The accessibility to improved water and sanitation has been understood as a crucial mechanism to save infants and children from the adverse health outcomes associated with diarrheal disease. This knowledge stimulated the worldwide donor community to develop a specific category of aid aimed at the water and sanitation sector. The actual impact of this assistance on increasing population access to improved water and sanitation and reducing child mortality has not been examined.We performed a country-level analysis of the relationship between water and sanitation designated official development assistance (WSS-ODA) per capita, water and sanitation coverage, and infant and child mortality in low-income countries as defined by the World Bank. We focused our inquiry to aid effectiveness since the establishment of the Millennium Development Goals (MDGs).Access to improved water has consistently improved since 2002. Countries receiving the most WSS-ODA ranged from odds ratios of 4 to 18 times more likely than countries in the lowest tertile of assistance to achieve greater gains in population access to improved water supply. However, while there were modestly increased odds of sanitation access, these were largely non-significant. The countries with greatest gains in sanitation were 8-9 times more likely to have greater reductions in infant and child mortality.Official development assistance is importantly impacting access to safe water, yet access to improved sanitation remains poor. This highlights the need for decision-makers to be more intentional with allocating WSS-ODA towards sanitation projects. Worldwide, 18% of all deaths in children under five are due to diarrheal diseases, accounting for approximately 1.4 million deaths per year. This makes diarrheal diseases a leading cause of child death globally. The mosSince diarrheal diseases are primarily spread through the faecal-oral route, preventive measures include improving access to safe drinking water and adequate sanitation. Wealthy nations and international bodies first began designating assistance for water and sanitation specifically through the World Bank in 1961 . In 2000Studies on aid effectiveness have been mixed. Most have dealt with the relationship between ODA and economic growth-16 the eOur study is a country-level analysis of the relationship between disbursements of official development assistance (ODA) per capita, improved water and sanitation coverage, and infant and child mortality since the establishment of the MDGs. Disbursed ODA was chosen since promised ODA has not yet had the chance to effect change. Countries included in this analysis were the 49 low-income economies of the world as defined by the World Bank . Nearly All included countries had data for water and sanitation access and ODA. All ODA statistics for the years 2002-2006 were sourced from the Organization for Economic Cooperation and Development Creditor Reporting System database . Data onWe gathered information on potential confounders and effect modifiers from various sources. Country population, gross domestic product (GDP) and health expenditure statistics are sourced from WHOSIS . For popWe calculated the change in access to improved water and sanitation as the difference in percent coverage between 2000 and 2006. Sao Tomé and Principe was excluded from the analysis due to an atypically high influx of ODA in 2002 and 2003, which made the ODA per capita out of the range of the other countries due to their small populations.Two values of change in outcomes  were calculated, namely absolute change and relative change. The absolute change was calculated simply by subtracting the value in 2000 from the value in 2006. The relative change was calculated by taking the absolute change and dividing by the 2000 baseline value. Unless otherwise stated, the values presented are relative change.Variables were assessed for normality, and found in general to have skewed distributions. Thus, Spearman rank correlation coefficients were obtained to identify statistically significant relationships between variables. To assess the associations between variables of interest, unadjusted and adjusted odds ratios and 95% confidence intervals were estimated by unconditional logistic regression. The Mantel-Haenszel Statistic and the Breslow-Day test for homogeneity of the odds ratio were used to assess potential confounding. Using these results, we adjusted for area and country population using logistic regression. We used 2-sided p-values and all p-values are exact. All statistical analysis was performed using Statistical Analysis Software (SAS) 9.1.Here it should be noted that the mismatch in years between ODA and outcomes , though not ideal, does not negate the findings of this analysis. The year 2000 was the closest year available to the beginning of the ODA data for outcome variables, and thus is considered as a baseline value. Analysis focuses on the absolute or relative change in outcomes in relation to ODA flows. All years of ODA are compared individually to the change in outcomes between 2000 and 2006 to attempt to quantify the average lag in effect between ODA delivery and change in outcome.Countries varied greatly in land area, and in total water and sanitation designated official development assistance (WSS-ODA) received, as evidenced by the differences between medians and their corresponding means. In general, WSS-ODA has risen steadily between 2002 and 2006. Overall increases in water and sanitation coverage alongside decreases in IMR and CMR were observed between 2000 and 2006. A summary of data for collected variables is displayed in Table Statistically significant correlations Table  were obsIn cases where no correlation was observed, we cannot conclude that there is indeed no true association due to the limitation on statistical power determined by the small sample size of the analysis. Hence it is with this disclaimer that we report that our analysis did not detect statistically significant correlations between total levels of ODA and any health or infrastructure changes; absolute change in water access and child health; WSS-ODA and changes in access to improved sanitation services; and finally country GDP and absolute change in access to improved water supply.Table Significant odds ratios for water access and WSS-ODA per capita were observed for all years in the adjusted model, ranging from 4.4 2003) to 32.7 (2004). Most odds ratios were not significant for sanitation and WSS-ODA per capita, with the exception of the adjusted model for 2002  in 2003 to 18.15 times (3.46-95.21) in 2004 more likely than the countries in the lowest tertile of WSS-ODA per capita. In general, countries falling in the highest tertile of per capita WSS-ODA are most likely to experience an increase in the relative percent of the population with access to improved water sources. For all years but 2004 and 2006, the countries falling within the middle tertile of WSS-ODA did not experience significantly higher odds of increasing population access to water than those in the lowest tertile. We propose this could be due to a lack of statistical power, or because of increasing population sizes, where WSS-ODA levels that fall below a certain threshold do not appear to increase access to coverage of water and sanitation services because the population is growing faster than additional services are being provided.Despite trends of improved access to sanitation, most evaluations were statistically non-significant. It is unclear whether or not the lack of association is due to a true lack of association between WSS-ODA and sanitation, or whether or not, because of the higher complexity of sanitation systems, there is a lag period for the association to emerge. It may seem a paradox that overall, smaller relative gains were made in access to water compared to access to sanitation, yet WSS-ODA was only significantly related to the change in water access. A large factor in explaining this paradox is that the median baseline value for water access was much higher compared to that of sanitation (59% vs. 28%). Sanitation appears in some ways to be at odds with ODA and government health expenditures, as negative correlations were observed for both the sum of the total ODA per capita between 2002 and 2006  and per capita government health expenditures in 2006 . Further analysis is required to explain the relationship between ODA and sanitation.Interestingly, there was no significant correlation between total ODA per capita received by a country and any of the child health indicators. There was however a significant association between higher levels of increase in sanitation and reductions in infant and child mortality, with adjusted odds ratios of 8 and 9 times for the highest compared to the lowest tertiles, respectively. It is unknown why there is an apparent lack of association between this relationship and WSS-ODA. It may be due to ineffectiveness in investments, a weak capacity of the mandated national institutions, or perhaps due to success on behalf of local, non-internationally funded efforts. The higher odds of sanitation, as compared to water access, producing significant reductions in child mortality is consistent with the literature including a study by Fewtrell and co-workers -31, who While public health practitioners may consider water and sanitation to go hand in hand, this natural association must not be assumed in all cultural contexts . Water, As with any study, this research was bound by certain limitations. First, due to the nature of the research question dealing with only low-income countries, our sample size was relatively small, which constrained some steps in our statistical analysis. It was further constrained for analysis of health outcomes by the fact that diarrhoeal diseases account for an estimated 18% of child deaths [Another limitation is that ecological studies are always to be interpreted with the understanding that cross-country comparisons cannot capture fully all of the unique socio-political, economic, cultural, and geographic factors that influence aid effectiveness in expanding water and sanitation infrastructure, and gains in child health made can be masked by other factors, such as increasing mortality from HIV/AIDS. Because of the scope of our research, we were unable to include an analysis of how conditions in conflict settings influence both ODA and its distribution and timeliness in expanding access to water and improved sanitation facilities. This is an important topic for future study.As we approach 2015 and the world continues to labour to meet its commitment to the Millennium Development Goals, regular assessments should be carried out on the goals and their components. This study draws attention to the need for more research around ODA effectiveness in the expansion and maintenance of water and sanitation infrastructure. Despite the transfer of large amounts of ODA, many of the MDG targets are not expected to be met ,23. The More research is needed to understand the seemingly paradoxical relationship between ODA and sanitation, how debt relief compares to grants and loans in proliferating water and sanitation infrastructure, what degree of public-private mixing in ownership and service provision is optimal for rapid expansion in certain resource-poor settings, and how public education can be used to compliment infrastructural expansion to produce synergistic benefits to child health. It would also be interesting to conduct an analysis determine the effectiveness of national allocations towards the water and sanitation sector.Preparation for this study uncovered the absence of important data. To begin, our initial aim was to use diarrheal-specific mortality rates as our health outcome, since it is expected to have a stronger association with water and sanitation infrastructure than overall infant and child mortality rates. This indicator could not be employed since the percentage of deaths from diarrheal disease, as reported by the World Health Organization, was only reported for the year 2000. In addition to diarrheal mortality, we had desired to control for conflict, but could not because we were unable to find an appropriate conflict index scale.Future research would benefit from the accessibility of sub-national level monitoring of progress in water and sanitation access as well as health surveillance. Since country-level data is often derived from census data, it is highly likely for many countries that district and even city-level data is available, but not accessible. We would strongly suggest that an international body, such as the UNICEF or the World Health Organization, solicit and make publicly available sub-national data, to help researchers avoid the ecological fallacy and be able to conduct precise and detailed inquiries.The authors declare that they have no competing interests.EP, MJB, MJ, and EM conceptualized the research question and developed the inclusion criteria, EP, MJB collected data on the variables. MJ, RB and MJB conceptualized and performed the statistical analysis. EP and MJB prepared the first draft of the manuscript. EP, MJB, MJ, EM, BJ and RB critiqued the draft, added text, and gave valuable input to refinement of the statistical analysis. Subsequent revisions were made by all authors. All authors reviewed the final draft and approved it for submission.


