A questionnaire of 15 questions was completed by four categories of respondents with the aim of establishing the experience and opinions of these groups on the constraints including animal health problems for communal, small-scale sheep and goat farming in the Eastern Cape province of South Africa. The questionnaires were completed independently and categories were representative of the areas investigated. Analysis of responses was done by means, ranges, votes and clusters of responses. Comparisons between the responses of the four categories were made to identify similarities or contrasts. The results revealed that of non-veterinary concerns, stock theft was the major problem for these farms. Nutrition was a further major constraint. A third area of significant concern was the provision or availability of facilities like fences, water troughs, dips and sheds. Lack of marketing and business skills were also seen as important deficiencies to be rectified so as to promote profitable farming. Of the most important veterinary problems identified, the provision, availability, cost and care of drugs and vaccines were seen as major stumbling blocks to effective disease control, as well as lack of access to veterinary services. The most important diseases that constrain small-ruminant livestock farming in the farming systems investigated were sheep scab and other ectoparasites, heart water, enterotoxaemia, internal parasites and bluetongue. A lack of knowledge in key areas of small-stock farming was revealed and should be rectified by an effective training and support programme to improve the contribution of small-ruminant farming to livelihoods in these communities. A questionnaire survey was undertaken among four interest groups as part of a project to improve livelihoods and create wealth through smallholder livestock production in the Eastern Cape province of South Africa. The aim was to determine the most important constraints experienced in small-scale ruminant production. Due to their cultural value in these communities, trading in cattle is less commonly practised than trading in sheep and goats, and for this reason, the study concentrated on the latter species.et al. et al. et al. The opinions and experiences of people actively involved in identifying and dealing with livestock farming health issues have too often been ignored or deprecated as being of little or no value, on the basis that this information is not sourced from scientific experiments or diagnostic tests  being overall viewpoints, the next two (E and F) concentrated on general animal disease and the last nine (G–O) dealt with sheep and goat health. Thus, there were 15 questions to be answered. Most questions  included a rating scale (0–10) to enable comparison and establish rankings. Question D was a category marking while J required three possible rankings. Questions B, F, J, K, M and O were partly or largely open-ended. For ease of reference, the list of questions is available as Appendix 1.The findings of the questionnaires, after analysis, were used as the basis for most of the training material generated and provided.Four important groups involved in farming livestock and in animal health, namely communities of livestock farmers, their livestock production advisors, animal health technicians and veterinarians were identified. The aim was to establish the degree of agreement among these groups on a range of selected topics, the importance rating of each aspect and solutions used or required. Where possible, reasons for significant disparities between groups were analysed.The veterinarians and animal health technicians were from the entire Eastern Cape province, including commercial regions, but especially the communal areas, while production advisors only serviced the communal areas. Communities were identified for participation by a random allocation of all communal regions but based on representation of all farming and climatological types. The four communal regions designated 20, 21, 23 and 24 in the results were identified by the National Wool Growers’ Association as groupings of communal farming areas in municipal districts in the Eastern Cape. Each one is regarded as reasonably homogeneous and together represent all the districts in this study. These allocations were based on previous surveys for other purposes Tapson .n = 40) varied from 4 to 22 (average 10.5) farmers or owners distributed throughout the survey region. There were 9 farm advisors paid by or seconded to the National Wool Growers’ Association and 1 supervisor, 30 animal health technicians and 28 veterinarians.The size of farming community groups . All interviews for this segment were conducted by explaining the question, then asking by show of hands which response was regarded as the correct answer. These responses were then recorded by the interviewer.Since veterinarians, animal health technicians and production advisors all completed their questionnaires on their own at the same time, there was no possibility of discussion, caucusing or mutual influence. Thus, the results can be seen as genuine, unbiased opinions. Farmers were interviewed in groups (communities), so peer influence could and probably did play a role in responses given. However, any community’s responses to questions were very unlikely to have been influenced by other communities.Questions were analysed by group category and where possible along similar lines (apart from the open-ended questions).All responses from all groups were collected, checked and filed in groups according to the categories of respondents. Because it was difficult to allocate veterinarians to the categories originally envisaged, the responses of all veterinarians including those in management positions were pooled for analysis. Similarly, the responses of all animal health technicians of any rank were pooled, including those who styled themselves as animal production advisors but were not part of the National Wool Growers’ Association team, who were clearly identified and analysed separately.Analysis of questions A, C, E, F, G, H, I, L and N was simply by calculating mean and range per answer per group. Questions D, K and J were recorded by the number of votes for various categories per group, and the answers to the more open-ended questions B, J, M and O and partially F and K were analysed by clusters of similar responses.There was general agreement among the groups that agriculture and ruminant livestock were important for livelihoods, with overall high averages, although with wide ranges .It is worth noting that, in contrast to the farming communities, the advisors, technicians and veterinarians emphasised lack of capacity on the part of the farmers compounded by lack of education, training and information as the major constraint for profitable farming . This waThe majority of farmers and advisors believed that more than 50% of the annual provincial agricultural budget should be spent on addressing the constraints identified, while the majority of technicians agreed that at least 30% to more than 50% should be allocated and the majority of veterinarians voted for between 20% and 50%.Although the Part II questions covered livestock in general, the categories of disease are all applicable to small ruminants  and all Parasites  and nutrition emerged as important disease categories, but only parasites were accorded high importance by all four groups. The technical groups considered nutrition to be highly important, with the technicians and veterinarians ranking it as most important, whereas the farmers rated it second last, behind parasites and infectious diseases. Toxic plants were rated lowest of the five categories by all four groups, although the farmers accorded relatively high ratings to all five categories .Coenurus cerebralis (‘gid’) and black quarter as among the most important diseases. Veterinarians considered malnutrition to be an important underlying factor for most of the disease conditions.The second question of Part II (F), on animal disease in general, was largely open-ended and received inconsistent responses, but all groups agreed on the diseases listed in In relation to production parameters , the numQuestion I provided a list of syndromes to be rated according to their importance . The farIn answer to questions on measures to manage the most important conditions, the three technical groups cited appropriate measures for the problems. The farmers’ responses indicated that the most popular measures were vaccination and treatments with tetracyclines, penicillin or macrocyclic lactones. However, these were often used for the wrong condition or alone when other remedies would have been better. Examples were the use of penicillin for heartwater and tetracyclines for pulpy kidney and bluetongue.The main challenges identified for controlling diseases are summarised in Major concerns not related directly to animal diseases included stock theft, veld management and nutrition and the provision and maintenance of facilities for farmers . FarmersUnlisted information requested by a majority of farmers involved instruction material for shearing and wool sorting. Production advisors emphasised the need for information or training on animal identification, shearing, genetic improvement and improvement of infrastructure. Animal health technicians wanted material for animal identification, as well as selection and culling, farming as a business, marketing of produce, disease recognition, disposal of carcasses, land tenure, facilities, movement of animals and advanced techniques like artificial insemination and embryo transfer. Veterinarians wanted farmer courses or training manuals for feed supplementation, marketing of produce, ram testing, farming as a business, nutrition, slaughter, zoonoses and udder hygiene.The results of the questionnaire survey revealed that farming communities rated agriculture and livestock as being of high importance, with the emphasis on ruminant livestock, indicating these are important for income generation. However, both the farmers and their service providers  identified numerous constraints that prevent livestock production from reaching its full potential in terms of income generation and wealth creation. The farmers reported experiencing many animal health problems but these were to a large extent dwarfed by larger problems, many of them related to land use, management and availability of products and services that can directly affect the well-being of the animals and the income of farmers. The survey revealed a lack of capacity on the part of the farmers to deal with the problems that could partly be overcome by access to training, information and expert assistance. Although not clearly articulated by farmers, the other groups all rated education, information and training as the most pressing issue.Although predation is rated by commercial farmers in the rest of South Africa as an enormous problem . This supported the contention that animal disease control requires significant continued support. Lack of access to veterinary support, including drugs and vaccines, was identified as a major problem. However, it emerged that many of the farmers did access vaccines and medicines but were not informed about their use and therefore often used them inappropriately or incorrectly. Ways to improve veterinary service delivery to communal farmers need to be explored with the help of pharmaceutical companies and other private sector veterinary service providers.Psoroptes communis ovis, and internal parasites were identified as highly important diseases of small stock. All categories of respondents consistently rated the control of sheep scab as the biggest area of concern. In spite of the fact that it is a controlled disease in South Africa and compulsory control measures have been in force since 1885 with continued efforts to improve their success, control remains problematic, compounded by the fact that alternatives to chemical control need to be sought because of concerns about ecological impacts, toxicity to humans and development of resistance  as important indicated the need for regular treatment of dogs for tapeworms and education to prevent the feeding of raw offal including sheep brains to dogs.Systems for sustainable control of internal parasites were already in place in the province and the indications were that they were working. However, the fact that some farmers identified ‘gid’  by veterinarians. Unless all those involved understand that meat sales  contribute the biggest proportion of income, the true importance of successful reproduction is lost.Lack of information and training for farmers is a major category of concern that can relatively easily be addressed by a sustained, coordinated programme, based on the training material provided in a full report submitted to the Wellcome Foundation . It was quite clear that most farmers did not know when vaccination was needed, how often to vaccinate or which animals to target. Similarly, drugs used by farmers were all too often completely wrong or ineffective. Training and education are clearly required to rectify these mistakes.Some of the responses were inconsistent or illogical; nevertheless, important observations and opinions emerged that reflect serious constraints for communal farmers in the Eastern Cape province of South Africa. These should be noted, discussed, analysed and acted on by all organisations involved to improve the livestock situation in the Eastern Cape province communal areas. These findings may have value in other areas not surveyed in this study.


