Protected Areas are a key component of nature conservation. They can play an important role in counterbalancing the impacts of ecosystem degradation. For an optimal protection of a Protected Area it is essential to account for the variables underlying the major Ecosystem Services an area delivers, and the threats upon them. Here we show that the perception of these important variables differs markedly between scientists and managers of Protected Areas in mountains and transitional waters. Scientists emphasise variables of abiotic and biotic nature, whereas managers highlight socio-economic, cultural and anthropogenic variables. This indicates fundamental differences in perception. To be able to better protect an area it would be advisable to bring the perception of scientists and managers closer together. Intensified and harmonised communication across disciplinary and professional boundaries will be needed to implement and improve Ecosystem Service oriented management strategies in current and future Protected Areas. Marine and terrestrial ecosystems play a vital and ever increasingly important role in providing essential Ecosystem Services to humanity and society . EcosystOver the course of the last century strong anthropogenic pressures have caused widespread habitat degradation and a noticeable decline in the environmental quality across many ecosystems, potentially leading to biodiversity loss and an increased risk of declining or even collapsing ecosystem functions, and subsequent loss of ES , 8–13.The very first Protected Areas (PAs) in the form as we now know them can be traced back to the nineteenth century. The first ‘modern’ protected area was Yellowstone National Park, founded in 1872, as “a public park or pleasuring ground for the benefit and enjoyment of the people” . Around Nowadays, Protected Areas have become a key component of nature conservation, human well-being and also of management and policy strategies from regional to global scales –23. Theyhttp://www.ecopotential-project.eu) surveyed the state-of-art view on the services and pressures in a representative selection of areas covering a variety of European regions. This survey elicited responses from environmental scientists as well as PA managers, and for two main groups of PAs, mountainous and transitional waters. In the surveys the importance of various biotic, abiotic, and socio-economic variables for the ecosystem services and pressures in different PAs were assessed.In the pursuit of identifying the most important variables in European PAs, the EcoPotential project  and mountainous PAs were assessed in two surveys; one survey distributed among environmental scientists  and the other distributed among the managers of the studied PAs. The link with the ecosystem structures and functions of these areas was only assessed in the survey distributed among the scientists. The surveys were sent by email to 15 scientists working in the EcoPotential project, and 11 managers of protected areas were interviewed face to face by scientists working in the EcoPotential project.To be able to obtain a proper overview of the major variables important for environmental scientists and PA managers in Europe, a broad range of PAs with different biogeographic settings and environmental conditions were included in the analyses . The anaIn the survey for scientists they were asked to identify the major ecosystem types for the PA and the most important ecosystem services in these ecosystems  per PA, across all ecosystem types, was adopted as the degree of importance of that variable in a given PA. The importance of each variable was then averaged over all surveyed PAs, and the standard error was calculated. Mean importance values of less than 2% were not included in further analyses.To overcome the critical issue that often similar variables were assigned by scientists with several different names, the variables were harmonised to a standard set of variables. An overview of this harmonisation of variables is given in To remain as close as possible to the original answers given by managers and scientists we have chosen for the analyses not to use the existing ES classification schemes of the Millennium Ecosystem Assessment , TEEB 3 and CICESome variables were miscategorised by the scientists. For example “water supply” was indicated as an ecosystem function whereas it is an ecosystem service. For further analysis, and to overcome this type of flaw, the variables were matched with the contextually most similar variable within a category. In this specific case “water supply” was matched with the variable “hydrodynamics” in the category of Ecosystem functions and structures  in each PA always summed up to 100%. The (average) relative importance of the specific variables, as viewed by all scientists and PA managers, both within and between the two different types of PAs, i.e. Transitional Waters and Mountains, were compared after examining for normality using a Kolmogorov-Smirnov test, and statistically analysed for significant differences by means of a Mann Whitney U Test .https://doi.org/10.6084/m9.figshare.5513530.v1All underlying data and analyses will be made available at publication through open access at The 5 most important ES for scientists were: leisure activities, habitat for feeding and breeding, animals of economic use, climate regulation, and waste and toxicant mediation . The sciPA managers also considered leisure activities and habitat for feeding and breeding to be important ES , althougMoreover, among PA managers, the difference in importance of most ES between transitional water and mountainous PAs was much smaller than among scientists (It became clear that scientists put more emphasis on the biotic and abiotic (system related) ES, whereas PA managers put more emphasis on the socio-economic and cultural ES .The most important threat to ecosystem services and underlying functions according to both scientists and PA managers was climate change .Furthermore, for scientists the overall top 5 also contains two abiotic and two anthropogenic threats , overexpFor PA managers the most important threats besides climate change consisted solely of anthropogenic pressures . PA manaFor threats the same holds as for ES, among PA managers the difference in importance of most threats between transitional water and mountainous PAs was much smaller than among scientists .Summing up the variables and distinguishing between those of biotic, abiotic and anthropogenic  nature showed differences in perception by scientists and managers, and differences between mountainous areas and transitional waters. This shows that the importance of biotic ES was considered higher among scientists of mountainous PAs than in transitional waters , whereasRegarding threats, PA managers indicated those of anthropogenic origin to be by far the most important, and threats of biotic and abiotic nature were least important  of the ES and threats as indicated by scientists versus those indicated by managers .When comparing the perception of the importance of ES and threats in mountainous PAs with those in transitional water PAs, the differences between both types of PAs were mostly non-significant in the view of scientists as well as in the view of managers .The results show that common categories of ES and threats are considered to be important across transitional water as well as mountainous PAs. This would allow to make a harmonised list of most important variables of ES and threats over both geographic domains. Such a harmonised list may in the future be helpful to overcome the difference in vocabulary between scientists and managers. This may also help include ES in PA management, since until now PA managers expressed that they did not explicitly apply the ES approach in their management, with only a few exceptions , 41.A noteworthy result of this study is that the variables mentioned, and the importance given to these variables by scientists and managers, are dissimilar. The overall view on important ES and threats by scientists does not match the view of PA managers. Although the set-up of the surveys  may have enhanced the differences, both groups had the liberty to identify variables of their choice which they regarded to be important. Moreover, the differentiation is also very apparent at a higher organisational level of factors. Scientists gave more importance to variables of abiotic and biotic nature, whereas the PA manager’s view was that the socio-economic, cultural and anthropogenic variables are more important. This indicates that there are fundamental differences in the perception of various categories of variables.In relation to this with regard to threats, it has been found that managers may have a low perception of environmental risks, which may explain a lower variability in views, yet at the same time may be reason for incidental strong mismatches between managers .A potential reason managers emphasise anthropogenic ES and threats more than scientists may be related to the fact that managers deal with various stakeholders, like municipalities, local businesses, farmers and fishermen, in day to day management of a PA , 44. TheAn important difference in the perception of the system by scientists and managers may also be caused by the spatial and temporal frame in which they observe the system. While scientists often model and observe long-term, large-scale processes and changes, managers commonly deal with decision-making on annual or sub-annual timeframes, and at local scales (for example managing tourist numbers or issuing licenses). Because of this, scientists are likely to pay more attention to long term processes, while managers will give more weight to issues they deal with in their daily work, such as anthropogenic disturbance –48.Furthermore, the formal goals of PA management, as indicated in the legal documents, when establishing National Parks, often include cultural services, like education, protection of cultural heritage, and recreation. For example, the regulation on the protection of Hardangervidda specifies that the aim of the park is to protect both the ecosystem itself and cultural services, including hunting, recreation and education (Regulation 4839/1981). Due to these formal aims and regular management of tourism activities in their PA, PA managers could be led to emphasise both anthropogenic threats and cultural ES .The observed differences in views may also be an effect of the more in-depth and theoretical view of scientists on ecosystems, and the more general and practical view of managers . The sciIn addition, the higher variation in the perception of important variables among scientists than among managers  may be cOf note here is that among stakeholders interested in the ES of a PA such as farmers or fishermen, the perception of ES may even be influenced by the scale and duration (in decades) that a PA has been managed and under protection –55. The It has to be kept in mind that the concept of ES is highly anthropogenic , and theScientists and managers of PAs differ markedly in their view on the importance of various major ecosystem services and threats. Managers emphasised the anthropogenic  variables, and scientists underlined the importance of abiotic and biotic variables. Obviously, the perception of problems and challenges is biased by day-to-day business and workload. Therefore, it is advisable that in cooperation between scientists and managers, the social and economic factors, including the requirements and pressures of ecosystem services beneficiaries and practitioners, need to be linked more closely to the progress in natural sciences, including the abiotic and biotic processes underlying ecosystem functions and services and changes therein. Intensified and harmonised communication across disciplinary and professional boundaries is needed to improve ES oriented management strategies in existing PAs. This is also crucial when networks of PAs need to be adapted or when new PAs are installed. A more overarching approach will enable a more successful and realistic assessment of management strategies and policy options for current and novel PAs.S1 Table(PDF)Click here for additional data file.S2 Table(S2a) ecosystem services, (S2b) threats, and the classification of the variables into variables of biotic, abiotic or socio-economic (anthropogenic) nature, grey cells are variables indicated by PA managers.(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S4 TableIndicated for the transitional waters (TW) and the mountainous (MO) protected areas.(PDF)Click here for additional data file.S5 TableCategories are Ecosystem Services (ES), Threats (Thr), and Ecosystem Types (ETy). The variable which was originally indicated (“between quotation marks”) is followed by our Remark on it (unless it may have been renamed). For the Actions taken: Split means that the term is split into two or three new terms, Rename means that the original term was renamed (and with its new name entered into the harmonisation tables of (PDF)Click here for additional data file.