Low-income countries with high HIV/AIDS burdens in sub-Saharan Africa must deal with severe shortages of qualified human resources for health. This situation has triggered the renewed interest in community health workers, as they may play an important role in scaling-up antiretroviral treatment for HIV/AIDS by taking over a number of tasks from the professional health workers. Currently, a wide variety of community health workers are active in many antiretroviral treatment delivery sites.This article investigates whether present community health worker programmes for antiretroviral treatment are taking into account the lessons learnt from past experiences with community health worker programmes in primary health care and to what extent they are seizing the new antiretroviral treatment-specific opportunities.Based on a desk review of multi-purpose community health worker programmes for primary health care and of recent experiences with antiretroviral treatment-related community health workers, we developed an analytic framework of 10 criteria: eight conditions for successful large-scale antiretroviral treatment-related community health worker programmes and two antiretroviral treatment-specific opportunities.Our appraisal of six community health worker programmes, which we identified during field work in Ethiopia, Malawi and Uganda in 2007, shows that while some lessons from the past have been learnt, others are not being sufficiently considered and antiretroviral treatment-specific opportunities are not being sufficiently seized.In particular, all programmes have learnt the lesson that without adequate remuneration, community health workers cannot be retained in the long term. Yet we contend that the apparently insufficient attention to issues such as quality supervision and continuous training will lead to decreasing quality of the programmes over time. The life experience of people living with HIV/AIDS is still a relatively neglected asset, even though it may give antiretroviral treatment-related community health worker programmes better chances of success than their predecessors and may be crucially important for adherence and retention in large-scale antiretroviral treatment programmes.Community health workers as a community-based extension of health services are essential for antiretroviral treatment scale-up and comprehensive primary health care. The renewed attention to community health workers is thus very welcome, but the scale-up of community health worker programmes runs a high risk of neglecting the necessary quality criteria if it is not aligned with broader health systems strengthening. To achieve universal access to antiretroviral treatment, this is of paramount importance and should receive urgent attention. Despite significant progress in scaling up antiretroviral treatment (ART) in low- and middle-income countries in recent years, the gap between the need for ART and the numbers currently receiving it is still wide in most of sub-Saharan Africa ,2.The health care systems of low-income countries with high HIV prevalence have been struggling to provide even basic health care to the population, let alone to deal with the additional burden of scaling up ART -5. MoreoWhile estimations of HRH needs for scaling up ART show wide variations depending on contexts and programme variables , there iIn this article we focus on task shifting for ART to community health workers (CHWs), asking how far they have taken on board the lessons learnt from past experiences with CHW programmes for primary health care and how far they are seizing the new HIV/AIDS-specific opportunities. Our framework for analysis is a list of 10 issues: eight conditions for successful large-scale CHW programmes plus two ART-specific opportunities.We have opted for the term CHWs because it illustrates better than the terms lay providers or non-professional health care workers that the use of this type of cadre has a history that may provide important lessons for today. It is also widely used in the recent literature on task shifting and HRH issues in the scale-up of priority interventions such as ART ,13. We rIn the first part of our paper we establish the list of 10 criteria for successful CHW programmes for ART, which is based on our literature review of task-shifting, on previous multi-purpose CHW programmes for primary health care and on the more recent specific HIV and ART-related CHW programmes. In the second part we give six examples of ART-related CHW programmes, which we identified during our field research in Ethiopia, Tanzania and Uganda in 2007. Finally, we appraise the six CHW programmes according to our list of 10 criteria and formulate a conclusion.Studies of the effectiveness of CHW programmes in sub-Saharan Africa in the past show a mixed picture. There is wide agreement on the potential of CHW programmes to improve access to and coverage of communities with basic health services. There is some evidence, too, that they can improve health outcomes under certain conditions -17. But Programa Agente Comunitario de Saude , with a coverage of more than 60 million people [Yet examples exist of large-scale programmes that are widely considered to be successful. One such example is the CHW programme set up by the Bangladesh Rural Advancement Committee (BRAC) in Bangladesh in the 1970s, which had expanded to more than 70 000 female CHWs by 2007. Taking a long-term view, BRAC has evolved the programme based on accumulating experience and learning [n people .From our literature analysis it emerges that there are several fundamental characteristics of successful CHW programmes, just as there are some fundamental problem areas. Successful CHW programmes fulfil a number of conditions to ensure performance with regard to quality assurance, long-term reliability and scale-up of activities. We consider eight issues as essential for the success of CHW programmes: five of them are basic conditions for all CHW projects and three are necessary for the scale-up to large programmes with wide coverage. The success of a CHW programme depends on all eight conditions, and the neglect of even one may jeopardize the success of the entire CHW programme.There is wide agreement that CHWs should be selected on the basis of their motivation to serve the community they will be working in. Belonging to this community is crucial. Prior level of education is less important, although literacy and numeracy facilitate participation in training and follow-up activities .Selection that has not been carefully considered can lead to a lack of trust from the community and become a contributing factor to a high turnover of CHWs, which will make sustained quality assurance unlikely ,22.This is of crucial importance and its length and content depend on the prior knowledge and the tasks and roles to be fulfilled by the future CHWs. Training should be practically oriented and not consist of transferring disease-specific knowledge alone, but also communication and counselling skills ,22. GuidThe use of protocols and standard guidelines is increasingly being recognized as an important tool for quality assurance in most health professions. CHWs are certainly no exception ,16,23. BEvaluations of PHC-CHW programmes in the past have shown that oftentimes CHWs were overwhelmed by a very broad range of tasks with negative effects on the overall quality of their performance. Also, CHWs with too many tasks tended to select only a few activities that they themselves regarded as most feasible. Clearly defined roles and standardized protocols should make sure that CHWs practise within the limits of what they can achieve and what they have been trained for. Simple guidelines and standards also greatly facilitate supervision and supply management.Programa Agente Comunitario de Saude in Brazil) or through a formal NGO network (e.g. BRAC in Bangladesh), but in both cases referrals to the formal health services need to be facilitated.Especially supervision and other forms of support, such as supplies, are widely acknowledged in the literature as crucial for the continued quality of service provision by CHWs. Particularly large-scale CHW programmes have often neglected these areas, mainly because they had overlooked their cost in the planning stage ,24-26. OAlso of crucial importance for sustaining the quality of performance of CHWs is continued support in terms of refresher training and regular mentoring. Several studies have shown that without refresher training, acquired skills are quickly lost ,25.Many instances of past CHW programmes have been described in which professional health care workers saw community members as lowly aides and failed to understand the potential value of their contribution. Thus the relationship between CHWs and the formal health services often became strained, negatively affecting the satisfaction and performance of CHWs ,14,25. TOne major socioeconomic challenge that has been the subject of ongoing debate is the issue of payment versus voluntarism. The initial idea of the CHW assumed the existence of a pool of willing volunteers, but lack of payment has emerged as an important cause of attrition of CHWs in many programmes ,26. ThisThree additional conditions for the successful scale-up of CHW programmes are:For national CHW programmes it is necessary to develop regulatory frameworks that demarcate the boundaries between CHWs and the professional health cadres and provide protection for patients as well as for health care workers . DependiAs Abbatt points out, training large numbers of CHW will not be a "quick win", as implied by the United Nations Millennium Project report in 2005, as long as it is not accompanied by broader efforts to strengthen health systems . Indeed,There is some indication that in order to be sustainable and remain relevant, CHW programmes need to evolve in continuous interaction with the formal health system and, more widely, with the society they are based in. As patterns of societies are changing and health systems are becoming increasingly pluralistic, CHW programmes should not remain static but need to be reactive to newly arising needs, changing expectations and other evolving challenges .It is becoming ever more obvious that for scaling up ART to the millions in need, not only the roles of professional health care workers must be redesigned but also the pool of other, non-professional HRH must be tapped ,30. AlreIn general, we can distinguish between CHWs who have long been established for a variety of health care activities and who have recently reassumed additional HIV/AIDS-related tasks, and those CHWs who have been especially introduced for specific HIV/AIDS-related tasks, such as serving as counsellors and expert patients. The majority of ART-related CHW programmes are not well documented and there is so far no systematic assessment of their performance and their potential to mitigate the HRH crisis. There are, however some studies that indicate that CHWs can make a positive contribution to the performance of ART programmes.accompagnateurs) in Haiti are involved in many HIV/AIDS and TB-related activities, including even the provision of ART to the patients.In Malawi, for example, Zachariah et al. describe the very positive experience of involving community