This study analyzed the burden of cancer treatment costs on patients by calculating the monthly amount of medical expenses paid by breast cancer patients for two years after mastectomy. Among those who were diagnosed with breast cancer and had received treatment at one of two academic medical centers in Seoul between 2003 and 2011, 1,087 patients who underwent mastectomy and received follow-up for at least two years were recruited. A micro-costing approach from the provider’s perspective, based on a retrospective review of patient medical claim records, was used to analyze cancer treatment cost of care. The cohort’s number of hospitalizations, total hospitalization duration, and number of outpatient visits were noted, and the total amount of medical expenses, out-of-pocket (OOP) expenditures, uninsured costs, and OOP ratio were calculated. The total amount of medical expenses tended to increase by year, whereas the OOP expenditure ratio decreased. The OOP expenditure ratio was highest in the first month post-operation. Around one quarter of the total OOP payments incurred over the course of three months: one month before the operation, the month of the operation, and one month post-operation. OOP payment burden on patients was concentrated in the initial phase of treatment, and items not covered by the National Health Insurance caused an additional increase in patients’ burden in the initial phase. The economic burden of cancer treatment varies considerably. In order to alleviate patients’ medical expenses burden, the timing of expenditures and the possible financial burden on cancer survivors, they should be understood more fully and possibly addressed in interventions aimed at reducing the cancer burden. Cancer is one of the most common serious diseases in South Korea, being the leading cause of death for both men and women since 2000. But due to continuous early diagnosis and prophylactic measures, the standardized incidence ratio of cancer has been on the decline, decreasing from 324.9 per 100 thousand people in 2011 to 289.1 per 100 thousand people in 2014. As a result of increased early treatment and advanced treatment technologies, cancer survival rates are also rising. The five-year relative survival rate of cancer patients from 2010 to 2014 was 70.3%, exceeding the 70% line for the first time. Due to the increase in life expectancy after cancer occurrence and active introduction of new medical technologies in diagnosis and treatment, the costs for treatment and the overall social burden from cancer is also continuously . Cancer accounts for 13-17% of the global burden of disease, and 4-7% of all medical expenses. In the United States, cancer comprises approximately 5% of gross medical expenses, and cancer treatment costs are expected to rise 40%—from $125 billion in 2010 to $175 billion in 2020 . South Korea is showing a similar trend, where cancer treatment costs accounted for 4.9% of the total payment made by the National Health Insurance Service (NHIS) in 2001, but in 2011 this amount increased to 8.2%.Until now, most studies on cancer treatment costs focused on estimating the total amount along with a detailed analysis based on the type of cancer, treatment method, stage of illness, survival period, and socio-demographic characteristics. Recent studies have analyzed the medical expenditure pattern from the moment of diagnosis to the moment of death (or other specific time), focusing on treatment cost burden for patients. Results of many studies show that the expenditure pattern starting at cancer diagnosis or the start of treatment forms a U-shaped curve, with the greatest amount of medical expenditures falling within the first year after diagnosis . Generally, cancer patients receive intensive treatment in the short time period right after the diagnosis, which puts a significant financial burden on patients due to the high medical expenditure . The financial burden of treatment is also called financial toxicity, and is known to affect not only the mental well-being of a person but also decision-making about the appropriate treatment . Because cancer treatment induces high treatment costs, the financial burden on patients is a crucial social issue and an important matter for the health insurance system . Cancer patients’ perception of the burden of medical costs can differ from that of insurers in terms of time. Because insurers manage insurance benefits or premiums from an aggregate viewpoint on a macro level, it is generally accepted they approach the burden of medical costs for cancer patients on a long-term basis that spans the entire treatment period or by year. Related studies also tend to be carried out in similar ways, for example, analyzing medical expenditures from the point of cancer diagnosis to death; trends in medical expenditure incurrence at the initial, follow-up, and terminal stages; and semiannual or annual trends in medical expenditure incurrence . However, from the cancer patients’ standpoint, medical expenditure and its burden should be assessed in accordance with the household’s income, so expenditures should be assessed on a weekly or monthly basis. Several previous studies analyzed the development of cancer treatment cost incurrence by short time periods in this fashion , but there have not yet been studies that analyze the aspect of the incurrence of out-of-pocket expenditures for cancer treatment on a short-term basis that spans less than a month. Thus, this study aimed to analyze the level of burden of treatment costs on patients by calculating the monthly amount of medical expenses paid by breast cancer patients for two years starting at their mastectomy.Subjects and dataA micro-costing approach from the provider’s perspective, based on detailed cost information for each patient at each admission or visit, was used in the analysis. This method analyzed the monthly incurrence of medical expenses of breast cancer patients for two years from the day they underwent mastectomy. Medical expenses for breast cancer patients include not only the cost of breast cancer surgery but also the cost of chemotherapy and radiation treatment. Among those who were diagnosed with breast cancer  and had received treatment at one of two academic medical centers in Seoul between 2003 and 2011, 1,087 patients who underwent mastectomy and received follow-up were assessed. Both hospitals from which the study participants were selected were general hospitals with 1,332 and 570 beds each, and were tertiary medical institutions in the healthcare delivery system. Both hospitals were top-ranked with a nationwide reputation in cancer treatment. Patients who underwent reoperation within two years after the first operation due to recurrence or other causes were excluded from the study. However, those who had less than three months between their first and second operation were included in the study because the second operation may be performed depending on the results of radiological examination or biopsy for metastasis of the surgical site after partial mastectomy. Due to the difficulty of determining the time of diagnosis of the study participants, the starting point of the medical expenditure study period was set as the day that the patient underwent mastectomy. The study period included one month before the operation date, considering the preparatory process including preliminary examinations before the operation. Because the treatment expenses study period was set as two years from the time of the operation, only the cases where there was a confirmed record of visit and treatment under the same diagnosis within at least two years after the operation were included. Accordingly, cases where the patient died within two years after the operation, changed hospitals, etc., were excluded from the study.The analyzed data were extracted from the hospital cost analysis system based on the corresponding hospitals’ medical bills, excluding the patients’ personal information. These are administrative data constructed with the purpose of charging patients medical costs, and contain detailed information on the type of service and its amount, time period, and costs, but do not offer much clinical information. Data used in this study were collected from only two hospitals, so the results are limited in terms of national representativeness. However, the data have the strong advantage of accuracy and reliability. This study was approved by the Institutional Review Board of The Catholic University of Korea (CUMC11U135) with a waiver for informed consent because the data were obtained from an administrative database and were analyzed anonymously.Statistical analysisYearly cohorts were drawn by the time of operation. Using medical expense data from 2003 to 2011, we rebuilt six yearly breast cancer cohorts (2003-2008) that included all medical expenses for two years after breast cancer surgery at the hospital. Total medical costs were defined as the aggregate amount of medical expenditure incurred during the two-year period after the mastectomy  in which the patient received treatments at the same hospital, and included all cases where the bills had C50 as the diagnosis. It included costs for outpatient, inpatient, and emergency treatment. South Korea implements National Health Insurance (NHI) that provides for all of its citizens. A diagnosis related groups-based payment system is applied to some patient groups, but in most cases, patients have their medical expenses calculated through the fee-for-service method. Service items covered by the NHI can be divided into the insurer’s payment and copayment by the patient (statutory copayment), and expenses for items not covered by the NHI are paid entirely by the patient (uninsured costs). Insured and uninsured services are determined based on medical validity and needs, with consideration of the NHI finances. Thus, some medically necessary services are included in uninsured items. Out-of-pocket (OOP) expenditures include copayments and uninsured costs, and the OOP ratio refers to the ratio of OOP expenditures to the total amount of medical expenses. The average and standard deviation for each yearly cohort’s number of hospitalizations during two years, total hospitalization duration, number of outpatient visits, total amount of medical expenses, OOP expenditure, uninsured costs, and OOP ratio were calculated. In order to determine at which point patient OOP ratio rose or fell, the OOP ratio value by month for two years was calculated and shown in a graph. In order to determine the size of the burden of medical expenses on patients by time during the study period, the ratio of the patients’ OOP payment to the total amount of medical expenses by month during two years were calculated and illustrated in a graph. This was divided into copayment costs and uninsured