recent years, there has been a great debate in the country regarding the decriminalization of abortion, which involves a complex set of political, legal, moral, religious, social and cultural aspects .According to data from the World Health Organization, Brazil is in the lead in the number of induced abortions, with a total of four million per year. One in nine Brazilian women uses abortion as a means of ending an unplanned pregnancy. However, it is not known precisely how many women have abortions or how many die annually from abortion-related causes because, as abortion is illegal in Brazil, it occurs predominantly under clandestine and precarious conditions; such circumstances contribute to the role of abortion in the high maternal mortality numbers in our country .Women residing in suburban areas and rural communities are more susceptible to maternal death. Age is also a factor; maternal death is more common in women under 15 and over 35 years old. Regarding education, illiterate women and those with a low education level are more susceptible to maternal death. In Brazil, because of racial miscegenation, it is difficult to associate race with the maternal death rate, but a 2006 study found that the MMR was higher among white women (61.5%) than among black women (17.9%). Regarding marital status, single women are more vulnerable to maternal death, and abandonment has been identified as a contributing factor , 22.Among the strategies for promoting health and reducing maternal mortality, health education can have a positive effect by reducing health inequities and promoting the autonomy and empowerment of individuals and social groups . Thus, hHome visits were cited as a health promotion strategy for pregnant women. When conducted during the postpartum period, such visits are an efficient way for professionals to monitor the prenatal and postpartum periods and interact with the family. These visits provide an opportunity for the woman to show the professional her actual living conditions, and they allow the professional to observe the family and social context that the woman operates, which can facilitate genuine and humanized actions .In this context, monitoring the postpartum period at the woman’s home facilitates safety and allows the professional and the family to identify factors that may put the health of the mother or child at risk. Once the family is able to identify risks to maternal health, it may request PHC support and take measures to reduce maternal death.Active searches were also identified as an action that health care teams performed within the community to bring pregnant women for prenatal care. Studies , 26 showAnother action that the study participants highlighted was prenatal consultations. Prenatal consultations provide an ideal opportunity to identify any risks to which pregnant women may be exposed. Risks can be identified via physical examinations, laboratory tests and imaging. When the professionals observed risks to the health of amother and/or child, they could contact the health care network to provide interventions. When they referred a pregnant woman to another level of health care, they were seeking comprehensive care for the woman. Access to specialized services occurs through referrals and is aimed at the pregnant woman’s well-being. Such access can minimize maternal health consequences, especially for women experiencing pregnancy-associated risk factors such as hypertension, obesity and gestational diabetes mellitus .The PHC system emphasizes humanized attention to the woman during the pregnancy cycle. The professionals participating in this study pointed out the importance of a humanized approach that provides an appropriate welcome, qualified listening, appreciation of the demands on the pregnant woman and respect for her privacy. This approach supports professionals’ ability to interact with women and identify social, demographic and health risks that may threaten their lives. This provides an opportunity for health services to act early, avoiding a disastrous outcome such as death .Professional competence, which reflects the PHC professional’s ability to perform their work with a recognition of the morbidity and mortality profile of the population being served, is an important component of the integration of health actions; it is possible to assess professionals’ performance according to the health needs of the population . By idenThis study shows that for professionals to be skilled and fully equipped to recognize and address gestational risk factors, they should receive training, which can be accomplished through the lifelong learning policy. This policy, which includes pedagogical concepts related to teaching health workers about management and social control, aims to support work processes related to planning and organization .In the context of providing adequate maternal health services, professionals face factors related to infrastructure and facilities, resource availability, training, professional promotion and knowledge of the reality and characteristics of the population they serve . The preThe study participants perceived a need for the FHE and SCFH to work together more closely in cross-sectoral efforts. The proposal of cross-sectoral work is related to the development of shared and integrated actions with the aim of sharing knowledge and experiences in a way that has a positive effect on individuals’ or communities’ living conditions .Therefore, to advance the development of cross-sectoral projects, it is essential to facilitate a commitment to health promotion actions and to improving people’s quality of life . To carrIt can be said that health care network integration ensures the equity of health services and the satisfaction and quality of life of users and their families as it promotes the rational use of health services and minimizes financial burdens . HoweverIn discussing the challenges of reducing MMR, the PHC professionals identified four attributes that are essential to health care for women during pregnancy and child birth: Access to care, continuity of care, comprehensiveness of care and coordination of care within the system. The Ministry of Health outlines that management must provide infrastructure, equipment and supplies at all health care levels and must promote lifelong learning to ensure the comprehensiveness of health care .Studies indicate that a reduction in the MMR is associated with expanded PHC coverage for the population by means of FHE teams. The decentralization of health services offers improved access and thus can increase the availability of maternal and child health care, curative and preventive care, health promotion, home visits and referrals .Effective public policies to ensure the quality of care represent a key factor in preventing maternal death. However, the effectiveness of public policy is independent of factors related to professional qualifications and available technological resources. In this context, public health policies should aim to identify the social determinants of health and the needs and rights of vulnerable individuals and groups, promote the comprehensiveness of and access to health systems, and eliminate discrimination and inequity .It is the responsibility of the public administration to implement policies that are efficient, immediate and involve all sectors of the health care network. This will enable professionals in the health services to respond in a timely manner to demands to perform a simple procedure or secure an inpatient intensive care unit to provide adequate treatment. It is also important to staff health care services with professionals capable of intervening in cases that require specific attention. These conditions are considered essential for reducing MMR.The study has limitations. The first is the discontinuation of the Federal Mortality Information System, which at the time of the study provided epidemiological data on maternal mortality up to 2015. In addition, the professionals comprising the sample did not always respond to all interview questions.Maternal and child health care is regulated by public policies, and it is a government priority to reorganize and strengthen women’s health care and reduce MMR. Reducing these rates is contingent on certain factors, and as this study shows, measures related to professional training, municipal management, and the pregnant woman and her family are integral to the fight against maternal mortality.The study shows that interdisciplinarity among PHC professionals facilitates integrated care for pregnant women. Actions that reduce the MMR include outreach, prenatal monitoring consultations, home visits, health education, active searches, and referrals to specialized care.One challenge in reducing maternal mortality is the discrepancy between what public health policies advocate and the applicability of those policies in practice. This study revealed a lack of integration of these policies. Their ineffectiveness could be correlated with the lack of the necessary infrastructure and basic resources to provide care for pregnant women in PHC.