Noise-induced hearing loss (NIHL) is an increasingly growing problem in young children. This is attributed to recreational noise being the most common cause of this problem. In young children, hearing problems can delay language development and reduce academic achievements. South Africa, in particular, has limited information and protective measures regarding the conservation of hearing in school-aged children.The main aim of the study was to determine the perception of primary school teachers regarding NIHL. The study also aimed to determine if any hearing conservation programmes are being implemented in schools and the need for training of primary school teachers regarding NIHL.A survey was conducted. In order to cover the population of interest, the sampled schools in Pretoria were clustered into urban, semi-urban and rural areas.The majority of the teachers included in this study are aware of NIHL and its effects. They, however, lack the necessary resources and knowledge to effectively use this information. Most (67.5%) of the teachers indicated that they have never been exposed to children with NIHL in a school setting. It was also found that the majority (84%) of the schools included in the study do not implement hearing screening and conservation programmes.Although the sample size was limited, the results correlate with other research in this field indicating a need for planning and implementation of hearing conservation programmes in schools, including training of teachers in order for these programmes to be effective. Noise-induced hearing loss (NIHL) is a hearing impairment caused by excessive or prolonged exposure to loud sounds. The sound results in changes in the mechanism and metabolism of the inner ear as the outer hair cells (OHCs) of the cochlea are over stimulated. The endolymphatic fluids of the cochlea are also affected in the sense that the high energy transfer causes metabolic stress, which in turn results in swelling and degeneration of the balance and hearing nerve terminals that attach to the inner hair cells (IHCs). Degeneration of the hair cells of the cochlea and damage to the auditory nerve result in either temporary or permanent noise-induced threshold shifts (NITS) Edwards, .NIHL may be sudden or progressive. With the latter, it develops gradually and is more rapid in the first decade of exposure with continuous exposure being more damaging than intermittent exposure. Sudden NIHL is caused by acoustic trauma, which results from sudden exposure to high intensity sound levels that cause instant damage to the hearing mechanism, for example, explosion or gun fire at close range .A TTS is defined as a temporary increase in hearing thresholds after exposure to loud sounds. It can be caused by continuous noise and impulse noise. Continuous noise can be harmful when exposed to noise of 85 dB or more for more than 8 h and impulse noise of 140 dB or more. With continuous noise, for every 5 dB increase from 80 dB, exposure time halves, for example, 80 dB = 16 h, 85 dB = 8 h [South African National Standards (SANS), what is too loud, and how loud is too loud.These experiences tend not to cause concern, partly, because there appears to be a full recovery. However, it is widely recognised that repeated episodes of TTS can result in permanent changes within the cochlea and hearing loss. If the OHCs in the cochlear do not recover within the hours mentioned above, then the hearing loss becomes permanent, which is known as permanent threshold shifts (PTSs)  connections in a network of auditory neurons at a more central  brain level and that these cells continue to fire spontaneously . Chronic tinnitus can be as damaging to quality of life as the effects of hearing loss . Parents and clinicians should be attentive. Measures of speech discrimination often more accurately reveal a hearing problem than the simple audiogram or hearing screening tests. Hearing loss can affect language development in young children. This cascading effect results in reduced academic achievements if information is being missed at school. For adolescents, communication difficulties can lead to social isolation. There have been reports of suicide resulting from social isolation. If hearing aid use is required, the adolescent may also have problems with the cosmetic appearance of the device or the stigma attached to wearing hearing aids. This may result in the adolescent not using the aids, or they may choose to become socially isolated or only socialise with small selected groups. This ultimately will have an influence on their quality of life Many research studies have been conducted internationally to investigate the prevalence and the prevention of NIHL in children; however, there is little research available on NIHL in South Africa. Considering the specific risks that are often unavoidable in South Africa, for example, exposure to excessively loud music in public transport vehicles, which is commonly a mode of transport in order to get to and from school as well as exposure at social gatherings and religious services, highlights the need for research specifically in the South African context. Current international research focuses more on setting standards and guidelines for PLD use. In South Africa, research studies regarding the prevalence of NIHL in youths are extremely limited. A study conducted in 2005 in Gauteng, South Africa, on teachers’ attitudes about hearing loss indicated that teachers do not have adequate knowledge, skills and training for effective implementation of hearing conservation programmes Pottas,  states tThe lack of research in South Africa highlights the need to determine the knowledge and perceptions of primary school teachers regarding NIHL, and hearing conservation is vital in order to identify possible solutions for effective implementation of hearing conservation programmes in schools. It may also create awareness that teachers and audiologists should work together for identification and management of learners with NIHL and also in promoting NIHL prevention programmes at schools. Healthy behaviours are more easily established during childhood compared with adulthood. It would, therefore, be better for children to grow up in an educational environment whereby health promotion is emphasised in order to change listening habits and attitudes. This can only be achieved if teachers are aware of NIHL as well as its effects.A descriptive research design was used for the purpose of this study, that is, a quantitative study whereby researchers seek to obtain insight and answer questions that the researcher has about the population of interest  in Pretoria, regarding NIHL. The study also aimed to determine what and if any hearing conservation programmes are being implemented in schools and the need for training and education of primary school teachers regarding NIHL and hearing conservation.A combination of purposive sampling (a form of non-probability sampling) and multistage sampling  methods was used. The purpose of using the two methods was to increase the feasibility and efficacy in order to accomplish certain goals of the research design. From a population of 283 public primary schools in Pretoria, a number of 164 schools were the representative sample. A 5% confidence interval and 95% confidence level was used to calculate the representative sample, which is most commonly used in quantitative research. To cover the population of interest, the sampled schools were clustered into urban , semi-urban (Ga-Rankuwa) and rural areas  with each cluster consisting of 55 schools. The selection criteria included qualified teachers, educating students in Grade 5–7. As most of the literature regarding NIHL in youths has focused on teenagers, targeting an age group before adolescence was deemed appropriate. All teachers that complied with the inclusion criteria were given the opportunity to participate in the study.Semi-structured questionnaires were used. These are the kind of questionnaires that include both close- and open-ended questions. The questionnaires were adapted from two studies. The first study was that conducted by Taljaard et. al.  about PLReliability is the consistency with which a measuring instrument yields a certain result when the entity being measured has not changed  was used to analyse the different variables. The Statistical Packages for Social Sciences software was used to store and analyse the data.Ethical approval was granted by Sefako Makgatho Health Sciences University Research Ethics Committee , Department of Basic Education and principals from the participating schools. Participants had to give written consent before completing the questionnaires and voluntary participation was emphasised. Researchers ensured confidentiality by having the participants complete the questionnaires anonymously. The semi-structured questionnaires were sent to the participating schools together with consent forms via emails, with some being hand delivered. Those that were hand delivered allowed clarification of questions and were collected immediately after being completed and some were collected a few days after completion. Those sent through emails were emailed back to the researchers.Out of the 164 targeted schools, only 59 were able to take part in the study. The return rate was 5% (59/283), with 19 schools from the urban area, 20 from the semi-urban area and 20 from the rural area. De Vos et al.  stated tFollowing statistical analysis, insignificant differences were found between teachers in urban, semi-urban and rural settings. This could be due to the fact that only seven universities in South Africa provide teacher training and they are in urban settings. The results are therefore mostly reported by combining the responses from all the 219 participants.n = 70) of the participants were able to describe the behaviours of a hearing impaired learner. According to Peel  of the participants indicated that they had experience in teaching learners with hearing loss, 74% (n = 162) had no experience within this area.In this study, only 26% (n = 173) of the participants indicated that audiologists, teachers and parents are responsible for identifying hearing loss in learners. Intensity of sounds was indicated as the most common risk condition for NIHL, followed by the frequency of the sound and the duration of exposure to the sounds. Non-occupational noise was identified as the least common risk condition. The majority of the participants indicated that all of the following are effects of hearing loss in order of most to least importance: academic failures, cognitive difficulties, language and speech difficulties, and social problems. These results suggest that the majority of the teachers have an idea of the impact of hearing loss in children; however, their knowledge