costs, the monthly ratio of which were each calculated and compared in a graph. In calculating the monthly values and showing their trends in a graph, cohorts were merged into three groups, combining two consecutive cohorts into one group each: 2003-2004, 2005-2006, and 2007-2008. In the graphing case, the six yearly cohorts were re-categorized into three to reduce complexity due to multiple trend lines and to reflect the lowering of the statutory copayment ratio from 20% to 10% in 2005. In order to reflect the inflation rate during the study period, each year was given a weight based on deflator calculated using Korea Consumer Price Index. We multiplied the total medical expenses by the deflator factors of each year. The annual average exchange rate of 2010  was applied to convert the currency from South Korean won to US dollars. For all statistical analyses in this study, SAS ver. 9.2  was used.This study is a descriptive study that tracked 1,087 breast cancer patients who underwent mastectomy at one of two academic medical centers in Seoul from one month prior to the operation to two years post-operation and analyzed medical expenditure incurrence trends. Analysis of total medical expenditures showed that over two years those who had surgery in 2003 paid $9,473, whereas those who had surgery in 2008 paid $13,670. In the analysis of medical utilizations, these results showed that the number of hospitalization and length of stay were similar, but the number of outpatient visits increased. As a result, the total medical expenses increased. It was analyzed that the increased medical expenses were borne mainly by the insurer rather than by patients.In other words, over five years the total amount of medical expenditures increased by 44%. However, the amount of the patient’s OOP expenditure decreased by 12.0%, from $5,268 for patients who had surgery in 2003 to $4,637 for patients who had surgery in 2007 . As a result, patient OOP ratio showed a significant reduction from 57.4% among the 2003 cohort to 36.1% among the 2007 cohort (slightly increasing to 39.6% in 2008). Thus, total medical expenditures over the course of two years post operation increased with time, but the amount of OOP payments decreased; this is similar to the results of previous studies . This can be explained by the introduction of the OOP payment cap system by NHI in 2004 to lessen the burden of medical expenses on patients, and the consequent lowering of the statutory copayment ratio from 20% to 10% in 2005, and to 5% in 2009. NHI’s continuous efforts to extend the range of insured items also appear to have contributed. However, in the case of patients who had surgery in 2008, both the amount of the OOP payments and the OOP ratio increased due to an increase in uninsured costs. Despite the extension of the range of items covered by the NHI, active introduction of new medical technology including anti-carcinogens, robot therapy, diagnosis, and follow-up examinations may have contributed to the increase in uninsured costs . Monthly OOP trends showed that the OOP ratio was the highest at the initial phase of treatment, i.e., at the time of the operation, and thereafter was maintained at a low level without any significant change. Analysis of the ratio of monthly OOP costs to the total OOP expenditure amount during the two-year treatment period also showed that the first three months accounted for 25% of the entire OOP payment. Previous studies that analyzed trends in the incurrence of cancer treatment costs showed that a large amount of costs were incurred in the initial phase after diagnosis, and costs incurred in continuing treatment phases were much smaller . This study confirmed that not only the total costs, but the actual payments made by patients were concentrated in the initial stage of treatment. During the continuing phase from three months after the operation, the OOP payment ratio tended to decrease by time (year), but at the time of the operation the OOP payment ratio barely showed a difference depending on year. In other words, the OOP payment ratio at the time of the operation did not change when it came to recent years. NHI’s policy to largely reduce the patient copayment ratios for insured items and extend the range of insured items showed distinct effects in the continuing phase, but not in the initial phase. Because many uninsured treatments related to examination and operations are concentrated in the operation period, the financial burden on patients in the initial phase did not decrease significantly despite NHI’s efforts to alleviate it. This is also supported by the results of the analysis of OOP medical expenditure by statutory copayment expenses and costs of uninsured services, which demonstrated that in case of copayment costs, the level of expenditure concentration at the initial phase around the time of the operation showed almost no fluctuation by time, but in cases of uninsured costs, the level of concentration of expenditures in the initial phase increased.NHI’s policies to reduce the financial burden on cancer patients did lower patient expenses in general, but it can be inferred that the high share of uninsured items among expenditures and the insufficient control of uninsured treatments reduced the effectiveness of the policy. The problem of the high concentration of patient burden in the initial phase of treatment (during the operation period) in comparison to the rest of the treatment period was especially evident after the implementation of this policy. Despite reduction in the copayment ratio and increased number of insured items for cancer patients, patients themselves may not have felt much of an effect in terms of alleviation of financial burden. In fact, even after the implementation of NHI’s policy, a significant number of cancer patients still felt that the burden of medical expenditure was too high . Aside from the insurer’s efforts to decrease the overall OOP payment ratio, there is also a need to smooth the medical expenditure or burden level by each period through managing patient expenditure time. In case of breast cancer patients, a large part of medical expenses incur in the initial phase around the operation date, whereas the cost burden in the continuing phase is relatively low, so alternatives measures such as flexible adjustment of the ratio of OOP expenditure amounts according to different treatment periods should be considered. For example, OOP payment for essential operations or treatments after diagnosis can be temporarily deferred for a set time period or be vastly decreased compared to the following period. Many countries implement an OOP maximum/limit system in order to reduce the burden of medical expenses . South Korea’s NHI has also set different upper limits according to income level, and returns expenditures surpassing the limit to patients. However, this is managed on a yearly total amount basis, and not based on individual periods. Moreover, this only includes OOP payments for insured items; uninsured items are not covered by this policy regardless of the costs, which makes it less effective in terms of alleviating the payment burden on patients with serious diseases such as cancer, which incurs a large amount of uninsured costs.This study has several limitations in its subjects and the analysis, and these limitations require caution when interpreting the results. This study used medical bills, but because medical bills do not include information that helps to determine the time of breast cancer diagnosis, incurrence of medical expenditures was analyzed based on the time of mastectomy. There is a possibility that the average medical expenditures were overestimated, considering that cases where surgery was impossible were excluded and cases where the diagnosed patient had chemotherapy first before the mastectomy were included. Second, cancer patient medical expenditures can vary depending on the treatment method according to the stage of disease, but because medical bills did not include this type of information, this study was not able to take this into account. Third, because this study analyzed the OOP expenditure trends among breast cancer patients, its results cannot be generalized to patients with different types of cancer. Fourth, because this study analyzed medical expenses directly related to cancer treatment, it did not take into account the indirect expenses such as transportation costs or payment for caregivers, and also cases where patients used other medical institutions during the study period. This is the first study to our knowledge that analyzed patient OOP expenditure trends by short time periods using actual medical bills from hospitals to calculate monthly OOP costs during the treatment period. According to its results, OOP payment burden on patients was concentrated in the initial phase of treatment around the time of operation, and items not covered by the NHI caused an additional increase in patient financial burden in the initial phase. In order to maximize effectiveness of policies that aim to alleviate cancer patients’ burden of medical expenses, there should be an individual and flexible approach to the issue that considers not only the average OOP ratio, but also the time expenditures are incurred and the possible burden on patients that new medical technology might bring.