Massive open online courses (MOOCs) have increased in popularity in recent years. They target a wide variety of learners and use novel teaching approaches, yet often exhibit low completion rates (10%). It is important to evaluate MOOCs to determine their impact and effectiveness, but little is known at this point about the methodologies that should be used for evaluation.The purpose of this paper is to provide a protocol for a systematic review on MOOC evaluation methods.We will use the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines for reporting this protocol. We developed a population, intervention, comparator, and outcome (PICO) framework to guide the search strategy, based on the overarching question, “What methods have been used to evaluate MOOCs?” The review will follow six stages: 1) literature search, 2) article selection, 3) data extraction, 4) quality appraisal, 5) data analysis, and 6) data synthesis.The systematic review is ongoing. We completed the data searches and data abstraction in October and November 2018. We are now analyzing the data and expect to complete the systematic review by March 2019.This systematic review will provide a useful summary of the methods used for evaluation of MOOCs and the strengths and limitations of each approach. It will also identify gaps in the literature and areas for future work.DERR1-10.2196/12087 Massive open online courses (MOOCs) are rapidly becoming an established method of online and distance education, growing in prominence since the launch of the first MOOC in 2008. The idea of a course accessible by anyone with a computer with no fees or prerequisites for joining has caught the attention and imagination of many involved in e-learning, with MOOC being called the educational buzzword of 2012 . The scoWhile the MOOC field is new territory, the means of evaluating MOOCs is newer still and a gap in knowledge exists with regard to the methodologies which should be used for evaluation. The novel combination of teaching approaches used, including prerecorded videos, live discussion forums, peer-assessed assignments, and social media debate, warrant thorough investigation to enable providers to maximize participation and impact . It is vAlthough there have been recent reviews conducted on MOOCs -10, noneThe purpose of this paper is to provide a protocol for a systematic review on MOOC evaluation methods. The systematic review is designed to identify all the relevant literature published thus far on methods of MOOC evaluation, extract methodologies and objectives, and synthesize these into a narrative describing the spectrum of methods available and recommendations for future research and practice.We will follow elements of the Cochrane Handbook for Systematic Reviews for conducting the review  and willeffectiveness [Course evaluations can have many definitions. In this review, we will focus on the definition by Edwards, which states that evaluations focus on the experience of teachers and the students to assess and illustrate their tiveness . TherefoPopulation: the target population will include learners in any geographic area who have participated in MOOCs.MOOC evaluation methods. This is intended to be broad to include qualitative, quantitative, and mixed methods.Intervention: the intervention will be Comparator: studies do not need to include a comparator for inclusion in this systematic review.Outcome: learner-focused outcomes such as attitudes, cognitive changes, learner satisfaction, etc, will be assessed.This PICO was converted to a search strategy with the assistance of a medical librarian, as shown in We will include studies with a primary focus on MOOC evaluation and studies that have applied or reviewed MOOC evaluation methods: quantitative, qualitative, or mixed. Evaluation of MOOCs does not need to be the primary focus of the paper for inclusion in this systematic review.Publication dates will be restricted from 2008 to 2018. The start date of 2008 was selected because MOOCs were introduced in 2008 . StudiesWe will restrict publications to the English language only. Studies will also be excluded if the primary focus is e-learning or blended learning, but not MOOCs.We will search the following databases: (1) Scopus, (2) Education Resources Information Center (ERIC); (3) Institute of Electrical and Electronics Engineers (IEEE) Xplore, (4) Medline/PubMed, (5) Web of Science, and (6) British Education Index. To identify potentially relevant grey literature, we will also search Google Scholar and Google search engines. The search strategy for Scopus was developed in consultation with a medical librarian. The search strategy was adjusted for the rest of the databases based on the keywords of each database. The complete search strategy is included in All records identified from the software searches will be recorded in a software management program, EndNote X8.2 . EndNote will also be used to remove any duplicates. Two independent reviewers will screen the title and abstract of all identified studies against the eligibility criteria. The full text of the identified studies will then be reviewed and assessed for eligibility. Disagreements will be resolved by discussion or by consultation with a third reviewer, if required.Once the final list of studies is determined, the references for each included article will be searched to identify additional studies that should be considered for inclusion.A PRISMA flow diagram will be created to document the selection process and reasons for article exclusions to ensure repeatability of the search results. This will include (1) Identification: records identified through database searching, additional records identified through other sources, and records after duplicates removed; (2) Screening (by title and abstract): including the number of records screened and records excluded; (3) Eligibility: full-text articles assessed for eligibility and full-text articles excluded, with reasons; and (4) Included: studies included in qualitative synthesis.The full text of each manuscript will be reviewed and data extracted with data points as defined in We will assess the quality of the included studies by conducting a risk of bias assessment. If there are any randomized controlled trials included, we will use the Cochrane Collaboration risk of bias tool . OtherwiWe do not expect to be able to conduct a meta-analysis due to the anticipated heterogeneity of studies. We will therefore summarize the data by conducting a descriptive analysis. To commence the analysis, we will compare the studies based on the evaluation method—quantitative, qualitative, or mixed methods—and data collection methods. We will include information on the evaluation methods, size of the groups of learners, characteristics of the learners, and description of the evaluation outcomes.We will also provide a narrative synthesis of the included studies. We will summarize the findings and present a table of the main results from all included papers. These will be supported by a narrative addressing the process as well as any rationale and challenges at each stage. These results will summarize and describe the MOOC evaluation methods, but also identify gaps and highlight areas where further research would be useful.The systematic review is ongoing. We completed the data searches and data abstraction in October and November 2018. We are now analyzing the data and expect to complete the systematic review by March 2019. We will submit the findings for publication and peer review.systematic and transparent review of the literature in order to better understand the strengths and weaknesses of methods currently used to evaluate various aspects of MOOCs. The key implications drawn from the synthesized data will help to inform future evaluation work. In this section, any researcher assumptions will be discussed, as well as conclusiveness of the data; strengths, weaknesses, and limitations of the systematic review; gaps in the current literature; and possibilities for future research.This systematic review will provide a