in this area is limited as social problems, language and speech problems were indicated as the least common impact of hearing loss, and it is clear that they do not understand the cascading impact of hearing loss on a child in school. According to Doyle and Dye  of the participants were of the opinion that hearing loss can be reversed, 86% (n = 188) said NIHL can happen to anyone at any age and 10% (n = 22) thought that hearing loss can be reversed and can happen to anyone at any age. Only one participant (0.5%) thought that hearing loss only happens to old people. The results suggest that most of the teachers are aware that NIHL can affect any one at any age; however, a small percentage of teachers are of the opinion that NIHL can be reversed. This emphasises the need for training teachers to work with hearing impaired learners. The teachers’ awareness of the characteristics of hearing loss will improve as they gain more experience and training in working with hearing impaired children  agree that loud sounds or music can damage hearing; however, 4% (n = 3) of the participants were not aware of this fact. Supporting these results is a study conducted by Richburg and Goldberg  of the participants in all clusters know the importance of early identification and treatment of hearing loss. This is supported by the results of the study conducted by Hayes  of the participants reported that they have hearing screening programmes, 6% (n = 5) from the semi-urban area and 16% (n = 10) in the rural areas. This suggests that the urban and the rural areas have more schools with hearing screening programmes than the semi-urban areas. However, overall only 13% (n = 29) of the schools from all clusters do have hearing screening programmes in place. It is also not clear if these hearing screening programmes are sensitive to identifying NIHL.From the urban areas, 19% (n = 18) of the schools indicated that these programmes have been functional for more than 3 years. National prevention programmes have been described in the United States , United Kingdom (Do not lose the music) and Australia , , WHO, ; howevern = 206) of the teachers reported that they do not have the necessary equipment required to run these programmes optimally. The professionals in charge of running the hearing conservation programmes were as follows: From the urban areas, 9% (n = 7) of the participants indicated audiologists, 3% (n = 2) of them revealed speech therapists and 12% (n = 9) of them indicated nurses. From the semi-urban areas, 1% (n = 1) of the participants indicated audiologists and 2% (n = 2) revealed speech therapists. From the rural areas, 8% (n = 5) of the participants indicated audiologists and 13% (n = 8) revealed nurses. This suggests that the majority  of the school programmes are run by nurses in the urban and rural areas, with audiologists being the second most common professionals across all clusters. Under normal circumstances, hearing screening programmes should be managed by educational audiologists as they are the ones who can train other professionals to effectively take part in the programmes habilitation  and collaboration with teachers and school personnel in order to develop and implement individualised education plans (IEPs) for each child identified with a hearing loss. Informational and affective counselling and guidance for children, parents and teachers is a key responsibility for educational audiologists. The process of selecting, fitting and determining effectiveness of amplification is also an essential duty of educational audiologists, including participation in measurement of classroom acoustics and instructions for teachers with assistive technology. Clearly, educational audiologists have the skills necessary to collaborate with teachers in order to ensure the academic success of children with hearing loss. With the guidance and support of educational audiologists, teachers can be provided with the necessary tools and education to make the appropriate adaptations for children with hearing loss and implement successful hearing conservation programmes  of the teachers from all clusters have not received any prior training. An even higher percentage  of the participants indicated that they would like to be trained. These results agree with those obtained by Pottas in 2005. The study indicated that teachers do not have adequate skills and lack training for effective implementation of the hearing conversation programmes. Although teachers are educated in the methodology of providing academic education to all students, they may lack detailed information regarding the specific needs of children with hearing loss in the typical classroom. However, with the knowledge and confidence to assist children with hearing loss in the classroom, teachers can promote academic success in this population as well as support hearing conservation programmes.The results obtained suggest that the majority ; the second most common method was presentations  with posters  being the least common method. In a study conducted by Thompson, Pakulski, Price and Kleinfelder  an educational orientation to identify children with a hearing loss that might have negative academic consequences or (2) medically oriented programmes designed for the early identification of existing health conditions that necessitate medical referral. Therefore, a preventive approach for the purposes of identifying early signs of NIHL has not been a focus for school-based hearing screening programmes  training and educating teachers about NIHL and (2) planning and implementation of hearing screening and hearing conservation programmes with an educational audiologist overseeing the programme.The study sample was obtained from different clusters, that is, urban areas, semi-urban areas and rural areas, representing all sectors of Gauteng. Furthermore, although the results of the study cannot be generalised, this study serves as an initial study that can be used to investigate hearing conservation programmes in other provinces and educational sectors. Additionally, the majority (85%) of the participants were able to complete the questionnaires appropriately, suggesting that the questionnaire was clear and the participants understood what the questionnaire required and can, therefore, be successfully used in future research. The anonymous aspect of this survey could be representative of the truthful responses of the teachers as there could be no consequences from their answers.There were insufficient participants in order to generalise the results of this study to the larger population. The limited participants could be due to method of questionnaire delivery and limited time frame of the research project. Nulty  reported


Although there have been many epidemiological reports of the inter-country transmission of measles, systematic analysis of the global transmission dynamics of the measles virus (MV) is limited. In this study, we applied phylogeographic analysis to characterize the global transmission dynamics of the MV using large-scale genetic sequence data (obtained for 7456 sequences) from 115 countries between 1954 and 2015. These analyses reveal the spatial and temporal characteristics of global transmission of the virus, especially in Australia, China, India, Japan, the UK, and the USA in the period since 1990. The transmission is frequently observed, not only within the same region but also among distant and frequently visited areas. Frequencies of export from measles-endemic countries, such as China, India, and Japan are high but decreasing, while the frequencies from countries where measles is no longer endemic, such as Australia, the UK, and the USA, are low but slightly increasing. The world is heading toward measles eradication, but the disease is still transmitted regionally and globally. Our analysis reveals that countries wherein measles is endemic and those having eliminated the disease  both remain a source of global transmission in this measles elimination era. It is therefore crucial to maintain vigilance in efforts to monitor and eradicate measles globally. The measles virus (MV) is responsible for a highly contagious febrile disease characterized by a rash; it remains one of the leading causes of death among young children worldwide despite the availability of a safe and effective vaccine. According to the World Health Organization (WHO), over 130,000 children died worldwide from the disease in 2015 , but theSalmonella typhimurium ..29].The instance of MV transmission has increased since 1995 in most countries in terms of both import and export . The incOther published studies monitoring the global distribution of MV genotypes have also discussed global transmission of the virus ,19. The It should be noted, however, that the genetic data on MV are insufficient to account for the entire global transmission picture since data from many countries are still missing. We therefore combined data from different countries into regions and focused on global transmission in six countries for which data were readily available. These six are all high- and middle-income countries. Unfortunately, we lack data from low-income countries. There is also a concern regarding bias in sampling. For example, the viruses in Africa could be underrepresented, although we regard that the number and distribution of samples from African region (875 sequence data from 33 countries) are not critically underrepresented for our analyses. A further concern is that the sequence data for the virus are insufficient in terms of temporal distribution. Unfortunately, we detected too few instances of transmission before 1990 to allow for analysis of temporal change in global transmission of the virus prior to that date, as interesting as such an analysis would be.N gene recommended for genotype classification (450 nucleotides). It is expected that future surveillance will analyze sequence data using a longer region, owing to recent advances in sequencing technology, thus conferring increased validity on this approach.Another limitation of this study is the short sequence (382 nucleotides) used in our analyses, which represents only a part of the The world is heading toward measles eradication, but transmission of the virus still occurs regionally and globally. Even countries have that have effectively eliminated measles can experience occasional outbreaks and consequently become sources of global transmission. Vigilance and enhanced testing are therefore necessary to eradicate the disease worldwide. This vigilance must extend to areas in which measles has been declared eliminated, since they clearly still play a role in transmission of the disease. Above all, we need more epidemiological information regarding measles and more MV sequence data from all over the world.