Urbanized river basins usually suffer from anthropogenic pressure, compromising the quality of water. Unsafe water is a risk to public health, especially when there are occurrences of HABs (Harmful Algae Blooms) as in the case of cyanobacteria, which cause different human health problems. In this paper, we aimed to review the scientific literature documenting what has been studied in the scope of the stratified reservoirs of urbanized basins. The mapping review method was used to categorize existing literature on urbanized watersheds and eutrophic reservoirs. Using the keywords “Eutrophic Reservoir” and “Urban” and selecting all the years of open publication on the Science web page, we obtained 69 results, 53 of them meeting the requirements established for the search. Many of the studies mention as the most important determinant for eutrophication of reservoirs and the proliferation of algae, the anthropogenic influence through the diffuse load of streets, domestic and industrial sewage, and even drainage water from agricultural areas in the basin. The results of this study reinforce that informal settlements without sanitary infrastructure are aggravating the deterioration of water quality in urban water sources and therefore posing many risks to public health. Scarcity of water may be absolute lack of water, or may be due to inadequate exploitation and distribution, lack of access by part of population, and, in the case of drinking water, it can be related to its insufficient quality . In thisPressure of uncontrolled urban growth has been compromising existing water sources around the world. In low and middle income countries, the paucity of basic sanitation results in domestic sewage dumped into water bodies . In addiAs the city grows, the riparian vegetation might be substituted by improvised dwellings, compromising the health of the ecosystem and of the population living on the margins of reservoirs. The poorest and most vulnerable families often occupy those areas designated by law for preservation, because they are not part of the formal real estate market. There are also frequent irregular occupations of the margins by commercial ventures, clubs and high-level residences that enjoy the scenic advantages that the reservoirs offer.The environmental impact of urban pressure on water sources is also compounded by contaminated untreated clandestine industrial effluents and by atmospheric pollution from industries and motorized transport carried by precipitation , contribLimnological imbalance caused by pollution as nutrient´s excess, triggers a succession of hindrances to drinking water´s potability, even after treatment. The consequence is cyanobacteria blooms, toxic algae that benefit from the abundance of organic matter and warm water temperatures . ConventCyanobacteria are widely known for their potential to produce cyanotoxins. Depending on the type of toxin, such as microcystin, nodularins and cylindrospermopsins (hepatotoxins)  which arCyanotoxins can be hepatotoxic, neurotoxic, cytotoxic, dermatotoxic, carcinogenic and gastric irritants ,3,4. TheChronic exposure to cyanotoxins is potentially alarming given the scale of exposure of urban populations and their accumulative effect . The bloGrowing world urbanization and climate change can accentuate the proliferation of these algae and the contamination of water sources ,2, transA mapping literature review was undertaken  in orderWe first looked for the words “Eutrophic reservoirs” resulting in 1586 studies, so we refined for “Eutrophic reservoirs” and “Cyanobacteria”, in order to know which of these contemplated the algae. This resulted in 357 studies, without limits of date or area. Among the indexed studies found in this initial phase, Brazil ranked as the first in numbers, with 72 publications; China followed with 38 publications; USA with 35; Poland with 26; and France with 23 publications. We found less than 5 manuscripts per country from Ethiopia, with 3 publications; Morocco, Nigeria, South Africa, Tunisia, Uganda, Vietnam and Singapore with 2 publications each.From this starting point, we refined the search by adding the word urban, in order to know which of these studies were located in urbanized basins. We then chose to map out the eutrophic reservoirs found in urban basins using those results to explore further information. The aim was to collect the studies that mentioned eutrophic reservoirs in urban environments, because the eutrophic water body is already a threat for water quality, even if the study doesn´t mention HABs or Cyanobacteria, once the environment is ready for its frequent proliferation because of the water body´s trophic state and of rising temperatures.This final search was done in November 2017, using the keywords “Eutrophic reservoirs” and “Urban”, setting no time span.From 69 articles found, 16 were discarded because they did not fulfill the study requirements: the study had to refer both to eutrophic reservoirs and to urban settings. Therefore 53 articles have been selected and then systematized and mapped.As shown in Of the total, 32 of the studies were done to monitor the water quality of reservoirs, 11 studies aimed at the dynamics and peculiarities of living organisms in the limnological/aquatic environment. Ten (10) of the studies reported cases and techniques for reservoir recovery. Thus, this categorization was made to analyze the reviewed articles .Results exhibited in Of the 53 studies selected in this literature mapping , 20 wereIn the 53 manuscripts, 39 reservoirs were studied as some merited more than one article, for they were analyzed in different aspects. The world spatial distribution of the studied reservoirs revealed locations in latitudes that span past the tropical and temperate zones, reaching cooler territories in the northern hemisphere. It was not possible to establish a distribution pattern of the studies according to the climatic classification of each area. This may indicate that aspects related to land use and water pollution play a more important role than climatic factors. However, the seasonality of time was presented in 28 of the studies (53%), indicating that variations in temperature, radiation, and precipitation are relevant factors for the proliferation of algae. The researches indicated as contributors to blooms: increased air temperatures , stabiliMore than 50% of the studies are in zones of continental humid climate or continental climates, characterized by rains in the summer or throughout the year. The climatic classification of Köppen-Geiger is represented by the abbreviations Dfa, Dfb, Dwa and Dwb as in However, only one of them mentioned “climate change” as important in the investigation approach . It dateInvestigations highlight the contribution of phosphorus  and nitrEven though the origin of the reservoirs was not the main object of the research, it allowed verifying its variability. Studies in Poland indicate that most of the reservoirs originated from mining caves and many were in the process of remediation. In China and Brazil, the reservoirs are mostly dammed rivers and streams. In temperate countries, reservoirs could be formed from snowmelt.Among the 10 studies describing techniques used for reservoir remediation, 9 showed positive results and a decrease in the presence of toxic algae.The results of this research, done without time or space limits, indicated reduced numbers of investigated reservoirs considering that this is such an important topic in a context of great worldwide concern with water resources. It is a limited number of papers that consider the approach of the theme identifying the reservoir as urban, recognizing this environmental characteristic as an important factor. Another limitation of the research may be the fact that the database used searches only in indexed journals that have digitized collections.Although literature indicates studies on these algae since 1992, the pioneering study was digitized in 2006. Other studies on the subject may have been done previously, although they have not been indexed in a bibliographic database. Our literature review shows that concerns and studies are growing in time. This may reflect an increase in the problem of reservoir eutrophication, which has been concentrated in large, less recent industrial urban centers, such as in the Great Lakes region of North America, the site of a significant number of studies on the subject. Nowadays, with the acceleration of urbanization in low- and middle-income countries, this problem reaches urban centers in these nations more intensely, mainly due to the deficits in sanitation they present, thus prompting further research. This is the case of Brazil, which has seen some of its water supply reservoirs, such as the Guarapiranga dam, threatened by the proliferation of cyanobacteria .Many of the studies mention as the most important determinant for eutrophication of reservoirs and the proliferation of algae the anthropogenic influence through diffuse loads of streets, domestic and industrial sewage, and even runoffs from agricultural areas in the drainage basin. The sediments in the reservoirs and the nutrient loads of phosphorus and nitrogen are directly related to the soil occupation for urban settlement, and to the removal of natural vegetation ,31. HoweThe outbreak of cyanobacteria changes the functional phytoplankton group and zooplankton communities in urban eutrophic lakes ,40, whicEven though the restoration studies, mentioned in this review, report good results in the control of nutrient load by wastewater treatment and prevention of diffuse sources to enter the water bodies, sewerage and adequate controls need also to be placed in regions upstream ,35 and aThe relationship found in some papers between climate variables and cyanobacteria blooms has raised concern that global climate change, by reinforcing favorable flowering time periods, could aggravate the frequency of the phenomenon , turningThese studies cited should base programs and actions that aim to limit water pollution, and reinforce arguments for the relevance of facing this problem urgently, often by giving economic value to reservoirs, but above all to protect human and animal life. Reducing water pollution can be done by government policies such as zoning or land use regulations, even though extensive basic sanitation programs in cities of middle and low-income countries may chiefly achieve this reduction. The conservation of water sources can be an important strategy to safeguard water supplies for coming decades.The quality of human water supply is, at the same time, a very old and a very recent topic. It is an area of interdisciplinary and multidisciplinary research and action that is gaining importance given the water scarcity that has affected populations in various parts of the globe, and because of large-scale climatic oscillations prompted increased attention to the issue. The proliferation of cyanobacteria, as well as the contamination of urban reservoirs, once considered topics of limnology, must also be considered a problem of urban planning and governance.The number of articles found in this mapping literature search does not reflect the real environmental issue of eutrophic reservoirs in urban areas of the world. However, there might be more abundant studies on the topic in specific scientific areas exclusively. The importance of our study was to highlight the relation between urban land and eutrophication of reservoirs, and the risk algae blooms pose to growing urban populations. We verified that little literature has been published bridging these knowledge areas.As it is such a widespread problem and few countries are studying it as an approach of urban environment, which makes it a true Challenge for Public Health, and we recommend further investigations in more countries and hydrographic basins. As mentioned, because these algae are resistant to most water treatment technologies, they pose health risks or they might cause the abandonment of water sources closer to cities, consequently increasing the costs for providing safe water to their inhabitants.Finally, we call for joint studies and cooperation of laboratories and study groups in limnology, hydrology and environmental health, but also in urban planning, and urban climatology.