While the majority of East Asian countries embraced the modern intrauterine device (IUD) during the 1960s, the sale and distribution of the IUD in Japan was not authorized until 1974. In this paper, I address why the Japanese Government took so long to permit the use of the IUD. Firstly, I examine scientific debates in Japan during the early 1950s on the efficacy of the IUD and associated health risks, to illustrate how the Government's conservative attitude was fostered by a co-constitutive relationship between health officials and leading obstetrician-gynaecologists who believed that the IUD was dangerous and likely to induce abortion. I also trace the Japanese Government's rapidly changing attitude through the 1960s, and analyse the influential interaction between national policy making and the enthusiastic response of a small number of Japanese doctors to the transnational movement to curb population growth in developing countries. I argue that the specific ways in which biomedical discourse was shaped by the sociopolitical position of doctors in relation to the Government's health administration explains the Japanese Government's resistance to use of the IUD. However, I also note that the Government's dramatic change in attitude was influenced directly by transnational reproductive politics. This paper will enhance the history of reproductive politics in post-war Japan, which has tended to focus on the politics surrounding abortion and the contraceptive pill. Since its inception in the 1960s, the modern form of the intrauterine device (IUD) has been one of the most commonly used contraceptives in the world , particuThe reasons behind this are multifaceted, but the Japanese Government's longstanding reluctance to approve use of the IUD provides a significant clue to understanding the current position. Commercial production and distribution of IUD contraceptives was only authorized in 1974. This is a remarkable fact when we consider the following three points. First, the Japanese physician, Tenrei Ōta, became internationally renowned for inventing a precursor of the modern IUD named the ‘Ōta ring’ . Despite this device being available in Japan from the early 1930s, it would be over 40 years before the Japanese Government officially recognized this contraceptive method as a legitimate form of birth control. Second, due to anxieties concerning over-population in the early post-war period, the Japanese Government was keen to promote birth control, and implemented a state policy to this effect in 1951. Despite this incentive, the Government did not sanction the Ōta ring – then being used in clinical trials – when licensing medical contraceptives. Finally, as indicated above, the governments of neighbouring Taiwan, South Korea and the People's Republic of China embraced the IUD enthusiastically during the 1960s, regarding it as an effective tool for the fertility reduction programmes in these countries. In this context, why did the Japanese Government remain practically impervious to events in the region, and take so long to authorize the commercial production and distribution of IUD contraceptives?In this paper, I engage with this question by examining how doctors working with the IUD interacted with policy makers in Japan during the post-war period. As Norgren and Steslicke have shown, doctors in post-war Japan, both as individuals and as a collective, had a great deal of leverage in shaping policies that had a direct impact on the reproductive lives of ordinary people . PrimariFirstly, I examine the Japanese Government's reluctance to authorize the IUD during the 1950s, in what became known as the ‘ring dispute’; a debate between clinical and academic doctors over the validity of the contraceptive for fertility regulation. While clinical doctors stressed the ring's ability to limit family size, leading academic doctors rejected this view and emphasized the contraceptive's potential health risks. The result of the debate was determined by relative proximity to political power; the anti-ring faction was closer to the decision-making process. I argue that the Japanese Government's conservative attitude to the contraceptive owed much to the advantageous position of anti-ring doctors, and the opportunity this afforded them to influence the trajectory of birth control policy.While the first part of this paper focuses on internal factors, the second part looks beyond the national framework. As recent work has shown, from the 1960s onwards, the IUD was promoted globally via transnational networks mobilizing family planning initiatives to reduce fertility rates as part of development programmes in Asia, Africa and Latin America . The proBirth control in Japan's modern history – taken in a broad sense, and therefore including abortion – has attracted substantial academic attention over the past few decades . This paSecond, by focusing on the IUD, this paper also departs from the existing English language history of birth control in post-war Japan, which has centred on the predominance of abortion and lack of interest in the contraceptive pill. This dominant narrative can lodge our perspective too tightly within the domestic framework, and consequently obscure the element of transnationalism that significantly influenced politics at the national level. This IUD case study illuminates the transnational dimension in the domestic policy-making process, and invites a reappraisal of how the state should be presented in historical discussions of Japanese reproductive politics.With this perspective, the paper first provides context by introducing the development of the IUD in pre-war and wartime Japan, and the adoption of the device by birth control activists immediately after the war. These sections will be followed by a discussion of the 1950s ‘ring dispute’ and the emerging factors that contributed to the Japanese Government's negative attitude towards the contraceptive. The final section will depict the rise of the transnational population-control movement, and describe how the engagement of Japanese doctors with this movement coincided with a shift in the Government's approach to the IUD, eventually leading to official approval of the contraceptive in 1974.Although my focus is the process towards governmental authorization of the IUD in Japan, I in no way advocate the progressivist view that the IUD was inherently a cutting-edge technology, and therefore should have gained approval earlier than 1974. Rather, my approach is similar to science, technology and society scholars such as Takeshita, who examined IUD development in the USA, and concluded that the technology was ‘politically versatile’ , shaped While an internalist account of the history of IUD contraceptives identifies the Berlin-based gynaecologist Ernst Gräfenberg as the chief pioneering figure, it simultaneously describes Ōta as another early inventor .Ōta was from a medical family with a strong gynaecological tradition. However, according to Ōta himself, it was sheer curiosity, rather than family tradition or financial gain, which motivated him to specialize in birth control . InspireThe Ōta ring did not gain popularity in the 1930s. Although there were various reasons for this, the negative attitude to birth control prevalent within Japanese officialdom certainly played a critical role. The birth control movement had been gaining popularity in Japan's cities during the 1920s, but associations with socialism and labour organizations led to concerns within the Japanese Government that its authority was being subverted, and the movement's activities were restricted . Ōta himFurthermore, the small group of doctors that had political influence during the 1930s were reluctant to publicly endorse the intrauterine contraceptive device. These doctors raised three main objections to justify their stance. The first was that there were health risks associated with the Ōta ring that outweighed any benefits e.g. . Second,Partly in response to these politically influential doctors, the Japanese Government passed legislation throughout the 1930s to eradicate birth control practices, which ultimately limited public access to the IUD. A regulation was issued in 1930 intending to limit the distribution of what were regarded as ‘harmful contraceptives’ (‘yūgai hiningu’), and in 1936, the IUD were defined as such. These regulations initially allowed the use of the IUD in clinical research, temporarily providing an opportunity for doctors such as Ōta to popularize the contraceptive . HoweverAfter the Second World War, there was a reverse in policy and the Japanese Government became among the first in the world to adopt the popularization of birth control as a national project . This poThis radical transformation in the Japanese Government's attitude to birth control derived from two circumstances emerging immediately after the Second World War. The first was rapid demographic change leading to escalating population figures. Between 1947 and 1949, Japan not only gained 8.06 million babies, but also approximately 7 million repatriates from former colonies and the warfront. From 71 million in October 1945, the population of Japan had increased by over 10 million by the early 1950s, and it was estimated that the figure would reach 100 million by 1962 . Confronde facto legalized the practice (The second factor was a surge in abortion figures following the Eugenic Protection Law (EPL) of 1948. Derived from the wartime National Eugenic Law (established 1940), this was intended to ‘prevent the birth of inferior offspring from the eugenic point of view’ and ‘protect the health and life of mothers’. The EPL was borne from anxiety among health officials and policy intellectuals over racial degeneration, fuelled by the increasing visibility of street children, mixed-race children, sexualized ‘pan pan girls’, and others perceived to symbolize post-war social degeneration . Once enpractice . Having practice , Koya alpractice . Koya mapractice .Meanwhile, a changing political climate was providing opportunities for previously