volunteers in programme-related activities, such as, for example, voluntary counselling and testing (VCT), ART adherence counselling and referrals for ART or opportunistic infections . The cruIn Zambia, a study of the effectiveness of adherence support workers (ASWs) in adherence counselling, treatment retention and addressing HRH constraints at health facilities showed a marked shift of workload from health care workers to ASWs without any compromise in the quality of counselling. The loss to follow-up rates of new clients declined from 15% to 0% after the deployment of ASWs .The AIDS Support Organisation (TASO) in Uganda has been working with lay providers, called "field officers", providing ART at home since June 2004. Adherence to ART has been shown to be very high and a recent study of the mortality under ART in this programme concluded that "the overall effect of ART on mortality was similar to or better than that seen in facility-based studies (...)" ,34.Based on such examples and on experiences with chronic care in high-income countries, we hold that in addition to the eight general conditions for successful CHW programmes, there are two more specific opportunities for ART-related CHW programmes, completing our list of ten issues:What makes HIV/AIDS special is that it is a chronic condition resulting in a growing pool of people living with the disease. The concept of using the personal experiences of people living with the disease is emerging as one important building block for chronic care programmes in industrialized countries -38. The Chronic-care models usually put a lot of emphasis on the self-management skills of patients in order to achieve the best results in terms of adherence to treatment and long-term retention in care. The problems of loss to follow-up and the negative effects of non-adherence are well documented for ART programmes ,42. We rOf the three countries, it is Uganda where we met with the widest range of CHWs involved in ART-related health activities. We identified the following eight types, which may not be exhaustive: ART aides, HIV medics, field officers, community ART and TB treatment supporters (CATTS), community AIDS support agents (CASAs), AIDS community workers (ACW), expert patients (network support agents) and TB tracers. According to our knowledge, only the field officers have been described in various publications ,43,44. WExpert patients are found in almost every ART site in Uganda. They are by no means a clearly defined group or cadre, as the characteristics of their recruitment, their training, their responsibilities and their remuneration depend on the respective NGO that is locally in charge of the expert patient programme. Accordingly, their salary ranges from less than USD 2 to USD 75 per month. The main common selection criterion is their positive HIV status. The most generally known "expert patients" are TASO's Network Support Agents, who receive five weeks' training in VCT and two weeks' training in ART-related tasks. While the term "expert patients" is clearly being used as a label for these and other HIV-positive lay providers, we did not find that the term had the same meaning as the original concept of the expert patient, as it was developed for the self-management of chronic disease care .ART aides are mostly but not necessarily PLHAs, trained in five days with the WHO Integrated Management of Adolescent and Adult Illness (IMAI) course by the NGO Uganda Cares. Most of the more than 20 ART aides in 2007 were chosen from among PLHAs who had received previous training as expert patients, also as part of the IMAI approach. The training of ART aides is focused on general support for HIV care and ART, with specific activities in triage, adherence support, group education, pre- and post-test counselling, drug dispensing and records management at health centre level. The ART aides receive a salary of USD 35 per month from Uganda Cares.HIV medics are trained by the NGO Uganda Cares and supported by the AIDS Healthcare Foundation. They are a mix of PLHAs on ART (about 25%) and non-PLHAs with no prior medical background. They are required to have a high school education and be able to read and write English. They follow a 12-week training course of which the curriculum includes six weeks of classroom teaching and six weeks of practical clinical training. It covers topics such as general knowledge of HIV/AIDS and ART, counselling, adherence support, medical history-taking, triage, examination and referral of patients and follow-up of patients. Some HIV medics have additionally been trained in doing CD4 tests and HIV tests. By June 2007, 55 participants had completed the course and were employed and paid by different NGOs. The ones employed by Uganda Cares receive a salary of USD 226 per month.Field Officers are mostly social workers with a university degree. They are employed by TASO. Their training lasts around two months and enables them to follow up clients on ART at home, including the delivery of ARVs, provision of home-based care and counselling and referral of complicated patients. They are selected by TASO centres and supervised monthly by the Parish AIDS Committee. They receive a monthly salary of about USD 350 and a daily lunch allowance of about USD 3. With their high level of education, they are fairly atypical CHWs.In Malawi we identified the following six types of CHWs involved in HIV-related activities: community health workers, community care providers, VCT community counsellors, volunteers trained at the health facilities, HBC volunteers and health surveillance assistants (HSAs). We chose to focus on the HSAs, as they are the most widely established. Also, while there is some literature on HSAs ,24, we fHSAs have been in existence since the 1960s and 1970s, when they were recruited as temporary "smallpox vaccinators" and "cholera assistants". Malawi's Ministry of Health and Population (MoHP) decided to keep these trained people for the purpose of surveying health risks and providing basic care before referral to a health facility. Over the years the mandate of HSAs has widened considerably and now includes vaccination of under-fives, growth monitoring, supervision of traditional birth attendants, sanitation, water source protection and water treatment, disease surveillance, health and nutrition advice, provision of family planning devices and the follow-up of TB patients . While tIn the context of the HIV/AIDS programme and the scaling-up of ART in a number of projects and districts, the HSAs have been assigned a number of additional tasks, such as HIV prevention, provision of VCT, basic care for opportunistic infections, administration of cotrimoxazole prophylaxis, ART defaulter tracing, prevention of mother-to-child transmission for the newborn and general support to ART clients. However, we found that the specific tasks given to HSAs differed greatly in the various facilities studied. Their HIV/AIDS-related roles and functions were determined by the level of resources available and the needs at each site.The initial training for HSAs lasts 10 weeks and focuses on their core tasks. Training for HIV-related activities is shorter and occurs after the initial training. HSAs are selected centrally. After training they are sent to the communities in which they are to work and live.While in 2004 there were around 4000 HSAs in the country, by 2008 their number had almost tripled, to nearly 11 000. This fast expansion was made possible with funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, but the formal training of new staff has not yet taken place and is being replaced by on-the-job initiation by NGOs or existing HSAs.In Ethiopia we identified six different types of CHWs involved in HIV-related activities: health extension workers (HEWs), care givers/care aides, expert patients, Kebele health workers, community counsellors and community health agents .We want to focus here on the HEWs, because the Government of Ethiopia is investing substantially in a Health Extension Programme for increasing the access of the population to promotive, preventive and curative care. Also, there are number of publications focusing on HEWs ,46,47, bThe cadre of HEWs was created in 2003; by the end of 2007 more than 17 600 people had been trained. There are now 24 000 HEWs, and the aim is to increase their number to 30 000 by 2009 . HEWs muTheir training lasts one year and includes theoretical as well as practical background, covering a wide array of mainly promotive and preventive topics within the four categories of hygiene and environmental sanitation, family health services, disease prevention and control and health education and communication.According to their job description they spend 25% of their time in the health posts and the other 75% in the community. HIV/AIDS is part of the curriculum, and we have identified the following activities of HEWs: provision of HIV education; psychological support; HIV counselling; prevention of mother-to-child transmission of HIV, including the provision of Nevirapine; patient care during home visits; ART adherence counselling; individual or group treatment support; referrals of complicated patients; and defaulter tracing . HEWs arBased on what we know about the CHW programmes described in the previous section, we want to attempt to examine them against the background of the eight conditions for the success of past CHW programmes and the two HIV/AIDS-specific opportunities.The ART aides and HIV medics in Uganda are selected and recruited by NGOs or the health facilities. Also, the field officers are selected by TASO and not by the community, but it should be noted that they are to some extent part of a wider community-based structure. Thus, TASO's AIDS community workers and community AIDS support agents are usually identified in dialogue between the programme managers and the communities. It is the communities themselves that decide on their final selection. The HSAs in Malawi must live in the community and profess the motivation to serve the community they will be working in. Their selection, however, is done centrally and not by the community. Only the HEWs in Ethiopia are selected with the participation of the community. Our finding that communities are not necessarily pivotal in the selection of CHWs may be related to the fact that some of the cadres reviewed are rather facility-based lower cadres than real community-based health care workers. Of all six programmes, only the expert patients and ART aides are chosen on the basis of having a positive HIV status.It is a matter of course for all six CHW programmes to provide initial training to the prospective CHWs. The length and type of initial training vary between programmes and it is not the purpose of our overview to assess its quality or adequacy. However, the example of the HSAs in Malawi indicates that the timely provision of adequate training can become a challenge. Recently, this cadre was vastly expanded, from 4000 to 11 000, but the plans for initial training in HIV-related tasks have not yet been realized. The new HSAs are still being trained on the job by the existing HSAs and by local NGOs. The 12-month-long training of HEWs in Ethiopia may well prove one important factor of success.In the four