Individuals with Attention Deficit Hyperactivity Disorder (ADHD) tend to perform cognitive tasks with greater Response Time Variability (RTV). Greater RTV in ADHD may be due to inefficient functional connectivity of the brain during information processing. This study aimed to investigate the relationship between brain connectivity, RTV, and levels of ADHD symptoms. Twenty-eight children aged 9–12 years and 49 adolescents aged 15–18 years performed the Sustained Attention to Response Task (SART) while EEG was recorded. The participants’ levels of ADHD symptoms were measured using self- and parent-rated questionnaires. The ex-Gaussian analysis and The Fast Fourier Transform were used to measure multiple aspects of RTV. Functional connectivity between 64 electrodes was computed during task performance, and global efficiency and modularity were calculated, reflecting integration and segregation of the brain, respectively. There was a positive association between multiple RTV measures and the level of ADHD symptoms, where participants with higher levels of ADHD symptoms showed greater RTV, except for sigma from the ex-Gaussian analysis. More efficient brain network activity, measured by global efficiency, was associated with reduced RTV. Children showed greater RTV and less efficient brain network activity compared with the adolescents. These findings support the view that stable responses are achieved with more integrated (and efficient) brain connectivity. ADHD is a neurodevelopmental disorder characterized by very high levels of inattention, hyperactivity, and impulsivity . Higher One widely-used RTV model is the ex-Gaussian distribution model, which provides an excellent fit to RT data . It exprAnother approach used to analyze RTV is the fast Fourier transform (FFT), allowing for the capture of periodic fluctuations in RT. The FFT measures the power of periodic changes in RT at different temporal frequencies. This analysis of periodic fluctuation has been applied to RT data from individuals diagnosed with ADHD  as they An alternative way to define frequency bands of RTV is by dividing frequency based on the experimental paradigm. This was the approach taken by The neural correlates of RTV have not been widely examined. One explanation of RTV is that increased RTV may reflect inefficient or inconsistent information flow through the brain during performance of a cognitive task . Stable One method with which to characterize patterns of brain connectivity is to apply graph theoretical analysis. In graph theoretical analysis, the brain is considered as a single network, and this analysis describes the patterns of connections between brain areas . The chaAbnormal brain connectivity in ADHD has been demonstrated using both functional and structural connectivity analyses . Using gWhen examining the relationship between RTV and ADHD symptoms it is critical to examine how the relationship changes from childhood to adolescence. During typical development RTV decreases, on average, from childhood to young adulthood, and young adulthood is associated with the most stable responses during the lifespan . With thThe symptoms of ADHD are distributed continuously within the population from extremely low to high levels of inattention, hyperactivity, and impulsivity. Individuals with ADHD populate the extreme high end of its continuum , 2009. HIndividuals with ADHD often, but not always, show difficulty in sustaining their attention. Sustained attention is the conscious processing of non-arousing stimuli over a period of time . BehavioThis study aims to investigate the relationship between brain connectivity, RTV, and levels of ADHD symptoms in children and adolescents on two measures of sustained attention. It is hypothesized that (1) Higher levels of ADHD symptoms will be associated with increased RTV; (2) Children will perform the sustained attention tasks with greater RTV than adolescents; (3) Greater functional integration and decreased strength of segregation of the brain will be associated with reduced RTV and lower levels of ADHD symptoms; and (4) Adolescents will show more integrated and more strongly segregated patterns of brain connectivity than children.M = 10.95 years, SD = 1.06; 9 females) and 49 adolescents aged 15–18 years  participated in this study. One participant from the adolescent group was removed from the sample before analysing the data due to excessive movement during the EEG recording, resulting in a total of 49 adolescents from the initial number of 50 adolescents. Children were recruited from local primary schools. Six adolescents were recruited from local secondary schools and forty-three were recruited from the university’s first year Psychology course. Participants were not pre-selected based on symptoms of ADHD.Twenty-eight children aged 9–12 years  and Psychtoolbox . The expThe Conners 3 questionnaire was used to measure levels of ADHD symptoms. Two forms were used in this study: The Conners 3 parent form was completed by parents of all children and the 6 adolescents recruited through secondary schools, while the self-report form was completed by the university-based adolescents. There was no significant difference between the adolescent  and child  groups on the ADHD Index, t(49.11) = –1.65, p = 0.10. The correlation between the parent and self-report forms is 0.57 for the ADHD Index . Eight cAn estimate of intelligence quotient (IQ) was obtained using the WASI  for partParticipants were asked to complete the SARTs while the EEG was recorded using a 64 electrode Biosemi system. For participants recruited from schools, the WASI was completed before the SART. Parents were asked to complete the Conners 3 questionnaires while the participants were performing the task. The undergraduate participants were asked to complete the Conners 3 questionnaires form while the EEG was being set up.For each participant, for the Fixed and Random SARTs separately, each dependent variable was computed following these steps. A count of the two types of errors was computed. Omission errors are the missed responses to the Go trials. Commission errors are the responses to the No-Go trials. Participants with more than 30 omission errors in either Fixed or Random SART were to be removed from the analysis: no participants were excluded. Trials containing commission errors, response times shorter than 100 ms, and No-Go trials were removed, and subsequently the Mean of RT and Standard Deviation of RT (SDRT) were computed. Three parameters, mu, sigma, tau were extracted by applying the ex-Gaussian model based on the approach by The analysis to compute fast and slow RTV followed the procedure of The frequency range was divided into fast and slow frequency bands using the peak at 0.0772 Hz. The frequency 0.0772 Hz was chosen as it is the reciprocal of one cycle of the 1–9 digit presentation in the Fixed SART (a SART cycle). The Fast Frequency Area Under the Spectra (FFAUS) encompassed all sources of variability faster than once per SART cycle, the area under the curve to the right of the peak at 0.0722 Hz. The Slow Frequency Area Under the Spectra (SFAUS) encompassed all sources of variability slower than once per SART cycle: the area under the curve to the left of the peak at 0.0772 Hz.The EEG was recorded using the 64 electrode BioSemi system with a sampling rate of 512 Hz. In the BioSemi system, a Common Mode Sense (CMS) active electrode placed on the surface of the head was used as a reference electrode during the recording. The recorded EEG with 64 electrodes was imported and pre-processed in Matlab and Fieldtrip .In the software, the EEG data were first referenced to an average of the two ear electrodes. The data were band pass filtered from 0.5 to 40 Hz, and then segmented into trials from -200 to 1200 ms, where 0 was set at the presentation of the target digit of the SART. The data were visually inspected and trials with artifacts such as extraordinary large amplitudes, jumps, and flat signals were removed. Noisy electrodes were manually identified and temporally separated from the data. Independent Component Analysis (ICA) was then applied to remove artifacts such as eye blinks, eye movements, and heartbeats. After ICA, noisy electrodes temporally separated in the previous step were interpolated using the spherical spline method and noisy trials, with amplitudes above 100 and below 100 microvolts, were manually removed from further analysis. The data were then referenced to a common average of the electrodes and detrended. Trials removed for the behavioral analysis were also removed in the EEG analysis, which included incorrect responses, No-Go trials, and trials with less than 100 ms responses.a priori to measure global efficiency and modularity during the baseline and task. The baseline period was from -200 to 0 ms and global efficiency and modularity were averaged over this period to produce baseline values separately for the three frequency bands. These two measures were baseline corrected by subtracting the baseline values, and the maximum absolute change from baseline was identified during the period between 30 and 600 ms after the digit presentation. This peak value reflects how large the two network measures change from the baseline: this could be either positive or negative depending on the direction of change. The period from 300 to 600 ms was selected for the task period. The brain is thought to be involved in higher cognitive processes during this period  with random intercepts. LMEM allows data to have missing values. The behavioral measures of this study were the number of omission and commission errors, mean RT, SDRT, mu, sigma, tau, FFAUS, and SFAUS. The network measures were global efficiency and modularity in three frequency bands  during the task. Additionally, there were three other variables; SART Task (fixed and random), Age (adolescent and child groups) and the ADHD Index scores.To examine the relationships between behavioral measures, ADHD Index, and network measures, three different types of models were examined. Two categorical variables (Age and SART Task) were inserted into all three types of models as predictors. The first type of model aimed to examine the association between the behavioral measures and the ADHD Index. Each behavioral measure was treated as an outcome variable, and the ADHD Index and the two categorical variables were the predictors. A single model was fitted for each behavioral measure. In addition to the association between the ADHD Index and the behavioral measures, the effects and interactions of the two categorical variables on behavioral performance were also examined. In the second type of model, the association between the behavioral measures and the network measures was examined. Each behavioral measure was treated as an outcome variable, and each single network measure was inserted as a predictor, along with the two categorical variables. A single model was fitted for each behavioral measure and network measure. In addition to the association between the behavioral measures and the network measures, interactions between the network measures and the two categorical variables were also examined. In the third type of model, the association between the network measures and the ADHD Index was examined. Each network measure was treated as an outcome variable, and the ADHD Index was inserted as a predictor, along with the two categorical variables. A single model was fitted for each network measure. In addition to the association between the network measures and the ADHD Index, the effects and interactions of the two categorical variables on network measures were also examined.P-values were adjusted using the False Discovery Rate (FDR) method  with 2000 resamples. If the confidence interval did not contain 0, it was considered to be a significant predictor. Pairwise comparisons were performed for the significant interaction terms in the models using the lsmeans package in R . P-value) method . As thisIn this first type of model, Generalized linear mixed effect models (GLMEM) were used for omission and commission errors with the Poisson distribution, given they are count data. LMEMs were used for the other behavioral measures. Behavioral measures were treated as outcome variables and three predictors were inserted in the models – ADHD Index, Age, and SART Task. ADHD Index was centered to reduce collinearity. Categorical variables, Age, and SART Task were coded using the sum contrasts, where children and the Random SART were coded as -1 and adolescents and the Fixed SART were coded as 1. Statistical results were summarized and reported in There were significant differences in task performance between the children and adolescents. The adolescent group performed the SARTs with faster mean RT smaller SDRT, faster mu, β = −35.0, 95% CI = , smaller sigma, smaller tau, smaller FFAUS, smaller SFAUS, and less omission, and commission errors.Participants made significantly more commission errors during the Random than the Fixed SART. There were no other significant differences in performance on the fixed and random SARTs.ADHD Index was positively associated with