suppressed birth control advocates to resume activities. Significant figures included Katō Shizue, Margaret Sanger's Japanese confidante, Kitaoka Juitsu, and physicians Majima Yutaka and Fukuda Masako . Ōta alsRiding on the increasing popularity of birth control, doctors created various IUDs during this period. In 1948, Ōta resumed production of his golden devices in Tokyo, and collected trial data by coordinating with doctors Kimura Hitoshi and Tanaka Kazuo, who ran small clinics in the city districts of Ikebukuro and Hatsudai, respectively . A formeThis boom in production was accompanied by an increase in the availability of raw materials, which generated diversification in the composition of IUDs. Ōta himself developed various models under the name of the Ōta ring. Having previously utilized mainly natural materials such as gold, rubber, silk gut and hair, he began to experiment with artificial materials immediately after the war. Ōta first tried Sunplatina (‘Sanpura’), a domestically produced nickel-based alloy used in dentistry, and as synthetic fabrics began to be imported from the USA in the late 1940s, tested many of these materials, including nylon in 1949, vinyl in 1951, plus combinations of vinyl and nylon in 1951, and combinations of polyethylene and nylon in 1954, 1955 and 1960.Along with changes in raw materials, the design of the Ōta ring also underwent various transformations. Having been either a simple, smooth-surfaced ball or ring before 1945, Ōta introduced notches to the outer part of the ring as elastic synthetic materials became available after the war. Continuing to experiment with various alternative designs thereafter, he finally settled on a version with nylon thread wrapped around a smooth-surfaced polyethylene ring with a polyethylene marble placed within the centre of the ring's inner circle and attached with three threads .This diversification in design during the early post-war period derived from creators' concerns about technical issues specific to intrauterine devices. Ōta, for example, introduced notches to solve the persistent problem of expulsion in the existing model. However, after 1951, he was compelled to reconsider the new design. The model produced that year became so firmly lodged in the uterine wall that, after several months of insertion, it was impossible to remove; a chemical reaction inside the uterus was causing the cog-like outer feature to harden. This example illustrates how a designer's constant efforts to balance efficacy and health risks drove changes in intrauterine contraceptives, but these changes did not necessarily always lead to improved welfare for users.Despite a boom in production, the IUD was marginalized within the state-endorsed birth control campaign for two main reasons. First, this method had already been excluded from the campaign's pilot studies, organized by Yoshio Koya throughout the 1950s to test the efficacy of a state-endorsed birth control programme . Koya diThe second and more significant reason was the Japanese Government's continuing ban on the IUD. In August 1948, in part to tackle population growth, a reformed Pharmaceutical Law was issued to deregulate the ban on those contraceptives previously deemed ‘harmful’. Throughout May 1949, the Ministry of Health and Welfare issued a series of authorizations for the distribution of 26 birth control medicines , includiWhile this reaction frustrated Ōta, from the point of view of health officials attempting to weigh the contraceptive's efficacy against its health risks, a cautious approach simply made sense. The main concern was that technology ‘foreign’ to the body might produce adverse reactions once inserted in the uterus, causing disorders such as necrosis, inflammation and infection. After careful consideration, the Ministry of Health and Welfare ultimately concluded that potential risks outweighed any benefits that the IUD could provide . HoweverIn such a favourable environment for birth control, the IUD could theoretically have been popularized widely during the early post-war period. The emerging discourse on the need to restrict population growth helped to generate birth control policies and liberated hitherto suppressed birth control activism. Furthermore, the availability of a wider range of materials triggered innovation and a diversification of contraceptive options. Despite this, the IUD continued to appear only in a clinical setting. This marginal position was attributable to the interaction between a government relying on Koya's pilot project for justification of its birth control policy, and Koya's scientific study emerging out of the government campaign. As neither the Japanese Government nor Koya valued the method, the IUD was absent from the state-endorsed birth control programme, and was only promoted sporadically in private clinics via clinical trials reliant on personal networks.In the process of marginalizing the contraceptive within official domains, government officials highlighted potential health risks, which they argued outweighed efficacy. Considerations of efficacy and risk, however, were not the only reasons for this marginalization. As I will illustrate in the following section, the pre-existing discourse relating to the device – the so-called ‘ring dispute’ – fostered by the relationship between prominent medical figures and central government, also contributed to suppressing dissemination of the IUD in the early post-war period.In part because of the surge in innovation described above, the 1950s witnessed the publication of an increasing number of clinical trial reports .Progress in Obstetric-Gynecology in 1950 (Having been conducting clinical trials to establish his contraceptive's efficacy prior to the period, Ōta was at the forefront of this trend. When his application for authorization of the Ōta ring was rejected, despite the Pharmaceutical Law reforms, he decided to put more energy into clinical trials. To start with, at a meeting of the Kinki Society of Gynaecology held in Takarazuka in November 1949, Ōta reported on 39 clinical trial cases using the Ōta ring based on data collected during the war, and published the presentation in the journal  in 1950 . This se in 1950 .The ‘ring dispute’ unfolded within a community of doctors specializing in obstetrics, gynaecology and paediatrics, with battle lines drawn between proponents of the device, largely clinicians, and those against the use of the IUD, who were mostly academic doctors at elite institutions with government connections. At the heart of the dispute lay the issue of the efficacy of the IUD for fertility control, and how the participants interpreted clinical trial data presented during the debate. Advocates of the IUD repeatedly emphasized efficacy by focusing on success rates, while their opponents pointed out the potential health risks revealed in the data, such as cases of bleeding and expulsion .in utero, Andō essentially agreed with Sawazaki that the accompanying health risks should be avoided by adopting other, simpler and easily available techniques, such as barrier methods. In response, Ōta accused Andō of being too theoretical and demanded he provide supporting data. After a long, heated discussion, a consensus could not be reached, and Andō concluded the meeting by reminding the audience that obstetrician-gynaecologists should never recommend any contraceptive method that was not proven to be 100% safe (The dispute reached a climax on 31 January 1952 at the Tokyo Local Meeting of the Japan Society of Obstetrics and Gynaecology. In Ōta's presence, the doyen of obstetric-gynaecology, Andō Kakuichi, from the prestigious private Keio University Medical School, harshly criticized the Ōta ring. Despite disagreeing with the claim by Sawazaki that the ring induced abortions, and accepting that the IUD did indeed prevent conception 00% safe .Participants in the ‘ring debate’ were characterized by their proximity to political decision-making. The main constituents who opposed the IUD were doctors at elite academic institutions, heavily involved in the process of establishing the Government's policies on reproduction. In contrast, many IUD proponents were rank-and-file clinicians or maverick doctors such as Ōta, who, while generally excluded from policy procedure, had significantly more contact with women actually using the device. Furthermore, while the majority of the opposing camp enjoyed physical proximity to central government, many – such as Yagi Hideo, who lived a long way from the capital – were more prone to political isolation.This sociopolitical position of the debate's participants, which translated into accessibility to political power, appears to have contributed to moulding official opinion on the IUD. The government consultation on the Ōta ring that started in September 1953 illustrates this point. In response to Ōta's formal appeal, the Ministry of Health and Welfare set up a Special Committee on Intrauterine Contraceptive Devices , but didvolte-face, the Japanese Government was enthusiastically embracing use of the