Ugandan programmes created exclusively for HIV/AIDS-related care, the CHWs adhere to a relatively narrow range of activities. HIV medics and ART aides, for example, are given very specific tasks at the laboratory, the pharmacy and the consultation room of the health facilities. By contrast, the HSAs and HEWs, who are working in much broader community health programmes, must fulfil a much larger range of tasks. Interviews with HSAs in Malawi revealed that many of them feel overloaded with work, as more and more tasks are being added to their job description. This was also seen as one of the reasons affecting the quality of their performance in key activity areas such as immunization . JudgingResponsibility for the supervision of ART aides, HIV medics and expert patients in Uganda lies with the respective health facility where the CHWs are based. The ART aides should be supervised by HIV medics, the home-based care coordinator or a health centre nurse; the HIV medics should work under the supervision of physicians, nurses or clinical officers . These CThe HSA programme in Malawi prescribes that HSAs should be supervised by environmental health officers and community health nurses. The survey by Kelly et al. described the actual supervision system as inadequate and reported that due to transport problems, supervision hardly ever occurred except on immunization days, when transport was available . In the The HEWs in Ethiopia are in most cases supervised by the Woreda Health Office and sometimes also by the health centre where they are based. An assessment by the Center for National Health Development in Ethiopia from May 2006 found that good guidelines for team supervision exist and that a lot of attention was given to the supervision of HEWs at all levels. However, the Woreda Health Offices as well as the health centres were usually neither sufficiently staffed nor trained to provide good supervision .It seems that in none of the programmes has the issue of refresher training received much attention in the initial planning process. Uganda, for example, had a well-organized network of community-based health care NGOs in the past, who variously developed criteria and trainer and facilitator manuals. But these have not been taken up by the new ART-oriented CHW programmes, except in those supported by TASO. Given the importance of continuing training for a sustained quality of service provision by CHWs, there is a risk that this may become a weakness of these CHW programmes.While in small CHW projects with strong NGO back-up the organization of sufficient support looks feasible, it is much more of a challenge for the large national programmes. There are major doubts about adequate supervision and support in these programmes, especially due to the overall lack of professional HRH. Also, clinicians are usually poorly trained for such tasks and the relationship between health professionals and CHWs may become strained because of frustrated expectations on both sides. There is a real risk that poor supervision and support will compromise the quality of the large-scale CHW programmes.In all six programmes the CHWs receive a regular salary. TASO's field officers earn a monthly USD 350 and the HIV medics earn – at USD 226 per month – only a little less than even a nursing or a clinical officer. Although the pay of ART aides is quite modest, at USD 35 a month, given the wide-scale rural unemployment it may constitute an important reason to continue service as a CHW. It is quite striking that there is such a wide range of salary options for CHWs with activity packages that do not differ greatly. In Malawi and Ethiopia, where the HSAs and HEWs are part of the MoH structure, their salary is below that of the professional health care workers.None of the CHW cadres in Uganda has so far been formally recognized by the MoH. The consequence is that they do not have structured career opportunities. A recent policy prescribes that there should be village health teams with the role, among other things, of selecting and supporting CHWs. The modalities of how this will actually operate are still under development, leaving room for various NGOs to experiment with different forms of CHW programmes.The HSAs in Malawi, by contrast, have a career path. According to the Ministry, they can be promoted to the position of senior HSA; plans have been made recently to create several levels of HSAs with increased salary scales. They also have a better chance of being accepted for further studies to become environmental health officers, clinical officers or nurses.The HEWs in Ethiopia have an opportunity to upgrade to nurses. This depends on their performance and recommendation from their supervisors. However, by 2008 none of the HEWs had so far upgraded.As the CHWs in Uganda are not officially recognized by the MoH they do not have a regulatory framework, despite working in MoH facilities. A system-wide scale-up of one specific CHW programme for the provision of ART does not seem to be intended. The HSAs in Malawi and the HEWs in Ethiopia are officially regulated by the Ministries of Health. In fact, in both countries it was the MoH, supported by donors, that decided to quickly and substantially expand these cadres.This point can be regarded as a summary of most of the previous points. The national scale-up of a CHW programme for ART is conceivable only in a strong health system that can provide regular follow-up training, organize and sustain adequate support and supervision, ensure adherence to protocols and implement and enforce a regulatory framework. CHWs are not a substitute for professional HRH, but only a complement.All programmes are reactions to the new challenges posed by HIV/AIDS and the scale-up of ART. The Ugandan CHWs have been newly created for HIV-related purposes; the Malawian and Ethiopian CHWs have been assigned new HIV-related functions. How far these CHW programmes will interact in flexible and dynamic ways with the formal health services and evolve along with broader changes in the societies, remains to be seen.We have mentioned that only two small-scale NGO projects select their CHWs on the basis of being PLHAs. Of course, there exist many other smaller projects in all three countries, such as mutual support groups, peer educators and community counsellors that specifically involve PLHAs, with good results. However, neither of the two large-scale national programmes uses this "positive discrimination" of PLHAs in their selection of CHWs. Not to tap the life experience of the ever-growing pool of PLHAs on ART means missing an important new HIV-related opportunity.Small-scale NGO projects, such as those described in Uganda, often pay high attention to the issues of adherence and retention in care. We have the impression, though, that these two crucially important aspects of long-term success of ART programmes have so far been relatively neglected in the large-scale national CHW programme in Malawi. Ethiopia has recently pilot-tested a case management programme as a strategy to provide a continuum of care and link the health facilities with the community to prevent loss to follow-up and improve adherence to treatment. The plan is to scale up the case management programme at national level once it is evaluated . HoweverOur appraisal of the CHW programmes in Uganda, Malawi and Ethiopia shows that some lessons seem to have been learnt from past experiences but that others have been neglected and that important weaknesses remain. New ART-related opportunities are not sufficiently seized.All programmes have learnt the lesson that CHWs cannot be retained in the long term if they do not receive adequate remuneration. Yet concerns about the long-term funding of NGO programmes with high CHW salaries have been voiced.Based on lessons from the past, we contend that while an adequate and competitive salary may prevent a high turnover of CHWs, the apparently insufficient attention to other issues such as quality supervision and continuous training will lead to decreasing quality of the programmes over time. The strong need for support and training illustrates clearly that CHWs are not a simple and cheap solution to the lack of qualified HRH. CHW programmes that seem to be successful show that quite the contrary may be the case: they usually employ many qualified HRH for training, supervision and support ,52. TherThe government programmes seem more attractive than the NGO-based programmes for scaling up ART and reaching coverage, as the CHWs are already part of the health system's structure, regulatory frameworks exist and career prospects can be created. However, we contend that they run the highest risk of neglecting quality assurance if their scale-up is not aligned with broader health systems strengthening. For scaling up ART, health systems need to fulfil many functions in a reliable way, including the provision of support, supervision and training of CHWs. Therefore, CHWs can only ever be an addition, never a substitute for health systems strengthening ,29.We have the impression that small NGO projects are more likely than large national programmes to select PLHAs as CHWs. Not to capitalize on the life skills of the growing number of PLHAs for the crucial programme aspect of long-term retention in care is a missed opportunity of large-scale CHW programmes. It is easy to imagine how much more motivating it would be, for example, for an HIV-positive pregnant woman to be counselled by an HIV-positive mother with a healthy child than by a CHW without this personal experience and with only limited training.We argue that current CHW programmes for ART should not be regarded as something entirely new but as standing in the context of a history of CHW programmes, so that lessons of failure and success, as outlined here in the form of eight conditions, can be incorporated in the design of new CHW programmes. The use of the life experience of PLHAs may give HIV/ART-related CHW programmes better chances of success than their predecessors and may be crucially important for adherence and retention in large-scale ART programmes .Due to our formal health system perspective, we did not deal with an important aspect of the original CHW concept, i.e. their role as agents of change in the relationship between health services and population and for community empowerment. More research on non-facility-based CHW programmes, their lessons of failure and success, and their present and potential role in the scale-up of ART, would be very useful and timely.CHWs as a community-based extension of health services are essential for ART scale-up and comprehensive PHC. The renewed attention to CHWs is thus very welcome, but the scale-up of CHW programmes runs a high risk of neglecting the necessary quality criteria. To achieve universal access to ART, this is of paramount importance and should receive urgent attention.The authors declare that they have no competing interests.KH reviewed the literature and drafted the manuscript. WVD conceptualized the study and reviewed the various drafts of the text. AC, WM and WVD designed and conducted the field studies. GWP, YA and EJS contributed country-specific data and reviewed the manuscript before submission. All authors have seen and approved the final version.