SDRT, tau, FFAUS, SFAUS, and negatively associated with mu. Other measures were not significantly associated with ADHD Index.There were no significant interactions found.In this second type of model, LMEMs were used to assess the relationship between the RT and network measures. The behavioral measures of mean RT, SDRT, mu, sigma, tau, FFAUS, and SFAUS, were treated as outcome variables. As trials with errors were excluded in order to be able to compute the network measures, associations between omission and commission errors with network measures were not examinable. Network measures, Age, and SART Task were treated as predictors in the models. Network measures were centered to reduce collinearity. Age and SART Task were coded in the same manner as described above. The network measures during the baseline were not examined as they were assumed to be task irrelevant. The network measures during the task and their interactions with Age and SART Task were specifically examined, where Age and SART Task were considered as control variables. Statistical results were summarized and reported in Global efficiency in the theta band was negatively associated with SDRT, tau, FFAUS, and SFAUS. Reduced RTV was associated with a greater increase in global efficiency in the theta band from the baseline to the task. No other significant associations or interactions were found between global efficiency in the three frequency bands and the behavioral measures.There was a significant three-way interaction between modularity in the theta band, Age, and SART Task on SDRT see , and on There were no other significant interactions or main effects.There was a significant two-way interaction between modularity in the alpha band and Age on SFAUS see . There wNo other significant effects or interactions were found.There was a significant two-way interaction between modularity in the beta band and Age for SDRT see . There wThere was a significant three-way interaction between modularity in the beta band, Age, and SART Task for SFAUS see . There wThere were no other significant associations or interactions between modularity in the beta band and the behavioral measures.In the third type of model, network measures were inserted as outcome variables for the three frequency bands  and two time periods . Three predictors were inserted in the models: ADHD Index, Age, and SART Task. ADHD Index was centered to reduce collinearity. Age and SART Task were coded in the same manner as described above. Statistical results were summarized and reported in Relative to children, adolescents performed the tasks with greater increases in global efficiency from the baseline to the task period in the theta and the alpha bands. Compared with children, adolescents showed a greater decline in modularity from the baseline to the task period in the theta, and alpha bands.There were no other significant effects of Age.ADHD Index was negatively associated with modularity in the beta band during the task period.There were no other significant effects of ADHD Index.There was a significant two-way interaction between ADHD Index and Age on global efficiency in the theta band during the task see . There wThere was a significant two-way interaction between Age, and SART Task on global efficiency in the alpha band during the task see . CompareThere were no other significant interactions.Children aged from 9 to 12 years and adolescents aged from 15 to 18 years completed the Fixed and Random SARTs while EEG was recorded. Higher ADHD Index was associated with greater RTV in all the RTV measures except for sigma. The same associations were found in both children and adolescents. As predicted, individuals with higher levels of ADHD symptoms tended to produce more variable responses. Adolescents showed a greater increase in global efficiency and decrease in modularity in the theta and alpha bands from the baseline to task periods, than the children. This suggests that adolescents may be better able to adjust their brain activity to perform the task smoothly relative to children, modifying brain activity be more integrated and less strongly segregated. A greater increase in global efficiency in the theta band was associated with all the RTV measures except for sigma. This indicates that having highly integrated brain activity is beneficial in producing more stable responses, possibly by combining information across the brain more efficiently. In adolescents only, a higher ADHD Index score was associated with a smaller increase from the baseline to the task period in global efficiency in the theta band. This may suggest that there might be a delay in maturation for adolescents with higher levels of ADHD symptoms. Their brains might be less efficient in shifting from the baseline to the task, which might lead to more variable responses.For stable performance, it may be important for the brain to be highly integrated. Global efficiency in the theta band during the task was significantly associated with SDRT, tau, FFAUS, and SFAUS, but it was not associated with mean RT, mu, or sigma. A greater increase of global efficiency in the theta band may be a key characteristic of the brain associated with RTV. The results suggest that greater integration of the brain during the task was associated with more stable performance. Greater integration of the brain, as measured by graph theoretical analysis, is thought to reflect efficiency of information processing . The curThe theta band may play a crucial role in the brain’s ability to perform the task with stable responses, as global efficiency only in the theta band was associated with RTV measures. The importance of this theta band integration in cognitive task performance has been reported in studies applying the event-related networks approach to performance on the oddball task  and the From late childhood to late adolescence, the brain may be developing the ability to efficiently adjust functional connectivity for maximal task performance. Compared with children, adolescents showed a greater increase in global efficiency and decrease in modularity in the theta and alpha bands from baseline to performing the fixed and random SARTs. The results indicate that adolescents were adjusting their brains to be more integrated and strength of segregation to be decreased compared with children when performing the task. Adolescents with higher levels of ADHD symptoms might have difficulty with the brain becoming more integrated when performing the task, which may possibly indicate a delay in maturation of the brain. Adolescents with lower levels of ADHD symptoms showed a greater increase of global efficiency in the theta band from the baseline to the task compared with adolescents with higher levels of ADHD symptoms. Previous studies have suggested that individuals with ADHD showed less brain integration, as measured by the characteristic path length and global efficiency . The assAs hypothesized, individuals with higher levels of ADHD symptoms showed more variable responses. The ADHD Index was positively associated with SDRT, tau, FFAUS, and SFAUS. The results were consistent with previous research and our prediction that higher levels of ADHD symptoms would be associated with greater RTV. In the Ex-Gaussian analysis, any extremely long responses, most likely representing lapses in attention during the task are captured by tau . The strThe level of segregation might be related to RTV differently depending on the age of the participant. Only in the child group was modularity in the beta band negatively associated with SDRT. Additionally, a negative association between modularity in the beta band and SFAUS was found in children only in the fixed version of the SART. Children who showed less reduction of modularity during the task relative to baseline produced more stable responses. Previous research in adults has shown that less segregated brain activity is associated with better cognitive performance . Our resAn expectation for upcoming stimuli helped participants to inhibit their responses to No/Go stimuli, but it might not influence RTV. Participants made more commission errors in the random version of the SART compared to the fixed version, but no other behavioral measures differed between the two SART tasks. A previous study by Even though the participants showed similar levels of RTV between the fixed and random version of the SART, the brain responded differently to the two conditions. Participants in this study were not clinically diagnosed with ADHD, and the analysis was performed using the levels of ADHD symptoms as measured by the Conners 3 ADHD Index. The results could be different with a clinically diagnosed group. Another limitation of the study is the mixed use of the self-report and parent forms of Conners 3 across individuals. The study treated the ADHD Index from parents and self-report as the same variable, as they are highly correlated , howeverOur analysis was performed using surface level EEG recording with 64 electrodes. This allowed us to infer overall connectivity patterns of the surface of the whole brain, but with limited resolution in space. Further studies could consider using source localization methods, fMRI, or simultaneous EEG/fMRI recording to form more complex networks with a greater number of nodes. This would allow for investigations into small local networks existing within the large network and how the small networks communicate each other, such as in the study of hubs of networks . This soAnother limitation of this study was the choice in defining the task period, which was 300–600 ms. It was assumed that this task period is associated with cognitive processes of humans, but this selection of the time window was set by choice rather than determined by a data driven approach. This process of deciding the time window might introduce subjective bias. Future studies could consider adopting different time windows or use a mass univariate approach  to avoidThis study found that a greater increase in global efficiency in the theta band from the baseline to task active status was negatively associated with RTV, where the more integrated the brain, the more stable the performance. We suggest that greater integration of the brain allows for smoother communication between different parts of the brain and subsequently more efficient information flow. As the level of integration was not associated with speed of responses, stability and speed of responses were influenced by different mechanisms in the brain. Adolescents showed greater increase in global efficiency and greater decrease in modularity in the theta and alpha bands during the task compared with children. As children develop into adults, their brains are more efficiently able to shift state as needed for the task at hand, possibly reflecting cognitive maturation. As predicted, individuals with higher levels of ADHD symptoms performed the SARTs with greater RTV. Through the measurement of different aspects of RTV, this research reveals that the general stability of responses is not simply linked to ADHD symptoms. Higher levels of ADHD symptoms might be associated with more lapses in attention (tau), greater difficulty in sustaining attention (FFAUS) and maintaining arousal levels (SFAUS), which may contribute to increased RTV. SDRT, tau, FFAUS, and SFAUS were associated with both ADHD symptoms and global efficiency in the theta band but not with sigma. With these similar patterns of associations, ADHD symptoms and global efficiency in the theta band might explain similar aspects of RTV. From the examination of associations between ADHD symptoms and network measures, only in the adolescent group was global efficiency in the theta band during the task associated with the ADHD Index. This suggests that adolescents with greater levels of ADHD might have a delay in maturation, thus exhibiting lower levels of integration activity and increased RTV.The datasets generated for this study are available on request to the corresponding author.The University of Melbourne Human Research Ethics Committee, the Victorian Department of Education and Training, and the Catholic Education Office in the Archdiocese of Melbourne approved the study, in accordance with the 1964 Declaration of Helsinki. Parents and children provided written informed consent prior to each child’s participation in the study. Adult participants provided written informed consent prior to the study.KM and KJ contributed to the design and implementation of the research, to the analysis of the results, and to the writing of the manuscript. MM helped with the analysis and the writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In Mali, small ruminants (SRs) are an important means for enhanced livelihood through income generation, especially for women and youth. Unfortunately, opportunities for livestock farmers to tap into these resources for economic growth are hindered by high burden of endemic diseases such as peste des petits ruminants (PPR). A key component for the control of PPR is vaccination of SRs. However, low participation of farmers to vaccination was identified by stakeholders of the