IUD, to the extent that in 1974, the Ministry of Health and Welfare permitted production of the Ōta and Yūsei rings as medical contraceptives. The Lippes loop, originally developed in the USA, also became available to the public in 1976. Also that year, Fuji Latex Co. Ltd. – a Japanese corporation known for producing condoms – began to produce FD-1, its own IUD, which resembled a fishbone. By 1978, a total of 2,166,250 IUDs had been produced in Japan, of which approximately 80%, or 1,730,570, were for domestic use (By the end of the 1960s, in a complete stic use .Why did the Japanese Government, hitherto so reluctant, finally give the IUD the green light? To answer, I argue that the Government's interest in this contraceptive method, which increased rapidly through the 1960s, was shaped by both domestic and transnational contexts.Within Japan, a sizable number of women had been exposed to various forms of IUD by the 1960s via clinical research. Influential institutions also began to participate in clinical research on the contraceptive in that decade, resulting in the distribution of over 40,000 Ōta rings . By the However, in addition to the domestic factor, I argue that the burgeoning transnational movement to curb population expansion in those regions deemed the ‘Third World’ ultimately swayed the Government's stance. Spurred by the emerging theory of socio-economic development that equated overpopulation with poverty, and by Cold War geopolitics, in which the USA came to consider development aids as tools of what Christina Klein termed the ‘global imaginary of containment’ , US instThe rapid global circulation of the IUD, and its popularity in Japan's neighbouring countries in particular, swayed bureaucratic attitudes to such an extent that the possibility of authorizing the IUD was reconsidered. In August 1964, the Ministry of Health and Welfare requested advice from the Japan Society of Obstetrics and Gynaecology regarding whether or not the IUD was safe and could be recommended to the public . Three yHowever, it must be stated categorically that the transnational movement was more than simply a phenomenon of ‘gaiatsu’, or ‘foreign pressure’, which Norgren has defined as a ‘blunt tool’ which ‘small, political weak groups can use effectively to turn attention to [a given] issue’ . InsteadWhat is particularly fascinating about this aspect of IUD history is that those Japanese doctors who participated in the transnational dialogue about the IUD were not the elite. In a shift from the previous era, when those with the most prestigious positions shaped government policy, the most significant Japanese actors for the development of the IUD from an international perspective were not Sawazaki and his noted colleagues, but Ōta and a seemingly unassuming doctor, Ishihama Astumi . Ōta becIshihama's career had humble origins. Although he was a graduate of one of the prestigious imperial universities, it was based on the island of Kyushu, a long distance from Tokyo. Furthermore, he spent most of his early career in the remote Iwate University. However, this peripheral position enabled Ishihama to establish his career with the contentious Ōta ring. Ishihama first considered recommending the Ōta ring after suffering exhaustion from repeatedly performing mid- to late-term abortions on female repatriates in the provincial Prefecture of Fukuoka. This was a covert operation organized by the Ministry of Health and Welfare to prevent the birth of children conceived potentially as a result of rape or other incidents that occurred during the repatriation process . IshihamYokohama Journal of Medicine, the English version eventually came to the notice of Alan Guttmacher at the Population Council, the driving force behind global promotion of the IUD, via Christopher Tieze and Clarence J. Gamble, who were both involved in the development and assessment of contraceptive methods deployed internationally (On the recommendation of Shinoda Tadasu, his senior colleague and Dean of the Medical School at Iwate University, Ishihama published the results of the latter study in both English and Japanese : 40. Pubtionally . Guttmactionally . Due to tionally .The international recognition of Ishihama and Ōta significantly altered the dynamics within the community of doctors responsible for government policy. Ishihama, the only Japanese doctor invited to speak at the first-ever international conference on the IUD, rapidly established himself in the international arena during the 1960s . Thus, tNevertheless, Ishihama could not alone have swayed the opinion of his anti-IUD colleagues. Throughout the 1960s, these doctors also began to engage with the transnational movement, which urged them to revise their conservative views on the IUD. For instance, Takashi Kobayashi, President of the Japan Society of Obstetrics and Gynaecology, immediately began to support IUD use after accepting an invitation from the Population Council and attending the Second International Conference on the IUD in 1964 . KobayasAdditionally, Koya, a renowned figure in international birth control since the 1950s, swiftly revised his view as the role of the IUD in transnational population control campaigns expanded . The dirAs this case illustrates, the transnational context of the 1960s played a pivotal role in the Japanese Government's eventual authorization of the sale and distribution of the IUD in 1974. Guttmacher's favourable opinion of the IUD, perceived as representing a voice of the translational population control movement, eventually urged elite medical circles and government health officials to revise their negative attitude to the contraceptive. Furthermore, a small number of Japanese doctors, such as Ishihama, changed the course of domestic policy making by being firmly embedded in the transnational movement with his internationally recognized medical research. The eventual official approval of the IUD was thus catalysed by those transnational elements which, far from being simply an external force imposed on national trends, helped erode the conservative attitude to the IUD from within Japan.So, why did the Japanese Government take so long to approve the intrauterine contraceptive method? To respond to this question, I have examined how medical doctors participated in the process of establishing state birth control policy, and played a significant role in the decision-making process in response to the assumption that their expert knowledge would provide insight.However, the ‘ring dispute’ demonstrated that expert knowledge was not influential on its own; proximity to political power was the crucial factor determining which scientific knowledge was deemed more credible. Although activist doctors, clinicians and provincial university doctors used scientific data to show the efficacy of the IUD, the anti-ring faction's conservative view and its emphasis on health risks struck a chord with the Government to a far greater extent than the pro-ring faction's allegedly scientifically-proven argument. The fact that health officials, who were compelled to consider health risks when assessing contraceptives, already shared the stance of the anti-ring doctors, enabled this view to pervade government policy. However, as has been shown above, anti-ring doctors were also better able to shape government decision-making due to their close proximity to political power. Consequently, at least during the 1950s, the Japanese Government maintained a cautious approach to this contraceptive device.During the 1960s, however, government policy changed dramatically and swiftly. This change in attitude corresponded with shifting dynamics within the body of doctors exerting political influence, and was partly generated by the boost to IUD distribution provided by the transnational population control movement, particularly in neighbouring societies within Asia. Crucially, this transnational trend was also firmly integrated in the domestic policy-making process. Those doctors who rose from relative obscurity to become major players in domestic reproductive politics, did so precisely because international audiences deemed them representative of the Japanese community of birth control researchers, and actively engaged with them in the global circulation of the IUD. Their scientific activities connected national and transnational arenas, and eventually superseded the previous approach, leading to authorization of the sale and distribution of the IUD in 1974.In answer to this paper's principal question, then, I argue that the specific ways in which hierarchies among doctors – informed by their sociopolitical positions – shaped official evaluations of biomedical arguments, was a major factor behind the relatively long time it took the Japanese Government to approve use of the IUD. However, I also note that interactions between transnational and domestic reproductive politics in the 1960s, mobilized by a small number of Japanese doctors, consequently impelled the Government to approve the IUD not a great deal later than other countries in East Asia.