An important health issue in urban areas is how changes arising from the regeneration of city-areas affect social determinants of health and equity. This paper examines the impacts attributable to a new fish market and to delays in the regeneration of a port area in a deteriorated region of the Bay of Pasaia (Spain). Potential differential impacts on local residents and socially vulnerable groups were evaluated to determine health inequalities.An in-depth, prospective and concurrent Health-Impact-Assessment (HIA) focused on equity was conducted by the regional Public Health Department, following the Merseyside guidelines. Data from different sources was triangulated and impacts were identified using qualitative and quantitative methods.The intervention area is characterised by poor social, environmental, and health indicators. The distinctness of the two projects generates contrasting health and inequality impacts: generally positive for the new fish market and negative for the port area. The former creates recreational spaces and improves urban quality and social cohesion. By contrast, inaction and stagnation of the project in the port area perpetuates deterioration, a lack of safety, and poor health, as well as increased social frustration.In addition to assessing the health impacts of both projects this HIA promoted intersectoral partnerships, boosted a holistic and positive view of health and incorporated health and equity into the political discourse. Community-level participatory action enabled public health institutions to respond to new urban planning challenges and responsibilities in a more democratic manner. All over the world urban populations are growing and urbanisation is one of today’s major public health challenges . In 2014In recent years Health Impact Assessment (HIA) has been proposed as an essential tool for addressing SDH and developing a Health in All Policies (HiAP) approach. It was launched in 2006  as a govThe present study describes an urban regeneration HIA in the Bay of Pasaia, a port area in the province of Gipuzkoa, northern Spain. Between 1960 and 1970, increased port activity led to a marked population increase and the growth of working-class neighbourhoods around the bay. These were characterised by a high population density, environmental degradation, and a lack of services. Decreased port activity in the 1980s was followed by social, economic, and urban deterioration, and successive revitalisation proposals were repeatedly postponed. The latest Master Plan for the comprehensive regeneration of the bay was presented in 2010. It outlined progressive urban redevelopment and contained several subprojects, centred on the construction of an outer port. The environmental and economic costs of the new port were highly controversial and the plan was rejected by many sectors of the population. Furthermore, due to the economic and political upheaval that followed the recent economic downturn, only two of the subprojects, the new fish market (NFM) and the redevelopment of the La Herrera (LH) zone, achieved a certain degree of concretion.The NFM project proposed constructing a wholesale fish market in the town centre, including a new recreational area. The LH project was designed to redevelop a disused and degraded area, located in the town centre next to the NFM. Progress in the LH project was impeded by disagreements between the two sponsor institutions, City Hall (CH) and the Port Authority (PA). This project was halted and no alternative solution approved. The lack of action was accompanied by progressive deterioration of the LH plot and complaints from the population. Focus was subsequently shifted to the effects of delaying the LH project.A HIA focusing on equity was then conducted to assess the health impacts of both the NFM project and the postponement of the LH project. The aim was to issue recommendations and promote informed and effective decision-making regarding public health. The HIA was part of the Basque Government’s Department of Health policy , which pThis article describes the process and outcomes of the HIA on regeneration projects in the bay of Pasaia, and discusses the main difficulties, opportunities and lessons learned that may be relevant to future urban regeneration HIAs.An in-depth, prospective and concurrent HIA focused on equity was conducted from 2012–2013. The HIA team comprised professionals from different backgrounds , and was led by the regional Public Health Department.Screening: a checklist proposed by the Devon Health Forum  was usedScoping: this involved defining the evaluation reference terms including the affected populations, data and methods, participation and involvement of stakeholder and decision-makers. Disagreements between the sponsor institutions (PA and CH) prevented the formation of a single Steering Committee. To overcome this, parallel meetings were held with the two sponsors to agree on the scope of the HIA and report and discuss the results and final recommendations.Characteristics of the projects: based on a desktop review and meetings between the HIA team and technical staff overseeing the projects.Characterisation of the study area and population: a comprehensive baseline review of data on health and health-related determinants was undertaken. Demographic, socioeconomic, urban, and environmental factors that influence health and health equity were assessed using the available data, existing reports, and through direct observation of the area by the HIA team , accessibility, security, transportation , employment, economic dynamism, social cohesion, and collective self-esteem. Tables Firstly, stakeholder and community perspectives were gathered qualitatively (18 in-depth interviews and 5 focus groups). In addition, to promote community participation in the evaluation process by giving an active voice to players in aspects of municipal life, this approach allowed people to give their views on the projects and impacts, and suggest potential improvements. It also provided data on the relationships between the socio-historical, urban, and health-related dimensions. Sessions were recorded and transcribed upon consent. Analysis was performed from a sociological discourse analysis perspective. More details of the qualitative study have already been published .Secondly, quantitative data was gathered to gauge the magnitude of the problems and impacts and complement the results of the qualitative study Table . Three hA mixed method involving both qualitative and quantitative research was applied to obtain detailed knowledge of the public perception of the projects, and the main impacts on health and health inequalities.Impact analysis: the information collected was integrated into an impact matrix for each project, combining health effects related to each SDH, their distribution in the population, and the data sources used  (Tables ) Tables  and 5.Evaluation: data from various sources was triangulated to fully define the characteristics of the study population, the nature of the projects, their differential effects on socially vulnerable groups, the public’s perception of them and their impact. Table Recommendations: based on the analysis of the health and inequalities impact data collected, a set of recommendations were developed for mitigating potential negative impacts and enhancing potential positive impacts Table .The HIA was conducted according the Merseyside guidelines , which pThis section presents the results of the evaluation and the recommendations (third and fourth stages described in the method). It includes an analysis of the projects, population characteristics, results of qualitative and quantitative research, impact matrix for each project, and recommended improvements.The scheduled timeframe for the NFM project was 2011–2014. The project proposed a landmark building with a walkable roof garden overlooking the bay. The building was designed to occupy the site of the old fish market, a 4-hectare plot in the urban centre, concealing the commercial activity of the market while still requiring trucks to pass through the town’s main street.The LH project proposed new residential and service-related uses for a much deteriorated 7-hectare plot, located in the town centre close to the NFM site. The project did not obtain municipal licensing due to disagreements between the sponsor institutions regarding the proposed future uses of the plot. The project did not obtain municipal licensing due to disagreements between the sponsor institutions regarding the proposed future uses of the plot. The PA mainly proposes new housing development whereas the CH proposes community infrastructure and recreation areas. As a consequence the regeneration project was halted and the plot in the town centre remained degraded and unsafe.In 2012, the study area had 20,862 inhabitants. Compared with the average for the Gipuzkoa province, the population was significantly older, had a higher unemployment rate, was less educated, and had a higher proportion of foreign-born residents. The study area was economically deprived, with 89.0 % of the census tracts within the three lowest deprivation index quintiles. It also had a higher housing density than the average for the province, as well as a lower percentage of green spaces . Peaks in daytime and night-time noise levels of more than 10 dB (A) above the reference limits were also recorded. The urban centre contained about 11 hectares of degraded land  than in Gipuzkoa in general. A higher consumption of anxiolytic and antidepressant drugs was observed, along with more hospital admissions than the average for the province. Unhealthy habits were more prevalent, with higher smoking and physical inactivity rates Table .Gathered through qualitative research. The general public’s perception of the regeneration projects’ health impacts pivoted around a biomedical understanding of health. A strong awareness of deficits in social endowments and a sense of institutional neglect dominated the discourse, often overlapping with issues more directly related to health. Political dissension between the two institutions and the resulting impact on the regeneration process (delays and area degradation), as well as a lack of information and transparency were all mentioned by participants.A certain degree of heterogeneity and complementarity of views according to social status was identified. Participants with higher socioeconomic status had a more technical-political perspective, focusing on macro aspects of life in society, while participants with the lowest socioeconomic status focused more on everyday problems.In addition to the importance per se of these factors and their influence beyond the areas of intervention, focus groups and in-depth interviews identified impacts associated with the projects. The NFM was generally perceived as enhancing the urban quality of the area, given the symbolic nature of the building, the creation of new recreational areas, and the associated improvements in walkability. Improvements in social cohesion and job creation as well as greater economic dynamism were also identified as potential positive effects associated with the creation of new, quality spaces. The NFM’s location in the town centre and goods vehicles associated with its commercial activity were perceived as factors that would increase the accident risk in addition to noise, odours, and contamination.The stagnation of the LH project resulted in outrage and frustration over repeatedly unfulfilled promises and the perpetuation of a deteriorated environment. The main concerns were related to unsatisfactory urban maintenance, poor health, insecurity, and a lack of recreational areas. These frustrations, expressed by the majority of citizens, had a negative impact on collective self-esteem, hindering the adoption of healthy habits such as physical activity or social interaction.The study participants also proposed further improvements, such as a pedestrian walkway along the bay that would connect the port with the metro station. This proposal called for an urban axis to integrate the NFM and LH, support civic activity, and enhance the urban quality of the area.A total of 303 people were surveyed with an average age of 47.6; 49 % were aged between 18 and 44 and 51 % were over 45. Women comprised 50.5 % of the sample group.Table The pedestrian walkway proposed in the qualitative phase was valued very positively given its potential to improve urban quality. The assessment was more positive among younger respondents and residents of the most deprived areas, who viewed the walkway as a means of increasing physical activity, facilitating use of the metro, providing more social and leisure opportunities, and enhancing the area’s attractiveness Table .The findings showed limited appropriation of and attachment to the public space among respondents. Of those surveyed, 35.0 % could not identify a place of special value and subjective significance in the area, a response that was more common among women.Tables Issued in two stages: (i) after the screening phase, before construction of the NFM began, in order to minimise impacts during the building work; and (ii) after analysing the