livestock value chains as a key constraint to successful vaccination programs. This study was implemented in the framework of a project which aimed at improving the domestic ruminant livestock value chains in Mali by upscaling proven interventions in animal health, feeds and feeding and livestock marketing. The objectives of the study were to review the context of livestock vaccination in Mali and evaluate the impact of innovation platforms (IP) as a means for engaging stakeholders in the vaccination process. Desk review, key informant interviews (KII) and net-mapping were used to understand the context of livestock vaccination, while vaccination coverage and sero-monitoring together with group interviews were used to measure the impact of the intervention. IPs were created in 24 communes in three regions: 15 IPs in Sikasso, 4 IPs in Mopti and 5 IPs in Timbuktu. They developed work plans and implemented activities focusing on improving interaction among key vaccine chain delivery stakeholders such as farmers, private veterinarians, vaccine manufacturers, local leaders and public veterinary services; involving them in the planning, implementation and evaluation of vaccination programs and fostering knowledge sharing, communication and capacity building. After 2 years of implementation of IPs, vaccination coverage for SRs increased significantly in target communes. During the first year, seroprevalence rate for PPR increased from 57% (CI95: 54–60%) at baseline to 70% (CI95: 67–73%) post-vaccination in Sikasso region, while in Mopti region, seroprevalence increased from 51% (CI95: 47–55%) at baseline to 57% (CI85: 53–61%) post-vaccination. Stakeholder engagement in the vaccination process through facilitated IPs was successful in fostering participation of farmers to vaccination. However, a sustainable vaccination strategy for Mali would benefit from consolidating the IP model, supported by Government investment to strengthen and adjust the underlying public-private-partnership. Mali's economy is primarily based on agriculture and agro-pastoralism . LivestoOur research was conducted through a development project that aimed at improving productivity of ruminant livestock in Sikasso, Mopti, and Timbuktu regions of Mali from 2016 to 2019. The project aimed at improving animal health, feeds and feeding systems and farmer's access to market  can trigLivestock vaccination in Mali shares characteristics of complex socio-economical systems given the fact that different stakeholders involved, both private and public, have distinct objectives, capacities and incentives. There is often remarkable lack of interaction among these stakeholders. This situation prevents learning and flow of information between them . DecisioThe study was carried out in three major livestock producing regions of Mali, namely, Mopti and Timbuktu  and Sikasso . The choice of the study area was dictated by the development project that supported the IP activities. In the Mopti and Timbuktu regions, reduced rainfall, overgrazing, expansion of grazing areas in crop land, drying of water points, and wind erosion results in major constraints related to feed availability. Therefore, pastoralists are forced to travel during part of the year to feed their animals. For the specific case of Timbuktu, insecurity is a major concern, making access to remote farmers difficult. In contrast, the Sikasso region is among the wettest areas of Mali with a clear dominance of agriculture over livestock farming. It is a system for which pasture rangeland is the basic diet of animals. Access of farmers to veterinary services is easier in this region, compared to other regions ; Figure .In order to understand the policy and institutional framework in which the livestock vaccination operates in Mali, several key reports related to animal health delivery system were reviewed. They include annual reports of 2016 and 2017 of the National Directorate of the Veterinary Services (DNSV) and the National Directorate of Industry and Animal Production (DNPIA), the OIE country Assessment of Performance of Veterinary Services, the National Strategy Plan for Eradication of PPR, the National One Health Plan (2019–2020) and the Strategic Framework for Economic and Sustainable Development Plan (2019–2023).This exercise enabled in-depth assessment of the different stakeholders of the vaccination process, their roles, locations, and perceptions about current vaccination strategies.KII can help determine not only what people do but why they do it. Such interviews are excellent for documenting people's reasons for their behavior and people's understandings or misunderstanding of issues . We usedA workshop was organized at the beginning of the project in 2016, and brought together high-level stakeholders, mostly those that were interviewed during the KII sessions to discuss issues of animal health service delivery in Mali. A special session was held with animal health experts to further discuss keys issues related to vaccination. Recommendations for improvement of vaccination coverage were also provided.Net-Mapping (NM) was carried out to gain more in-depth understanding of the vaccination process tailored to the local context. It also enabled further scrutinization of the mains issues of vaccination from the field and local perspectives. NM was a powerful tool to explore the roles and relations between the different stakeholders on the ground. Drawing on social network approaches , the tooTo establish the IPs, we adopted guidelines as described by Schut et al. . IPs werBaseline data on numbers of SRs vaccinated was provided by the “mandataires” in their respective communes and backed up with data obtained from the public veterinary services in each target communes prior the start of the intervention in 2016. The same information was collected after two consecutive vaccination campaigns (2016–2017 and 2017–2018). In addition, a post-vaccination sero-monitoring survey was carried out for the 2016–2017 vaccination campaign, 1 year after the implementation of the IPs. The calculation of the sample size for the sero-monitoring study was based on the recommended 80% sero-prevalence to achieve herd immunity. Blood and serum samples were randomly collected from 1,500 animals before vaccination and the same number starting from 4 months after vaccination. Competitive ELISA was used to measure the level of sero-conversion of animals following vaccination. Laboratory tests were carried out at the LCV in Bamako, Mali.An evaluation of the status of the IPs was carried out by the project team in 2018, with 15 IPs that responded to the survey. The evaluation team was composed of the project expert on capacity development and implementing partner in each region. An evaluation guideline was developed and administered to a group of two to three IP steering committee members who were selected to be part of the interviews. However, a single response based on group-consensus was recorded. In total, 40 members participated in the interviews. The criteria that were retained for the evaluation were: good understanding of the basic concepts and objectives of the IP by their members; good understanding of the roles of the steering committee; structuration process of the IP in place to see if the process is taking shape; functioning of the IPs and mechanism of self-funding for sustainability.Currently, disease control in Mali (esp. vaccination) is run through a public-private-partnership (PPP) with farmers largely covering vaccination costs. In the PPP model, private veterinarians hold the sanitary mandate, so they are called “mandataires.” They are supervised by the public veterinary services to implement livestock vaccination in their assigned areas. In areas where private veterinarians are not operating, vaccination campaigns are carried out directly by public veterinary agents. Development organizations support free of charge vaccination in specific areas such as those of high insecurity like Timbuktu region. The objectives of the vaccination campaigns are set by the public veterinary services in consultation with the “mandataires” of each region. The targets  depend on the capacities of both public and private veterinary services including availability of funds, equipment and human resources. Several factors that limit performance of vaccination campaigns have been identified in our study. They were groups into three categories: limited participation of farmers to vaccination, limited access of farmers to quality vaccines and socio-economic factors including policy, gender and cultural barriers.The high cost of vaccination was pointed out by various stakeholders as being a limitation to farmer's participation to vaccination. Contrary to what is observed for drugs, where costs for SR are below costs for cattle, the cost of vaccination of SR is the same as that for cattle and camel for any disease. This is perceived as not economically sound and psychologically acceptable to farmers who think that it is unfair given the huge difference in value of these animals. Making farmers better understand the purpose and procedures of vaccination was thus seen as necessary. This situation is exacerbated by the packaging size of the vaccine  which is not suited to farmers who hold small flock sizes who would require group vaccination to reduce the cost. However, such arrangements (group vaccination) entail additional costs related to farmer mobilization which requires extra time, especially for women, if not well-coordinated. On the other hand, the lack of transparency in the communication of the conditions and side-effects of vaccination was considered by stakeholders as a major concern to farmers. This is caused by the fact that many farmers think that PPR vaccination may result in serious side effects as observed for CBPP vaccine. This situation causes reluctance and fuels the lack of trust between farmers and veterinarians. Therefore, the acceptance of vaccination by farmers will largely depend on their level of awareness about the vaccines used (efficiency and safety). In addition, there is mis-perception about the objectives of vaccination by some farmers who think that vaccination is for fattening animals or for treating already sick animals. This leads to farmers missing opportunity to vaccinate their animals at the right time. Added to that, the poor planning, coordination and evaluation of vaccination campaigns was regarded as a major constraint, causing a fragmented vaccine chain delivery where stakeholders do not have the same information at the same time.Frequent vaccine shortages during the vaccination campaigns have been reported. The inaccurate livestock census prior to vaccination is a major cause for this. Often, animal population statistics provided by veterinary services as a basis for forecasting the vaccine demand are far underestimated because most farmers do not declare all their animals to avoid being taxed, yet the census of animals for vaccination is different to the one for tax collectors, and they are even carried out by different government bodies. In addition, the limited capacities of “mandataires” to stock large quantities of vaccines at required temperatures has raised concerns about the quality of vaccines delivered to farmers. This situation creates a fragile business environment for “mandataires” who need to be supported according to stakeholders. Support to the “mandataires” could be achieved through strengthening their business opportunities by facilitating their access to financial institutions to access loans to purchase equipment and grow their business.In traditional livestock systems, sheep, goats, and poultry are the main livestock owned and managed by women, who then play an important role in disease prevention and control. The fact that SRs belong to women or are primarily managed by them, especially in sedentary areas, means that men do not feel bothered by their vaccination, so women do not get enough support to participate in vaccination programs. Furthermore, women face time constraints and limited access to information about vaccination schedules. In addition, in most rural communities, women cannot declare ownership of their animals or register themselves for vaccination because they are not recognized as head of the household. For example, during the livestock census, women who own livestock register them under the name of their husband or son. This situation often leads to wrong perception of communities  that SRs do not need to get vaccinated.Often factors affecting performance of vaccination programs are present at all levels of the vaccine delivery chain, and they are interlinked and often involve a range of stakeholders at a time. Thus, an integrated participatory process through IP to tackle the main issues seemed a promising approach.The results of the net- mapping revealed a diversity of stakeholders involved in the livestock vaccination process. In both pastoral (Mopti) and agro-pastoral (Sikasso) regions, farmers, vaccine producers, and “mandataires” were perceived as having the greatest level of influence by stakeholders. However, in pastoral area, the