Schemes to reduce road impacts on amphibians have been implemented for decades in Europe, yet, several aspects on the effectiveness of such schemes remain poorly understood. Particularly in northern Europe, including Sweden, there is a lack of available information on road mitigation for amphibians, which is hampering implementation progress and cost-effectiveness analyses of mitigation options. Here, we present data derived from systematic counts of amphibians during spring migration at three previous hot-spots for amphibian roadkill in Sweden, where amphibian tunnels with guiding fences have been installed. We used the data in combination with a risk model to estimate the number of roadkills and successful crossings before vs. after mitigation and mitigated vs. adjacent non-mitigated road sections. In mitigated road sections, the estimated number of amphibians killed or at risk of being killed by car traffic decreased by 85–100% and the estimated number successfully crossing the road increased by 25–340%. Data, however, suggested fence-end effects that may moderate the reduction in roadkill. We discuss possible explanations for the observed differences between sites and construction types, and implications for amphibian conservation. We show how effectiveness estimates can be used for prioritizing amphibian passages along the existing road network. Finally, we emphasize the importance of careful monitoring of amphibian roadkill and successful crossings before and after amphibian passages are constructed. Amphibian populations may be severely impacted by road mortality and barrier effects of roads and traffic . Mass moBufo bufo), the common frog (Rana temporaria) and the great crested newt (Triturus cristatus)  . HoweverTo minimize the road impacts on amphibians, road managers in and near Stockholm  constructed passages for amphibians at three sites where large concentrations of amphibians were killed on roads, particularly during spring migration, and thus were considered road sections in critical need of ecological mitigation. The passages were in the form of permanent tunnels with double-sided guiding fences intended to lead the amphibians safely under the road in both directions. The constructions largely followed the European  and SwedBefore and after the construction of these passages, the number and location of amphibians on the road as well as along the fences and in the tunnels were recorded, as the basis for planning of the mitigation constructions and monitoring of their effectiveness. Here, we summarize the results of these counts, and discuss the implications in terms of reduced roadkill and barrier effect, differences between constructions and improved amphibian conservation. We propose a baseline for prioritizing amphibian passages along the existing road network, and suggest some directions for further studies that would support the planning of amphibian mitigation schemes.Rana arvalis), smooth newt (Lissotriton vulgaris) and great crested newt.The three monitored sites are similar in several respects. The roads are all of intermediate size , aiming to identify the most critical road sections for mitigation and to locate major migration routes where tunnels should be placed. Amphibians were also counted post-mitigation (“after”), along the road, along fences and in tunnels, to assess the anticipated reduction in roadkill and evaluate the use of the tunnels. While the field efforts varied between sites and periods  and also a large breeding population of smooth newt . The numbers of other amphibians are small. The amphibian mitigation system was constructed at the major road (Spångavägen) going past the area, in connection to an upgrade of the road in autumn 2014. Amphibians were counted during 17 evenings in 2012, before mitigation was installed, at a one-sided temporary fence and pitfall traps along the section to be permanently mitigated, and by searching the road and verges. Only on 7 of the 17 nights a relatively large number of amphibians were found or trapped, and accordingly could be labeled significant migration night. Amphibians were counted during three evenings in 2015, with the mitigation in place, along the permanent fences and on the road and verges. Evenings for fieldwork were selected to represent important migration evenings (suitable weather conditions and timing). Dead amphibians had accumulated between evenings, thus representing a total period of ca 8 days. The total road section searched was ca 1,000 m (same section before and after), therefore extending in both directions >200 m outside of the fenced section. Customized infrared timelapse cameras  assembled by Froglife  per night (site 1) or evening (sites 2–3) and 50 m road interval, assuming that these data were collected with a similar effort and expertise over the road section searched, and with a similar effort and expertise before and after mitigation, within each site.To be able to tentatively compare the performance of different tunnels at a site, we calculated the number through each tunnel per night (at site 1) or number of movements (in + out) and the net number through each tunnel per 24 h-period (at sites 2–3). To assess the number of amphibians successfully crossing a mitigated road section through the tunnels we summarized the net number through all tunnels at the site.x is the number of successful crossings and y is the risk of getting killed on the road. Concomitantly, a number of amphibians found dead on the road should also represent a certain number that survived and managed to cross, following:x is the number of successful crossings, z is the number of amphibians found dead on the road, and y is the risk of getting killed on the road. Based on average traffic intensity at site 1, we estimated that 62% of newts trying to cross the road surface would be killed by traffic  indicate that the passages were effective in reducing amphibian roadkill during spring migration, compared to the situation before mitigation measures were implemented. None or very few amphibians were found on the fenced road sections, where prior to mitigation amphibians had been killed in the hundreds or thousands each spring. These results are well in line with those from many other studies, showing significant reductions in amphibian roadkill after the construction of adequate road fences .However, the data from at least two of our sites suggested the presence of fence-end effects  which maThese fence-end effects, and the fact that many amphibians crossed and were killed on the road outside the fenced sections, imply that longer fences are likely to result in a larger reduction in roadkill . While tIt is imperative that the effectiveness of amphibian passages in the form of under-road tunnels with associated guiding fences are not only assessed on the basis of the reduction in roadkill but also on the number of animals making it successfully to the other side of the road . PreviouThe results from our three sites indicated that the mitigation schemes likely reduced the barrier effects of the roads. We assumed that even without mitigation in place, a certain proportion of amphibians manage to cross a road without getting killed by traffic, that most amphibians survive where the traffic intensity is very low, but that the proportion surviving decreases exponentially with increasing traffic . ImportaSeveral factors in the technical construction of amphibian passages may affect their effectiveness: width, shape and length of tunnels, distance between tunnels, height and shape of guiding barriers, substrate in tunnels and along barriers, construction material, moisture, vegetation and drainage in and around the passages, special features such as cover objects, guiding structures at entrances and slotted tops , other than the potential bypass effect described above. The most obvious is that the field effort at some sites and time periods was insufficient (three nights or less for data collection) and the data therefore were influenced by random events. Another is that the fieldwork methods were in fact not similar enough with regard to how the basic method was applied in practice to allow the data standardization and comparisons. The changes observed may also depend on annual differences in population numbers or temporal migration patterns. In this case, the effect sizes on mitigated sections can be adjusted according to the changes on non-mitigated