Intentional injury presents a threat to the physical and psychological well being of young people, especially in developing countries, which carry the greatest part of the global injury burden. While the importance of this problem is recognized, there are limited population data in low and middle income countries that can guide public health action. The present study investigates the prevalence and distribution of intentional injury among young people in three Pacific Island societies, and examines behavioural and psychosocial factors related to risk of intentional injury.students aged 11–17 years in Pohnpei State in the Federated States of Micronesia (n = 1495), the Kingdom of Tonga (n = 2808) and Vanuatu (n = 4474). Surveys measured self-reported injury and intentional injury, sources of intentional injury, and the range of behavioural, psychological, educational and social variables that may be related to injury risk.Population surveys were conducted with Among boys and girls aged 14–17 years the respective period prevalence of intentional injury was 62% and 56% in Pohnpei, 58% and 41% in Tonga, and 33% and 24% in Vanuatu. The prevalence of intentional injury declined with age in Tonga and Vanuatu, but there was little evidence of an age-trend in Pohnpei. Across the three societies, the major sources of intentional injury among boys were 'other persons' followed by boyfriends/girlfriends and fathers. Mothers, boyfriends/girlfriends and other persons were primary sources of injury among girls. An intentional injury was reported more often by those who had been bullied , by regular smokers in Tonga and Vanuatu , and illicit drug users in Pohnpei and Vanuatu .Intentional injury was reported extensively in these three populations. Interventions directed towards the school environment and which take into account the role of bullying and drug use need to be considered. Global data on the burden of injury show that in 2002 intentional injuries accounted for 1.5% of Disability Adjusted Life Years (DALYs) among 5–14 year old girls and 2% among boys in this age group [All forms of injury present threats to physical and psychological well-being, and for children and adolescents an important focus of research has been the nature and impact of injury arising from interpersonal violence. This encompasses violence inflicted by parents and family members, peers, dating partners, teachers and other authority figures such as police. The 1997–98 Health Behavior in School Children (HBSC) survey of 11–15 year old students in Europe and North America found that fighting caused about 4% of total injury . AdditioExposure to harsh discipline from parents and authority figures has been investigated in a number of countries. In Egypt it has been reported that 37% of preparatory and high school students had been disciplined physically by parents and 26% had been physically injured as a result of such discipline .The psychological and behavioural impacts of interpersonal violence, which include depression, anxiety, substance abuse, delinquent behaviours, poor school performance and self-harm , mean thThe purpose of the present study is to examine the extent and sources of intentional injury among young people in three Pacific island societies; the state of Pohnpei in the Federated States of Micronesia (FSM), Vanuatu and the Kingdom of Tonga. Injury and violence have been recognized as a health priority across the Pacific region, but there are little country-specific data to guide action. The health and education authorities in these locations agreed to collaborate with UNICEF in the development of a Lifeskills program for adolescents, and the data presented here formed part of the baseline measures for this initiative. This investigation provides an opportunity to examine the extent of intentional injury in populations with high proportions of children and adolescents  which arThe Health Behaviour and Lifestyle of Pacific Youth (HBLPY) study comprised cross-sectional surveys of representative samples of school students aged 11 to 17 years in Tonga, Vanuatu and Pohnpei State of FSM. The methodology of this study has been described in detail elsewhere .Briefly, cluster random sampling was used to select primary and secondary school students; international schools and schools located in remote areas were removed from the sampling frame. Cluster sampling is used in the HBSC studies in numerous countries  because Students in all locations were asked about: socio-demographic characteristics; substance use ; mental well-being; perceptions of the school environment; ease of communication with family, peers and others; bullying, and; injury. The injury and violence questions asked students to report the frequency of physical injury during the last 12 months. Following this students were asked if they had experienced a physical injury that was deliberately caused by: father; mother; teacher; police; boyfriend/girlfriend, or; other persons.The questionnaire was extensively pre-tested with school students and key stakeholders to ensure relevance, comprehension and acceptability. All surveys were administered in the local languages.The data collection protocol for this study was ethically reviewed and approved by UNICEF and the Ministries of Education, Health, and Youth Affairs in each country. Permission for implementation of the survey was also obtained directly from the relevant school systems. Information about the survey was distributed to parents and only those providing notification of a wish not to take part were excluded (passive consent). Consenting students were informed of the aims and procedures of the study, their right to abstain from completing any of the questions or withdraw from the survey, and the confidentiality of all data collected. Students self-completed the questionnaire either in their classrooms or in designated areas under the supervision of survey staff. To ensure students' privacy and to allow for anonymous participation, teachers or any authority figures were not present during the surveys. The surveys were conducted between September and October 2000 in Vanuatu, October and November 2000 in Tonga, and in April 2001 in Pohnpei.Surveymeans and Surveylogistic procedures to account for the clustering within schools. Descriptive statistics on the source of intentional injury were tabulated by sex and age. As indicated above and described elsewhere [Analyses were conducted using SAS software V9.1.3 . We used lsewhere , the samProc Logistic function. Highly collinear variables (Spearman correlation >0.4) were identified by examining the correlation matrix of all the independent variables. Only one correlation between "school score" and "teacher score" met this threshold. The change in deviance (as a chi-square) when each of these variables was added or subtracted from a model was used to select the variable that was excluded.Independent factors associated with intentional injury were investigated using stepwise multiple logistic regression analyses. Factors of interest were substance use , behavioural factors , school environment and teacher ratings. Different models were constructed for each country; age and sex were included in all models and other variables were entered if p < 0.20 and retained if p < 0.15 using the SAS The number of participating students in Pohnpei was 1495, while in Tonga the sample size was 2808 and in Vanuatu it was 4474. The response rates achieved in each location were 80%, 62% and 75%, respectively. Within each population there were similar proportions of boys and girls at each age level.In Tonga and Vanuatu there were declines in the proportion of boys and girls reporting an intentional injury between the youngest and oldest age groups, with boys more often reporting an intentional injury at each age level Figure . In PohnTable Among boys the most frequently cited source of injury was "other persons", although in Pohnpei the period prevalence of injury from this source did not differ significantly from that of the next two primary sources, namely boyfriend/girlfriend and fathers. In Tonga boyfriend/girlfriend ranked as the second major source of injury, followed by fathers, mothers, teachers and police, which were reported with similar levels of frequency. Boyfriends/girlfriends and fathers were the second most frequently reported sources of injury in Vanuatu, followed by the other sources.The sources of intentional injury reported by girls showed some differences from that of boys. In Pohnpei mothers were the most frequently reported source, followed by fathers, boyfriends/girlfriends and other persons. In Tonga, other persons and boyfriends/girlfriends were most often identified, as for boys, followed by fathers, mothers and teachers. In Vanuatu there was a more even distribution in the sources of injury reported, with other persons, fathers, mothers and boyfriends/girlfriends being reported with similar level of frequency.Multivariable analysis showed that among 14–17 year olds the odds of intentional injury were higher among boys than girls in Tonga and Vanuatu. In these two populations 16 and 17 year olds were the least likely to report an injury of this type Table . In PohnAcross the three societies the factor consistently associated with a higher odds of intentional injury was reporting being bullied at least sometimes in the past school term. In Pohnpei bullying other students in the past term was also associated with a greater likelihood of intentional injury, while in Vanuatu being excluded or ignored by other students at least once per week was associated with this type of injury.There was evidence of a relationship between intentional injury and drug use. In Tonga and Vanuatu smoking at least once per week was related to a greater likelihood of this type of injury, while in Pohnpei and Vanuatu use of an illicit drug at least once per week showed a positive association with intentional injury.Reporting a negative perception of school teachers was related to higher odds of intentional injury in Tonga and Vanuatu. In Tonga a negative overall rating of the school environment showed a similar relationship.In Pohnpei living with parents was related to higher odds of intentional