decentralized public veterinary services such as Veterinary Sector (SV), Veterinary Post (PV), and the CAHWs held medium level power of influence because they provide vaccination in areas without “mandataires.” In agro-pastoral areas, the central decision-making units such as MEP and DNSV were attributed medium level of power because they are more present. CAHWs scored more in pastoral areas, as compared to agro-pastoral areas. This is probably because in pastoral areas, qualified veterinarians are not readily available. In both areas, the administrative officers, police, and the community leaders scored low. This shows their limited involvement in the vaccination process .Initially, multiple functions were assigned to IPs besides livestock disease control. However, challenges related to the implementation of vaccination campaigns were considered as a priority to be immediately addressed. Main issues were the poor communication among vaccine chain delivery stakeholders, the poor knowledge of farmers about benefits of vaccination, their low awareness about vaccination schedules, the inappropriate estimation of livestock population for vaccination, the limited implication of women in vaccination and the low capacity of “mandataires.” Each IP developed a yearly work-plan in a participatory manner and carried out the following key activities during each vaccination campaign:In each commune, a committee made up of the area “mandataire,” a representative of the IP and a local leader (mayor delegate or village chief) was created to carry out census of SRs prior vaccination to better inform the vaccine demand. Information collected in each village was relayed to the veterinary services and used by the association of “mandataires” to forecast their vaccine stocks with the vaccine manufacturer.Every year an official launching ceremony of the vaccination campaign is organized by the government in one of the communes. During this meeting, the national vaccination calendar and the objectives of the vaccination campaign are communicated. IP members sent a representative to the meeting to get information about these plans. The information is then used to plan sensitization campaigns in their respective communes.IPs supported the public veterinary services in organizing awareness campaign about vaccination and dissemination of vaccination calendar through community radio broadcasting in several local languages.IP facilitated the creation of village vaccination teams. The teams were made up of the area “mandataire,” a public authority, a representative of the IP and a local leader. The main roles of the vaccination team were to facilitate the linkage between the community and the vaccinators by setting up the vaccination dates in each village in consultation with the communities and mobilizing farmers for vaccination. Overall, the vaccination team supported the local planning execution, supervision and evaluation of vaccination campaigns together with the veterinary services. Because of insecurity, vaccination teams in Timbuktu region were exclusively composed of CAHWs who are usually supported by GNOs.IPs facilitated the implementation of capacity development activities for value chain actors on animal health, food safety and livestock production through the promotion of an integrated technological package composed of health, feeding and SR housing training modules.IPs facilitated linkage between “mandataires” and financial institutions. They supported development of bankable business models through facilitation of trainings of mandataires on business development and management through the project.Besides vaccination, IPs also discussed and carried out interventions on other topics relevant to them to improve productivity of their livestock such as feeds and feeding, fattening and access markets. Non-specific activities to animal health carried out by IPs to support the livestock value chains include:The main roles of the IPs were to facilitate sheep and cattle fattening activities with an emphasis on promoting group marketing and facilitating linkage between farmers and local and regional markets.IPs foster a conducive environment for women farmer cooperatives to diversify their sources of income through the development and rolling out of viable business models, such as the production and sale of mineral blocks for livestock feeding.IPs, supported model farmers to produce Brachia seed for business. They also mentored farmers to upscale the innovation.In total, 911 IP events and 495 meetings between IPs and project implementing partners were reported . BecauseIncreased participation of farmers to vaccination was shown by the increase in vaccination coverage. Vaccination coverage of SRs has more than doubled over 2 years in target communes compared to previous campaigns . High vaPost-vaccination sero-monitoring after 1 year implementation of the IPs revealed an increased sero-prevalence rate for PPR in Mopti and Sikasso regions from 57% (CI95: 54–60%) at baseline to 70% (CI95: 67–73%) post-vaccination, and from 51% (CI95: 47–55%) at baseline to 58% (CI85: 53–61%) post-vaccination, respectively .Assessment of the IPs showed a good understanding of the objectives of the IPs by their members, clear activities, and road map were defined and a good documentation of activities was in place for most IPs. There was however a medium to low level of understanding of the IP concepts by IP members, as well as a medium to low frequency of meetings among the steering committee members. Most IPs did not yet have a sustainable self-funding mechanism in place, so they still rely of project support to run their activities . Major rVaccines are one of the most cost-effective and sometimes the only means to prevent disease in livestock. Commercial vaccines are available for prevention and control of many livestock diseases, however, these vaccines frequently do not reach, and thus are not often used by, smallholder farmers . A key cThe IPs focused on three pillars: knowledge sharing, capacity building and communication. A study in Bolivia and India highlighted the importance of knowledge sharing. The authors concluded that uptake of livestock vaccination was unlikely to improve without knowledge transfer that acknowledges local epistemologies for livestock disease , 37. AccThe involvement of key stakeholders in all steps of the vaccination process might have contributed to the consolidation of trust among stakeholders, especially between “mandataires” and farmers, resulting in better appreciation of the roles and relations among stakeholders of the vaccine chain delivery. The sensitization campaings that have raised awareness of farmers about the roles and benefits of vaccination might have also motivated farmers to participate in vaccination, hence improvement in vaccination coverage achieved after implementation in the target communes. Although IPs used participatory community approaches for knowledge sharing and dissemination of information, to reach more farmers digital communication channels tools such as interactive voice recording, and text messaging service should be promoted alongside IPs. These are valuable technologies and likely to succeed given the increasing number of farmers who uses mobile phones for business.The PPP in the form of the sanitary mandate is considered by as a suitable approach to control PPR. However, its implementation in Mali has faced many challenges. First, the public good nature of vaccination against diseases such as PPR, that should entail limited vaccine cost to farmers, is contradicted by the current policy of full vaccine cost recovery underway. Resource poor farmers may not see vaccination of their livestock assets as their priority investments, especially if they do not understand the possible long-term benefits. Hence vaccination coverage is below target, which hampers effective disease control. Second, there is an increasing demand from stakeholders to review the legal roles of para-veterinarians and CAHWs who seems to be the only animal health service resource for farmers in areas where qualified veterinarians are absent. In those areas, community initiatives would be a solution to support disease control; and third given the lack of financial incentive in private veterinary practice, many veterinarians have redirected their efforts to other activities in the livestock sector such as production, or even other professions, because current business models are not profitable. Which seems a paradox given the importance of livestock for the country. Therefore, there is imminent need for strengthening PPP and ensure that they are fair.In the short term the focus should be on finding ways of improving the situation for the already established private veterinarians by strengthening their capacity. This could be achieved through diversification of their activities beyond the sanitary mandate to generate more business opportunities, which could serve as an incentive for them to remain in the job. This could for example be the extension of their mandate to the control of food of animal origin and contribution to epidemiological surveillance or include more activities such as provision of extension services. There is also an urgent need to fill up the current critically low human capacity in the public and private veterinary sector through increasing the number of trained qualified veterinarians and support them in establishing private businesses. This could be achieved by creating a Government support fund for the newly graduated veterinarians. Furthermore, business models that uses private partners such as socio-professional organizations of farmers, economic operators or financial institution for financing vaccination campaigns against major endemic livestock diseases could be tested. In any case, the level of the financial cost contribution of the farmers to vaccination of important endemic diseases such as PPR should be reviewed to ensure these are affordable and fair given that PPR vaccination is considered a public good.Agricultural innovation has an important institutional dimension that takes time . AyantunIn our case, 3 years of implementation was considered short to fully assess sustainably of IPs. However, present achievements provide a basis to capitalize on. Long term monitoring the IPs is necessary to lay solid foundation that will lead to sustainability. Follow up studies will focus on better understanding the social dimensions and dynamics of IPs, to better reveal key drivers for behavioral change of stakeholders.Stakeholder involvement in the vaccination process through IP approach has led to an increase of participation of farmers to vaccination, resulting in an increase in vaccination coverage against PPR in target communes. While we promote the upscaling of IPs in other parts of the country, we also call for addressing critical challenges they face in their sustainability pathway. A private business model supported by a solid policy framework is required to sustain such innovation. Although significant progress has been made in increasing vaccination coverage in Mali, the national vaccination coverage is still not enough to guarantee control of PPR anytime soon. A sustainable vaccination strategy will require concerted efforts among stakeholders of the livestock value chains and those of the vaccine delivery, supported by Government investment to strengthen and adjust the PPP models.The datasets generated for this study are available on request to the corresponding author.Ethical approval was not provided for this study on human participants because the activity was implemented with the National Directorate of Veterinary Services (DNSV) in the framework of their national legal mandate under authorization number: N0057/MEP-DNSV. The human subjects were the program beneficiaries. They provided their written informed consent to participate in this study. Ethical review and approval were not required for the animal study because the sero-monitoring activity was carried out by the Central Veterinary Laboratory (LCV) with the approval of the DNSV (reference: N0057/MEP-DNSV) in accordance with their national mandate. Written informed consent for participation was not obtained from the owners of the animals because the sero-monitoring is a routine activity carried under the same approval.AF and MMD conceived the study. MMD compiled the whole information and wrote the manuscript. MMD, IT, HK, ANS, CT, CS, AS, AY, MD, OD, MN, CF, MT, and AF participated in the data collection for key informants and workshops. MMD and AY designed the net mapping tools and collected the data. MMD, IT, and AF designed the questionnaire for the assessment of the innovation platforms. MMD, BW, CS, and AS designed the sero-monitoring study and tools. CS, MD, and AS collected the data for the sero-monitoring and carried out the laboratory analysis. BW, AF, OD, and MMD participated in the structuring and orientation of the write-up. All authors contributed to the literature review performed to build this review, critical review of the manuscript, and approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.