sections. However, it is important to note that the non-mitigated sections studied were not true controls (comparators), as they may have been affected by the mitigation measure (the intervention).The standardization of data required a number of assumptions and simplifications that may have introduced errors. We adopted an approach where we tried finding the unifying patterns in studies of amphibian passages conducted with slightly different aims, budgets, staffing and time frames. Despite these limitations, which are unfortunately common in applied conservation projects, we believe that the general picture given by these studies, before vs. after mitigation and along vs. outside the mitigated road section, contributes significantly to the knowledge of how amphibian passages at roads can reduce roadkill and barrier effects on amphibians during spring migration.There is scant evidence in literature that amphibian passages lead to long-term conservation of amphibian populations , and forBy contrast, the low number of amphibians successfully crossing through the tunnels at site 3 —ca 10 individuals per night, an increase with only two per night compared to what may have crossed the road successfully without any mitigation—may appear discouraging. The reduction in the number killed (some 25 per peak migration night) sums up to nowhere near the total estimated number of amphibians breeding at the site (ca 1,300 individuals; It is important to point out that there should be a minimal level of road traffic where amphibian passages of the kind described here need to be considered, as implied by the relationship between traffic intensity and risk of getting killed described by All data treatment in our work relies heavily on At all three sites the mitigation was restricted solely to the most critical road sections see , despiteAn alternative approach to decrease fence-end effect could be to fortify fence-ends, for example, by modifying the angles or extending fences perpendicularly from the road, compared to what was done at our sites 2 and 3  and 3F. Amphibian passages tend to be costly, not least when constructed on existing roads, and it is therefore crucial for road managers to know where passages may be critical for amphibian conservation and how passages can best be designed. To build up the knowledge of amphibian passages at roads, the reduction in roadkill and barrier effects should be monitored when new amphibian passages are constructed, or when existing passages are adapted . The monFinally, it is important to note that our results only focused on adult breeding migrations in spring, without including the summer and autumn migrations of juveniles away from the breeding ponds. Recent population models indicate that the survival rate of post-metamorphic juveniles is of fundamental importance for the persistence of amphibian populations . Adults 10.7717/peerj.7518/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.7518/supp-2Supplemental Information 2The file presents the primary data that were selected for analyses, with sources and steps taken in standardising these for comparability. Work sheet 1 = number of amphibians on/near the road, work sheet 2 = number of amphibians in tunnels.Click here for additional data file.


Ensuring reduction in transmission of lymphatic Filariasis (LF) and addressing the compliance of people to mass drug administration (MDA) has led to renewed efforts in the field. School-based health education (SBHE) intervention, considered a cost-effective strategy with potential to reach the wider public through young people, was adopted as a strategy for social mobilization. This study assessed SBHE perceptions, implementation barriers, and factors in the supporting environment as well as its efficiency to successfully change LF MDA-related knowledge and practice.This mixed methods study was conducted in four sites of Lalitpur district, Nepal. Classroom-based interactive health education sessions were used as the main intervention strategy in the study. In total, 572 students were assigned to intervention and control groups. Questionnaires were distributed before and after the intervention. Mann-Whitney and McNemar tests were used for analysis. Focus-group discussions with teachers and students and in-depth interviews with the district LF program manager as well as Education Office and school management authorities were conducted. Qualitative thematic analysis approach was adopted.Intervention curriculum played a significant role in increasing children’s knowledge and practice (p<0.001). Barriers for school-based interventions were budget constraints, human resource deficiencies, lack of opportunities to conduct practical classes under the curriculum, and lack of collaboration with parents. Supportive factors were training provision, monitoring and evaluation practice, adequate facilities and equipment, positive parental attitudes, presence of interested teachers and students, and prioritization by program implementers.Effective program planning practices such as proper fiscal management, human resource management, training mechanisms, and efforts to promote practical classes and coordination with parents are required to develop and institutionalize the intervention. Effective learning and a supportive school environment appear to be important components to support implementation. The SBHE intervention is a feasible and promising intervention for accelerating compliance towards MDA to eliminate LF. In Nepal, Lymphatic Filariasis (LF) is endemic in two-thirds of its districts accounting risk for 60% of the total population ,2. NatioStudies show that transmission of the disease can be disrupted through annual treatment with anti-filarial drugs for an estimate of at least > 90% of the population . HoweverSince MDA drugs are distributed to an entire group of people regardless of their age except for <2 years children and pregnant women, targeting school children who occupy one-third of population could provide a sustainable information flow to larger population as they can act as “messengers” to their family and community –23. MoreThe motivation of this study is based on the PRISM  domains to examine how an evidence-based program like SBHE interacts with recipients in order to influence program implementation and continuation . The queThis mixed method study utilized the convergent design approach to provide both a qualitative and quantitative picture. This study will involve the separate collection and analysis of quantitative and qualitative data. The results thus will be merged to produce two interpretations for both statistical and thematic qualitative results to key assessment of feasibility of intervention. In this study, a quasi-experimental design was utilized, which included an intervention and a control group and a pre-post assessment to observe the effect of the intervention. The selected sites in study area were assigned to intervention (two sites) and control group (two sites) by lottery method. We simultaneously illustrated SBHE perceptions, implementation barriers, and the supporting operational environment based on five key stakeholder groups: students, teachers, the LF focal person, the school principal, and an officer from education office.2 with a dense population of 468,132 . In. In28]. The SBHE intervention consists of classroom-based interactive health education sessions targeted at school children with the intention to enhance their knowledge and practices regarding LF MDA. An intervention manual was developed to do so, based on information from existing LF IEC materials that were reviewed and approved by a panel of experts .The sessions covered by the manual consisted of both educational and interactive components . The educational component consisted of sessions on LF  and MDA  whereas the interactive component consisted of group work, role play, quizzes, and games. At the end of each session, students were asked to develop short key messages and were encouraged to share these messages with their family members and friends.The sessions were delivered by the principal investigator with the assistance from other team members. Each session was approximately 40–60 minutes  in duration. The intervention was delivered two times before the MDA program in each school with a total of two visits in each school. The primary outcome of the intervention was the assessment of the level