evaluation process, based on the participants’ requests and the potential improvements identified.The recommendations were grouped into three categories focused on: a) improving the impact of the NFM project; b) minimising the negative effects of the delays and inaction affecting the LH; and c) new opportunities for improvement, particularly the pedestrian walkway due to both its expected effect on the SDH and the community support it received Table .The final report containing the results of the evaluation and the resulting recommendations  was presThe assessed projects were part of a comprehensive regeneration plan, the complexity of which was conditioned by the historical and political context of the affected community . The intThe differing nature of the two projects, as well as their development, resulted in opposing health and health inequality impacts; overall, these were positive for the NFM and negative for LH. The NFM project responded to a degraded urban environment with few recreational or social areas and poor walkability, contributing to improved urban quality and social cohesion. The lack of intervention in the case of LH had a negative impact as it perpetuated the deterioration, insecurity, poor health, and social frustration. Fourteen recommendations were proposed for improving the projects, their health effects and their distribution within the population. These have been partially accepted, and their compliance will be evaluated at the end of the projects.Beyond effectiveness in implementing recommendations, this HIA produced other relevant outcomes, in terms of changing the views and attitudes of community participants and decision-makers, raising awareness of health issues, and promoting intersectoral partnerships. The HIA therefore functioned not only as a decision-making tool for urban planning but also as a way to construct a practical framework for supporting and developing the HiAP strategy, by integrating health considerations into decisions made outside the health sector .Regeneration processes are complex with varied and diffuse impacts; these can influence and be influenced by contextual factors . AddressIn this HIA, data obtained through the qualitative study helped explain the situation of conflict, low collective self-esteem, and social pessimism. Moreover, these findings revealed the importance of the area’s historical background, with repeated rehabilitation proposals that were never realised due to a lack of institutional consensus, generating feelings of abandonment in the population. According to urban psychology , environThe findings also highlighted characteristics of the regeneration processes that should be considered during the evaluation. One such example is the labile and evolving nature of the projects, with frequent changes and delays in their development, having collateral effects through differential perceptions of the proposed time frame , 21. ThuThe lack of information and transparency in project management was another source of mistrust. These deficiencies are common in young democracies with little experience of public participation in decision-making, as described in other urban regeneration HIAs in Spain , 23. In The evaluation process also revealed that identifying the project’s potential health impacts presented a challenge for some of the participants. Similar difficulties have been described in relation to HIA, due to the general public’s predominantly biomedical perspective . HoweverThe quantitative study assessed the importance of social and urban problems in the area and their relevance to different population subgroups. People positively valued the incorporation of quality urban spaces, given that these promote sociability, leisure, exercise, and walkability, and related health improvements. Moreover, the population’s broad endorsement of this feature and its likely promotion of healthy behaviour in the most disadvantaged social groups underlined the value of these measures as mechanisms for generating equity.The lack of urban landmarks or areas of special significance likely to generate some form of place attachment was one of the key findings. The fact that more than one third of the respondents had difficulty identifying a place of subjective significance in the area emphasises the importance of this deficit and the need for regeneration projects. Some studies show that spaces which can create a sense of attachment or establish emotional links have a positive effect on the formation of identity, the sense of community, and emotional and social wellbeing , 26. TheAlthough equity is a key principle in an HIA, its comprehensive introduction into the analysis often poses a challenge, given that it adds complexity . One of An important aspect of the HIA is its flexibility: it evaluates not only the effects of proposed projects, but also the impact of inaction and delays in project implementation. Non-intervention is generally regarded as a control situation, necessary to identify the effects of an intervention in the short or medium term . In our Urban redevelopment projects may promote place attachment and increase a community’s physical and psychosocial capital . IncludiThe use of multiple data sources and the triangulation of qualitative and quantitative data is another strength of this HIA. While a HIA is a context-sensitive tool, in-depth understanding of context requires different methods . The appThis HIA has additional limitations that, although not affecting the overall results, should be taken into consideration. The division of competences between institutions governed by different political parties further complicated the HIA process, hindering consensus dynamics. The institutional confrontation made it impossible to bring together all of the sponsors in a single HIA steering committee, and necessitated parallel briefings and discussions with the two main institutions (PA and CH). Another limitation is that the HIA cannot be separated from the context in which it was undertaken. Spain has little tradition of intersectoral collaboration and participation in decision-making processes . DespiteThe limited sample size and design of the quantitative research could also be a weakness of this study. Although, a larger sample would have provided more statistically reliable and powerful estimates, the surveyed population was considered adequate for statistical analysis considering the descriptive nature of the research and the available resources. Moreover, quota sampling did not ensure the representativeness of the sample, but it did provide information on key groups and variables for this HIA, such as social disadvantage, age and gender.Despite these limitations, the HIA process was positive as it helped identify impacts, informed decision-makers, integrated health and health equity considerations into urban planning, and placed value on intersectoral partnerships. It therefore aided in putting the HiAP strategy into practice, which is one of the Basque Government’s 2013–2020 Health Plan objectives . MoreoveThe differing context, nature, and implementation of the two projects generate contrasting health and inequality impacts: generally positive for the NFM and negative for LH. The HIA, as a structured framework for participatory action at community level, allows public health institutions to respond to new urban planning challenges and responsibilities in a more democratic manner. The present evaluation process promoted a holistic and positive vision of health, incorporating health and equity into the political discourse. It provided a platform for the communication and negotiation necessary in the context of high levels of institutional-community conflict and dissension, which often accompanies urban redevelopment projects. In addition to a framework based on values of equity and dialogue, this HIA facilitated partnerships between sectors, institutions and citizens and fostered transparency and public accountability.


Child health interventions were drastically scaled up in the period leading up to 2015 as countries aimed at meeting the 2015 target of the Millennium Development Goals (MDGs). MDGs were defined in terms of achieving improvements in average health. Significant improvements in average child health are documented, but evidence also points to rising inequality. It is important to investigate factors that drive the increasing disparities in order to inform the post-2015 development agenda of reducing inequality, as captured in the Sustainable Development Goals (SDGs). We investigated changes in socioeconomic inequality in stunting and fever in Zambia in 2007 and 2014. Unlike the huge literature that seeks to quantify the contribution of different determinants on the observed inequality at any given time, we quantify determinants of changes in inequality.Data from the 2007 and 2014 waves of the Zambia Demographic and Health Survey (DHS) were utilized. Our sample consisted of children aged 0–5 years . We employed multilevel models to assess the determinants of stunting and fever, which are two important child health indicators. The concentration index (CI) was used to measure the magnitude of inequality. Changes in inequality of stunting and fever were investigated using Oaxaca-type decomposition of the CI. In this approach, the change in the CI for stunting/fever is decomposed into changes in CI for each determinant and changes in the effect—measured as an elasticity—of each determinant on stunting/fever.While average rates of stunting reduced in 2014 socioeconomic inequality in stunting increased significantly. Inequality in fever incidence also increased significantly, but average rates of fever did not reduce.The increase in the inequality (CI) of determinants accounted for the largest part (42.5%) of the increase in inequality of stunting, while the increase in the effect of determinants explained 35% of the increase. The determinants with the greatest total contribution (change in CI plus change in effect) to the increase in inequality of stunting were mother’s height and weight, wealth, birth order, facility delivery, duration of breastfeeding, and maternal education.For fever, almost all (86%) the increase in inequality was accounted for by the increase in the effect of determinants of fever, while the distribution of determinants mattered less. The determinants with the greatest total contribution to the increase in inequality of fever were wealth, maternal education, birth order and breastfeeding duration.In the multilevel model, we found that the likelihood of a child being stunted or experiencing fever depends on the community in which they live.To curb the increase in inequality of stunting and fever, policy may focus on improving levels of, and reducing inequality in, access to facility deliveries, maternal nutrition , complementary feeding (for breastfed children), wealth, maternal education, and child care (related to birth order effects). Improving overall levels of these determinants contribute to the persistence of inequality if these determinants are unequally concentrated on the well off to begin with. Socioeconomic inequalities in childhood health have persisted, with children from poor households experiencing a disproportionately larger burden , 2. ThisFever is a broad measure of ill-health which may signal a number of sicknesses, including malaria and bacterial as well as viral infections –9. In chOf particular concern is the fact that fever and stunting, either directly or indirectly, constitutes a large share of childhood morbidity and mortality in low and middle income countries . PerhapsSecond, persistence in inequalities in childhood ill-health is a source of concern on grounds that disease (whether infectious or not) in some parts of the population may affect the whole population . On a naAgainst this backdrop, reducing inequality has been espoused as one of the goals of the post 2015 development agenda, the Sustainable Development Goals (SDG). This is noteworthy because inequality was not an explicit goal in the Millennium Development Goals (MDGs), the predecessor to the SDGs. Despite the fact that policy documents in the MDG period emphasized the importance of reducing inequality, which they argued was key to achieving the MDGs on health –19, therZambia experienced sharp increases in a number of child health interventions in the MDG period , 23. At This paper uses large nationally representative household survey data from the Zambia Demographic and Health Survey (DHS) collected in 2007 and 2014 to examine changes in inequality in stunting and fever. Three objectives are pursued. First, and as a starting point, it explores the determinants of (factors associated with) stunting as well as fever and examines whether the community in which the child lives affects their health. Second, the paper investigates the significance of socioeconomic inequality in stunting and fever in 2007 and 2014 as well as whether or not the magnitude of inequality changed in any significant way over this period. The concentration index (CI) is used to quantify socioeconomic inequality in these measures of childhood ill-health.Third, this paper examines how determinants