injury, whereas in Tonga the relationship was in the opposite direction. In Vanuatu reporting close relationships with family members and with friends, indicated by easy communication about personal difficulties, was related to a greater likelihood of intentional injury.This study has found that at least one-third of boys and one-quarter of girls aged 14–17 years in these Pacific Island societies reported an intentional injury in the past 12 months, with a markedly higher prevalence among 11–12 year olds in the two populations where they were measured. The data highlight an adolescent health issue that has not been examined at the population level in the Pacific Islands region and which deserves closer attention by public health practitioners.The limitations of the study need to be acknowledged before detailed consideration of the results. First, the findings may be subject to measurement bias as data were obtained by self-report and the validity and reliability of the questions has not been confirmed in the languages in which the study was conducted. All items were, however, translated and back-translated and efforts were made to improve confidentiality and accuracy by removing teachers from classrooms during the administration of surveys. Secondly, the data are only generalisable to in-school youth, whose characteristics may differ significantly from young people not in school. Thirdly, as a cross-sectional study the temporal sequence of the relationship between injury and other risk behaviours and psychosocial factors cannot be disentangled. The data do, however, highlight issues that are relevant to the problem of intentional injury that may assist in the design of injury control programs.Despite its limitations, this is the first population based study of injury among school students in these Pacific Island societies. In the 14–17 years age group, for which comparable data were available from all locations, the highest period prevalence of intentionally inflicted injury was found in Pohnpei. A notable aspect of the finding in Pohnpei was that there was little difference between boys (62%) and girls (56%), whereas in both Tonga and Vanuatu girls were significantly less likely to have been intentionally injured than boys. The situation in these latter populations is consistent with literature, largely drawn from developed countries, which reports that boys are more likely to be intentionally injured, at least in the context of physical punishments at home ,16, physFor both boys and girls in Tonga and Vanuatu, there was a decrease in intentionally inflicted injuries with increasing age. Again, this contrasted with Pohnpei, where for girls there was no apparent pattern by age and for boys levels remained stable after a peak at age 14 years. Studies concerning intentional injury among young people have reported mixed findings in relation to age trends, depending on the type of injuries examined. For example, parental mistreatment of children has been seen to increase with age in studies in the United States  and New For boys, the primary source of injury across all societies was 'other persons'. This category was also reported as an important source of injury for girls. Given the significant association in each of the three populations between being bullied and having sustained an intentional injury, it is likely that the 'other person' category included injuries due to violence inflicted by other students. In Pohnpei students who reported bullying others were also more likely to report an intentional injury, suggesting that bullying may have resulted in violent reprisals.In each of the three societies boyfriends/girlfriends were reported as the second primary source of injury for boys. While this was also an important source of injury for girls across the populations, boys tended to report this more frequently. Studies conducted in other countries have reported that dating violence may be inflicted in at least equal rates between genders -26, indiParents were a frequently identified source of injury for both boys and girls across all three societies. Previous research in Pacific Island countries has found that physical punishment of children may be seen as appropriate and responsible parenting . A studyThere were inconsistent findings across the three populations about the associations between living arrangements, social relationships and intentional injury. Past studies have reported that living in an extended-family may be a protective factor for children, potentially decreasing stresses and other demands associated with child-rearing ,30. In sIn Tonga and Vanuatu intentional injury was associated with smoking, while in Pohnpei and Vanuatu it was associated with illicit drug use. These findings support literature which reports that substance abuse may be correlated with violent behaviour among youth  and thatSeveral indicators of the school environment, including a negative perception of teachers in Tonga and Vanuatu and a poor overall rating of the physical and social environment at school in Tonga, were related to a greater risk of intentional injury. Research from the United States indicates that the school environment can have a significant effect upon injury risk , with stThis study has found that intentional injury is an important issue for examination and discussion by community leaders, health and educational authorities and families in these Pacific Island societies. Action should take into account the associated issues of bullying, drug use and dissatisfaction with the school environment, with relationships between peers, boyfriends and girlfriends, and parents and children being key domains for attention. The limited availability of data about the types, severity, causes and circumstances of intentional injury needs to be addressed, not only in these Pacific Island societies but in other countries where this issue has not been thoroughly examined, in order to strengthen the evidence base for injury prevention strategies.The authors declare that they have no competing interests.BJS assisted with data analysis and undertook manuscript preparation. PP was responsible for study design and field work and contributed to data analysis and manuscript preparation. DB assisted with data analysis and undertook manuscript preparation. GP assisted with data analysis and manuscript preparation. MG contributed to study design and field work. DH contributed to study design and field work. TC held primary responsibility for data analysis. AB contributed to study design and data analysis. All authors read and approved the final manuscriptThe pre-publication history for this paper can be accessed here:


This paper argues for a twofold perspective on human adaptation to climate change in the Amazon. First, we need to understand the processes that mediate perceptions of environmental change and the behavioural responses at the levels of the individual and the local population. Second, we should take into account the process of production and dissemination of global and national climate information and models to regional and local populations, especially small farmers. We discuss the sociocultural and environmental diversity of small farmers in the Amazon and their susceptibility to climate change associated with drought, flooding and accidental fire. Using survey, ethnographic and archival data from study areas in the state of Pará, we discuss farmers' sources of knowledge and long-term memory of climatic events, drought and accidental fire; their sources of climate information; their responses to drought and fire events and the impact of changing rainfall patterns on land use. We highlight the challenges of adaptation to climate change created by the influence of migration and family turnover on collective action and memory, the mismatch of scales used to monitor and disseminate climate data and the lack of extension services to translate large-scale forecasts to local needs. We found that for most farmers, memories of extended drought tend to decrease significantly after 3 years. Over 50% of the farmers interviewed in 2002 did not remember as significant the El Niño Southern Oscillation (ENSO) drought of 1997/1998. This helps explain why approximately 40% of the farmers have not changed their land-use behaviours in the face of the strongest ENSO event of the twentieth century. Why do local populations in the Amazon take different approaches to adapt to climate change than those suggested by outside experts? We argue that two sets of factors are influencing their adaptive strategies: culture and information. First, we need to understand the processes that mediate the perception of environmental change and the differential behavioural adaptations at the levels of the individual and the local population. In this context, adaptation to change and the degree of vulnerability of small farmers are functions of culture , society and economics  and the environment . Second, we should take into account the interlinkages of global and national climate information and prognostic models and their dissemination to and interpretation by regional and local populations. We found that for most farmers, memories of extended drought tend to decrease significantly after 3 years. Over 50% of the farmers interviewed in 2002 did not remember as significant the El Niño Southern Oscillation (ENSO) drought of 1997/1998, one of the strongest on record. This helps explain why approximately 40% of the farmers have not changed their land-use behaviours in the face of the strongest ENSO event of the twentieth century. Adaptation to climate change depends on forms of institutional arrangements that facilitate human activities within and across levels .The diversity of an economic portfolio and its use of technology can give greater flexibility to individuals for adjusting to changes. In this sense, many of the world's small farmers have an advantage over large, monocropping farmers when climatic change makes an area inappropriate for one crop. Changing to another crop may be difficult for the larger operator due to the lack of knowledge, having to change large-scale technology for a new crop and the risk of being worse off. Small