of knowledge and practice.The total population from seven selected schools was the study population. The list of the number of students from each of the selected seven schools was obtained from the school registry of each respective school, which resulted in a total number of 611 students from grade 6 to 9. Students from grade 10 were excluded due to their unavailability for post-assessment as they would not be available in the schools after the national level centralized examination. All the students who were interested and present on the day of data collection as well as had both parental consent and student assent, were included as participants in the study. However, considering the possibility of absentee students and refusal or drop out in the middle of the study, a non-response rate of 5–10% was acknowledged. Accounting for missing data, we obtained a total sample size of 572. However, due to the loss of 34 students (6.3%) on the follow up, the final sample size was 538 participants in the end line survey.For the qualitative study, we conducted six focus-group discussion (FGD) with 8 to 10 participants among teachers and students independently in each intervention school, along with one-on-one in-depth interviews (IDI) with school management in each of the intervention schools, the LF focal person from the District Public Health Office, and an officer from the District Education Office. The discussion and interview were conducted with the related stakeholders depending on their availability.The data were collected using qualitative FGD guidelines, interviews, and assessment questionnaires. The questionnaires and guidelines were pilot-tested and then revised before use. Those pilot-tested questionnaires and guidelines were not used for the study. For both the quantitative and qualitative method, a Nepali  version of the structured questionnaire was used to collect data by the research team.The assessment questionnaire consisted of nine questions on LF MDA knowledge and one question assessing the person’s participation in previous MDA. Self-administered questionnaires were distributed to each participant before and after the intervention to collect the demographics of each participant and their information concerning their knowledge and practice towards mass drug administration of LF. FGDs and IDIs were conducted by the research team to obtain insight into the perceptions of relevant parties, identify barriers to implementation, and understand the influence of the supportive environment on SBHE implementation.The research assistants were trained before the survey to orient them to the study instruments in order to ensure completeness during the field survey. The questionnaire used at baseline was used again at the end-line with necessary adjustments. The research team was recruited based on the criteria that the researchers had been from a public health field. The questionnaire was developed based on a previous study ,25,29.Quantitative data were analyzed using Stata software version 13 for Windows. Each filled questionnaire was checked for completeness every time after data collection. For any missed variables and errors, computer frequencies were used and the identified errors were corrected by revising the original questionnaire. LF MDA-related knowledge was assessed using nine items. The responses to the information were either stated as ‘1 = yes’, ‘2 = no’, and ‘3 = don’t know’ and were re-categorized into two groupings of ‘no’ and ‘don’t know’ as 0 and ‘yes’ as 1 and for those participants with multiple responses, that is participants who mentioned two or more answers, they were labeled as knowledgeable. Counting every correct answer score of 1 resulted in producing a total score of 9 points. This scoring system applied was based on previous studies –32. HoweQualitative data were analyzed using the thematic analysis approach where coding was performed first, in order to develop the themes from raw data. To assess consistency, the author and research assistant independently coded each passage, and this was developed in a matrix form for the analysis. During coding, relevant segments of text were labeled as either pertaining to perceptions, barriers, or a supportive operational environment as themes. Through the identification of the important themes within the understanding of participants, coding was done before the interpretation.The ethical application and consent procedure of this study was reviewed and the grant of approval for the study was obtained from the Ethical Review Board of Nepal Health Research Council (NHRC). A formal approval letter from the Epidemiology and Disease Control Division (EDCD), the District Education Office (DEO), and respective schools under study were obtained for data collection. Letters were distributed to all the schools in the study requesting for their cooperation and participation. Consent forms were given to participants and were obtained prior to the study. Students’ assent forms and informed parental consent forms were given to participants to explain the study in advance and request them to obtain written consent. Students who received the consent from their parents/ guardians, were provided with detailed explanations of this study, and they were requested to sign the informed consent forms. Participants were informed participation was voluntary, that their information would be confidential, and their rights to refuse participation at any time during the study.There were 572 participants at baseline (intervention = 289 and control = 283) and 538 (intervention = 276 and control = 262) at end-line. The mean age of participants in the study population was 13.7 years (± SD 1.5 years) with the majority being from the Tamang ethnicity and followers of Hinduism. When assessing the knowledge score, we found significant improvements in the mean score of the participants in the intervention group whereas in the control group, the mean scores were not statistically different at any level smaller than 2.03% . There wOf the students targeted by the SBHE intervention with the aim of effecting a change in their practice, primarily, in their intake of drugs as the major change, there was a significant change (p < 0.001) as 26 percent of the participants reported a change in their practice of drug uptake . WhereasThe results from the study identified the primary reason for abstaining from taking the drugs by the participants and fear of side effects and parents forbidding the children to take the drugs were reported to be the most important factors for not taking drugs . ResultsThe findings from qualitative study are summarized in The results of the study were able to identify that effective health education has the capability to not only result in the acquisition of knowledge but also bring about desired changes in practice . DocumenOur findings also showed school-based intervention and health curriculum have increased the level of children’s knowledge scores, which had its impact on the practice of drug compliance compared to the control curriculum (p<0.001) ,25,33. TThis study also revealed some of the barriers for MDA drug uptake . During We also found that change in practice after the educational intervention can be sustained in the long term, which was also supported by the qualitative findings from the study as the stakeholders perceive the program to be sustainable . We founWe also identified issues in program planning as the most important implementation barrier as there was no proper budget allocation causing budget deficits, improper training methods, and lack of collaboration, which were also identified in other studies ,38. The Though there have been few studies to show the impact of school health ,41. TherOur study concluded that the SBHE intervention could improve the compliance to mass drugs administration for lymphatic Filariasis. The intervention is feasible, with some consideration of facilitating factors particularly in planning and executing the program. Effective program planning practices such as proper fiscal management, human resource management, training mechanisms, and efforts to promote practical classes and coordination with parents are required to develop and institutionalize the intervention. Effective learning and a supportive school environment appear to be important components to support implementation.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.