of fever and stunting may explain changes in socioeconomic inequality as captured by the change in the CI over the 2007–2014 period. The change in the CI for stunting/fever is decomposed into the relative contribution of each determinant, which is further broken down into two components: changes in the CI of each determinant and changes in the effect of each determinant on stunting/fever, measured as an elasticity. By adding up the percentage contributions of each of the two components, we are able to look at the change in the CI of stunting/fever that was accounted for by changes in CI of determinants on one hand and changes in the effect (elasticity) of determinants on the other hand.Our study directly relates to studies from Vietnam that attempted to decompose the change in the concentration index of height for age. These studies found that rising inequality in height for age between 1990 and 2010 were mainly accounted for by both the increase in inequality in wealth and its elasticity , 27. TheOur study also relates to a rich literature that decomposes inequality in other dimensions of child health. As opposed to decomposing changes in inequality, such decompositions are only able to decompose a single concentration index and are thus not able to explain or quantify the sources of the observed change in two concentration indices that differ in time or space. Most studies that conduct decompositions over time have centered on explaining changes in average health and not changes in inequality .This study also contributes to the literature that explores the effect of key determinants such as maternal education, wealth, maternal nutrition and other key covariates, on child health. Despite the fact that our estimates cannot be viewed as causal due to the cross sectional nature of our data, the rich set of covariates enables us to gain useful insight into the drivers of childhood ill-health.In this paper, we say inequality to mean socioeconomic inequality in health as opposed to total inequality in health.Data were obtained from the 2007 and the 2014 Demographic and Health Survey (DHS). For children under the age of 5 years, our final dataset consisted of 5,616 observations in 2007 and 12,714 in 2014. The large difference in the number of observations between the two periods was due to the fact that the sample size for the 2014 DHS was more than doubled in order to provide reliable estimates for rural and urban areas within provinces .The DHS uses a two stage sampling design where in the first stage, enumeration areas (clusters) are selected with probability proportional to size. The second stage selects households. In each household, three questionnaires are administered to eligible members by trained enumerators. The three questionnaires are the household’s, woman’s and man’s questionnaires .Child health information is captured in both the household’s and woman’s questionnaire. Since, we are interested in children under the age of 5 years, only women who had given birth within the five-year period preceding the relevant survey year were included. Using mother’s identification variable, we merged the household and women data files. Children with missing mother identification variable either due to the mother being absent during the survey or due to incomplete interview were not included in the analysis.zscore06 package in Stata [Fever was measured by asking the mother whether her child had any fever within the two weeks preceding the survey. On the other hand, stunting was defined as having a height for age z-score of less than 2 standard deviations of the reference population using the WHO 2006 growth standards. Anthropometric measures (height and weight) were measured by the interviewer during each survey. Using the in Stata , we compThe wealth index was calculated using principal component analysis and is provided together with the DHS data. Observations were ranked using the raw wealth index for purposes of computing concentration indices. In the decomposition analysis however, we grouped observations into quartiles.yijt is a binary variable equal to one if the outcome (fever or stunting) for child i residing in community j in year t is true. αjt, is the random effect for community j in year t, with δj being the time average random effect for community j. xijt is a vector of determinants of yijt while β is a vector of regression coefficients which show the effect of xijt on yijt. The variable εijt represents all other individual level determinants of yit that we are not able to observe. It is normally distributed with mean zero and variance, μjt represents all other community level unobservable determinants of child i’s outcome. It has mean zero and variance, For each survey year and each outcome, we fit a two level random intercept (multilevel) regression model. The first level is for the individual (child) while the second level is the community (enumeration area or cluster) where the child lives. The model takes the form:β.This paper does not aim to conduct a full multilevel analysis. Our only interest is to see whether or not, broadly viewed, the community in which a child lives matters for their health. As such, no covariates are included at the second level. We are only interested in the ICC and the coefficients in yijt is binary. Our interest is to also use the coefficients in β in the decomposition of the concentration index. However, since logistic regression is nonlinear while the decomposition of the concentration index requires linearity, we can either compute partial effects (probabilities) from the log odds, β, or use the log odds themselves in the decomposition.The above regression model can be estimated using multilevel logistic regression since β in multilevel logistic regression is complicated. Since we are interested in partial effects, and for ease of interpretation as well as computation simplicity, we used the multilevel linear regression which yields direct estimates of partial effects. Linear regression as a method of modelling binary variables, formally termed linear probability models (LPM), has seen widespread use in the literature lately and yields partial effects that are not different from probit or logistic regression partial effects [β, then the LPM is very appropriate [Partial effects have the advantage of being easily understood. However, generating them from the vector  effects –32. It hropriate .We use the concentration index to quantify the extent of socio-economic inequality in the prevalence of stunting and incidence of fever in 2007 and 2014. The concentration index summarizes the extent to which good or bad health is dependent on income or wealth and it may be explained using the concentration curve concept. The concentration curve plots the cumulative share of health (on the y-axis) against the cumulative proportion of the population, ranked by wealth, from poor to richest (on the x-axis). For example, the concentration curve may show the cumulative percentage of stunting accruing to the poorest 25% of the population. To be complete, suppose that we want to look at inequality in ill-health. If the concentration curve lies on the 45-degree line, then the cumulative share of ill-health is equally shared between the rich and the poor and there is no socioeconomic inequality in health. However, if the concentration curve lies on the left of the 45-degree line, then the poor carry a disproportionately high share of ill-health.t, it can be written as:t. Rijt is the rank of child i’s household in the wealth distribution, in our case measured by the wealth index from principal component analysis. The concentration index ranges from -1 to 1. It is zero if there is no socioeconomic inequality in health, -1 if all the ill-health is borne by the poor, and +1 if the richest have all the ill-health. It has been shown however that the concentration index may not be bounded between -1 and +1 if the health variable is binary [The standard concentration index is twice the area between the concentration curve and the 45-degree line and in any given year, s binary , as it iTwo alternative normalizations of the standard CI have been proposed by Wagstaff  and ErreFor each outcome, we computed this index in 2007 and 2014 to assess the extent of inequality in each year.y, we computed the change in the concentration index as follows;For each outcome, The computation of the normalized CI based on Our challenge is that since each estimate in these stages is computed from survey data, it has uncertainties which have to be taken into account when computing standard errors. Using analytical standard errors (from the last stage only) would make confidence intervals appear narrower than they actually are. To guard against this problem, we employ a bootstrap procedure with 1,000 replications. This involves repeating the above four step procedure 1,000 times, each time collecting the estimates, and then using these estimates to compute confidence intervals—which are then called bootstrap confidences intervals.β, from y in year t can then be written as a sum of the weighted concentration indices for all the determinants of y plus the generalized concentration index for the error term:CIkt is the concentration index for determinant k at time t computed as in yijt in xijt to get CIkt. The weight, kth variable with respect to the health variable yijt at time t and GCεt is the generalized concentration index for the error term. GCεt is obtained by multiplying the concentration index for the error term by the mean of the outcome, t, yt can be written as a weighted sum of the concentration indices of the K determinants plus the concentration index of the unobserved determinants of yt. The weight for each concentration index of the determinant, CIkt, is the elasticity of yt with respect to that determinant , or the change in it’s the elasticity, (ηk2014 − ηk2007), or both. An increase in the concentration index of the kth determinant in 2014 increases its contribution to inequality. On the other hand, the increase in its elasticity in 2014—resulting from a change in kth determinant is concentrated on the well-off (CIkt > 0) and it has a protective effect  between 2007 and 2014 . This inThe determinants that contributed most to the increase in inequality of stunting were mother’s height and weight (37%), being in the two wealthiest quartiles (32%), birth order (27%), facility delivery (26%), duration of breastfeeding (13%), and higher level of maternal education (9%). Other factors worked to reduce inequality and hence have negative percentage contribution to the increase in inequality. But how did the change in CI and effect of each of these determinants contribute to the increase in inequality of stunting? Since the CI of facility deliveries itself reduced (became less pro-rich—facility deliveries increased more among the poor), the contribution of facility deliveries to the increase in inequality of stunting was almost entirely driven by the increase in its effect on stunting. Despite the reduction in the CI, however, inequality in facility deliveries remained pro-rich (the rich still had higher access to facility deliveries). Hence the increase in the protective effect of facility deliveries disproportionately benefited the better off. The same can be said about maternal education; the effect strengthened but this benefit accrued more to the better off since they had a disproportionately larger share of higher education. The contribution of duration of breastfeeding to the increase in inequality was entirely due to the inequality effect; longer periods of breastfeeding becoming more concentrated on the poor.While both changes in the CI  of determinants as well as the effects (elasticity) of determinants were important in explaining increasing inequality of stunting, almost all (86%) the increase in the inequality of fever incidence was accounted for the change in the effects of determinants . The chaAs indicated earlier, the CI for wealth reduced slightly although it remained pro-rich. However, there was a substantial strengthening of the effect of wealth on fever in 2014, and due to the highly pro-rich distribution of wealth, most of this benefit accrued to the better off. This drove inequality in fever up, as did maternal secondary or higher education.Even if almost all the increase in inequality of fever was accounted for by the increase in the effect of determinants, some determinants’ contribution were both due to the change in their effect and their concentration indices. This can be said of birth order whose contribution to the increase in inequality of fever was due to the two mechanisms reinforcing each other—higher birth order becoming more concentrated on the poor and a strengthening of effect of birth order on fever.We investigated determinants of, and socioeconomic inequality in, stunting and fever in Zambia between 2007 and 2014, a period when child health interventions were rapidly scaled up to meet the 2015 MDG target on child health. We find that although stunting prevalence reduced, inequality increased. On the other hand, fever incidence did not fall but inequality still increased. The increase in inequality of stunting