farmers, who commonly plant a diversity of crops, are likely to see impact in some but not all their crops and can change the composition. However, as illustrated below, small farmers in the Amazon have acute technological limitations , little access to extension services and market disadvantages, all of which limit their ability to curb the use of burning, expand construction of firebreaks or invest in more intensive forms of land use.Amazonian rural populations are diverse and dynamic, varying in their history and time in the region, knowledge of and dependency on the environment, land-use portfolio, cultural ties to the region and density of social networks. They are strongly shaped by cycles of migratory flows, global commodity markets and their interconnection to large-scale infrastructure and environmental systems. Small farming populations in the region are particularly susceptible to three interrelated environmental conditions associated with climate change: extended drought; variation and duration of floods; and spread of accidental fire. These conditions directly affect their economic activities, land uses, livelihoods, residential patterns, dependencies on social networks and exposure to diseases . The levWe focus our attention in this paper to areas in Amazônia, which have undergone colonization since the 1960s, including farm settlement areas and rural communities along the Transamazon Highway (BR-230) between Altamira and Medicilândia, and the BR-163 highway between Rurópolis and Santarém, both in the state of Pará. Research along the Br-230 has been carried out since 1972, by our team, with major surveys conducted in 1997/1998, 2002 and 2005 using a stratified random sample of arriving cohorts of settlers. The properties chosen for sampling were based on when they began to deforest, leading to membership in a cohort, from each of which a random sample was drawn. Our study began in 2001 along the BR-163 and Santarém, with a major survey of households in 2002 and 2003 derived randomly from a spatially gridded map over all major roads representing the migration waves that took place in the past .We found that for most farmers, memories of extended drought tend to decrease significantly after 3 years. Over 50% of the farmers interviewed in 2002 did not remember as significant the ENSO drought of 1997/1998, one of the strongest on record. This helps explain why approximately 40% of the farmers have not changed their land-use behaviours in the face of the strongest ENSO event of the twentieth century. Our household survey data in Pará State document conditions underlying this important finding. Farmers report various impacts of climate anomalies, such as lost productivity in ENSO years (57% in Santarém and 51% in Altamira) and direct economic losses from accidental fire (37% in Santarém and 38% in Altamira). Survey data show the rate of accidental fire triples during ENSO years. However, the reality of most small farmers in the Amazon is a lack of extension services for adoption of new agricultural techniques, and climate information relevant to local level land-use decision is also nearly absent. When asked to rank their priorities, farmers elicit poor infrastructure (e.g. roads/transportation cited as top concern of farmers) and limited access to credit and technology as their main problems. For the two surveyed areas, the proportion of farmers depending on manual labour and simple tools exceeded 95% with only 18% reporting some access to tractors, for instance, to construct ponds and/or open firebreaks. Among other factors, poor infrastructure and the lack of extension services and commercialization support lead to high rates of lot turnover, which has averaged 75% in the two settlements, where over one-third of rural communities have existed less than 20 years. The pressure from capitalized, large farms further accentuates this problem: land buyouts leading to loss of population, which consequently impacts the availability of services  in rural communities. Under these circumstances, adaptive decision making is made infinitely more difficult since it disrupts sharing of farming experiences as well as the rise of collective action at the community level.Although farmers pay attention to climate information provided by the media (cited by over 40% of farmers surveyed), the scale of information  does not motivate changes in local farming behaviour. Less than 5% of farmers surveyed reported receiving specific information about the 1997/1998 ENSO event. In this context, farmers tend to use local methods, such as animal behaviour, plant phenology, testing salt humidity and sharing information  to cope with lost productivity. Those who changed their land-use behaviours did so in small steps. Adaptation strategies to drought included delays in burning and planting, additional opening of firebreaks and seeking more communication with neighbours regarding agreements about when, where and how to burn.One of the best documented challenges to climate change is human response to extreme floods and droughts. From early literature on natural hazards , the finRural populations are highly variable in their position in society; have varying degrees of knowledge and access to resources such as land, labour and capital; and have varying degrees of institutional self-organization that affect their ability to adapt to changing conditions . At a loIn this context, the rate of lot turnover in the Amazon and continuous formation and transformation of rural communities undermine the ability of rural populations to learn, share and develop forms of individual adaptation and collective action to cope with climate change. The density of social networks plays a key role in adaptation because social networks embody community knowledge that contributes to assessing the best adaptive paths consistent with community integrity. This ensures that change is consistent with community values, but it can also retard adaptation, especially during the periods of rapid change. Conflict can arise between individuals who want to change and adjust and those who wield more power in the network and resist adaptation in fear of threats to the local system of authority. In general, however, communities with dense social networks have an advantage in group response. For instance, kinship systems and customary rules among ‘traditional communities’ in the Santarém-Belterra region minimize transaction costs and motivate forms of collective action to avoid the spread of accidental fire during years of extended drought, which contrasts with neighbouring, recently colonized communities that have higher transaction costs for organization and where the frequency and extent of accidental fire are significantly higher .At a regional scale, the spatial distribution of rural population is important, as this creates differential conditions for acquiring knowledge and for moving people and resources across a changing landscape; differences in physical infrastructure give farmers different opportunities to adjust their behaviours; access to respected extension services can shorten the adjustment time, but small farmers worldwide tend to have less access than large farmers. Because small farmers rarely occupy prime lands and locations, they are harder to serve than large farmers, and the pay-off to the agencies that serve them is smaller. Farmers in both study areas reported that some extension agents actually requested help with fuel cost to visit farms and often had no available transportation. The effective activities of institutional networks such as churches, NGOs and cooperatives can reduce uncertainties for farmers, or augment them if they promote certain kinds of change but are unable to provide the necessary infrastructure. At national and global scales, the challenge is how to create monitoring systems and flows of information that can serve the needs of the rural sector, including small farmers. Given the above constraints, particularly location and infrastructure limitations faced by small farmers, it is not surprising that dissemination, to them, of information relevant to climatic change has been difficult or meaningless from a practical perspective . The effThis impasse can be broken in a variety of ways. First, more micromet stations are needed to collect data that are locally relevant and that can inform climate models and forecasts at a finer spatial resolution. Second, agricultural extension organizations working with farm organizations need to pass this information to farmers in a timely fashion, such as through radio and television programmes. Third, farmer organizations and communities should be encouraged to be participants in the production of scientific and reliable information, rather than be treated only as consumers of such information. It is unlikely that federal, state or local governments have the budget flexibility to put a dense network of micromet stations for an area as large as the Amazon in the near future. Yet, farmers need this kind of information now, as climate change is taking place at a pace that is outpacing the ability of governments to generate timely information. Farmers, and schools in rural communities, could work together to implement micromet stations at low cost (following something akin to the GLOBE approach), and engage students in monitoring climate changes in temperature and precipitation as part of their school work and learning about science.1We call attention to the importance of nesting our understanding of individual environmental cognition and behaviour into larger social, cultural and environmental contexts. This includes considering the role of climate monitoring, forecasting and dissemination systems that are framing for society and policy makers the connections between the climate change and the fate of the Amazon.Several processes mediate the perception of change in environment and climate and differ at individual, household, community and regional scales. Perhaps the most important among them are various social conditions that differentiate between individuals and communities in their adaptability to climatic change, which, in the Amazon, require new approaches to understanding adaptation.