and fever implies that the rapid scale up of child health interventions may not have been successful in reducing childhood disease burden among the most vulnerable, suggesting the need for policy reform if the goal of reducing inequality, as captured by the Sustainable Development Goals (SDGs), is to be achieved.We also find evidence of clustering for both stunting and fever implying that the likelihood of being stunted or having fever partly depends on the area in which the child lives, which is particularly apparent for fever. Elsewhere, fever has also been shown to exhibit substantial clustering –39, and Our study included a rich set of determinants that potentially explain the likelihood of a child getting fever or being stunted. We document a very strong association between maternal size (height and weight) and stunting. The association between maternal height and weight on one hand and stunting on the other hand may be due to genetic factors or maternal nutritional deficiencies—showing up as low maternal weight and short maternal height. Maternal nutritional deficiencies may lead to in-utero growth restriction, , so thatIn line with the strong and consistent correlation, the decomposition analysis showed that inequality of maternal height and weight was the biggest driver of the increase in inequality in stunting over the period 2007–2014. The increase in inequality was mainly due to the fact that more advantageous heights and weights became more concentrated on wealthier mothers. It is therefore important to reduce inequality in maternal nutrition, both early in life and during pregnancy, to halt increases in inequality in stunting.Another interesting finding relates to birth order. We found that higher birth order was a risk factor for stunting and fever. These findings are consistent with a number of studies that have documented a negative association between higher birth order and child health –49, educWe also document a consistent correlation between duration of breastfeeding and childhood ill-health where possible confounders, including wealth, are adjusted for. In results not reported, this correlation was generally maintained in all households after stratifying by wealth quartile. There is mixed evidence on the effect of breastfeeding duration on child health. A number of studies find a positive correlation between duration of breastfeeding and poor growth –62 whileAlthough longer breastfeeding duration was a risk in all wealth quartiles, poorer households breastfed longer than their well off counterparts. The concentration of longer breastfeeding duration on poorer households contributed to the increase in inequality of childhood illness. One should however, interpret these results with caution because breastfeeding in itself has been shown to have other beneficial effects . PerhapsFacility deliveries may be an important entry point for feeding counselling and support interventions. This assertion is supported by evidence from Uganda were being delivered at a facility was associated with better child feeding practices and nutritional status of children . We findThe question emerges, how can policy halt the increasing socioeconomic inequalities in stunting prevalence and fever incidence?One possible option would be to reduce, and possibly eliminate, the effect of determinants that increase the risk of stunting and fever. This can be done in three ways, as can be seen when the elasticity formula is unpacked (we discussed this mechanism in the last part of the methods section). First, the average level of determinants that are risk factors for child health can be reduced. Second, the association  between (of) the determinant and (on) child health can be eliminated. For example, in the case of birth order, routine health education programs may emphasize the importance of giving as much attention to children of higher birth order as those of lower birth order. This may diminish the association and thus reduce inequality. Third, and lastly, the incidence or prevalence of the relevant childhood ill-health can be reduced.The other option would be to reduce inequality (concentration indices) in (of) determinants such as wealth, education, maternal nutrition, etcetera, which are protective for child health. These determinants are unequally concentrated on the well off and reducing their inequality may be beyond the scope of health interventions. It is important to realize that health interventions can mainly affect the effect, in terms of elasticity, of these determinants on child health but not their distribution. For example, since more educated mothers are likely to understand and follow health instructions better, health interventions such as infant and child feeding, breastfeeding counselling, etc., may increase the association between maternal education and stunting but are not able to reduce inequality in education. The same can be said about wealth. Therefore, it is easy to see why, despite the rapid increase in child health intervention coverage (such as infant and child feeding counselling and support) and the accompanying increase in the effects of determinants, inequality in childhood-ill-health still increased. The dichotomy is that increasing the effect of determinants with protective effects, which is a good thing in general, worsens inequality if these determinants are disproportionately concentrated on the rich in the first place. This is an example of the classical equity-efficiency trade off. Despite the persistence of inequality, other studies have documented substantial improvements in other measures of child health, such as under-five mortality , 71. OurOur study has limitations and due caution must be excised when interpreting the findings. It must be noted that no community level covariates were included at the second stage of the multilevel model. This raises a possibility of confounding if the omitted community level covariates are correlated with both childhood ill health (stunting or fever) and any included individual or household level variable. Moreover, being based on cross-sectional data, our results cannot be viewed as causal.It is worth mentioning, however, that the data we have used, the Demographic and Health Survey (DHS) presents both limitations and strengths for inequality analyses. It is a limitation because DHS relies on wealth indices and does not contain finer measures of household living standards, such as consumption or income. Income or consumption has the advantage of being able to be objectively measured and compared across different places or surveys with less difficulty. Wealth indices may be problematic if one is comparing two populations  as the type of assets and their valuation may differ across populations and time. Although some methods on how to make wealth indices collected in two different populations or two different points of time have been proposed , they arUsing the DHS is also a strength of our study. This is because it contains a rich set of health variables. As an alternative, we could have followed studies from Vietnam and used data from the Living Conditions Measurement Surveys(LCMS)which have information on income, consumption and anthropometric measurements. However, the LCMS does not contain a rich set of health variables, as does the DHS, and this can potentially confound the relationship between key socioeconomic variables and child health. It also does not contain other child health outcomes such as fever.Childhood ill-health has serious consequences. Apart from increasing under-5 mortality rates, it negatively affects cognitive abilities, education attainment, later life income, and adult health. However, children in low socioeconomic background bear a significantly larger share of childhood ill-health implying that they will continue to shoulder a larger share of these adverse consequences. This raises ethical issues. Why should children from poor backgrounds experience more ill-health when the determinants of ill-health are beyond their control, and to a large extent beyond the control of their parents. How can such inequalities be justified when they are hugely generated by inequality of opportunities to determinants of good health, such as education and health care? Against this backdrop, reducing inequality constitutes one of the most important development goals and is now part of the post 2015 development agenda, the Sustainable Development Goals (SDG), the successor to the Millennium Development Goals (MDG). To derive lessons for the post 2015 agenda of designing interventions that are effective in improving overall child health and reducing inequality, it is important go beyond asking whether or not inequalities increased by undertaking an in-depth analysis of the forces that drive inequality.We examined the determinants of stunting and fever using the 2007 and 2014 Zambia DHS data to explore the existence of socioeconomic inequalities in childhood ill-health indicators, and whether this inequality changed over the period. Most importantly, we quantified how changes in inequality of determinants and the changes in elasticity of stunting and fever with respect to their determinants could have contributed to the change in inequality between 2007 and 2014.While the prevalence of stunting reduced substantially, inequality increased between 2007 and 2014. In fact, inequalities were worsened by the fact that the prevalence of stunting was reduced in all quartiles, except the poorest. This increase in inequality was largely a result of the increase in the inequality of factors that are associated with stunting. These factors include maternal height and weight, wealth, birth order, breastfeeding duration, facility deliveries and maternal education. Although the responsive of stunting to most of these factors, e.g. facility deliveries, increased in 2014, this benefit mostly accrued to the better off because the factors remained concentrated on the better off. As a consequence, the improved responsiveness of stunting to its determinants also contributed to the increase in inequality.Regarding fever, almost all the increase in the inequality was account for by the increase in the responsiveness of the disease to the factors that determine it. By far the biggest driver of this change was wealth, then maternal education, birth order and breastfeeding duration.The key message in this study is that halting the increase in the inequality in childhood ill-health depends heavily on reducing inequality in the factors that affect childhood ill-health while at the same time improving the impact (elasticity) of these factors using both health and non-health interventions. It is important to note that although improving impact of factors that affect child health is desirable, this in itself can be a source of increase in inequality if the factors whose impact are being improved are unequally concentrated on the better off to begin with.Halting the increase in child health inequality is dependent on reducing inequality in the factors associated with child health. These include wealth, maternal education, appropriate feeding and weaning (related to breastfeeding duration effects), adequate care giving (related to birth order effects) and maternal nutrition . We believe that a more sustainable way of doing this is to ensure equality of opportunities in access to these factors among children from different socioeconomic backgrounds—who are future parents. This may call for policies that delink the dependence of child health on parental circumstances and the community they live. Specifically, group specific interventions aimed at the most vulnerable may need to be implemented along with population level interventions. For example, under the current social cash transfer scheme in Zambia, policy may aim at providing more cash benefits to the poorest households who have children under the age of five years. Poor households may also have special educational needs. For example, children from poor backgrounds may have challenges learning and concentrating even when given access to school due to persistent hunger. Child school feeding programs may help in improving attendance among poor children and also reducing inequality in learning and concentration.Moreover, despite the fact that all households require appropriate breastfeeding and weaning educational interventions—due to the observed association between duration of breastfeeding and child health—poorer households may require special interventions since they have disproportionately longer breastfeeding durations. In general, the propensity to breastfeed longer may be due to lack of appropriate food or knowledge on how to use existing traditional food stuffs. Thus, policy may focus on introducing and scaling up complementary feeding and nutritional programs among poor households. Additionally, since the community in which a child lives matters for child health, policy may also focus on improving living conditions in disadvantaged communities, e.g. sanitation facilities, water, child care centers, etc. The implementation of such group specific intervention may enhance equality of opportunity and halt the increase in child health inequality.


To overcome difficulties associated with conventional techniques, impressions with IOS  and CAD/CAM (computer-aided design and manufacturing) technologies were developed for dental practice. The last decade has seen an increasing number of optical IOS devices, and these are based on different technologies; the choice of which may impact on clinical use. To allow informed choice before purchasing or renewing an IOS, this article summarizes first the technologies currently used . In the second section, the clinical considerations of each strategy such as handling, learning curve, powdering, scanning paths, tracking, and mesh quality are discussed. The last section is dedicated to the accuracy of files and of the intermaxillary relationship registered with IOS as the rendering of files in the graphical user interface is often misleading. This overview leads to the conclusion that the current IOS is adapted for a common practice, although differences exist between the technologies employed. An important aspect highlighted in this review is the reduction in the volume of hardware which has led to an increase in the importance of software-based technologies. Since the eighteenth century, conventional impression techniques have been used to register the three-dimensional geometry of dental tissues. Nevertheless, volumetric changes of impression materials and expansion of dental stone seem error-prone, and thus the process requires the services of an excellent dental laboratory –3. To ovTo allow the practitioner to make an informed choice before purchasing or renewing an IOS, this article is divided in three distinct parts. The first presents the different technologies employed by the current IOS for the capture of image and the generation of a digital file by the software, the second is dedicated to the clinical pitfalls associated with these technologies during IOS use, and the last part reports on the accuracy of these current technologies.x and y) of each point are evaluated on the image, and the third coordinate (z) is then calculated depending on the distance to object technologies of each camera, as explained below , a computer, and a software. The goal of IOS is to record with precision the three-dimensional geometry of an object. The most widely used digital format is the open STL (Standard Tessellation Language) or locked STL‐like . This foed below .Within the 3D reconstruction field, there is a clear distinction between passive and active techniques. Passive techniques use only ambient lighting to illuminate intraoral tissues and are reliant on a certain level of texture of an object. Active techniques use white, red, or blue structured lights projected from the camera onto the object that is less reliant on the real texture and color of tissues for reconstruction , 9. In aTriangulation is based on a principle that the position of a point of a triangle (the object) can be calculated knowing the positions and angles of two points of view . These tConfocal imaging is a technique based on acquisition of focused and defocused images from selected depths . This teAWS is a surface imaging technique, requiring a camera and an off-axis aperture module. The module moves on a circular path around the optical axis and produces a rotation of POI . Distancx, y, and z) only through an algorithmic analysis of images [Stereophotogrammetry estimates all coordinates  is extracted from the projection matrix, and a file is then generated.One of the major challenges of generating a 3D numerical model is the matching of POI taken under different angles. Distances between different pictures may be calculated using an accelerometer integrated in the camera, but a similarity calculation is more often used to determine the point of view of the image. Using algorithms, similarity calculation defines POI coincident on different images . These PRecent studies have indicated that the digital impression technique was more comfortable and faster than the current impression technique –19. Lee Each scanner also includes specific technology and captors that impact size and weight of the scan head . For insμm powder coating is required during the digitizing process to reduce reflectivity  so that the software has enough information if tracking is lost. Manufacturers are currently developing different strategies and software algorithms to continue scanning when tracking is lost mainly by recognizing saved geometry of the object. For this, practitioners need to rescan a meaningful area without being stationary to give enough information to the camera and software. The second scan will allow matching the previous POI, and the software will complete this missed area . This reThe IOS software can generate files of varying mesh densities Figures . HoweverNevertheless, the rendering of file in the graphical user interface is often misleading on the accuracy of a scan due to the use of shaders and of smoothing algorithms. A thorough analysis of trueness and precision appears to be more relevant factors to evaluate the scanner accuracy of the current IOS, and these aspects are discussed below.According to ISO 5725, the accuracy is described by two measurement methods: trueness and precision , 34. Truμm and the precision is between 4 and 16 μm, when the impression is partial and compared to conventional impression [Many papers have reported clinically valuable precision and trueness of current IOS, both in vitro and in vivo , 38–42. pression . The conpression , 42. Howpression , 43, 44.Concerning implantology, various in vitro studies concluded that triangulation, confocal and AWS technologies can be feasible alternatives to high-accuracy scans currently used for scanning conventional impressions or plaster models , 45–47. Dentists always require to take the intermaxillary relationship to perform prosthetic rehabilitation for patients. This complex clinical step is a common source of error due to cumbersome and imprecision of bite registration materials. By contrast, impressions using IOS only require a new acquisition of vestibular faces when the patient is in occlusion . MaxillaAfter an objective overview of the literature, IOS seems clinically adapted for common practice, irrespective of the technology used. Each technology has to be considered in the context of individual activity, requirements, and expectations of practitioners. An understanding of the IOS technology is necessary for any practitioner to have a successful clinical strategy during the scanning of prepared teeth. However, there is no scanning technique, scanner, or technology that can currently be unanimously considered more accurate due to the lack of standardized procedures or comparable in vivo studies. Although IOS is currently mainly based on confocal technology, the requirement of voluminous hardware means that alternatives are sought such as software-based technologies, especially for ergonomic reasons, patient comfort, and manufacturing price (20–25 k€ for software based instead of 35–40 k€ for hardware based).


Legionella risk management and control plans. Here, we present our views regarding this suggestion, drawing upon our own experiences in the UK. We urge caution against the removal of routine monitoring from guidelines due to the impending public health risks that would result.In their recent article, Whiley makes an interesting case for the abolishment of routine testing in  Legionella Risk Management and Control in Potable Water Systems: Argument for the Abolishment of Routine Testing’. The author correctly highlights a number of issues that hamper the ability to define the public health risk from water systems contaminated with Legionella. Among these issues are the drawbacks associated with the current ISO 11731 ‘gold-standard’ culture method, which include an inability to detect viable but nonculturable (VBNC) cells . Colonisation and risk were only identified by epidemiological data, i.e., when cases of LD were reported. Routine testing at these critical control points would have given an early warning and may have prevented these cases from occurring. The availability of planned routine sampling results can also prove very useful in public health investigations of LD, where the colonisation history of a system under investigation  can help focus investigations and pin-point sources more readily.The author states that routine testing of potable water systems for ctice L8  and assoctice L8 , and thectice L8 . As the ctice L8 . HoweverLegionella, but not all. It may be a false assumption that Legionella are ubiquitous in all potable water systems. For most UK hospitals, a zero-tolerance approach to Legionella is based on the assumption that there is no known safe level of Legionella and that remedial actions are therefore implemented at the detection of any concentration of Legionella [Legionella in a sample and the variability of the test methods; however, it is logical to assume that the higher the concentration of Legionella present in a system the greater the potential for transmission and exposure. An increase in the concentration of Legionella should therefore be indicative of a potential problem and be investigated without delay. Moreover, the cost of routine testing and system-wide control measures needs to be carefully balanced against the use of alternative local approaches to protect high risk populations such as point-of-use filters, which, if used permanently, can be costly and may unknowingly introduce infection control risks themselves [The author makes reference to health-care facilities where reducing the exposure of vulnerable individuals is a key priority. Like many potable water systems, a number of hospitals in the UK are colonised with gionella . Unlike gionella , routinegionella . It is uemselves .Legionella monitoring, surely the safest approach is to combine risk assessment, control measures (including meticulous monitoring), and routine water testing. Routine testing should be implemented on a system-by-system basis, informed by the risk assessment to reduce inappropriate or meaningless testing and expenditure and take into account the history of the system, the control measures, the previous test results, the population at risk, etc. The absence and detection of low concentrations of Legionella by culture  combined with verified control measures are the ultimate reassurances that the microbiological risk has been managed appropriately. After all, cases of LD do not tend to be linked to systems where Legionella has not been detected [Even with the well acknowledged limitations of detected ,11,12.Legionella field, particularly with regard to water system risk assessment and control, there is an urgent need for better and more robust studies to inform future control policies, particularly in light of a global rising incidence of LD and an increasingly older and immunocompromised population.Given the controversies and multiple uncertainties in the