In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications.We use two different types of premises: factual  and value premises .Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation.Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging. New England Journal of Medicine suggested "prophylactic cesarean" at term to avoid the risks linked to "passive anticipation of vaginal delivery" [Cesarean delivery on maternal request (CDMR), patient choice cesarean, or cesarean on demand all refer to elective caesarean section (CS) for singleton term pregnancy carried out on maternal request in the absence of maternal or fetal indications . The notelivery" . Over a elivery" . Since telivery" ,4-14.Reported rates of CDMR range from 2.6% of all caesarean sections in Flanders  to 26.8%This paper presents an ethical analysis of the problem posed by CDMR, carried out using the principlist approach. We assess whether the approach contributes to resolving the conflict. The analysis uses both value premises (the principles) and the findings of a European multi-centre study (EUROBS) which compared the attitudes of a large, representative sample of obstetricians in eight European countries: France, Germany, Italy, Luxembourg, the Netherlands, Spain, Sweden, and the UK .We used two different types of premises. The first are factual premises, i.e. the European obstetricians' stated attitudes to CDMR. Previous studies have shown that in ethical matters physicians' practices (i.e. "what physicians do")  reflect The second are value premises, which in this case are the ethical principles formulated by Beauchamp and Childress : respectThe findings from the EUROBS study concerning doctors' attitudes to CDMR were reported elsewhere . ObstetrThe questionnaire included the following clinical case description: "A 25-year old pregnant woman starts labour at 39 completed weeks. The foetus is apparently normally formed, healthy, and in cephalic presentation. Despite being informed that a vaginal delivery is indicated, and of the higher morbidity and mortality associated with cesarean delivery, the woman insists on cesarean section". Physicians were asked to report what they would do in response to a range of scenarios, including the case where no additional factors related to previous pregnancies or psychosocial factors were present, and where the patient's request was based simply on her personal choice. Respondents who indicated compliance with maternal request were then asked to clarify their rationale.Results are presented in Table Values and norms, of which ethical principles are a subclass, are crucial to the assessment of the ethical standing of the different recommendations that may ensue . This anIn line with the recommendation of the Council for International Organizations of Medical Sciences (CIOMS) we shall consider beneficence to encompass non-maleficence (do no harm) . Thus, tThe most important stakeholders are the pregnant woman, the foetus, and the physicians responsible for patient care. Where applicable, third party payers and society at large will be considered because of the impact on resource allocation and policy. Other health care practitioners and staff whose time, skills and resources might be used differently depending on the choices made, and the father or other relatives or carers will also be affected; however, their involvement, as far as we can see, is unlikely to raise unique challenges not considered elsewhere in this analysis.beneficence  affirms the obligation on health care professionals to minimise harm and maximise benefits. Harm can only be justified if unavoidable and if it occurs during attempts to achieve greater good (mostly but perhaps not exclusively) to the individual concerned.The principle of Decisions contrary to the pregnant woman's will, could negatively affect her experience of labour and her relationship with health care providers, and even with her child. Operative vaginal delivery and emergency CS, which might become necessary during labour, carry greater risk compared to elective CDMR ,28. But A CS is relatively safe for the foetus, but it is not without risks, particularly respiratory problems and an increased length of hospital stay ,12,34-37There is lack of agreement on whether beneficence or harm to the physicians is to be considered in an ethical analysis . ComplicJudicial use of resources is probably the only relevant concern for third party payers. CS incurs higher costs compared to vaginal birth ,45, althAt the public health level the increasing CS rates, a trend common to most countries, is a source of worry. While a variety of counter measures such as educational programs and guidelines have been proposed, CDMR has the potential to aggravate the trend, particularly as a first CS appears to be strongly predictive of subsequent cesareans. It has been argued that this could result in loss of obstetric and midwifery skills in the management of vaginal birth .utonomy is inextricably linked to the Western tradition of liberalism, and is given central status in Kantian moral philosophy and in Mill's utilitarian liberalism [respect for autonomy requires that the views of those who are capable of deliberation about their personal goals be sought and respected. As the foetus lacks such capabilities, the question of foetal autonomy does not arise.Aberalism ,48. The There is consensus that a pregnant woman should be adequately informed about the management of delivery and the consequences of different decisions, and this pre-requisite was specified in our case scenario description. The principle of respect for autonomy could be seen to assign higher priority to a pregnant woman's wishes in case of disagreement. However, such a conclusion is compounded by conflicting views of autonomy itself, and different conclusions may be drawn depending on whether one specifies autonomy in terms of negative or positive rights: that is, the right to refuse a certain intervention, or also the right to demand it. There seems to be a generally accepted view, supported by case law, that a pregnant woman's desire for non-intervention overrides other considerations , but a rGood obstetric practice requires the physician to act in the best interest of both mother and foetus. To this end, a physician's autonomy and medical training require him/her to inform the patient and recommend the most appropriate course of action. Traditional medical teaching is that a surgical intervention such as CS requires justification. Thus, in case of disagreement, physician's autonomy and professional integrity allows him/her to reject the patient's request, provided that the patient is not put at risk and that timely provisions could be made for the transfer of care to another physician.Public provisions account for the vast majority of funding for obstetric services in the countries participating in the EUROBS study. Concerns have been raised in many of these countries about the rising CS rates ,52, but justice. Whilst the principle of formal justice that requires equals to be treated equally raises no disagreement, there are many different material principles of distributive justice [Rival theories produce different interpretations of the ethical principle of  justice . These iAvoiding unjust discrimination and allowing fair access to health care permit individualisation of care based on need. Many would argue that an obligation to provide such access is limited to the provision of basic need. The difficulties inherent in delimiting what constitutes basic provision invite public and policy debate and decision.It could be argued on ethical  grounds, that the requirements of justice should provide the unborn with a fair opportunity at the start of life. This may not be applicable in cases of CDMR because of the absence of fetal indication for the intervention.No ethical problems need to arise here provided that the standard is uniformly applied, but the issue of legal justice is important. The different medico-legal environments in Europe may at least partly explain the differences in the obstetricians' perceptions of threat of litigation seen in the EUROBS study. The physicians may also have a role in ensuring efficient use of resources, and avoiding unnecessary expenditure.Budgetary constraints argue against more expensive interventions unless linked to tangible benefit. Furthermore, limited resources often mean that additional expenditure in one area can have adverse impact on other services. Transparency and accountability are important means towards achieving distributive and legal justice, but are unlikely to resolve the controversies surrounding priority setting. Additional costs incurred by CDMR may impact on different groups of patients. Co-payment by patient to cover the extra costs has been suggested , but it The findings from the EUROBS study indicate that European obstetricians generally accept two propositions: woman's self-determination and medical utility. The right to self-determination is considered important, as between 79 and 97% of those who agreed to perform CS based on the woman's request quoted respect for autonomy as justification. The view that vaginal birth is preferable in the absence of medical indications for CS is evidence of the weight given to medical utility, a concept encompassing calculations of risk and benefit as well as concerns for optimising the use of resources. How are these apparently conflicting positions to be balanced?Partly because of lack of convincing empirical evidence, the balance of our analysis of benefits and harm of CDMR does not clearly shift one way or the other. There is evidence that a spontaneous, non-operative vaginal delivery is the safest option for the mother and the neonate, but such favourable outcome cannot be predicted with certainty. Overall, the benefits and burdens of elective non labour cesarean delivery appear to equal those of planned vaginal birth, as most of the risks of caesarean section may be linked to its primary indication, or to procedures done as an emergency. However, confounding is difficult to control, and randomized comparisons of "planned vaginal delivery" versus "planned cesarean" in the absence of medical indications are not available. An additional difficulty is linked to the somewhat different types and time of occurrence of the risks. Most reviews and recently issued guidelines on the topic have therefore concluded that overall no major differences in outcome exist between CDMR and planned vaginal delivery, but the evidence is too weak to state definitely that differences are completely absent ,10,12. TAn appeal to autonomy as a basis for CDMR requires that the woman's choice is free from controlling influences . SeveralThe doctrine of informed consent requires the physician to discuss with the patient the available diagnostic and therapeutic alternatives, to explain the relevant risks and benefits, and to make recommendations . Such duThe application of the principle-based approach has provided a useful framework for orderly analysis of the rights and duties of the parties involved taking account of available scientific evidence, and enabled us to reach a general conclusion about what should be considered an acceptable standard. On beneficence/non maleficence grounds CDMR cannot currently be considered the safest option. On autonomy grounds, concerns about the influence of interfering factors on the women's choice, and differences between positive and negative rights, argue against CDMR. Finally, on justice grounds, the view that CDMR is an acceptable alternative to vaginal birth in case of normal pregnancy would require including this information in the routine prenatal counselling, with the paradoxical consequence of supporting rather then merely accepting the practice. These arguments, based on the application of principlism analysis, have allowed to conclude that vaginal birth should remain the standard of care in uncomplicated pregnancy.The remaining question to be answered is what to do in the cases when appropriate information and persuasion fail, and where a woman insists on cesarean delivery against the obstetrician's recommendation: a situation which is illustrated by the vignette used in the EUROBS study. Research has shown that, apart from those derived from social pressures and obstetricians' influences, spontaneous maternal requests for caesarean delivery are probably for the time being a more limited phenomenon than suggested by the amount and virulence of the debate raised around it . Many caThe authors declare that they have no competing interests.TN conceived the paper and drafted the manuscript. MH and GL contributed to the analysis of the obstetrical literature, and RS to the interpretation of the epidemiological evidence. MDF performed the analyses of the EUROBS database. MC was principal investigator of the EUROBS project, and participated in preparing the discussion. All authors contributed to finalize the paper, read and approved the final manuscript.The pre-publication history for this paper can be accessed here: